November, 2015 - SUPPORT Summary of a systematic review | print this article |

Can community-based interventions increase uptake of treatment modalities for diarrhea and pneumonia and reduce childhood mortality?

Few children in low-income countries receive appropriate treatment for diarrhea and pneumonia, which are the leading causes of under-five child deaths. Community-based interventions can increase the uptake of specific treatments for diarrhea and pneumonia, potentially leading to a decrease in under five child mortality.

Key messages

  • Community-based interventions probably increase care seeking for diarrhea in children, increase use of oral rehydration solution, and reduce mortality due to diarrhea among children age 0-4 years.
  • Community-based interventions probably increase care seeking for pneumonia in children, increase use of antibiotics, and reduce mortality due to acute pneumonia among children age 0-4 years.

 

Background

Few children in low-income countries receive appropriate treatment for diarrhea and pneumonia. Poor access to clinics and shortages of trained primary health workers are the major reasons for this situation. Community-based interventions include provision of health services at the community and household level with the help of lay health workers. This review assessed whether community-based interventions can increase the uptake of specific treatments (such as oral rehydration solution and zinc for diarrhea, and antibiotics for pneumonia) for childhood diarrhea and pneumonia, and decrease under five child mortality.

 



About the systematic review underlying this summary

Review objectives: To estimate the effect of community-based interventions including community case management on the coverage of various commodities and on mortality due to diarrhea and pneumonia
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, quasi-experimental and observational studies of community-based interventions.
24 studies were found, including randomised trials, quasi-experimental and observational studies.
Participants Impacts on children under 5 years.
Children under 5 years.
Settings Community-based settings in any country.
Asia and Africa: India, Bangladesh, Pakistan, Malaysia, Nepal, Tanzania, China, Fiji, Zambia, Mali, Mozambique, Thailand, Uganda.
Outcomes Care seeking rates, use of oral rehydration solutions and zinc for diarrhea, antibiotics use and treatment failure rates for diarrhea and pneumonia; and for case management studies: incidence of moderate or severe episodes of acute lower respiratory infection, diarrhea-specific mortality, pneumonia-specific mortality, and all-cause mortality.
Use of oral rehydration solution in childhood diarrhea, use of zinc in childhood diarrhea, care seeking rates for diarrhea, care seeking rates for pneumonia (12 studies); pneumonia case management outcomes (12 studies); diarrhea case management outcomes (2 studies).
Date of most recent search: November 2012
Limitations: This review has important limitations. It does not provide any information on risk of bias. In addition, it does not report how studies were weighted in the analysis.

Das JK, Lassi ZS, Salam RA, Bhutta ZA. Effect of community based interventions on childhood diarrhea and pneumonia: uptake of treatment modalities and impact on mortality. BMC Public Health 2013 13(Suppl 3):S29.

Summary of findings

This review included 24 studies mainly from low- and middle-income countries. Interventions delivered at community level through lay health workers and health staff which are not based at clinics were considered community-based interventions. Most community-based interventions used WHO defined criteria for diarrhea and pneumonia case management.

1) Community-based interventions compared with routine care

 

  • Community-based interventions in addition to usual care practices probably increase care seeking for diarrhea in children. The certainty of this evidence is moderate.
  • Community-based interventions probably increase use of oral rehydration solutions and zinc for childhood diarrhea. The certainty of this evidence is moderate.
  • Community-based interventions probably reduce diarrhea specific mortality among children age 0-4 years. The certainty of this evidence is moderate.
  • Community-based interventions probably increase care seeking rates for pneumonia in children. The certainty of this evidence is moderate.
  • Community-based interventions may increase use of antibiotics for pneumonia in children. The certainty of this evidence is moderate.
  • Community-based interventions probably reduce pneumonia-specific mortality among children age 0-4 years. The certainty of this evidence is moderate.

Impact of community-based interventions on childhood diarhea and pneumonia

People               Parents and children

Settings             Asia and Africa: India, Bangladesh, Pakistan, Malaysia, Nepal, Tanzania, China, Fiji, Zambia, Mali, Mozambique, Thailand,                                 Uganda

Intervention       Community-based interventions delivered through lay health workers

Comparison        Usual care practices for childhood diarrhea

Outcomes

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Care seeking rates for diarrhea

RR 1.09

(1.06 to 1.12)

Moderate

Use of oral rehydration solution for diarrhea

RR 2.60

(1.59 to 4.27)

Moderate

Use of zinc for diarrhea

RR 29.79

(12.33 to 71.97)

Moderate

Diarrhea-specific mortality 0-4 years

RR 0.37

(0.15 to 0.93)

Moderate

Care seeking rates for pneumonia

RR 1.13

(1.08 to 1.18)

Moderate

Use of antibiotics for pneumonia

RR 1.13

(0.99 to 1.30)

Moderate

Pneumonia-specific mortality 0-4 years

RR 0.68

(0.53 to 0.88)


Moderate

GRADE: GRADE Working Group grades of evidence (see above and last page)

RR: risk ratio CI: confidence interval


Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies included in this review were carried out in low- and middle-income countries.

Most studies reported using lay health workers in addition to existing systems of health service delivery.


Since findings are consistent in most low- and middle-income settings, it is likely that the findings are broadly applicable.

The types of incentives provided to lay health workers in different settings might modify the effects. In addition, formal healthcare systems can affect the applicability of interventions.

Coverage of lay health workers in remote rural areas might vary.


EQUITY
This review does not provide any information on the effect of community-based interventions between disadvantaged and less disadvantaged populations.
Because the interventions are targeted at underserved populations, they likely reduce inequities. However, differences in the availability of lay health workers might have impacts on equity within those underserved populations.
ECONOMIC CONSIDERATIONS
This review does not provide any information on costs of community-based interventions.

Resources required for implementing the community-based interventions and training of lay health workers need to be considered when assessing whether the interventions can be implemented in low-income countries.

Changes in use of healthcare resources include increased use of transportation, human resources, and material resources.


MONITORING & EVALUATION
No evidence on monitoring of community-based interventions was reported in this review.

Monitoring of community-based interventions might influence their success, as well as ensuring that the interventions are performing as expected.

Context-specific economic evaluations might help inform policy decisions regarding scaling up and continuing investments in community-based interventions.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev 2010; (3):CD004015.

 

Glenton C, Colvin CJ, Carlsen B, et al. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev 2013; (10):CD010414

 

Druetz T, Siekmans K, Goossens S,  et al. The community case management of pneumonia in Africa: a review of the evidence. Health Policy Plan 2015; 30:253–66.

 

This summary was prepared by

Atif Riaz, Aga Khan University, Karachi, Pakistan

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Tomas Pantoja, Andrea Basagoitia and Zulfiqar Bhutta.

 

This review should be cited as

Das JK, Lassi ZS, Salam RA, Bhutta ZA. Effect of community based interventions on childhood diarrhea and

pneumonia: uptake of treatment modalities and impact on mortality. BMC Public Health 2013 13(Suppl 3):

S29.

 

The summary should be cited as

Atif Riaz. Can community-based interventions increase uptake of treatment modalities for diarrhea and pneumonia and reduce childhood mortality? A SUPPORT Summary of a systematic review. May 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, community-based interventions, childhood mortality, diarrhea, pneumonia



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