SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
November, 2015 - SUPPORT Summary of a systematic review | print this article | download PDF
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
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
| 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.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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.
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Impact of community-based interventions on childhood diarhea and pneumonia |
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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 |
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Outcomes |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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Care seeking rates for diarrhea |
RR 1.09 (1.06 to 1.12) |
Moderate |
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Use of oral rehydration solution for diarrhea |
RR 2.60 (1.59 to 4.27) |
Moderate |
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Use of zinc for diarrhea |
RR 29.79 (12.33 to 71.97) |
Moderate |
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Diarrhea-specific mortality 0-4 years |
RR 0.37 (0.15 to 0.93) |
Moderate |
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Care seeking rates for pneumonia |
RR 1.13 (1.08 to 1.18) |
Moderate |
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Use of antibiotics for pneumonia |
RR 1.13 (0.99 to 1.30) |
Moderate |
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Pneumonia-specific mortality 0-4 years |
RR 0.68 (0.53 to 0.88) |
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GRADE: GRADE Working Group grades of evidence (see above and last page) RR: risk ratio CI: confidence interval |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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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. |
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*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 |
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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.
Atif Riaz, Aga Khan University, Karachi, Pakistan
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Tomas Pantoja, Andrea Basagoitia and Zulfiqar Bhutta.
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.
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
