Digital stethoscope use by non-physician primary care health workers on under-five-year-old children in rural Bangladesh: feasibility study

Digital stethoscope use by non-physician primary care health workers on under-five-year-old children in rural Bangladesh: feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Digital stethoscope use by non-physician primary care health workers on under-five-year-old children in rural Bangladesh: feasibility study Salahuddin Ahmed, Harish Nair, Steve Cunningham, Ahad Mahmud Khan, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7243236/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract The diagnostic performance of the World Health Organization’s Integrated Management of Childhood Illness guidelines for child pneumonia could be improved by incorporating lung auscultation. Although challenging for non-physician health workers to effectively use a conventional stethoscope, a digital stethoscope enhanced by artificial intelligence capabilities may be an alternative. In this feasibility study we aimed to evaluate whether non-physician primary care health workers can record quality lung sounds from under-5-year-old children. Non-physician primary care health workers called community health care providers recorded lung sounds from four protocolised chest positions using a digital stethoscope in 2-59-month-old children attending first-level rural clinics in Bangladesh. A paediatrician listening panel, trained to a standardised interpretation protocol, classified the recordings. A quality recording was defined a priori as the panel classifying three of four chest positions on a participant as interpretable. Lung sounds were recorded from 990 children, and the panel classified 867 children as having a quality recording (87.6%; 95% confidence interval: 85.4%, 89.6%). Of these, 89.8% (766/853) were recorded within five minutes. This study demonstrates non-physician primary care health workers at rural, first-level clinics in Bangladesh are capable of timely, quality recordings of lung sounds from most children using a digital stethoscope. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Preschool Child Infant Pneumonia Practice Guidelines as a Topic Stethoscopes Community Health Workers Developing Countries Figures Figure 1 Figure 2 Introduction Although there has been a significant decline in the incidence, morbidity, and mortality of pneumonia over recent years 1 , it remains a leading cause of death in children under-5-years-of-age globally 2 . The World Health Organisation’s (WHO) South-East Asia and African Regions contribute more than 75% of pneumonia-related deaths in this age group 3 . The WHO and United Nations Children's Fund (UNICEF) developed the Integrated Management of Childhood Illness (IMCI) in the mid-1990s, with updates in 2014 and 2024. The algorithm has been the cornerstone of pneumonia management in low- and middle-income countries (LMICs) ever since, reducing pneumonia mortality by 36% among children under-five-years-old 4 . The IMCI approach mainly relies on non-physician healthcare workers to deliver primary healthcare services from frontline clinics, including pneumonia treatment, in community settings. While the IMCI algorithm is highly sensitive, and ensures that children with possible pneumonia are identified, its specificity is low, indicating that a large proportion of children unnecessarily receive antibiotic treatment and contribute to growing antibiotic resistance patterns 5 . Various studies have shown that the algorithm’s sensitivity ranged from 76–97%, while specificity ranged from 49% for pneumonia without any clinical danger signs to 89% for disease with danger signs 6 . Notably, the IMCI algorithm does not include lung auscultation in its pneumonia classification, likely due to the lack of training and skills of non-physician frontline healthcare workers in auscultation and the high inter-observer variability and subjectivity associated with traditional stethoscopes. Since Rene Laennec’s invention of monoaural stethoscope over two centuries ago 7 , stethoscope technology has advanced significantly, culminating in the development of digital stethoscopes. These digital stethoscopes are capable of amplifying and filtering recordings and transferring them for further analysis 8 . These stethoscopes have potential advantages over conventional analogue stethoscopes, particularly in settings with non-physician health workers. In terms of device positioning on patients, digital stethoscopes allow accurate sound capture even if the chest piece is not perfectly placed 9 . For listening, they mitigate environmental noise – common in crowded, resource-limited healthcare settings - through noise-cancelling technologies 10 and sound amplification 11 . Regarding interpretation, digital stethoscopes can integrate artificial intelligence to assist in analysing and diagnosing based on auscultated sounds 12 , helping to reduce high inter-rater variability 13 . There is limited evidence on the feasibility of digital auscultation when used by non-physician primary care health workers on young children in resource-constrained settings 14 . Given their critical role in community-based healthcare delivery, we aimed to evaluate the feasibility of non-physician health workers recording lung sounds with a digital stethoscope on children attending primary care community clinics in Bangladesh. Materials and methods Study design, area and period This cross-sectional study was conducted in nine rural primary care clinics called community clinics (CCs) in Zakiganj sub-district of Sylhet in Bangladesh between November 2019 and December 2020. Enrolment was suspended between April and August 2020 due to the COVID-19 pandemic. Bangladesh has established about 13,000 CCs, roughly translating to one CC per 6,000 population 15 . Each CC is staffed by a non-physician health worker called a community health care provider (CHCP) with at least a 12th grade education and three months of preservice training, including the IMCI algorithm. We purposively selected nine out of 24 CCs in Zakiganj sub-district of Sylhet district in Bangladesh, based on patient volume, specifically focusing on those that provided care to the highest number of under-5-year-old children in the year preceding the study. The selected CHCPs received a three-day training that included child assessment according to IMCI guidelines, identification of respiratory danger signs (head nodding, tracheal tugging, nasal flaring, grunting, intercostal retractions, stridor when calm), pulse oximetry, anthropometric measurements (weight, height/length, mid-upper arm circumference), use of a digital stethoscope, transfer of recorded sound files, completion of case record forms, and obtaining consent. Further details on the study design and setting have been described elsewhere 16 . Study population Children aged 2–59 months presenting to the selected CCs with a respiratory illness characterised by cough and/or difficulty breathing were eligible for enrolment in the study. Children were excluded if they showed any IMCI-defined clinical danger signs (inability to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child), or hypoxemia (low blood oxygen levels defined by a peripheral oxyhaemoglobin saturation (SpO 2 ) < 90%), enrolment in this study within the past 30 days, not a permanent resident of the study area, or if their parents did not provide consent. Study procedure After obtaining informed consent, CHCPs examined the child for fast breathing by manually counting the respiratory rate over one minute and observing for lower chest wall indrawing (bilateral inward pulling of the lower ribs and subcostal tissue during inspiration). Lung sounds were recorded using a digital stethoscope (Sonavi Labs, United States) 9 from four chest locations sequentially – left and right back, left and right front – for 10 seconds in each position, allowing for the recording of 3–4 breath cycles per position. CHCPs also measured the SpO 2 using a pulse oximeter (Masimo Rad5, United States) with a paediatric clip probe while the child breathed in room air, temperature with a calibrated digital thermometer, and anthropometry (weight, height/length and mid-upper arm circumference) using standard tools and techniques. A listening panel of five paediatricians were trained and standardised in listening and classifying recordings to identify adventitial lung sounds. Each child’s lung sound files were randomly sent to any two panel members. These panel members were blinded to participant clinical information. They independently listened to the recordings using high quality headsets (Sennheiser HD 599 SE) while simultaneously viewing the sound spectrograms in open-source software (Audacity). Panellists entered their classification either normal (no wheeze and no crackles), only wheeze, only crackles, both wheeze and crackles, or uninterpretable into an online electronic platform. They could listen to the recordings with the freedom to stop or repeat parts or the entire recording, if necessary. Each child’s summary classification across all chest locations by two panel members was compared, and if they did not match, a senior member of the study team (EDM), also masked to participant information and other recording interpretations, served as an arbitrator. Study definitions Pneumonia The presence of cough and/or difficulty breathing, along with fast breathing for age (respiratory rate ≥ 50 breaths/minute for 2 to < 12 month olds, ≥ 40 breaths/minute for 12 to 59 month olds) and/or lower chest wall indrawing, and the absence of any IMCI-defined clinical danger signs, severe malnutrition, or hypoxemia. 