Karin Källander

Karolinska Institutet | KI · Health systems and policy research

Objective: To map how social, commercial, political and digital determinants of health have changed or emerged during the recent digital transformation of the society and to identify priority areas for policy action. Methods: We systematically searched MEDLINE, Embase and Web of Science on 24 September 2023, to identify eligible reviews published 2...

The global digital health ecosystem is project-centric: point solutions are developed for vertical health programs and financed through vertical funding allocations. This results in data fragmentation and technology lock-in, compromising health care delivery. A convergence of trends enabled by interoperability and digital governance makes possible...

Background: In Ethiopia, childhood pneumonia is diagnosed in primary health care settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children’s Automated Respiration Mo...

The international response to the COVID-19 pandemic provided opportunities for countries to use digital technologies for vaccine deployment and associated activities, but misaligned digital investments could weaken or fragment national systems. In this review of 311 funding applications from 120 country governments to four donor agencies (UNICEF; G...

Timely recognition and referral of severely ill children is especially critical in low-resource health systems. Pulse-oximeters can improve health outcomes of children by detecting hypoxaemia, a severity indicator of the most common causes of death in children. Cost-effectiveness of pulse-oximeters has been proven in low-income settings. However, e...

Background: Digital health interventions designed through human-centered design have shown potential to impact health equity. This scoping review aims to understand how human-centered design approaches in digital health impact health equity. Methodology: A scoping review was undertaken. Searches were conducted on PubMed, EMBASE, Web of Science, AMC...

Background The majority of post-neonatal deaths in children under 5 are due to malaria, diarrhoea and pneumonia (MDP). The WHO recommends integrated community case management (iCCM) of these conditions using community-based health workers (CHW). However iCCM programmes have suffered from poor implementation and mixed outcomes. We designed and evalu...

The inSCALE cluster randomised controlled trial in Uganda evaluated two interventions, mHealth and Village Health Clubs (VHCs) which aimed to improve Community Health Worker (CHW) treatment for malaria, diarrhoea, and pneumonia within the national Integrated Community Case Management (iCCM) programme. The interventions were compared with standard c...

Background Globally, nearly half of all deaths among children under the age of 5 years can be attributed to malaria, diarrhoea, and pneumonia. A significant proportion of these deaths occur in sub-Saharan Africa. Despite several programmes implemented in sub-Saharan Africa, the burden of these illnesses remains persistently high. To mobilise resour...

Background The majority of post-neonatal deaths in children under 5 are due to malaria, diarrhoea and pneumonia (MDP). The WHO recommends integrated community case management (iCCM) of these conditions using community-based health workers. However iCCM programmes have suffered from poor implementation and mixed outcomes. We designed and evaluated a...

UNICEF operates in 190 countries and territories, where it advocates for the protection of children’s rights and helps meet children’s basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers;...

Over 50% of sick children are treated by private primary-level facilities, but data on patient referral processes from such facilities are limited. We explored the perspectives of healthcare providers and child caretakers on the referral process of children with common childhood infections from private low-level health facilities in Mbarara Distric...

Background Low-level private health facilities (LLPHFs) handle a considerable magnitude of sick children in low-resource countries. We assessed capacity of LLPHFs to manage malaria, pneumonia, diarrhea, and, possible severe bacterial infections (PSBIs) in under-five-year-olds. Methods We conducted a cross-sectional survey in 110 LLPHFs and 129 hea...

BACKGROUND The field of digital health has grown rapidly in part due to the potential to reduce heath inequities. However, such potential has not always been realized. The design approaches used in digital health are one of the known aspects to have an impact on health equity. OBJECTIVE The aim of this scoping review will be to understand how desi...

Background: The field of digital health has grown rapidly in part due to digital health tools' potential to reduce health inequities. However, such potential has not always been realized. The design approaches used in digital health are one of the known aspects that have an impact on health equity. Objective: The aim of our scoping review will b...

Background With the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda should accelerate measures to reduce child deaths to achieve the Sustainable Development Goal 3. While 60–70% of frontline health services are provided by the private sector, many low-level private health facilities (LLPHF) are unregistered, unregulated,...

Background Low blood oxygen saturation (SpO2), or hypoxaemia, is an indicator of severe illness in children. Pulse oximetry is a globally accepted, non-invasive method to identify hypoxaemia, but rarely available outside higher-level facilities in resource-constrained countries. This study aims to evaluate the performance of different types of puls...

In Uganda, >50% of sick children receive treatment from primary level-private health facilities (HF). We assessed the appropriateness of care for common infections in under-five-year-old children and explored perspectives of healthcare workers (HCW) and policymakers on the quality of healthcare at low-level private health facilities (LLPHF) in west...

This report details an assessment undertaken in June 2021 as part of the Digital Public Goods Alliance’s Health Community of Practice (CoP) co-chaired by UNICEF Health, whose efforts have focused on identifying and highlighting mature digital public goods/global goods that are relevant to immunization delivery management.

