Introduction
Pneumonia is an acute infection of the lungs caused by bacteria, viruses or fungi1 that begins as a mild infection and progressively worsens to a moderate or severe infection if untreated or if treatment is delayed.2 The condition is characterized by inflammation of the alveoli, which causes the air sacs to fill with fluid or pus leading to symptoms such as fever, chills, cough and difficulty in breathing, thus limiting oxygen intake.3 There are risk factors associated with developing pneumonia, including indoor air pollution, undernutrition, lack of immunization, lack of safe water and poor sanitation.4 Low socio-economic status, limited education of caregivers and inability to access proper health care can also contribute to pneumonia.4 Although pneumonia can occur in anyone, older individuals and children, particularly those younger than five years of age, are the most susceptible. This systematic review will focus on children.
Edmond et al.5 demonstrate that every child who contracts pneumonia is at risk of developing long-term respiratory complications. The evidence indicates that childhood pneumonia is associated with decreased lung function and asthma.6 Babies are particularly vulnerable to pneumonia-related complications, supporting the theory that early childhood pneumonia episodes damage the developing lungs, leading to long-term respiratory complications later in adulthood.7 The available data indicate that an estimated 200 million adults currently suffer from chronic obstructive pulmonary disease, and 235 million people worldwide have asthma as a consequence of childhood pneumonia.7 Other long-term consequences of childhood pneumonia include restrictive airway disease and abnormal lung function, which are dependent on the frequency and severity of pneumonia episodes.5,8
Pneumonia is one of the leading causes of death in children younger than five years of age.9 The Millennium Development Goal 4 was established to reduce child morbidity and mortality. It aimed to reduce the pneumonia mortality rate by two-thirds in children younger than five years of age by 2015.9 Progress has been made since this goal was set in 1986, with childhood pneumonia decreasing from 178 million to 138 million in 2000.6 More than 54% of global childhood pneumonia episodes occur in five countries: India, China, Indonesia, Nigeria and Pakistan. Mortality associated with pneumonia in children younger than five years declined substantially from 2000 to 2015 in those countries: India (from 390,000 to 350,000), China (from 280,000 to 90,000), Indonesia (from 470,000 to 270,000), Nigeria (from 280,000 to 230,000) and Pakistan (from 250,000 to 170,000).10
In spite of this, pneumonia remains the leading cause of mortality in this age group, with deaths estimated at 880,000 in 2016. This translates to 2500 deaths per day, 100 deaths per hour and one death every 35 seconds from pneumonia in children younger than five years.6 The annual cost associated with the treatment of childhood pneumonia is USD 109 million, and an estimated USD 4.5 billion is spent on public health interventions.9 Childhood pneumonia places an enormous economic burden on families and the healthcare system, particularly in resource-limited settings. Currently, around 90% of pneumonia-related deaths in children younger than five years occur in low- and middle-income countries where poverty is severe,3 and the rate is increasing predominantly in sub-Saharan Africa and South Asia.11 In 2016, 49% of all childhood pneumonia deaths occurred in India (158,176), Nigeria (140,520), Pakistan (62,782), Democratic Republic of Congo (49,115) and Ethiopia (30,733).12 These deaths pose a threat to the sustainable development for the world's underprivileged people.3
Pneumonia typically begins as a mild infection13 that can be treated with proven, cost-effective interventions. The evidence shows that most children who die have severe or very severe pneumonia, which could have been averted if identified and treated sooner.14 Delayed identification and treatment of pneumonia early in the disease course can lead to severe illness that may cause death.8 Initiating antibiotic therapy soon after the onset of symptoms can reduce mortality and complications associated with pneumonia.8 However, only one-third of the world's children receive antibiotics.13 Globally, around 400 million children in developing countries are unable to access health care, including antibiotics, because of high costs.12 For instance, out-of-pocket health expenditure is 41% in Uganda and 65% in India, making it impossible for ordinary citizens to purchase much-needed antibiotics.15 Incorrect diagnosis and lack of appropriate antibiotics are some factors that hinder appropriate care.12
Of the 151 million global pneumonia episodes every year, 300,000 people die due to poor care-seeking attitude, inability to access health care or both.12 In 2010, 7 million pneumonia-related deaths in children occurred in low- and middle-income countries, and the majority of these deaths occurred due to lack of medical attention.16 Caregivers play an essential role, as their ability to detect early symptoms of pneumonia and seek prompt medical care is fundamental to decreasing the long-term effects of pneumonia, as well as pneumonia-related mortality. According to Noordam et al.,17 only two out of five children with symptoms of pneumonia are taken to a reliable healthcare provider in sub-Saharan Africa. The authors concluded that caregivers lacked knowledge regarding the symptoms of pneumonia and were unable to identify the more severe symptoms of pneumonia, such as intercostal retraction and central cyanosis.17 Another study found that only 30% of caregivers in rural Bangladesh were able to identify one of the two main symptoms of pneumonia (fast breathing and difficulty breathing), and caregivers reported being unable to seek medical care due to poor road conditions and long waiting times at the hospital.14 A study by Muro et al.13 reported that caregivers had good understanding of the symptoms of pneumonia, but accessing health care was a hindrance due to distance, security and financial barriers. Moreover, Kallander et al.15 implied that the majority of the caregivers chose to self-medicate their children with either antibiotics obtained from private clinics or with herbal or old-fashioned medicines.