17 No pneumonia The presence of cough and/or difficulty breathing but without fast breathing for age and without lower chest wall indrawing, and without any IMCI-defined clinical danger signs, severe malnutrition, and hypoxemia. Quality recording At least 75% interpretable lung sound segments per child (i.e., ≥ 3 out of 4 chest positions) determined by the listening panel. Statistical analysis Descriptive statistics were used to summarise the characteristics of the children, including age, sex, nutritional and immunisation status, and clinical signs of pneumonia. Lung sound recording details, including interpretability in ≥ 3 chest positions and across different chest positions, were also described. The distribution of sound files, including the number recorded, transferred to the laptop, and classified as interpretable, was presented. All analyses were reported as frequencies and percentages, along with exact binomial confidence intervals (CIs). The time required to record quality lung sounds was documented. Children were categorised into pneumonia and no pneumonia, and all analyses were stratified accordingly. Data analysis was done using STATA version 18.0, with statistical significance set at a p-value of < 0.05. Ethical approval and consent to participate We obtained ethical approval for this study from the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (Registration Number: 09630012018), and Academic and Clinical Central Office for Research and Development Medical Research Ethics Committee, NHS, Lothian, Edinburgh, UK (REC Reference: 18-HV-051). Written informed consent was obtained from parents or legal guardians of the children. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki. Results Figure 1 presents the Standards for Reporting of Diagnostic Accuracy Studies (STARD) flow diagram. Out of 2,434 children screened, 1,046 (42.9%) were eligible for the study. Of these 1,046, 56 (5.3%) children’s carers declined enrolment, leaving a total of 990 children enrolled. Among these 990 children, 389 (3.9%) were classified as having pneumonia. Of the 389 children with pneumonia, lung sounds from any chest position were recorded in 385 (99.0%) children. Similarly, among the 601 children without pneumonia, lung sounds were recorded in 595 (99.0%) children from any chest position (Fig. 1 ). Lung sound files in 381 (97.9%, 381/389) children in the pneumonia group and 593 (98.7%, 593/601) children in the no pneumonia group, were successfully transferred from the digital stethoscope to a secure study laptop. Lung sounds from ≥ 3 chest positions were transferred to the laptop in 378 (98.2%, 378/385) children in the pneumonia group and 588 (98.8%, 588/595) in the no pneumonia group. Children’s characteristics Table 1 shows the characteristics of children in the pneumonia and no pneumonia groups. The majority of children were 12 months or older (74.7%, 740/990). There was 1 male for every 0.8 females enrolled. The proportion of children fully immunised for age was 83.7% (829/990), while 86.2% (853/990) of children had received age-appropriate PCV vaccination. Table 1 Baseline characteristics of children Selected child characteristics at enrolment Total Pneumonia No pneumonia p-value N (%) n (%) n (%) Number of children 990 389 601 Age group 2–11 months 250 (25.3) 92 (23.7) 158 (26.3) 0.35 12–59 months 740 (74.7) 297 (76.3) 443 (73.7) Sex Male 552 (55.8) 231 (59.4) 321 (53.4) 0.07 Female 438(44.2) 158 (40.6) 280 (46.6) Weight for age Normal (Z Score ≥ -2) 626 (63.2) 249 (64.0) 377 (62.7) 0.66 Mild underweight (Z Score ≥ -3 to < -2) 251 (25.4) 93 (23.9) 158 (26.3) Severe underweight (Z Score < -3) 113 (11.4) 47 (12.1) 66 (11.0) Height for age Normal (Z Score ≥ -2) 532 (53.7) 203 (52.2) 329 (54.7) 0.10 Mild stunting (Z Score ≥ -3 to < -2) 286 (28.9) 106 (27.2) 180 (30.0) Severe stunting (Z Score < -3) 172 (17.4) 80 (20.6) 92 (15.3) Weight for height Normal (Z Score ≥ -2) 822 (83.0) 322 (82.8) 500 (83.2) 0.97 Mild wasting (Z Score ≥ -3 to < -2) 129 (13.1) 51 (13.1) 78 (13.0) Severe wasting (Z Score < -3) 39 (3.9) 16 (4.1) 23 (3.8) Diarrhoea within the past two weeks Yes 171 (17.3) 69 (17.7) 102 (17.0) 0.76 No 819 (82.7) 320 (82.3) 499 (83.0) Immunisation status (all vaccines) Fully immunised for age 829 (83.7) 326 (83.8) 503 (83.7) 1.00 Partially immunised for age 143 (14.4) 56 (14.4) 87 (14.5) Unvaccinated 18 (1.8) 7 (1.8) 11 (1.8) PCV Vaccination status Fully immunised for age 853 (86.2) 334 (85.9) 519 (86.4) 0.81 Partially immunised for age 106 (10.7) 44 (11.3) 62 (10.3) Unvaccinated 31 (3.1) 11 (2.8) 20 (3.3) PCV - pneumococcal conjugate vaccine Clinical features The CHCPs identified fast breathing for age, lower chest wall indrawing and any respiratory danger signs in 37.6% (372/990), 2.5% (25/990) and 4.7% (47/990) of children, respectively ( Table 2 ) . Table 2 Distribution of signs during enrolment identified by community healthcare providers (multiple responses) Clinical signs Total Pneumonia No pneumonia N (%) n (%) n (%) Number of children 990 389 601 Age-specific fast breathing 372 (37.6) 372 (95.6) 0 (0.0) Chest indrawing 25 (2.5) 25 (6.4) 0 (0.0) Any respiratory danger sign 47 (4.7) 47 (12.1) 0 (0.0) Axillary temperature ≥ 100.4°F 76 (7.7) 42 (10.8) 34 (5.7) Lung sound recordings Table 3 presents the distribution of lung sound recordings by the number of chest positions, as well as the number of quality recordings identified by the listening panel. CHCPs recorded lung sounds from ≥ 3 chest positions in 98.3% ((973/990); 95% CI: 97.3%, 99.0%) of children. There was no statistically significant difference in the percentage of children with ≥ 3 chest position recordings between the pneumonia and the no pneumonia groups (p = 0.73). Table 3 Recorded and interpretable lung sounds Children with chest position Recorded lung sounds Interpretable lung sounds Total Pneumonia No pneumonia p-value Total Pneumonia No pneumonia p-value % (95% CI) [n] % (95% CI) [n] % (95% CI) [n] % (95% CI) [n] % (95% CI) [n] % (95% CI) [n] Number of children N = 990 n = 389 n = 601 N = 990 n = 389 n = 601 ≥ 3 chest positions 98.3 (97.3, 99.0) [973] 98.5 (96.7, 99.4) [383] 98.2 (96.7, 99.1) [590] 0.73 87.6 (85.4, 89.6) [867] 88.2 (84.5, 91.2) [343] 87.2 (84.2, 89.8) [524] 0.65 ≤ 2 chest positions 0.7 (0.3, 1.5) [7] 0.5 (0.1, 1.8) [2] 0.8 (0.3, 1.9) [5] 0.56 6.5 (5.0, 8.2) [64] 5.9 (3.8, 8.7) [23] 6.8 (4.9, 9.1) [41] 0.57 No recording or all four positions uninterpretable 1.0 (0.5, 1.8) [10] 1.0 (0.3, 2.6) [4] 1.0 (0.4, 2.2) [6] 0.96 6.0 (4.6, 7.6) [59] 5.9 (3.8, 8.7) [23] 6.0 (4.2, 8.2) [36] 0.96 CI - Confidence interval Quality recordings ( ≥ 3 chest position recordings of a child were interpretable) Overall, the listening panel assessed 87.6% ((867/990); 95% CI: 85.4%, 89.6%) of children to have quality recordings ( Table 3 ) , though this proportion varied by CHCP, ranging from 73.1% (19/26) to 94.7% (177/187) ( Supplementary table 1 ). The fitted linear regression model indicated a positive association between the number of quality recordings and enrolments per CHCP, with a 1% increase in quality recordings for every ten new children auscultated (Supplementary Fig. 1) . Table 4 shows the number of chest positions recorded and deemed interpretable by chest positions. There was little variation in successfully recorded lung sounds by chest position, although the success rate was significantly higher for both back positions (left and right back) compared to both front positions (left and right front) (92.0% (1782/1938) vs 87.9% (1690/1923); p < 0.01). Table 4 Distribution of the number of sound files recorded, transferred from the digital stethoscope to a laptop, and interpretable by chest position Position Number of sound files recorded Number of sound files transferred from digital stethoscope to laptop Percentage of sound files interpretable by the panel n n % (95% CI) [n] Position 1: (left back) 977 968 92.6 (90.7, 94.1) [896] Position 2: (right back) 978 970 91.3 (89.4, 93.0) [886] Position 3: (left front) 968 960 88.0 (85.8, 90.0) [845] Position 4: (right front) 971 963 87.7 (85.5, 89.8) [845] Back (left back and right back) 1955 1938 92.0 (90.6, 93.1) [1782] Front (left front and right front) 1939 1923 87.9 (86.3, 89.3) [1690] CI - Confidence interval Lung sound classification Among quality recordings, Table 5 shows the distribution of lung sounds classified by the listening panel. Adventitious lung sounds were identified more frequently in the pneumonia group than in the no pneumonia group (36.7% (126/343) pneumonia, 27.9% (146/524) no pneumonia, p = 0.01). Thus, in the pneumonia group, 63.3% (217/343) of children had normal lung sounds according to the listening panel. Although the frequency for only wheeze, only crackles, and both wheeze and crackles was higher in the pneumonia group than the no pneumonia group, these differences did not reach statistical significance. Table 5 Distribution of lung sounds classification Classification Pneumonia No pneumonia p-value % (95% CI), [n] % (95% CI), [n] Number of children 343 524 Normal sounds (No wheeze and no crackle) 63.3 (57.9,68.4), [217] 72.1 (68.1, 75.9), [378] 0.01 Adventitious sounds 36.7 (31.6,42.1) [126] 27.9 (24.1, 31.9), [146] 0.01 Wheeze only 15.5 (11.8, 19.7), [53] 11.3 (8.7, 14.3), [59] 0.07 Crackles only 9.9 (7.0, 13.6), [34] 8.0 (5.8, 10.7), [42] 0.33 Wheeze and crackles 11.4 (8.2,15.2) [39] 8.6 (6.3, 11.3), [45] 0.18 CI - Confidence interval Duration of quality recordings CHCPs completed quality recordings in 56.6% (483/853) of children within one minute and in 89.8% (766/853) within five minutes ( Fig. 2 ) . The recording time for participants with quality recordings ranged from 1 to 18 minutes. Recording durations exceeding five minutes were attributed to technical issues with the digital stethoscope. Child cooperation during lung sound recordings The proportion of cooperative and quiet children during lung sound recordings was high in both the pneumonia (81.6%, 314/385) and no pneumonia (78.7%, 468/595) groups (p = 0.27) ( Table 6 ) . Table 6 Children’s cooperation status during lung sounds recording Children’s cooperation status Total Pneumonia No pneumonia p-Value %; (95% CI); [n] %; (95% CI); [n] %; (95% CI); [n] Number of children 980 385 595 Cooperative and quiet throughout 79.8 (77.1, 82.3) [782] 81.6 (77.3, 85.3) [314] 78.7 (75.1, 81.9) [468] 0.27 Cooperative but vocalized 2.7 (1.7, 3.9) [26] 2.3 (1.1, 4.4) [9] 2.9 (1.7, 4.5) [17] 0.62 Initially cooperative, became agitated but did not cry 3.5 (2.4, 4.8) [34] 3.9 (2.2, 6.3) [15] 3.2 (1.9, 4.9) [19] 0.56 Initially cooperative but agitated and cried 10.9 (9.0, 13.0) [107] 9.9 (7.1, 13.3) [38] 11.6 (9.1, 14.4) [69] 0.40 Did not cooperate throughout and cried 2.8 (1.8, 4.0) [27] 2.1 (0.9, 4.1) [8] 3.2 (1.9, 4.9) [19] 0.30 Data missing 0.4 (0.1, 1.0) [4] 0.3 (0.0, 1.4) [1] 0.5 (0.1, 1.5) [3] 