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Meta-Analysis
. 2023 Feb 3:13:04016.
doi: 10.7189/jogh.13.04016.

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: A systematic review and meta-analysis

Ahad Mahmud Khan  1   2 , Saima Sultana  2 , Salahuddin Ahmed  1   2 , Ting Shi  1 , Eric D McCollum  3   4 , Abdullah H Baqui  4 , Steve Cunningham  5 , Harry Campbell  1 ; RESPIRE Collaboration
Affiliations
Meta-Analysis

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: A systematic review and meta-analysis

Ahad Mahmud Khan et al. J Glob Health. .

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. New studies are needed to assess the new generation of health workers.

Registration: PROSPERO (CRD42022306954).

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Conflict of interest statement

Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form 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.

Figures

Figure 1
Figure 1
A child with chest indrawing. Reproduced with permission from World Health Organization.
Figure 2
Figure 2
PRISMA flow diagram; CI – chest indrawing, HW – health worker, RS – reference standard.
Figure 3
Figure 3
Risk of bias and applicability concerns summary: review authors’ judgements about each domain for each included study.
Figure 4
Figure 4
Accuracy of health workers’ chest indrawing identification compared to reference standards. Forest plots of individual and summary estimates of sensitivity and specificity.
See this image and copyright information in PMC

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