With more than 95% of the global population living in areas connected by a mobile-cellular network, the opportunity for digital solutions to address health needs and accelerate the attainment of the sustainable development goals by 2030 has never been more possible. And the need is urgent. Leveraging open source oers opportunities to rapidly scale...

Current recommendations within integrated community case management (iCCM) programmes advise community health workers (CHWs) to refer cases of chest indrawing pneumonia to health facilities for treatment, but many children die due to delays or non-compliance with referral advice. Recent revision of World Health Organization (WHO) pneumonia guidelin...

Background: The private health sector is an important source of sick child care, yet evidence gaps persist in best practices for integrated management of private sector child health services. Further, there is no prioritized research agenda to address these gaps. We used a Child Health and Nutrition Research Initiative (CHNRI) process to identify...

Aim Pneumonia is the leading infectious cause of death among children under five globally. Many pneumonia deaths result from inappropriate treatment due to misdiagnosis of signs and symptoms. This study aims to identify whether health extension workers (HEWs) in Ethiopia, using an automated multimodal device (Masimo Rad‐G), adhere to required guide...

Background: With the under-five child mortality rate of 46.4 deaths per 1000 live births, Uganda needs to accelerate measures to reduce child deaths in order to achieve the Sustainable Development Goal 3. While 60-70 % of frontline health services are provided by the private sector, many low level private health facilities are unregistered, unregul...

Objectives Fathers play an important role in household decision-making processes and child health development. Nevertheless, they are under-represented in child health research, especially in low-income settings. Little is known about what roles fathers play in the care-seeking processes or how they interact with the health system when their child...

Introduction: Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into progra...

Abstract Background Staphylococcus aureus carriage is a known risk factor for staphylococcal disease. However, the carriage rates vary by country, demographic group and profession. This study aimed to determine the S. aureus carriage rate in children in Eastern Uganda, and identify S. aureus lineages that cause infection in Uganda. Methods Nasophar...

Background: Methicillin resistant Staphylococcus aureus (MRSA) strains were once confined to hospitals however, in the last 20 years MRSA infections have emerged in the community in people with no prior exposure to hospitals. Strains causing such infections were novel and referred to as community-associated MRSA (CA-MRSA). The aim of this study wa...

Pneumonia is one of the leading causes of death in children under 5 years worldwide. In resource-limited settings, WHO recommendations state that pneumonia can be presumptively diagnosed through the presence of cough and/or difficult breathing and a respiratory rate (RR) that is higher than age-specific cutoffs. As a new diagnostic aid, the childre...

Aim: Pneumonia is the leading cause of child death after the neonatal period; resulting from late care seeking and inappropriate treatment. Diagnosis involves counting respiratory rate (RR), however, RR counting remains challenging for health workers and miscounting and misclassification of RR is common. We evaluated the usability of a new automat...

BACKGROUND Acute respiratory infections (ARIs), primarily pneumonia, are the leading infectious cause of under-five mortality worldwide. Manually counting respiratory rate (RR) for 60 seconds using an ARI timer is commonly practiced by community health workers to detect fast breathing, an important sign of pneumonia. However, correctly counting bre...

Background: Acute respiratory infections (ARIs), primarily pneumonia, are the leading infectious cause of under-5 mortality worldwide. Manually counting respiratory rate (RR) for 60 seconds using an ARI timer is commonly practiced by community health workers to detect fast breathing, an important sign of pneumonia. However, correctly counting brea...

Aim: Manually counting respiratory rate (RR) is commonly practiced by community health workers to detect fast breathing, an important sign of childhood pneumonia. Correctly counting and classifying breaths manually is challenging, often leading to inappropriate treatment. This study aimed to determine the usability of a new automated RR counter (Ch...

Background: Mozambique has one of the highest under-5 mortality rates in the world. Community health workers (CHWs) are deployed to increase access to care; in Mozambique they are known as agentes polivalentes elementares (APEs). This study aimed to investigate child deaths in an area served by APEs by analysing the causes, care seeking patterns,...

Background: Pneumonia is one of the leading causes of death in children under-five globally. The current diagnostic criteria for pneumonia are based on increased respiratory rate (RR) or chest in-drawing in children with cough and/or difficulty breathing. Accurately counting RR is difficult for community health workers (CHWs). Current RR counting...

Background: Manually counting a child's respiratory rate (RR) for 60 seconds using an acute respiratory infection timer is the World Health Organization (WHO) recommended method for detecting fast breathing as a sign of pneumonia. However, counting the RR is challenging and misclassification of an observed rate is common, often leading to inapprop...

BACKGROUND Manually counting a child’s respiratory rate (RR) for 60 seconds using an acute respiratory infection timer is the World Health Organization (WHO) recommended method for detecting fast breathing as a sign of pneumonia. However, counting the RR is challenging and misclassification of an observed rate is common, often leading to inappropri...

