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. 2025 Nov 27;10(Suppl 8):e017301.
doi: 10.1136/bmjgh-2024-017301.

Missed opportunities for hospital referral of young children with severe pneumonia identified at primary care using pulse oximetry: an analysis from the AIRE study in West Africa

Désiré Lucien Dahourou  1   2 , Désiré Neboua  3 , Kessièdé Gildas Boris Hedible  2 , Zineb Zair  2 , Sarah Louart  4 , Jean-Paul Yassa Guilavogui  5 , Abdoul Guaniyi Sawadogo  6 , Bertrand Meda  7 , Solange Ouédraogo Yugbaré  8 , Ibrahima Sory Diallo  9 , Abdoul Aziz Diakite  10 , Hannatou Abarry Souleymane  11 , Valéry Ridde  12   13 , Valériane Leroy  14 ; AIRE Research Study Group
Collaborators, Affiliations

Missed opportunities for hospital referral of young children with severe pneumonia identified at primary care using pulse oximetry: an analysis from the AIRE study in West Africa

Désiré Lucien Dahourou et al. BMJ Glob Health. .

Abstract

Background: In line with the Integrated Management of Childhood Illness (IMCI) guidelines, healthcare workers (HCWs) should refer all severe pneumonia among children under 5 seen in primary care in resource-limited settings. We investigated the frequency and correlates of missed opportunities for hospital referral (MOHR) of clinical severe pneumonia. Our study was embedded within the Améliorer l'Identification des détresses Respiratoires chez l'Enfant project, which involved the routine implementation of pulse oximetry (PO) within IMCI consultations at primary healthcare centres (PHCs) in West Africa: Burkina Faso, Guinea, Mali and Niger.

Methods: All children aged 2-59 months attending IMCI consultations in 16 PHCs and classified as severe cases using IMCI+PO were enrolled into a prospective cohort for 14 days, with parental consent. We estimated the rate of MOHR for IMCI-defined severe pneumonia, which was either not referred, or referred but did not make it to hospital. Correlates of MOHR at day 14 were investigated using logistic mixed regression with random effect for PHCs.

Results: From June 2021 to June 2022, among the 1786 children aged 2-59 months classified as severe cases by IMCI+PO, 682 (38.2%) were severe pneumonia. Of these, 35 (5.1%) also had severe anaemia, 47 (6.9%) severe hypoxaemia (SpO2 <90%) and 602 (88.3%) severe malaria. HCW made the referral decision for 125 (18.3%) children, refused by three (2.4%) families; 560 (82.1%) were MOHR. Severe anaemia reduced the odds of MOHR (adjusted OR (aOR): 0.02; 95% CI 0.01 to 0.07) whereas having an SpO2 between 90% and 93% (aOR: 12.16; 95% CI 3.47 to 42.61) or greater than 94% (aOR: 11.81; 95% CI 3.98 to 35.02) or severe malaria (aOR:2.55; 95% CI 1.04 to 6.26) significantly increased it.

Conclusion: MOHR for severe pneumonia was extremely high at PHC level in these settings, mainly explained by HCW's decisions. Strengthening the referral system and training HCW to reinforce their adherence to IMCI guidelines remains essential to improve the management of severe pneumonia.

Trial registration number: PACTR202206525204526; Pan African Clinical Trials Registry on 15 June 2022.

Keywords: Africa South of the Sahara; Child health; Decision Making; Health systems evaluation; Other diagnostic or tool.

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Conflict of interest statement

Competing interests: VR is a member of the Editorial Board of the journal BMJ Global Health. He was not involved in the peer‑ review or handling of the manuscript. All other authors have no competing interest to declare.

Figures

Figure 1
Figure 1. Flowchart of the inclusion process of children 2–59 months of age enrolled in the pneumonia substudy of missed opportunities of hospital referral in the AIRE research study, June 2021–June 2022. AIRE, Améliorer l'Identification des détresses Respiratoires chez l'Enfant; BF, Burkina Faso; IMCI, Integrated Management of Childhood Illness; PO, pulse oximetry.
See this image and copyright information in PMC

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