Evaluating the performance of community health care providers in detecting fast breathing in children using a reference video expert panel in Bangladesh.

Background: The World Health Organization's Integrated Management of Childhood Illness guidelines emphasise respiratory rate (RR) counting for diagnosing childhood pneumonia. Community health workers (CHWs) play a crucial role in managing pneumonia in children in low- and middle-income countries (LMICs). In Bangladesh, community clinics (CCs) are the lowest tier of health facilities, where services are provided by CHWs designated as Community Health Care Providers (CHCPs). This study evaluated the ability of CHCPs to measure RR and identify fast breathing for the diagnosis of pneumonia. Methods: We conducted a cross-sectional study of children aged 0-59 months presenting with suspected pneumonia at three purposively selected CCs in Bangladesh. CHCPs from respective CCs counted RR manually, with chest movements simultaneously videotaped. Six physicians were trained to form a video expert panel (VEP) that interpreted the RR from the recorded videos. We assessed the ability of CHCPs to count RR and identify fast breathing, using VEP as the reference standard. Results: Among the 123 enrolled children, CHCPs were able to count an RR of 110 children (89.4%). VEP reached a consensus (i.e., RR count difference within two breaths per minute (bpm) between two VEP members) for 103 out of 110 children (93.6%). CHCPs and VEP reached consensus (RR counts within two bpm) for 80 of these 103 children (77.7%), with a mean difference of 0.8 bpm and limits of agreement ranging from - 4.9 to 6.5 bpm. The CHCPs classified fast and normal breathing with a sensitivity of 100% (95% CI 73.5-100.0) and a specificity of 95.6% (95% CI 89.1-98.8), demonstrating an agreement of 96.1% (95% CI 90.4-98.9) and a kappa of 0.84. Conclusions: CHCPs demonstrated safe and reliable RR counting, with a tendency to overestimate fast breathing, yet they did not miss any cases. However, challenges such as the failure to measure RR in some children and the lack of consensus on RR count among VEP members point to potential limitations in the assessment process. Moreover, the selection of well-trained health workers and the recruitment of patients with relatively less severe conditions in CCs limit the generalisability of these findings. Supplementary Information: The online version contains supplementary material available at 10.1186/s12982-026-01513-0.