Summary of findings 3. LHWs compared to usual care for reducing mortality and morbidity in children <5 years.
| LHWs compared to usual care for reducing mortality and morbidity in children <5 years | ||||||
| Patient or population: patients with reducing mortality and morbidity in children <5 years Settings: Bangladesh (3 studies), Ethiopia, Tanzania, Nepal, Ghana, Thailand, Viet Nam, India, Burkina Faso Intervention: LHWs Comparison: usual care | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | No of Participants (studies) | Quality of the evidence (GRADE) | Comments | |
| Assumed risk | Corresponding risk | |||||
| usual care | LHWs | |||||
| Mortality among children less than 5 years Verbal autopsy Follow‐up: 1‐2 years | Study population1 | RR 0.75 (0.55 to 1.03) | 56378 (3 studies5) | ⊕⊕⊝⊝ low2,3,4 | ||
| 74 per 1000 | 56 per 1000 (41 to 76) | |||||
| Medium risk population1 | ||||||
| 50 per 1000 | 38 per 1000 (28 to 51) | |||||
| Morbidity e.g. fever, diarrhoea, ARI Verbal reports obtained during home visits, record reviews Follow‐up: 4‐33 months | Study population6 | RR 0.86 (0.75 to 0.99) | 17408 (7 studies9) | ⊕⊕⊝⊝ low7,8 | ||
| 398 per 1000 | 342 per 1000 (298 to 394) | |||||
| Low risk population6 | ||||||
| 300 per 1000 | 258 per 1000 (225 to 297) | |||||
| High risk population6 | ||||||
| 540 per 1000 | 464 per 1000 (405 to 535) | |||||
| Neonatal Mortality verbal autopsy Follow‐up: 12 ‐ 24 months | 45 per 1000 | 34 per 1000 (26 to 46) | RR 0.76 (0.57 to 1.02) | 29217 (4 studies12) | ⊕⊕⊝⊝ low10,11 | |
| Morbidity ‐ care seeking practice hospital record review Follow‐up: 12 ‐ 33 months | 131 per 1000 | 174 per 1000 (113 to 269) | RR 1.33 (0.86 to 2.05) | 11195 (3 studies15) | ⊕⊕⊝⊝ low13,14 | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; | ||||||
| GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. | ||||||
1 Median baseline control group risk among included studies. 2 In Pence 2005, only 2 clusters were randomised for this comparison and there were significant baseline imbalances. The quality of evidence was therefore downgraded for limitations in design. None of the 3 trials in this analysis adjusted adequately for clustering in the original report. After the design effect was taken into account, the CIs for the effect estimates were wider than reported in the original papers. 3 In Kidane 2000, cause of death from malaria was obtained from verbal autopsies during a period when measles and chronic wasting were also important health problems. Some of the deaths attributed to malaria may have been due to these other causes. In addition, authors verified only 1/3 of the deaths using a second assessor who was blinded. 4 The quality of evidence was downgraded for imprecision as the pooled estimate of effect included both no effect and appreciable benefit. The imprecision is related to the small number of clusters in Pence 2005 (2 clusters) and Kidane 2000 (24 clusters), giving a design effect of 267,7 and 12.4 for these two studies respectively. 5 Mtango 1986, Kidane 2000, Pence 2005. 6 Selected the next to lowest and next to highest control group risk. 7 For all studies it is not clear whether outcome assessors were blinded or not. The reliance on verbal reporting of outcomes may have introduced reporting bias. 8 There are moderate levels of heterogeneity across these studies (I2=69%, p=0.003) and the confidence intervals do not overlap for all of the studies. The reasons for this heterogeneity are not clear. 9 Chongsuvivatwong 1996, Sripaipan 2002, Manandhar 2004, Sloan 2008, Kumar 2008, Kouyate 2008, Bari 2006 10 There are high levels of heterogeneity across these studies (I2=78%, p=0.003) and the confidence intervals of the studies do not overlap. The effect sizes of the studies range from no effect to a 50% relative reduction. The reasons for this heterogeneity are not clear, but may relate to differences in the length of follow up across the studies (12‐24 months). 11 The quality of evidence was downgraded for imprecision as the pooled estimate of effect included both no effect and appreciable benefit. 12 Baqui 2008, Kumar 2008, Manandhar 2004, Sloan 2008. 13 There are high levels of heterogeneity across these studies (I2=77%, p=0.01) and the confidence intervals have minimal overlap. The reasons for this heterogeneity are not clear, but may relate to differences in the length of follow up across the studies (12‐33 months). 14 The 95% CI includes both no effect and appreciable benefit. 15 Bari 2006, Manandhar 2004, Sloan 2008.