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Distribution and determinants of pneumonia diagnosis using Integrated Management of Childhood Illness guidelines: a nationally representative study in Malawi
  1. Omolara T Uwemedimo1,
  2. Todd P Lewis2,
  3. Elsie A Essien3,
  4. Grace J Chan2,
  5. Humphreys Nsona4,
  6. Margaret E Kruk2,
  7. Hannah H Leslie2
  1. 1 Department of Pediatrics and Occupational Medicine, Epidemiology and Prevention, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell GLOhBAL (Global Learning. Optimizing health. Building Alliances Locally), Hempstead, New York, USA
  2. 2 Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, New York, USA
  3. 3 GLOhBAL (Global Learning. Optimizing health. Building Alliances Locally) at Cohen, Children’s Medical Center, New Hyde Park, New York, USA
  4. 4 Malawi Ministry of Health (IMCI), Lilongwe, Malawi
  1. Correspondence to Dr Omolara T Uwemedimo; Ouwemedimo{at}


Background Pneumonia remains the leading cause of child mortality in sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) strategy was developed to standardise care in low-income and middle-income countries for major childhood illnesses and can effectively improve healthcare worker performance. Suboptimal clinical evaluation can result in missed diagnoses and excess morbidity and mortality. We estimate the sensitivity of pneumonia diagnosis and investigate its determinants among children in Malawi.

Methods Data were obtained from the 2013–2014 Service Provision Assessment survey, a census of health facilities in Malawi that included direct observation of care and re-examination of children by trained observers. We calculated sensitivity of pneumonia diagnosis and used multilevel log-binomial regression to assess factors associated with diagnostic sensitivity.

Results 3136 clinical visits for children 2–59 months old were observed at 742 health facilities. Healthcare workers completed an average of 30% (SD 13%) of IMCI guidelines in each encounter. 573 children met the IMCI criteria for pneumonia; 118 (21%) were correctly diagnosed. Advanced practice clinicians were more likely than other providers to diagnose pneumonia correctly (adjusted relative risk 2.00, 95% CI 1.21 to 3.29). Clinical quality was strongly associated with correct diagnosis: sensitivity was 23% in providers at the 75th percentile for guideline adherence compared with 14% for those at the 25th percentile. Contextual factors, facility structural readiness, and training or supervision were not associated with sensitivity.

Conclusions Care quality for Malawian children is poor, with low guideline adherence and missed diagnosis for four of five children with pneumonia. Better sensitivity is associated with provider type and higher adherence to IMCI. Existing interventions such as training and supportive supervision are associated with higher guideline adherence, but are insufficient to meaningfully improve sensitivity. Innovative and scalable quality improvement interventions are needed to strengthen health systems and reduce avoidable child mortality.

  • pneumonia
  • health systems
  • child health
  • cross-sectional survey

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Handling editor Seye Abimbola

  • Contributors Conceived of study: MEK, HHL. Designed study question: OTU, GJC, HN, MEK, HHL. Defined analysis: OTU, TPL, EAE, HHL. Conducted analysis: TPL, HHL. Drafted manuscript: OTU, EAE, TPL. Critically reviewed manuscript: all authors.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval National Health Science Research Committee, Ministry of Health Malawi; IRB of ICF International; Harvard University Human Research Protection Program.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data used in this analysis are publicly available from the Demographic and Health Survey Program ( and WorldPop (

  • Correction notice This article has been corrected since it first published. Owing to a communication lapse within the author team, the authors were not aware that findings from a related article that included co-author Humphreys Nsona were published while this article wasunder review and could be cited.

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