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Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh
  1. Carina King1,
  2. Nicholas Boyd2,
  3. Isabeau Walker2,
  4. Beatiwel Zadutsa3,
  5. Abdullah H Baqui4,
  6. Salahuddin Ahmed4,
  7. Mazharul Islam5,
  8. Esther Kainja3,
  9. Bejoy Nambiar1,
  10. Iain Wilson6,
  11. Eric D McCollum7,8
    1. 1 Institute for Global Health, University College London, London, UK
    2. 2 UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
    3. 3 Parent and Child Health Initiative, Lilongwe, Malawi
    4. 4 International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
    5. 5 Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh
    6. 6 Lifebox Foundation, London, UK
    7. 7 Eudowood Division of Pediatric Respiratory Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
    8. 8 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
    1. Correspondence to Dr Carina King; c.king{at}


    Objective To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries.

    Design Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach.

    Setting Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care.

    Participants Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors.

    Results We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability.

    Conclusions Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations.

    Trial registration number NCT02941237.

    • Pulse oximeter
    • oxygen saturation
    • pneumonia
    • sub-Saharan Africa
    • South Asia
    • children

    This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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    • Contributors The qualitative study was designed and topic guides developed by IWi, IWa, CK and EDM, and the field manual written by CK. Oversight of the study was conducted by CK, BN and BZ in Malawi and EDM, AHB and MI in Bangladesh. In Malawi, BZ and EK arranged, conducted, transcribed and translated the focusgroup discussions (FGDs). In Bangladesh, SA and MI arranged and conducted the FGDs. The data were coded and analysed by CK. The manuscript was written by CK, with considerable input from EDM. IWi, IWa, EDM, BZ, EK, SA, MI, NB, AHB and BN read, commented and approved the manuscript.

    • Funding This study was funded by the Bill & Melinda Gates Foundation (grant number: OPP1133291).

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval University College London REC (8075/003); Johns Hopkins Medicine Institutional Review Board (IRB00047406); Malawi National Health Sciences Research Committee (16/4/1570); Bangladesh Medical Research Council (BMRC/NREC/2013-2016/1272).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Anonymised transcripts can be shared, following the signing of a data sharing agreement, subject to approval from the relevant national ethics committees. For further information, contact CK (

    • Collaborators Katie Fernandez, Charles Makwenda, Tambosi Phiri, Tim Colbourn, Mike Bernstein, Nazma Begum, Arun Dutta Roy, Abu Abdullah, Mohammad Hanif.

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