0.56 CI - Confidence interval Discussion Based upon the high proportion of acutely ill children with both timely and quality recordings obtained, our study demonstrates non-physician health workers in Bangladesh called CHCPs can feasibly use a digital stethoscope on children presenting to care at rural primary care clinics. Digital auscultation is a new technology for non-physician frontline health workers, such as CHCPs in Bangladesh, where conventional stethoscopes are not typically used in routine care. To the best of our knowledge, this was the first study to investigate the ability of frontline health workers to record lung sounds in first-level facilities in LMICs. Previous studies, such as the Pneumonia Etiology Research for Child Health (PERCH) study, trained either nurses or physicians to record lung sounds in hospital settings with a digital stethoscope 18 . In PERCH, a listening panel classified 89.5% of 792 pneumonia cases and 92.4% of 301 controls as interpretable 19 , which closely aligns with our findings. Our study extends these findings to non-physician CHCPs. CHCPs work in crowded and noisy environments and often face time pressure from a high-volume of patients, limiting the amount of time available to calm ill, often scared, and agitated children. It is therefore crucial to understand whether obtaining quality lung sounds in these settings using a digital stethoscope is feasible for frontline healthcare workers with minimal training. In this study, CHCPs followed a sequential recording procedure refined from our prior methodology 19 , starting with two recordings on the back followed by two on the front, screening both upper and lower lung lobe fields of each hemithorax. CHCPs successfully recorded lung sounds in 97.6% of children, with no difference in the success rate between those with and without pneumonia. Importantly, CHCPs recorded lung sounds from only one or two chest positions in just seven children overall and failed to record any lung sounds from any of the chest positions in only ten children. These failures were primarily due to stethoscope malfunction or software errors during the sound file transfer from the stethoscope to the laptop. This finding reinforces the notion that quality lung sounds from under-five-years-old children can be feasibly recorded at first-level facilities by CHCPs capacitated with supportive tools and training. Our overall hypothesis for this analysis was that if CHCPs could record lung sounds from three or four chest positions, and if at least three of these recordings were deemed interpretable by the paediatric listening panel, the overall process would meet a minimum quality threshold. The rationale for this threshold is that such recordings would capture sounds from at least three of the five major lobes and from both hemithoraces. Typically, in children younger than five years, inflammation from pneumonia is present in multiple lobes of the lung, and so these criteria would balance feasibility with identifying most pneumonia cases. In this study, 87.6% of children had quality recordings according to the listening panel, identifying the presence of only wheeze, only crackles, both, or neither, with no significant difference in the frequency of quality recordings between children with and without pneumonia. In our study, the proportion of children with three or more interpretable lung sound recordings per CHCP ranged from 73.1% (19/26) to 94.7% (177/187), indicating considerable variability in performance. CHCPs with the lowest enrolment numbers (26 and 38 children) had the lowest success rates (73.1% (19/26) and 76.3% (29/38)), while those with the highest enrolment numbers (187 and 179 children) achieved the highest success rates (94.7% (177/187) and 92.7% (166/179)). Our data shows the percentage of successful recordings increased by 1% with every ten children recorded. This suggests a learning curve, with CHCPs becoming more proficient in obtaining quality recordings over time as they gained experience. The sequential recording approach that started on the participant’s back was intended to balance optimising child cooperation with identifying most pneumonia cases, as children are often more comfortable when facing their carer being held, which allows the health worker access to the child’s back. Our findings revealed no significant variation in the success rate of lung sound recordings across the four chest positions. However, there was a significant difference in interpretability with recordings obtained from the back more likely to meet quality criteria than those from the front (92.0% (1782/1938) vs 87.9% (1690/1923); p < 0.01). This difference is likely due to the less intrusive nature of posterior recordings and the fact that these were consistently performed before anterior recordings, when the children were generally calmer. Despite these variations, three out of every four children remained cooperative and quiet throughout. The time required to obtain quality recordings was also encouraging, with 89.8% (766/853) of children having at least three interpretable chest position recordings captured under five minutes. This finding suggests that incorporating digital auscultation into the IMCI algorithm is unlikely to significantly increase the workload of frontline health workers, supporting the potential scalability of this technology in programmatic settings. Interestingly, there was no relationship between the number of children enrolled and the overall time taken by the CHCP to record the lung sounds. However, several challenges were consistently identified when recordings took longer than one minute. The device occasionally froze, requiring the CHCP to either perform a complete restart or drain the device's battery charge. Children younger than five years of age can be active, and although most children were initially cooperative, some became agitated during the recording process. In such cases, CHCPs had to pause recording and take additional time to calm the child down before reattempting to record the lung sounds. Additionally, ambient noise, such as loudspeaker announcements outside the CC or calls for prayer, which can occur multiple times per day in Bangladesh, sometimes interrupted the recording process. CHCPs had to delay recordings until the background noise had subsided. This study has several limitations. First, we purposively selected nine out of 24 CCs in the Zakiganj sub-district of Sylhet District, Bangladesh. This may limit the generalisability of our findings to other CCs with different patient volumes, case mixes, or clinical environments. Second, this study only included non-severe pneumonia cases, as the CCs lack the capacity to manage severe pneumonia, which requires parenteral antibiotics and hospitalisation regardless of their lung sounds findings. Therefore, our findings may not be generalisable to children with severe pneumonia. Third, several technical issues were identified with the digital stethoscope. These included recordings stopping prematurely, recordings failing to stop, inadequate durability of the device hardware, freezing of the device software during the recording process, and in some cases the battery losing its charge too quickly 20 . This highlights the need for addressing these issues to ensure future versions of the device are more effective and user-friendly for a LMIC clinical environment. Finally, the fact that the digital stethoscope requires charging once daily is a limitation for its use in remote first-level facilities in LMICs, where the power supply is erratic or there is no power supply at all. Providing alternative power solutions, such as solar panels and portable power banks to charge the stethoscope may solve this issue. Conclusions This study demonstrated that non-physician health workers called CHCPs at first-level primary care facilities in Bangladesh can feasibly record quality lung sounds in under-five-year-old children using a digital stethoscope. While several challenges exist in these settings, including a lack of provider training and experience auscultating the lungs of children, the active and sometimes uncooperative nature of young children, and a noisy environment, CHCPs in this study were able to record quality lung sounds without substantially increasing their workload. A larger study involving a higher number of CCs across diverse geographic locations with varying patient volumes, potentially including different countries and a range of outpatient settings and contexts, is an important next step in assessing the broader feasibility of using digital auscultation by front-line health workers. Declarations Competing interests The authors declare no competing interests. Funding This research was funded by the UK National Institute for Health and Care Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Government. Author Contribution SA, EDM, HN and AHB conceptualised and designed this study. SA advised on the implementation of the study. AAI organised the data collection. NHC managed the data curation. MSI conducted the data analysis with support from SA, AMK, NHC, HN, SC and EDM. EDM, LG, MMJ, IJ, and MW interpreted the recorded lung sound files. SA wrote the first draft of the manuscript. AMK, AHB, SC, HN and EDM provided critical feedback on the manuscript structure and contents. All authors contributed to interpreting the results, reviewed the manuscript, and approved the submitted version. Acknowledgement The authors extend their deepest gratitude to the Ministry of Health and Family Welfare, Government of Bangladesh, National Newborn Health Program, and CHCPs of the respective community clinics in Zakiganj, Sylhet, Bangladesh, for their invaluable assistance in supporting activities for this research. We also thank the RESPIRE collaboration, including UK and LMICs Grant holders, partners, and research teams, as listed on their website (www.ed.ac.uk/usher/respire), for their contribution, including Siân Williams. Data Availability The data are available from the corresponding author on reasonable request. References GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect. Dis. 18 , 1191–1210. 10.1016/s1473-3099(18)30310-4 (2018). Perin, J. et al. Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child. Adolesc. Health . 6 , 106–115. 10.1016/s2352-4642(21)00311-4 (2022). McAllister, D. A. et al. Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis. Lancet Global Health . 7 , e47–e57 (2019). Sazawal, S. & Black, R. E. Pneumonia Case Management Trials, G. Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. Lancet. Infect. Dis . 3 , 547–556 (2003). Grant, G. B. et al. Recommendations for treatment of childhood non-severe pneumonia. Lancet. Infect. Dis . 9 , 185–196 (2009). Palafox, M., Guiscafré, H., Reyes, H., Muñoz, O. & Martínez, H. Diagnostic value of tachypnoea in pneumonia defined radiologically. Arch. Dis. Child. 82 , 41–45 (2000). Roguin, A. Rene Theophile Hyacinthe Laënnec (1781–1826): the man behind the stethoscope. Clin. Med. Res. 4 , 230–235 (2006). Leng, S. et al. The electronic stethoscope. Biomed. Eng. Online . 14 , 66 (2015). Elhilali, M. & West, J. E. The Stethoscope Gets Smart: Engineers from Johns Hopkins are giving the humble stethoscope an AI upgrade. IEEE Spectr. 56 , 36–41 (2019). Kevat, A. C., Kalirajah, A. & Roseby, R. Digital stethoscopes compared to standard auscultation for detecting abnormal paediatric breath sounds. Eur. J. Pediatrics . 176 , 989–992. 10.1007/s00431-017-2929-5 (2017). Thinklabs Thinklabs One Digital Stethoscope , < (2015). https://www.thinklabs.com/ Pramono, R. X. A. & Bowyer, S. Rodriguez-Villegas, E. Automatic adventitious respiratory sound analysis: A systematic review. PloS one . 12 , e0177926 (2017). Brooks, D. & Thomas, J. Interrater reliability of auscultation of breath sounds among physical therapists. Phys. Ther. 75 , 1082–1088 (1995). Ahmed, S. et al. Digital auscultation as a diagnostic aid to detect childhood pneumonia: A systematic review. Journal global health 12 (2022). Riaz, B. K. et al. Community clinics in Bangladesh: A unique example of public-private partnership. Heliyon 6 , e03950 (2020). Ahmed, S. et al. Digital auscultation as a novel childhood pneumonia diagnostic tool for community clinics in Sylhet, Bangladesh: protocol for a cross-sectional study. BMJ open. 12 , e059630 (2022). World Health Organization. Integrated Management of Childhood Illness; Chart Booklet (World Health Organization, 2014). McCollum, E. D. et al. Digital auscultation in PERCH: Associations with chest radiography and pneumonia mortality in children. Pediatr. Pulmonol. 55 , 3197–3208. 10.1002/ppul.25046 (2020). McCollum, E. D. et al. Listening panel agreement and characteristics of lung sounds digitally recorded from children aged 1–59 months enrolled in the Pneumonia Etiology Research for Child Health (PERCH) case–control study. BMJ open respiratory research 4, e000193 (2017). Joarder, T. et al. End-user acceptability of a prototype digital stethoscope to diagnose childhood pneumonia-a qualitative exploration from Sylhet, Bangladesh. BMC Digit. Health . 1 , 26 (2023). Additional Declarations No competing interests reported. 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Health","correspondingAuthor":false,"prefix":"","firstName":"Mohammod","middleName":"","lastName":"Shahidullah","suffix":""},{"id":495349895,"identity":"0b8f8c0d-6240-4bf1-9cdf-0e653aab86e7","order_by":15,"name":"Abdullah H. Baqui","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"H.","lastName":"Baqui","suffix":""},{"id":495349896,"identity":"a84bb337-a8fd-4e1c-8a8a-44edf9cd7b67","order_by":16,"name":"Eric D. McCollum","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"D.","lastName":"McCollum","suffix":""}],"badges":[],"createdAt":"2025-07-29 12:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7243236/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7243236/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88350756,"identity":"01201bee-3cbb-4a3c-bce3-e362b6520ff9","added_by":"auto","created_at":"2025-08-05 14:18:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27099,"visible":true,"origin":"","legend":"\u003cp\u003eStandards for Reporting of Diagnostic Accuracy Studies (STARD) flow diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7243236/v1/2558b68c60d7b2a29afc21e7.png"},{"id":88352034,"identity":"320dedef-59a9-41e2-976d-670ea92282bd","added_by":"auto","created_at":"2025-08-05 14:26:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79485,"visible":true,"origin":"","legend":"\u003cp\u003eTime to obtain quality recordings by non-physician health workers\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7243236/v1/e44410a6e80d831374a063a1.png"},{"id":88352506,"identity":"176a63c3-5f28-4188-8c63-6b92ad7e0998","added_by":"auto","created_at":"2025-08-05 14:34:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1623629,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7243236/v1/748e3500-06c8-45fc-a7a0-5256d94d66dd.pdf"},{"id":88349199,"identity":"c089cf05-ff10-49df-aa67-9fb0e7d680a7","added_by":"auto","created_at":"2025-08-05 14:02:51","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":112540,"visible":true,"origin":"","legend":"","description":"","filename":"Supplimentarytablesandfigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-7243236/v1/319928d22abc6e16764b5f8d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Digital stethoscope use by non-physician primary care health workers on under-five-year-old children in rural Bangladesh: feasibility study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlthough there has been a significant decline in the incidence, morbidity, and mortality of pneumonia over recent years\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, it remains a leading cause of death in children under-5-years-of-age globally\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The World Health Organisation\u0026rsquo;s (WHO) South-East Asia and African Regions contribute more than 75% of pneumonia-related deaths in this age group\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The WHO and United Nations Children's Fund (UNICEF) developed the Integrated Management of Childhood Illness (IMCI) in the mid-1990s, with updates in 2014 and 2024. The algorithm has been the cornerstone of pneumonia management in low- and middle-income countries (LMICs) ever since, reducing pneumonia mortality by 36% among children under-five-years-old\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The IMCI approach mainly relies on non-physician healthcare workers to deliver primary healthcare services from frontline clinics, including pneumonia treatment, in community settings.\u003c/p\u003e\u003cp\u003eWhile the IMCI algorithm is highly sensitive, and ensures that children with possible pneumonia are identified, its specificity is low, indicating that a large proportion of children unnecessarily receive antibiotic treatment and contribute to growing antibiotic resistance patterns\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Various studies have shown that the algorithm\u0026rsquo;s sensitivity ranged from 76\u0026ndash;97%, while specificity ranged from 49% for pneumonia without any clinical danger signs to 89% for disease with danger signs\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Notably, the IMCI algorithm does not include lung auscultation in its pneumonia classification, likely due to the lack of training and skills of non-physician frontline healthcare workers in auscultation and the high inter-observer variability and subjectivity associated with traditional stethoscopes.\u003c/p\u003e\u003cp\u003eSince Rene Laennec\u0026rsquo;s invention of monoaural stethoscope over two centuries ago\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, stethoscope technology has advanced significantly, culminating in the development of digital stethoscopes. These digital stethoscopes are capable of amplifying and filtering recordings and transferring them for further analysis\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. These stethoscopes have potential advantages over conventional analogue stethoscopes, particularly in settings with non-physician health workers. In terms of device positioning on patients, digital stethoscopes allow accurate sound capture even if the chest piece is not perfectly placed\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. For listening, they mitigate environmental noise \u0026ndash; common in crowded, resource-limited healthcare settings - through noise-cancelling technologies\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and sound amplification\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Regarding interpretation, digital stethoscopes can integrate artificial intelligence to assist in analysing and diagnosing based on auscultated sounds\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, helping to reduce high inter-rater variability\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThere is limited evidence on the feasibility of digital auscultation when used by non-physician primary care health workers on young children in resource-constrained settings\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Given their critical role in community-based healthcare delivery, we aimed to evaluate the feasibility of non-physician health workers recording lung sounds with a digital stethoscope on children attending primary care community clinics in Bangladesh.