The management of children with pneumonia depends on the ability of healthcare workers to correctly diagnose and initiate early and effective treatment. This is fundamental to reduce pneumonia-related long-term complications and mortality in children. According to Rabbani et al.,18 healthcare workers in one district in Pakistan identified pneumonia as a leading cause of death in children younger than five years, but lacked the expertise to initiate appropriate treatment and attributed this to inadequate training, delayed wages and lack of medical supplies. Furthermore, a report released by Lancet Global Health in 2015 indicated that only 54% of children with symptoms of pneumonia received medical care,19 and this was likely due to healthcare workers' lack of ability to adequately diagnose and treat pneumonia.12 Additionally, a study by Wanduru et al.20 that assessed the performance of community healthcare workers in northern Uganda reported that 88% scored poorly regarding knowledge of pneumonia. The evidence shows that when healthcare workers use appropriate clinical protocols, pneumonia is managed rapidly and appropriately, thereby reducing mortality rates.3
In Malawi, where there is poor adherence to clinical guidelines, one in five children is misdiagnosed and mistreated for pneumonia. Even experienced clinicians who are familiar with the protocol misdiagnose pneumonia. Factors such as education and supervision are shown to improve use of the treatment algorithm.21 Other factors such as reduced workload, regular training and availability of medicine and other medical supplies enhance healthcare workers' performance and increase motivation.17
Given the critical role of caregivers and healthcare workers in managing childhood pneumonia, this systematic review will aim to identify and synthesize the available data regarding the experiences of caregivers and healthcare workers regarding the management of pneumonia.
A preliminary search of PROSPERO, PubMed, Embase, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or underway systematic reviews were identified on caregivers' health-seeking behavior and healthcare workers' experiences in the management of childhood pneumonia in low- and lower middle-income countries.
This systematic review will explore caregivers' health-seeking behaviors and healthcare workers' experiences in the management of childhood pneumonia in low- and lower middle-income countries.
Review objectives
The overall objective of this review is to identify and synthesize the evidence regarding caregivers' health-seeking behaviors and healthcare workers' experiences concerning the management of childhood pneumonia in low- and lower middle-income countries. The specific objectives of this review are:
i. To explore the experiences of caregivers of children younger than five years regarding their health-seeking behaviors for pneumonia.
ii. To explore the experiences of healthcare workers regarding the management of pneumonia in children less than five years of age.
Inclusion criteria
Participants
This review will consider studies that include caregivers of children younger than five years exhibiting symptoms of pneumonia such as cough, fast breathing and difficulty breathing who receive a diagnosis of pneumonia. The term "caregivers" refers to the parents of children, immediate family members, extended family members or anyone in the community who participates in caregiving responsibilities.
This review will also consider studies that include healthcare workers who are involved in the identification and treatment of pneumonia in children younger than five years. "Healthcare worker" refers to nurses, doctors, community health workers and lay health workers.
Phenomena of interest
This review will consider studies that explored caregivers' experiences related to their health-seeking practices. This review will also consider studies that explored healthcare workers' experiences of identifying and treating childhood pneumonia.
Context
The review will include studies undertaken in low- and lower middle-income countries identified according to the World Bank Classification system.22 The review will consider studies conducted in any healthcare setting such as hospitals, healthcare or community centers, ambulatory care or homes.
Types of studies
This review will consider primary qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, case study and action research. Descriptive qualitative studies that describe the experiences of caregivers and healthcare workers will also be considered. Only studies published in English will be included, with no date restrictions.
Methods
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.23
Search strategy
The search strategy will aim to locate both published and unpublished studies. An initial limited search of PubMed was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant studies, and the index terms used to describe the article, were used to develop a full search strategy for PubMed (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.
Information sources
The databases to be searched include PubMed (National Library of Medicine), Embase (Elsevier), Scopus (Elsevier) and CINAHL (EBSCOhost). The search for unpublished studies and gray literature will be undertaken in ProQuest Dissertations and Theses and Networked Digital Library of Theses and Dissertations.
Study selection
Following the search, all identified citations will be collated and uploaded into EndNote X8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported to the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.24
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research.23 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between reviewers will be resolved through discussion, or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table.
From a scoping search, the authors identified a limited number of potentially eligible studies. Therefore, all studies, regardless of their methodological quality, will undergo data extraction and synthesis (where possible). However, the impact of the methodological quality of the included studies will be considered in the analysis of findings and conclusions of the review.
Data extraction
Data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool.23 The data extracted will include specific details about the populations, context, culture, geographic location, study methods and phenomena of interest relevant to the review objective. Findings and their illustrations will be extracted and assigned a level of credibility. There are three levels of credibility based on the JBI approach to qualitative systematic reviews: i) unequivocal, where findings can be accompanied by an illustration that is beyond reasonable doubt and is therefore not open to challenge, ii) credible, where findings can be accompanied by an illustration that lacks clear association with it and is therefore open to challenge and (3) not supported, where findings are not supported by the data.23 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Data synthesis
Qualitative research findings will, where possible, be pooled in JBI SUMARI using the meta-aggregation approach.23 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.25 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest and context for the review. Each synthesized finding from the review will then be presented along with the type of research informing it, scores for dependability and credibility, and the overall ConQual score.
Funding
The author SJK is a recipient of The University of Adelaide International Wildcard Scholarship.
Appendix I: Search strategy for PubMed
Search conducted on 18th August 2018
References