Abstract
Background Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers’ ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs. Methods We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity. Results We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97). Conclusions We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children.
Original language | English (US) |
---|---|
Article number | 04016 |
Journal | Journal of global health |
Volume | 13 |
DOIs | |
State | Published - 2023 |
ASJC Scopus subject areas
- Public Health, Environmental and Occupational Health
- Health Policy
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In: Journal of global health, Vol. 13, 04016, 2023.
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TY - JOUR
T1 - The ability of non-physician health workers to identify chest indrawing to detect pneumonia in children below five years of age in low and middle-income countries
T2 - A systematic review and meta-analysis
AU - Khan, Ahad Mahmud
AU - Sultana, Saima
AU - Ahmed, Salahuddin
AU - Shi, Ting
AU - McCollum, Eric D.
AU - Baqui, Abdullah H.
AU - Cunningham, Steve
AU - Campbell, Harry
N1 - Funding Information: Acknowledgments: We are grateful to Ruth Jenkins, Academic Librarian, and Bohee Lee, Systematic Review Tutor, at the University of Edinburgh, for their help in developing the search strategy. We also thank RESPIRE collaboration for their contribution in bringing the manuscript to its final shape. The RESPIRE collaboration comprises the UK Grant holders, Partners, and research teams as listed on the RESPIRE website (www.ed.ac.uk/usher/respire). Data availability: Input data used for the meta-analysis is available in Table S5 in the Online Supplementary Document. Funding: This research was funded by the UK National Institute for Health 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. Authorship contributions: AMK and HC conceptualized, AMK performed database searches, AMK and SS screened the title and abstract, reviewed the studies and extracted the data, AMK performed the data analysis, drafted the first version, HC, SS, SA, SC, AHB, EDM, and TS contributed substantially to the writing of the paper. All authors have read and approved the final manuscript. Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose the following activities and relationships: Harry Campbell is the Co-Editor in Chief of the Journal of Global Health. To ensure that any possible conflict of interest relevant to the journal has been addressed, this article was reviewed according to the best practice guidelines of international editorial organisations. Additional material Online Supplementary Document 1 Perin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, 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. 2022;6:106-15. Medline:34800370 doi:10.1016/S2352-4642(21)00311-4 2 GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortal-ity, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Bur-den of Disease Study 2016. Lancet Infect Dis. 2018;18:1191-210. Medline:30243584 doi:10.1016/S1473-3099(18)30310-4 3 Nair H, Simões EA, Rudan I, Gessner BD, Azziz-Baumgartner E, Zhang JSF, et al. Global and regional burden of hos-pital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis. Lancet. 2013;381:1380-90. Medline:23369797 doi:10.1016/S0140-6736(12)61901-1 4 Geldsetzer P, Williams TC, Kirolos A, Mitchell S, Ratcliffe LA, Kohli-Lynch MK, et al. The recognition of and care seeking behaviour for childhood illness in developing countries: a systematic review. PLoS One. 2014;9:e93427. Medline:24718483 doi:10.1371/journal.pone.0093427 5 World Health Organization. Global Health Workforce statistics database. Available: https://www.who.int/data/gho/data/ themes/topics/health-workforce. Accessed: 1 October 2022. 6 Blanford JI, Kumar S, Luo W, MacEachren AM. It’s a long, long walk: accessibility to hospitals, maternity and integrated health centers in Niger. Int J Health Geogr. 2012;11:24. Medline:22737990 doi:10.1186/1476-072X-11-24 7 Lungu EA, Biesma R, Chirwa M, Darker C. Healthcare seeking practices and barriers to accessing under-five child health services in urban slums in Malawi: a qualitative study. BMC Health Serv Res. 2016;16:410. Medline:27542836 doi:10.1186/ s12913-016-1678-x 8 Zhang S, Sammon PM, King I, Andrade AL, Toscano CM, Araujo SN, et al. Cost of management of severe pneumonia in young children: systematic analysis. J Glob Health. 2016;6:010408. Medline:27231544 doi:10.7189/jogh.06.010408 9 Izadnegahdar R, Cohen AL, Klugman KP, Qazi SA. Childhood pneumonia in developing countries. Lancet Respir Med. 2013;1:574-84. Medline:24461618 doi:10.1016/S2213-2600(13)70075-4 10 Whidden C, Thwing J, Gutman J, Wohl E, Leyrat C, Kayentao K, et al. Proactive case detection of common childhood illness-es by community health workers: a systematic review. BMJ Glob Health. 2019;4:e001799. Medline:31908858 doi:10.1136/ bmjgh-2019-001799 11 Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bull World Health Organ. 1997;75 Suppl 1:7-24. Medline:9529714 12 Sazawal S, Black RE. Meta-analysis of intervention trials on case-management of pneumonia in community settings. Lan-cet. 1992;340:528-33. Medline:1354286 doi:10.1016/0140-6736(92)91720-S 13 World Health Organization. IMCI information package. Integrated Management of Childhood Illness (IMCI). Geneva: World Health Organization, 1999. 14 World Health Organization. Integrated Management of Childhood Illness: Chart Booklet. Geneva: World Health Orga-nization, 2014. 