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cb\u003eStudy design, area and period\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis cross-sectional study was conducted in nine rural primary care clinics called community clinics (CCs) in Zakiganj sub-district of Sylhet in Bangladesh between November 2019 and December 2020. Enrolment was suspended between April and August 2020 due to the COVID-19 pandemic. Bangladesh has established about 13,000 CCs, roughly translating to one CC per 6,000 population\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Each CC is staffed by a non-physician health worker called a community health care provider (CHCP) with at least a 12th grade education and three months of preservice training, including the IMCI algorithm. We purposively selected nine out of 24 CCs in Zakiganj sub-district of Sylhet district in Bangladesh, based on patient volume, specifically focusing on those that provided care to the highest number of under-5-year-old children in the year preceding the study. The selected CHCPs received a three-day training that included child assessment according to IMCI guidelines, identification of respiratory danger signs (head nodding, tracheal tugging, nasal flaring, grunting, intercostal retractions, stridor when calm), pulse oximetry, anthropometric measurements (weight, height/length, mid-upper arm circumference), use of a digital stethoscope, transfer of recorded sound files, completion of case record forms, and obtaining consent. Further details on the study design and setting have been described elsewhere\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eChildren aged 2\u0026ndash;59 months presenting to the selected CCs with a respiratory illness characterised by cough and/or difficulty breathing were eligible for enrolment in the study. Children were excluded if they showed any IMCI-defined clinical danger signs (inability to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child), or hypoxemia (low blood oxygen levels defined by a peripheral oxyhaemoglobin saturation (SpO\u003csub\u003e2\u003c/sub\u003e)\u0026thinsp;\u0026lt;\u0026thinsp;90%), enrolment in this study within the past 30 days, not a permanent resident of the study area, or if their parents did not provide consent.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter obtaining informed consent, CHCPs examined the child for fast breathing by manually counting the respiratory rate over one minute and observing for lower chest wall indrawing (bilateral inward pulling of the lower ribs and subcostal tissue during inspiration). Lung sounds were recorded using a digital stethoscope (Sonavi Labs, United States)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e from four chest locations sequentially \u0026ndash; left and right back, left and right front \u0026ndash; for 10 seconds in each position, allowing for the recording of 3\u0026ndash;4 breath cycles per position. CHCPs also measured the SpO\u003csub\u003e2\u003c/sub\u003e using a pulse oximeter (Masimo Rad5, United States) with a paediatric clip probe while the child breathed in room air, temperature with a calibrated digital thermometer, and anthropometry (weight, height/length and mid-upper arm circumference) using standard tools and techniques.\u003c/p\u003e\u003cp\u003eA listening panel of five paediatricians were trained and standardised in listening and classifying recordings to identify adventitial lung sounds. Each child\u0026rsquo;s lung sound files were randomly sent to any two panel members. These panel members were blinded to participant clinical information. They independently listened to the recordings using high quality headsets (Sennheiser HD 599 SE) while simultaneously viewing the sound spectrograms in open-source software (Audacity). Panellists entered their classification either normal (no wheeze and no crackles), only wheeze, only crackles, both wheeze and crackles, or uninterpretable into an online electronic platform. They could listen to the recordings with the freedom to stop or repeat parts or the entire recording, if necessary. Each child\u0026rsquo;s summary classification across all chest locations by two panel members was compared, and if they did not match, a senior member of the study team (EDM), also masked to participant information and other recording interpretations, served as an arbitrator.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy definitions\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePneumonia\u003c/strong\u003e\u003cp\u003eThe presence of cough and/or difficulty breathing, along with fast breathing for age (respiratory rate\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;50 breaths/minute for 2 to \u0026lt;\u0026thinsp;12 month olds, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;40 breaths/minute for 12 to 59 month olds) and/or lower chest wall indrawing, and the absence of any IMCI-defined clinical danger signs, severe malnutrition, or hypoxemia.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNo pneumonia\u003c/strong\u003e\u003cp\u003eThe presence of cough and/or difficulty breathing but without fast breathing for age and without lower chest wall indrawing, and without any IMCI-defined clinical danger signs, severe malnutrition, and hypoxemia.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQuality recording\u003c/strong\u003e\u003cp\u003eAt least 75% interpretable lung sound segments per child (i.e., \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;3 out of 4 chest positions) determined by the listening panel.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were used to summarise the characteristics of the children, including age, sex, nutritional and immunisation status, and clinical signs of pneumonia. Lung sound recording details, including interpretability in \u0026ge;\u0026thinsp;3 chest positions and across different chest positions, were also described. The distribution of sound files, including the number recorded, transferred to the laptop, and classified as interpretable, was presented. All analyses were reported as frequencies and percentages, along with exact binomial confidence intervals (CIs). The time required to record quality lung sounds was documented. Children were categorised into pneumonia and no pneumonia, and all analyses were stratified accordingly. Data analysis was done using STATA version 18.0, with statistical significance set at a p-value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003cp\u003e We obtained ethical approval for this study from the National Research Ethics Committee of Bangladesh Medical Research Council, Bangladesh (Registration Number: 09630012018), and Academic and Clinical Central Office for Research and Development Medical Research Ethics Committee, NHS, Lothian, Edinburgh, UK (REC Reference: 18-HV-051). Written informed consent was obtained from parents or legal guardians of the children. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the Standards for Reporting of Diagnostic Accuracy Studies (STARD) flow diagram. Out of 2,434 children screened, 1,046 (42.9%) were eligible for the study. Of these 1,046, 56 (5.3%) children\u0026rsquo;s carers declined enrolment, leaving a total of 990 children enrolled. Among these 990 children, 389 (3.9%) were classified as having pneumonia. Of the 389 children with pneumonia, lung sounds from any chest position were recorded in 385 (99.0%) children. Similarly, among the 601 children without pneumonia, lung sounds were recorded in 595 (99.0%) children from any chest position (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Lung sound files in 381 (97.9%, 381/389) children in the pneumonia group and 593 (98.7%, 593/601) children in the no pneumonia group, were successfully transferred from the digital stethoscope to a secure study laptop. Lung sounds from \u0026ge;\u0026thinsp;3 chest positions were transferred to the laptop in 378 (98.2%, 378/385) children in the pneumonia group and 588 (98.8%, 588/595) in the no pneumonia group.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eChildren\u0026rsquo;s characteristics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the characteristics of children in the pneumonia and no pneumonia groups. The majority of children were 12 months or older (74.7%, 740/990). There was 1 male for every 0.8 females enrolled. The proportion of children fully immunised for age was 83.7% (829/990), while 86.2% (853/990) of children had received age-appropriate PCV vaccination.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of children\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSelected child characteristics at enrolment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo pneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e990\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e601\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;11 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e250 (25.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e158 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;59 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e740 (74.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e297 (76.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e443 (73.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e552 (55.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e231 (59.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e321 (53.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e438(44.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e158 (40.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e280 (46.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeight for age\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal (Z Score \u0026ge; -2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e626 (63.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e249 (64.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e377 (62.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild underweight (Z Score \u0026ge; -3 to \u0026lt; -2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e251 (25.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93 (23.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e158 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere underweight (Z Score \u0026lt; -3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113 (11.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66 (11.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHeight for age\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal (Z Score \u0026ge; -2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e532 (53.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e203 (52.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e329 (54.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild stunting (Z Score \u0026ge; -3 to \u0026lt; -2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e286 (28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106 (27.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e180 (30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere stunting (Z Score \u0026lt; -3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e172 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80 (20.