Volume 99, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Hypoxemia measured by pulse oximetry predicts child pneumonia mortality in low-resource settings (LRS). Existing pediatric oximeter probes are prohibitively expensive and/or difficult to use, limiting LRS implementation. Using a human-centered design, we developed a low-cost, reusable pediatric oximeter probe for LRS health-care workers (HCWs). Here, we report probe usability testing. Fifty-one HCWs from Malawi, Bangladesh, and the United Kingdom participated, and seven experts provided reference measurements. Health-care workers and experts measured the peripheral arterial oxyhemoglobin saturation (SpO) independently in < 5 year olds. Health-care worker measurements were classed as successful if recorded in 5 minutes (or shorter) and physiologically appropriate for the child, using expert measurements as the reference. All expert measurements were considered successful if obtained in < 5 minutes. We analyzed the proportion of successful SpO measurements obtained in < 1, < 2, and < 5 minutes and used multivariable logistic regression to predict < 1 minute successful measurements. We conducted four testing rounds with probe modifications between rounds, and obtained 1,307 SpO readings. Overall, 67% (876) of measurements were successful and achieved in < 1 minute, 81% (1,059) < 2 minutes, and 90% (1,181) < 5 minutes. Compared with neonates, increasing age (infant adjusted odds ratio [aOR]; 1.87, 95% confidence interval [CI]: 1.16, 3.02; toddler aOR: 4.33, 95% CI: 2.36, 7.97; child aOR; 3.90, 95% CI: 1.73, 8.81) and being asleep versus being calm (aOR; 3.53, 95% CI: 1.89, 6.58), were associated with < 1 minute successful measurements. In conclusion, we designed a novel, reusable pediatric oximetry probe that was effectively used by LRS HCWs on children. This probe may be suitable for LRS implementation.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, Lawn JE, Cousens S, Mathers C, Black RE, , 2016. Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet 388: 30273035. [Google Scholar]
  2. Global Burden of Disease Study, 2017. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis 17: 11331161. [Google Scholar]
  3. WHO, 2013. Guidelines for the Management of Common Childhood Illnesses: Second Edition. Geneva, Switzerland: World Health Organization.
  4. Lazzerini M, Sonego M, Pellegrin MC, , 2015. Hypoxaemia as a mortality risk factor in acute lower respiratory infections in children in low and middle-income countries: systematic review and meta-analysis. PLoS One 10: e0136166. [Google Scholar]
  5. Duke T, Wandi F, Jonathan M, Matai S, Kaupa M, Saavu M, Subhi R, Peel D, , 2008. Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet 372: 13281333. [Google Scholar]
  6. WHO/UNICEF, 2011. Manual for the Community Health Worker. Geneva, Switzerland: World Health Organization.
  7. WHO, 2014. Integrated Management of Childhood Illness: Chart Booklet. Geneva, Switzerland: World Health Organization.
  8. McCollum ED, Ginsburg AS, , 2017. Outpatient management of children with World Health Organization chest indrawing pneumonia: implementation risks and proposed solutions. Clin Infect Dis 65: 15601564. [Google Scholar]
  9. McCollum ED, 2016. Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi. Bull World Health Organ 94: 893902. [Google Scholar]
  10. McCollum ED, King C, Hammitt LL, Ginsburg AS, Colbourn T, Baqui AH, O’Brien KL, , 2016. Reduction of childhood pneumonia mortality in the Sustainable Development era. Lancet Respir Med 4: 932933. [Google Scholar]
  11. McCollum ED, Bjornstad E, Preidis GA, Hosseinipour MC, Lufesi N, , 2013. Multicenter study of hypoxemia prevalence and quality of oxygen treatment for hospitalized Malawian children. Trans R Soc Trop Med Hyg 107: 285292. [Google Scholar]
  12. McCollum ED, 2017. Impact of the 13-valent pneumococcal conjugate vaccine on clinical and hypoxemic childhood pneumonia over three years in central Malawi: an observational study. PLoS One 12: e0168209. [Google Scholar]
  13. Bazzano AN, Martin J, Hicks E, Faughnan M, Murphy L, , 2017. Human-centred design in global health: a scoping review of applications and contexts. PLoS One 12: e0186744. [Google Scholar]
  14. United States Food and Drug Administration, 2013. Pulse Oximeters—Premarket Notification Submissions [510(k)s]: Guidance for Industry and Food and Drug Administration Staff. Available at: https://www.fda.gov/RegulatoryInformation/Guidances/ucm341718.htm. Accessed March 21, 2018.
  15. International Organization for Standardization, 2017. Medical Electrical Equipment—Part 2–61: Particular Requirements for Basic Safety and Essential Performance of Pulse Oximeter Equipment (ISO 80601-2-61:2017). Available at: https://www.iso.org/standard/67963.html. Accessed March 21, 2018.
  16. Powell C, , 2003. The Delphi technique: myths and realities. J Adv Nurs 41: 376382. [Google Scholar]
  17. NSO, 2017. Malawi Demographic and Health Survey 2015–16. Zomba, Malawi: National Statistical Office.
  18. Faulkner L, , 2003. Beyond the five-user assumption: benefits of increased sample sizes in usability testing. Behav Res Methods Instrum Comput 35: 379383. [Google Scholar]
  19. FDA, 2016. Applying Human Factors and Usability Engineering to Medical Devices. Rockville, MD: U.S. Food and Drug Administration.
  20. Fleming S, Thompson M, Stevens R, Heneghan C, Plüddemann A, Maconochie I, Tarassenko L, Mant D, , 2011. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet 377: 10111018. [Google Scholar]
  21. Emdin CA, Mir F, Sultana S, Kazi A, Zaidi AKM, Dimitris MC, Roth DE, , 2015. Utility and feasibility of integrating pulse oximetry into the routine assessment of young infants at primary care clinics in Karachi, Pakistan: a cross-sectional study. BMC Pediatr 15: 141. [Google Scholar]
  22. Fouzas S, Priftis KN, Anthracopoulos MB, , 2011. Pulse oximetry in pediatric practice. Pediatrics 128: 740752. [Google Scholar]
  23. Van Niekerk AM, Cullis RM, Linley LL, Zuhlke L, , 2016. Feasibility of pulse oximetry pre-discharge screening implementation for detecting critical congenital heart lesions in newborns in a secondary level maternity hospital in the Western Cape, South Africa: the ‘POPSICLe’ study. S Afr Med J 106: 817821. [Google Scholar]
  24. King C, 2018. Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh. BMJ Open 8: e019177. [Google Scholar]
  25. Holden JD, , 2001. Hawthorne effects and research into professional practice. J Eval Clin Pract 7: 6570. [Google Scholar]

Data & Media loading...

Supplemental appendices and tables

  • Received : 09 Jan 2018
  • Accepted : 18 Jun 2018
  • Published online : 20 Aug 2018

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error