15 Khan AM, O’Donald A, Shi T, Ahmed S, McCollum ED, King C, et al. Accuracy of non-physician health workers in respi-ratory rate measurement to identify paediatric pneumonia in low-and middle-income countries: A systematic review and meta-analysis. J Glob Health. 2022;12:04037. Medline:9037577 doi:10.7189/jogh.12.04037 16 World Health Organization, United Nations Children’s Fund. (UNICEF). Caring for newborns and children in the commu-nity: caring for the sick child in the community: a training course for community health workers, adaptation for high HIV or TB settings: chart booklet. 2020. Available: https://apps.who.int/iris/handle/10665/340213. Accessed: 18 September 2022. 17 McCollum ED, Ginsburg AS. Outpatient Management of Children With World Health Organization Chest Indrawing Pneu-monia: Implementation Risks and Proposed Solutions. Clin Infect Dis. 2017;65:1560-4. Medline:29020216 doi:10.1093/ cid/cix543 18 Rambaud-Althaus C, Althaus F, Genton B, D’Acremont V. Clinical features for diagnosis of pneumonia in children young-er than 5 years: a systematic review and meta-analysis. Lancet Infect Dis. 2015;15:439-50. Medline:25769269 doi:10.1016/ S1473-3099(15)70017-4 19 Onono M, Abdi M, Mutai K, Asadhi E, Nyamai R, Okoth P, et al. Community case management of lower chest indraw-ing pneumonia with oral amoxicillin in children in Kenya. Acta Paediatr. 2018;107 Suppl 471:44-52. Medline:30570795 doi:10.1111/apa.14405 20 Baqui AH, Arifeen SE, Rosen HE, Mannan I, Rahman SM, Al-Mahmud AB, et al. Community-based validation of assess-ment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh. Trop Med Int Health. 2009;14:1448-56. Medline:19807901 doi:10.1111/j.1365-3156.2009.02397.x 21 Perkins BA, Zucker JR, Otieno J, Jafari HS, Paxton L, Redd SC, et al. Evaluation of an algorithm for integrated manage-ment of childhood illness in an area of Kenya with high malaria transmission. Bull World Health Organ. 1997;75 Suppl 1:33-42. Medline:9529716 22 Nguyen DT, Leung KK, McIntyre L, Ghali WA, Sauve R. Does integrated management of childhood illness (IMCI) training improve the skills of health workers? A systematic review and meta-analysis. PLoS One. 2013;8:e66030. Medline:23776599 doi:10.1371/journal.pone.0066030 23 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int J Surg. 2021;88:105906. Medline:33789826 doi:10.1016/j.ijsu.2021.105906 24 McInnes MDF, Moher D, Thombs BD, McGrath TA, Bossuyt PM, Clifford T, et al. Preferred Reporting Items for a System-atic Review and Meta-analysis of Diagnostic Test Accuracy Studies: The PRISMA-DTA Statement. JAMA. 2018;319:388-96. Medline:29362800 doi:10.1001/jama.2017.19163 Publisher Copyright: © 2023 The Author(s)
PY - 2023
Y1 - 2023
N2 - Background Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers’ ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs. Methods We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity. Results We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97). Conclusions We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children.
AB - Background Non-physician health workers play a vital role in diagnosing and treating pneumonia in children in low and middle-income countries (LMICs). Chest indrawing is a key indicator for pneumonia diagnosis, signifying the severity of the disease. We conducted this systematic review to summarize the evidence on non-physician health workers’ ability to identify chest indrawing to detect pneumonia in children below five years of age in LMICs. Methods We comprehensively searched four electronic databases, including MEDLINE, Embase, Web of Science, and Scopus, and reference lists from the identified studies, from January 1, 1990, to January 20, 2022, with no language restrictions. Studies evaluating the performance of non-physician health workers in identifying chest indrawing compared to a reference standard were included. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess the methodological quality of the selected studies and conducted a meta-analysis following a bivariate random effects model to estimate the pooled sensitivity and specificity. Results We identified nine studies covering 4468 children that reported the accuracy of a non-physician health worker in identifying chest indrawing. Most studies were conducted in the 1990s, based at health facility settings, with children aged 2-59 months, and with pediatricians/physicians as the reference standard. Using the QUADAS-2, we evaluated most studies as having a low risk of bias and a low concern regarding applicability in all domains. The median sensitivity, specificity, positive predictive value, and negative predictive value were 44%, 97%, 55%, and 95%, respectively. We selected five studies for the meta-analysis. The pooled sensitivity was 46% (95% confidence interval (CI) = 37-56), and the pooled specificity was 95% (95% CI = 91-97). Conclusions We found the ability of non-physician health workers in LMICs in identifying chest indrawing pneumonia is relatively poor. Appropriate measures, such as targeted identification and training, supportive supervision, regular performance assessment, and feedback for those who have a poor ability to recognize chest indrawing, should be taken to improve the diagnosis of pneumonia in children.
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U2 - 10.7189/jogh.13.04016
DO - 10.7189/jogh.13.04016
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C2 - 36730094
AN - SCOPUS:85147319021
SN - 2047-2978
VL - 13
JO - Journal of global health
JF - Journal of global health
M1 - 04016
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