Introducing pulse oximetry for outpatient management of childhood pneumonia: An implementation research adopting a district implementation model in selected rural facilities in Bangladesh

Ahmed Ehsanur Rahman, Shafiqul Ameen, Aniqa Tasnim Hossain, Janet Perkins, Sabrina Jabeen, Tamanna Majid, Afm Azim Uddin, Md. Ziaul Haque Shaikh, Muhammad Shariful Islam, Md. Jahurul Islam, Sabina Ashrafee, Husam Md. Shah Alam, Ashfia Saberin, Sabbir Ahmed, Goutom Banik, Anm Ehtesham Kabir, Anisuddin Ahmed, Mohammod Jobayer Chisti, Steve Cunningham, David H DockrellHarish Nair, Shams El Arifeen, Harry Campbell

Research output: Contribution to journalArticlepeer-review


Background: Pulse oximetry has potential for identifying hypoxaemic pneumonia and substantially reducing under-five deaths in low- and middle-income countries (LMICs) setting. However, there are few examples of introducing pulse oximetry in resource-constrained paediatric outpatient settings, such as Integrated Management of Childhood Illness (IMCI) services.

Methods: The National IMCI-programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in routine IMCI services through stakeholder engagement and demonstrated the model in Kushtia district adopting a health system strengthening approach. Between December 2020 and June 2021, two rounds of assessment were conducted based on WHO's implementation research framework and outcome variables, involving 22 IMCI service-providers and 1680 children presenting with cough/difficulty-in-breathing in 12 health facilities. The data collection procedures included structured-observations, re-assessments, interviews, and data-extraction by trained study personnel.

Findings: We observed that IMCI service-providers conducted pulse oximetry assessments on all eligible children in routine outpatient settings, of which 99% of assessments were successful; 85% (95% CI 83,87) in one attempt, and 69% (95% CI 67,71) within one minute. The adherence to standard operating procedure related to pulse oximetry was 92% (95% CI 91,93), and agreement regarding identifying hypoxaemia was 97% (95% CI 96,98). The median performance-time was 36 seconds (IQR 20,75), which was longer among younger children (2-11 months: 44s, IQR 22,78; 12-59 months: 30s, IQR 18,53, p < 0.01) and among those classified as pneumonia/severe-pneumonia than as no-pneumonia (41s, IQR 22,70; 32s, IQR 20,62, p < 0.01). We observed improvements in almost all indicators in round-2. IMCI service-providers and caregivers showed positive attitudes towards using this novel technology for assessing their children.

Interpretation: This implementation research study suggested the adoption, feasibility, fidelity, appropriateness, acceptability, and sustainability of pulse oximetry introduction in routine IMCI services in resource-poor settings. The learning may inform the evidence-based scale-up of pulse oximetry linked with an oxygen delivery system in Bangladesh and other LMICs.

Funding: This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research.

Original languageEnglish
Article number101511
Publication statusPublished - 28 Jun 2022


  • Bangladesh
  • Feasibility
  • IMCI
  • Implementation research
  • Pneumonia
  • Pulse oximetry


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