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92 (15.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeight for height\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal (Z Score \u0026ge; -2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e822 (83.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e322 (82.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e500 (83.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild wasting (Z Score \u0026ge; -3 to \u0026lt; -2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129 (13.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (13.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78 (13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere wasting (Z Score \u0026lt; -3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiarrhoea within the past two weeks\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e171 (17.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e102 (17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e819 (82.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e320 (82.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e499 (83.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImmunisation status (all vaccines)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFully immunised for age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e829 (83.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e326 (83.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e503 (83.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartially immunised for age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e143 (14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56 (14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87 (14.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnvaccinated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePCV Vaccination status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFully immunised for age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e853 (86.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e334 (85.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e519 (86.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartially immunised for age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106 (10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnvaccinated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (3.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003ePCV - pneumococcal conjugate vaccine\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eClinical features\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe CHCPs identified fast breathing for age, lower chest wall indrawing and any respiratory danger signs in 37.6% (372/990), 2.5% (25/990) and 4.7% (47/990) of children, respectively \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of signs during enrolment identified by community healthcare providers (multiple responses)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eClinical signs\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo pneumonia\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e990\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e601\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge-specific fast breathing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e372 (37.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e372 (95.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChest indrawing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAny respiratory danger sign\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAxillary temperature\u0026thinsp;\u0026ge;\u0026thinsp;100.4\u0026deg;F\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (10.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34 (5.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eLung sound recordings\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the distribution of lung sound recordings by the number of chest positions, as well as the number of quality recordings identified by the listening panel. CHCPs recorded lung sounds from \u0026ge;\u0026thinsp;3 chest positions in 98.3% ((973/990); 95% CI: 97.3%, 99.0%) of children. There was no statistically significant difference in the percentage of children with \u0026ge;\u0026thinsp;3 chest position recordings between the pneumonia and the no pneumonia groups (p\u0026thinsp;=\u0026thinsp;0.73).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRecorded and interpretable lung sounds\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eChildren with chest position\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eRecorded lung sounds\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eInterpretable lung sounds\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo pneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo pneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eN\u0026thinsp;=\u0026thinsp;990\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;389\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;601\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eN\u0026thinsp;=\u0026thinsp;990\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;389\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;601\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;3 chest positions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98.3 (97.3, 99.0) [973]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.5 (96.7, 99.4) [383]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e98.2 (96.7, 99.1) [590]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e87.6 (85.4, 89.6) [867]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e88.2 (84.5, 91.2) [343]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e87.2 (84.2, 89.8) [524]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026le;\u0026thinsp;2 chest positions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.7 (0.3, 1.5) [7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5 (0.1, 1.8) [2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8 (0.3, 1.9) [5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.5 (5.0, 8.2) [64]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.9 (3.8, 8.7) [23]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.8 (4.9, 9.1) [41]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNo recording or all four positions uninterpretable\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.0 (0.5, 1.8) [10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0 (0.3, 2.6) [4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0 (0.4, 2.2) [6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.0 (4.6, 7.6) [59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.9 (3.8, 8.7) [23]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.0 (4.2, 8.2) [36]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eCI - Confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eQuality recordings\u003c/em\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e(\u003c/span\u003e\u0026ge;\u0026thinsp;3 chest position recordings of a child were interpretable)\u003c/p\u003e\u003cp\u003eOverall, the listening panel assessed 87.6% ((867/990); 95% CI: 85.4%, 89.6%) of children to have quality recordings \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, though this proportion varied by CHCP, ranging from 73.1% (19/26) to 94.7% (177/187) (\u003cb\u003eSupplementary table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/b\u003e). The fitted linear regression model indicated a positive association between the number of quality recordings and enrolments per CHCP, with a 1% increase in quality recordings for every ten new children auscultated \u003cb\u003e(Supplementary Fig.\u0026nbsp;1)\u003c/b\u003e. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the number of chest positions recorded and deemed interpretable by chest positions. There was little variation in successfully recorded lung sounds by chest position, although the success rate was significantly higher for both back positions (left and right back) compared to both front positions (left and right front) (92.0% (1782/1938) vs 87.9% (1690/1923); p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of the number of sound files recorded, transferred from the digital stethoscope to a laptop, and interpretable by chest position\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of sound files recorded\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of sound files transferred from digital stethoscope to laptop\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage of sound files interpretable by the panel\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% (95% CI) [n]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePosition 1: (left back)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e977\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e968\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e92.6 (90.7, 94.1) [896]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePosition 2: (right back)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e978\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e970\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e91.3 (89.4, 93.0) [886]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePosition 3: (left front)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e968\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e960\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88.0 (85.8, 90.0) [845]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePosition 4: (right front)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e963\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87.7 (85.5, 89.8) [845]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBack (left back and right back)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1955\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1938\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e92.0 (90.6, 93.1) [1782]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFront (left front and right front)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1939\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1923\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87.9 (86.3, 89.3) [1690]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI - Confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eLung sound classification\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAmong quality recordings, Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the distribution of lung sounds classified by the listening panel. Adventitious lung sounds were identified more frequently in the pneumonia group than in the no pneumonia group (36.7% (126/343) pneumonia, 27.9% (146/524) no pneumonia, p\u0026thinsp;=\u0026thinsp;0.01). Thus, in the pneumonia group, 63.3% (217/343) of children had normal lung sounds according to the listening panel. Although the frequency for only wheeze, only crackles, and both wheeze and crackles was higher in the pneumonia group than the no pneumonia group, these differences did not reach statistical significance.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of lung sounds classification\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eClassification\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo pneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e% (95% CI), [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (95% CI), [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e524\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNormal sounds (No wheeze and no crackle)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63.3 (57.9,68.4), [217]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.1 (68.1, 75.9), [378]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdventitious sounds\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.7 (31.6,42.1) [126]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.9 (24.1, 31.9), [146]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWheeze only\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.5 (11.8, 19.7), [53]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.3 (8.7, 14.3), [59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCrackles only\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.9 (7.0, 13.6), [34]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.0 (5.8, 10.7), [42]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWheeze and crackles\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.4 (8.2,15.2) [39]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.6 (6.3, 11.3), [45]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI - Confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eDuration of quality recordings\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCHCPs completed quality recordings in 56.6% (483/853) of children within one minute and in 89.8% (766/853) within five minutes \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The recording time for participants with quality recordings ranged from 1 to 18 minutes. Recording durations exceeding five minutes were attributed to technical issues with the digital stethoscope.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eChild cooperation during lung sound recordings\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe proportion of cooperative and quiet children during lung sound recordings was high in both the pneumonia (81.6%, 314/385) and no pneumonia (78.7%, 468/595) groups (p\u0026thinsp;=\u0026thinsp;0.27) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChildren\u0026rsquo;s cooperation status during lung sounds recording\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eChildren\u0026rsquo;s cooperation status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo pneumonia\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%; (95% CI); [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%; (95% CI); [n]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%; (95% CI); [n]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e980\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e385\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e595\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCooperative and quiet throughout\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79.8 (77.1, 82.3) [782]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81.6 (77.3, 85.3) [314]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.7 (75.1, 81.9) [468]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCooperative but vocalized\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.7 (1.7, 3.9) [26]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3 (1.1, 4.4) [9]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.9 (1.7, 4.5) [17]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInitially cooperative, became agitated but did not cry\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.5 (2.4, 4.8) [34]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.9 (2.2, 6.3) [15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2 (1.9, 4.9) [19]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInitially cooperative but agitated and cried\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.9 (9.0, 13.0) [107]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.9 (7.1, 13.3) [38]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.6 (9.1, 14.4) [69]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDid not cooperate throughout and cried\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.8 (1.8, 4.0) [27]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.1 (0.9, 4.1) [8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2 (1.9, 4.9) [19]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eData missing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.4 (0.1, 1.0) [4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.3 (0.0, 1.4) [1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5 (0.1, 1.5) [3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eCI - Confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBased upon the high proportion of acutely ill children with both timely and quality recordings obtained, our study demonstrates non-physician health workers in Bangladesh called CHCPs can feasibly use a digital stethoscope on children presenting to care at rural primary care clinics. Digital auscultation is a new technology for non-physician frontline health workers, such as CHCPs in Bangladesh, where conventional stethoscopes are not typically used in routine care. To the best of our knowledge, this was the first study to investigate the ability of frontline health workers to record lung sounds in first-level facilities in LMICs. Previous studies, such as the Pneumonia Etiology Research for Child Health (PERCH) study, trained either nurses or physicians to record lung sounds in hospital settings with a digital stethoscope\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. In PERCH, a listening panel classified 89.5% of 792 pneumonia cases and 92.4% of 301 controls as interpretable\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, which closely aligns with our findings. Our study extends these findings to non-physician CHCPs. CHCPs work in crowded and noisy environments and often face time pressure from a high-volume of patients, limiting the amount of time available to calm ill, often scared, and agitated children. It is therefore crucial to understand whether obtaining quality lung sounds in these settings using a digital stethoscope is feasible for frontline healthcare workers with minimal training.\u003c/p\u003e\u003cp\u003eIn this study, CHCPs followed a sequential recording procedure refined from our prior methodology\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, starting with two recordings on the back followed by two on the front, screening both upper and lower lung lobe fields of each hemithorax. CHCPs successfully recorded lung sounds in 97.6% of children, with no difference in the success rate between those with and without pneumonia. Importantly, CHCPs recorded lung sounds from only one or two chest positions in just seven children overall and failed to record any lung sounds from any of the chest positions in only ten children. These failures were primarily due to stethoscope malfunction or software errors during the sound file transfer from the stethoscope to the laptop. This finding reinforces the notion that quality lung sounds from under-five-years-old children can be feasibly recorded at first-level facilities by CHCPs capacitated with supportive tools and training.\u003c/p\u003e\u003cp\u003eOur overall hypothesis for this analysis was that if CHCPs could record lung sounds from three or four chest positions, and if at least three of these recordings were deemed interpretable by the paediatric listening panel, the overall process would meet a minimum quality threshold. The rationale for this threshold is that such recordings would capture sounds from at least three of the five major lobes and from both hemithoraces. Typically, in children younger than five years, inflammation from pneumonia is present in multiple lobes of the lung, and so these criteria would balance feasibility with identifying most pneumonia cases. In this study, 87.6% of children had quality recordings according to the listening panel, identifying the presence of only wheeze, only crackles, both, or neither, with no significant difference in the frequency of quality recordings between children with and without pneumonia.\u003c/p\u003e\u003cp\u003eIn our study, the proportion of children with three or more interpretable lung sound recordings per CHCP ranged from 73.1% (19/26) to 94.7% (177/187), indicating considerable variability in performance. CHCPs with the lowest enrolment numbers (26 and 38 children) had the lowest success rates (73.1% (19/26) and 76.3% (29/38)), while those with the highest enrolment numbers (187 and 179 children) achieved the highest success rates (94.7% (177/187) and 92.7% (166/179)). Our data shows the percentage of successful recordings increased by 1% with every ten children recorded. This suggests a learning curve, with CHCPs becoming more proficient in obtaining quality recordings over time as they gained experience.