A Human Factors Approach to Childhood Pneumonia A qualitative study in Malawian primary care

Introduction Pneumonia is one of the major causes of childhood mortality worldwide. Most of these deaths are readily preventable or treatable with proven cost effective interventions. The aim of this study is to investigate the assessment and management of childhood pneumonia in primary care in Malawi. Methods Semi-structured interviews were used to elicit accounts of the assessment, treatment and referral process as experienced by staff and caregivers in 10 health facilities in Northern Malawi. Staff members dealing with assessment of children under-five years of age (Doctors, Clinical Officers, Medical Assistants, Nurses, Nurse Midwife Technicians, Student Nurses and Health Surveillance Assistants) were included. It also involved policy makers from the area and caregivers of children presenting with pneumonia. Data was analysed using thematic analysis following the SEIPS 101 tools (task sequence, use of technology and tools, and work system barriers and facilitators). Results 43 interviews were undertaken. A process map of the flow of patients with pneumonia was created, showing the tasks undertaken and the interactions between staff and patients. In their interviews caregivers identified a number of barriers to appropriate care including insufficient education for caregivers on the management of sick children and distance to healthcare availability. Staff identified several organisational elements that served as barriers to the implementation of care. They included workload, lack of resources such as medications and batteries, uncertainty regarding markers of severity and need to give all antibiotics. The health passport system and effective teamwork and community were highlighted as being important facilitators. Conclusion This study provides information on the challenges and issues involved in managing childhood pneumonia in primary care in Malawi. These barriers included a lack of resources, staff and caregiver education and heavy workload. The ability to identify severe illness accurately and identify those who do not require antibiotics were highlighted as issues for health workers. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by Science Foundation Ireland (SFI) and the Department of Foreign Affairs (DFA) under the SDG Challenge Grant Number SFI/21/FIP/SDG/9948 ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Ethics committee of Mzuzu University gave ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors