Pulse oximetry and oxygen services for under-five children with community-acquired pneumonia attending primary and secondary level health facilities in Lagos, Nigeria (INSPIRING-Lagos): a pre-implementation and post implementation study

Abstract

Introduction Childhood pneumonia is a leading cause of child mortality in Nigeria and poor quality of care is a persistent issue. We aimed to understand whether introducing primary care stabilisation rooms equipped with pulse oximetry and oxygen systems alongside healthcare worker (HCW) training improved the quality of care for children with pneumonia in Lagos State.Methods Setting: Ikorodu local government area, Lagos. Population: children aged 0–59 months with clinically diagnosed pneumonia. Intervention: establishment of ‘stabilisation rooms’ within government (n=7) and private (n=7) primary care facilities, designed for short-term oxygen delivery for hypoxaemic children prior to hospital transfer, alongside HCW training on integrated management of childhood illness (IMCI), pulse oximetry and oxygen therapy. Two secondary facilities with inpatient oxygen systems received training and pulse oximeters. Primary outcome: composite ‘correct management’ of hypoxaemic pneumonia including oxygen therapy administration, referral and admission to hospital. Analysis: mixed-effects logistic regression comparing baseline (September 2020–August 2021) and implementation (September 2021–November 2022) periods, adjusted for clustering by facility.Results We screened 20 158 children, of which 160 children with hypoxaemic pneumonia (SpO2<90%) were recruited. The proportion of hypoxaemic children with ‘correct management’ remained low and unchanged: 9/98 (9%) with data on referral and admission at baseline, and 6/52 (12%) during implementation (mixed effects logistic regression adjusted OR (aOR): 1.17 (95% CI 0.30, 4.52), p=0.822). Oxygen use for children with hypoxaemia increased from baseline 10/105 (10%) to 13/55 (24%) during implementation (aOR 3.01 (95% CI 1.05, 8.65), p=0.040). But subsequent referral and hospital admission remained low. Low pulse oximetry use by health workers in children with clinical pneumonia persisted through baseline (73/798, 9%) and implementation (122/1125, 11%).Conclusion Equipping primary care stabilisation rooms with pulse oximetry and oxygen increased oxygen use for children with hypoxaemia but did not improve referral or hospital admission rates. Persistent failure to assess children with pulse oximetry likely contributed to under-recognition of hypoxaemia and therefore failure to initiate correct care. Further work to improve initial triage, assessment and treatment of children with severe pneumonia in Lagos is urgently needed.Trial registration number ACTRN12621001071819.