Remarkable achievements have been made in global child health, with the global under-five mortality halved between 1990 and 2015. However almost 6 million children die every year before their 5th birthday; mostly due to preventable causes. Acknowledging that the clinical presentation of the sick child is complex and does not match individual guidel...

Background A key barrier to appropriate treatment for malaria, diarrhoea, and pneumonia (MDP) in children under 5 years of age in low income rural settings is the lack of access to quality health care. The WHO and UNICEF have therefore called for the scale-up of integrated community case management (iCCM) using community health workers (CHWs). The...

The collection of journal articles, systematic reviews, and reports published over the last decade that attest to the potential of digital technologies to achieve health workforce improvements across all aspects of the health system is vast. As a capacity-building mechanism, digital technology has potential for low- and middle-income countries (LMI...

Different health-care management guidelines by the World Health Organization exist to help health workers in resource-limited settings treat patients. However, for children with unclassified fever and no danger signs, management guidelines are less clear and follow-up recommendations differ. Both "universal follow-up" for all children, irrespective...

Background With declining malaria prevalence and improved use of malaria diagnostic tests, an increasing proportion of children seen by community health workers (CHWs) have unclassified fever. Current community management guidelines by WHO advise that children seen with non-severe unclassified fever (on day 1) should return to CHWs on day 3 for rea...

Checklist for cluster-randomised controlled trials. (DOCX)

Original dataset for enrolment and follow-up of enrolled children. (XLSX)

Questionniare form used by IEs to assess children at follow-up. (XLSX)

Participant consent form for caregivers. (DOCX)

Participant information sheet for caregivers. (DOCX)

Questionniare form used by HEWs to enrol children into the study. (XLSX)

Background: Under the World Health Organization's integrated community case management strategy, febrile children seen by community health workers (on day 1) without a diagnosable illness and without danger signs are advised to return on day 3, regardless of symptom resolution. This advice might be unnecessary and place additional time and cost bu...

Background: Pneumonia is one of the leading causes of death in children aged under 5 years in both sub-Saharan Africa and Southeast Asia. The current diagnostic criterion for pneumonia is based on the increased respiratory rate (RR) in children with cough or difficulty breathing. Low oxygen saturation, measured using pulse oximeters, is indicative...

BACKGROUND Pneumonia is one of the leading causes of death in children aged under 5 years in both sub-Saharan Africa and Southeast Asia. The current diagnostic criterion for pneumonia is based on the increased respiratory rate (RR) in children with cough or difficulty breathing. Low oxygen saturation, measured using pulse oximeters, is indicative o...

Increasing proportion of children seen by community health workers (CHW) with unknown fever origin, due to declining malaria prevalence and increasing use of malaria diagnostic tests. According to the WHO, children with non-severe unclassified fever are advised to return to CHWs after two days for a re-assessment (universal follow-up visit). Ethiop...

Background Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas,...

Background: Pneumonia heavily contributes to global under-five mortality. Many countries use community case management to detect and treat childhood pneumonia. Community health workers (CHWs) have limited tools to help them assess signs of pneumonia. New respiratory rate (RR) counting devices and pulse oximeters are being considered for this purpos...

Background: Pneumonia is the major cause of death in children globally, with more than 900,000 deaths annually in children under five years of age. Streptococcus pneumoniae causes most deaths, most often in the form of community acquired pneumonia. Pneumococcal conjugate vaccines (PCVs) are currently being implemented in many low-income countries....

This Comment is based on a round-table discussion held at University College London on Oct 17, 2016, funded by a Health Systems Research Initiative grant from the UK Department for International Development (DFID)/Medical Research Council (MRC)/Wellcome Trust/Economic and Social Research Council (ESRC) (MR/N005597/1). We declare no competing intere...

Background: Antibiotic resistance is an issue of growing global concern. One key strategy to minimise further development of resistance is the rational use of antibiotics, by providers and patients alike. Through integrated community case management (iCCM), children diagnosed with suspected pneumonia are treated with antibiotics; one component of...

Background: Pneumonia is the leading infectious cause of mortality in children under five worldwide. Community-level interventions, such as integrated community case management, have great potential to reduce the burden of pneumonia, as well as other diseases, especially in remote populations. However, there are still questions as to whether commu...

Pneumonia and diarrhoea disproportionately affect children in resource-poor settings. Integrated community case management (iCCM) involves community health workers treating diarrhoea, pneumonia and malaria. Studies on impact of iCCM on appropriate treatment and its effects on equity in access to the same are limited. The objective of this study was...

Background: Integrated community case management (iCCM) relies on community health workers (CHWs) managing children with malaria, pneumonia, diarrhoea, and referring children when management is not possible. This study sought to establish the cost per sick child referred to seek care from a higher-level health facility by a CHW and to estimate car...

In Uganda, the main causes of death in children under 5 years of age are malaria and pneumonia-often due to delayed diagnosis and treatment. In preparation for a community case management intervention for pneumonia and malaria, the bacterial composition of the nasopharyngeal flora and its in vitro resistance were determined in children aged five or...