\u003c/p\u003e\u003cp\u003eThe sequential recording approach that started on the participant\u0026rsquo;s back was intended to balance optimising child cooperation with identifying most pneumonia cases, as children are often more comfortable when facing their carer being held, which allows the health worker access to the child\u0026rsquo;s back. Our findings revealed no significant variation in the success rate of lung sound recordings across the four chest positions. However, there was a significant difference in interpretability with recordings obtained from the back more likely to meet quality criteria than those from the front (92.0% (1782/1938) vs 87.9% (1690/1923); p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This difference is likely due to the less intrusive nature of posterior recordings and the fact that these were consistently performed before anterior recordings, when the children were generally calmer. Despite these variations, three out of every four children remained cooperative and quiet throughout.\u003c/p\u003e\u003cp\u003eThe time required to obtain quality recordings was also encouraging, with 89.8% (766/853) of children having at least three interpretable chest position recordings captured under five minutes. This finding suggests that incorporating digital auscultation into the IMCI algorithm is unlikely to significantly increase the workload of frontline health workers, supporting the potential scalability of this technology in programmatic settings. Interestingly, there was no relationship between the number of children enrolled and the overall time taken by the CHCP to record the lung sounds. However, several challenges were consistently identified when recordings took longer than one minute. The device occasionally froze, requiring the CHCP to either perform a complete restart or drain the device's battery charge. Children younger than five years of age can be active, and although most children were initially cooperative, some became agitated during the recording process. In such cases, CHCPs had to pause recording and take additional time to calm the child down before reattempting to record the lung sounds. Additionally, ambient noise, such as loudspeaker announcements outside the CC or calls for prayer, which can occur multiple times per day in Bangladesh, sometimes interrupted the recording process. CHCPs had to delay recordings until the background noise had subsided.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, we purposively selected nine out of 24 CCs in the Zakiganj sub-district of Sylhet District, Bangladesh. This may limit the generalisability of our findings to other CCs with different patient volumes, case mixes, or clinical environments. Second, this study only included non-severe pneumonia cases, as the CCs lack the capacity to manage severe pneumonia, which requires parenteral antibiotics and hospitalisation regardless of their lung sounds findings. Therefore, our findings may not be generalisable to children with severe pneumonia. Third, several technical issues were identified with the digital stethoscope. These included recordings stopping prematurely, recordings failing to stop, inadequate durability of the device hardware, freezing of the device software during the recording process, and in some cases the battery losing its charge too quickly \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. This highlights the need for addressing these issues to ensure future versions of the device are more effective and user-friendly for a LMIC clinical environment. Finally, the fact that the digital stethoscope requires charging once daily is a limitation for its use in remote first-level facilities in LMICs, where the power supply is erratic or there is no power supply at all. Providing alternative power solutions, such as solar panels and portable power banks to charge the stethoscope may solve this issue.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrated that non-physician health workers called CHCPs at first-level primary care facilities in Bangladesh can feasibly record quality lung sounds in under-five-year-old children using a digital stethoscope. While several challenges exist in these settings, including a lack of provider training and experience auscultating the lungs of children, the active and sometimes uncooperative nature of young children, and a noisy environment, CHCPs in this study were able to record quality lung sounds without substantially increasing their workload. A larger study involving a higher number of CCs across diverse geographic locations with varying patient volumes, potentially including different countries and a range of outpatient settings and contexts, is an important next step in assessing the broader feasibility of using digital auscultation by front-line health workers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003e This research was funded by the UK National Institute for Health and Care Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Government.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSA, EDM, HN and AHB conceptualised and designed this study. SA advised on the implementation of the study. AAI organised the data collection. NHC managed the data curation. MSI conducted the data analysis with support from SA, AMK, NHC, HN, SC and EDM. EDM, LG, MMJ, IJ, and MW interpreted the recorded lung sound files. SA wrote the first draft of the manuscript. AMK, AHB, SC, HN and EDM provided critical feedback on the manuscript structure and contents. All authors contributed to interpreting the results, reviewed the manuscript, and approved the submitted version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors extend their deepest gratitude to the Ministry of Health and Family Welfare, Government of Bangladesh, National Newborn Health Program, and CHCPs of the respective community clinics in Zakiganj, Sylhet, Bangladesh, for their invaluable assistance in supporting activities for this research. We also thank the RESPIRE collaboration, including UK and LMICs Grant holders, partners, and research teams, as listed on their website (www.ed.ac.uk/usher/respire), for their contribution, including Si\u0026acirc;n Williams.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990\u0026ndash;2016: a systematic analysis for the Global Burden of Disease Study 2016. \u003cem\u003eLancet Infect. 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Health\u003c/em\u003e. \u003cb\u003e1\u003c/b\u003e, 26 (2023).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Preschool Child, Infant, Pneumonia, Practice Guidelines as a Topic, Stethoscopes, Community Health Workers, Developing Countries","lastPublishedDoi":"10.21203/rs.3.rs-7243236/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7243236/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e The diagnostic performance of the World Health Organization\u0026rsquo;s Integrated Management of Childhood Illness guidelines for child pneumonia could be improved by incorporating lung auscultation. Although challenging for non-physician health workers to effectively use a conventional stethoscope, a digital stethoscope enhanced by artificial intelligence capabilities may be an alternative. In this feasibility study we aimed to evaluate whether non-physician primary care health workers can record quality lung sounds from under-5-year-old children. Non-physician primary care health workers called community health care providers recorded lung sounds from four protocolised chest positions using a digital stethoscope in 2-59-month-old children attending first-level rural clinics in Bangladesh. A paediatrician listening panel, trained to a standardised interpretation protocol, classified the recordings. A quality recording was defined a priori as the panel classifying three of four chest positions on a participant as interpretable. Lung sounds were recorded from 990 children, and the panel classified 867 children as having a quality recording (87.6%; 95% confidence interval: 85.4%, 89.6%). Of these, 89.8% (766/853) were recorded within five minutes. This study demonstrates non-physician primary care health workers at rural, first-level clinics in Bangladesh are capable of timely, quality recordings of lung sounds from most children using a digital stethoscope.\u003c/p\u003e","manuscriptTitle":"Digital stethoscope use by non-physician primary care health workers on under-five-year-old children in rural Bangladesh: feasibility study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 14:02:47","doi":"10.21203/rs.3.rs-7243236/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-01T10:28:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-01T05:48:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1329433888932814251977110684684337285","date":"2025-11-30T04:31:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145227505010110920691901538314755454649","date":"2025-11-27T15:45:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-26T23:24:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20521378594764844188395102494439470557","date":"2025-11-25T16:41:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287315612324107767443217098050063541616","date":"2025-11-25T14:44:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285564236939131549349864591979622137958","date":"2025-11-25T14:24:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151706520797468796252739301138856071246","date":"2025-11-25T13:58:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174019222997403378251798454866653459264","date":"2025-11-17T15:00:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-17T09:50:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-17T09:49:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-29T10:12:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-04T11:12:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-08-04T09:26:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c11a157-b97e-4453-bdf9-3183e21d9c07","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":52605510,"name":"Health sciences/Diseases"},{"id":52605511,"name":"Health sciences/Health care"},{"id":52605512,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-05-08T06:38:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 14:02:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7243236","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7243236","identity":"rs-7243236","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}