Ke

lompok3:

-Ma
riaLe
li
anaPoiLa
gama
kin(
201702020)

-Se
rvusGut
haGa
ni (
201702032)

-Yoha
naAdv
ent
aCi
la (
201702041)

Cr
it
ica
lAppr
ais
alWor
kshe
et:Sys
tema
ticRe
vie
w

J
udulJ
urna
l :Ef
fec
tive
nes
sofs
ola
rdi
sinf
ect
ionwate
rtr
eat
mentmethodf
orr
educ
ingc
hil
dhooddi
arr
hoe
a:a
sys
temat
icrevi
ewandmeta
-ana
lysi
s

1
.Ske
nar
ioKa
sus

Se
ora
ngi
buda
tangkepol
ikl
ini
kme
mba
waa
nakya
ngbe
rna
maAn.S(
10t
ahun)de
nga
nke
luh
ans
uda
h2
h
arime
nga
lamidi
are
.Ke
ada
anumum An.Sl
ema
h,ma
tac uhu370c
owong,s ,na
di88×/
meni
t,t
eka
nanda
rah
1
00/
60mmHg.Ha
linime
nye
babka
nibunyas
anga
tkha
wat
irde
nga
nkondi
sia
naknya
.Ibut
ers
ebutbe
rko
nsu
lta
si
d
enga
npe
rawa
tVme
nge
naia
daka
hca
raya
nge
fekt
ifunt
ukme
nce
gaht
erj
adi
nyadi
arepa
daa
naknya
.Pe
rawa
tV
me
nemuka
njur
nalp
ene
lit
ianba
hwaa
irya
ngd
ide
sinf
eks
ide
nga
nma
taha
rida
patme
nce
gaht
erj
adi
nyadi
arep
ada
a
nak.Pe
rawa
tVke
mudi
anme
nca
rie
vide
nceba
sedt
inj
aua
nsi
st
ema
tikme
nge
naii
nte
rve
nside
sinf
eks
iai
rde
nga
n
ma
taha
ris
ehi
nggada
patme
mbe
rika
ninf
orma
siya
nga
kur
atke
padai
bupa
sie
n.

2
.PI
CO

a
)Pe
rta
nya
anKl
ini
k

Apa
kahde
nga
nme
lakuka
nme
todepe
ngol
aha
nai
rde
sinf
eks
ima
taha
rida
patme
ngur
angidi
areya
ngt
erj
adip
ada
a
nak-
ana
k?

b
)Me
rumus
kanPI
CO

Pa
tie
nt/
popul
ati
on:Ana
k-a
nak

I
nte
rve
nti
on :Me
todepe
ngol
aha
nai
rde
sinf
eks
ima
taha
ri

Compa
rat
ion :Ti
dakd
ila
kuka
nme
todepe
ngol
aha
nai
rde
sinf
eks
ima
taha
ri

Out
came :Pe
nce
gaha
ndi
are

3
.St
rat
egiPe
nca
ria
nDa
tab
ase

a
)Is
ti
lahpe
nca
ria
n

Pe
nca
ria
nar
ti
kela
tauj
urna
lme
ngguna
kan ke
ywor
d ka
takunc
iya
ngdi
guna
kanunt
ukme
mpe
sif
ika
nda
n
me
mpe
rlua
spe
nca
ria
n,s
ehi
nggamuda
hda
lampe
nent
uana
rti
kela
tauj
urna
l.Ka
takunc
iya
ngdi
guna
kana
dal
ah
s
yst
ema
ticr
evi
ewa
ndme
taa
nal
ysi
sofdi
arr
heai
nchi
ldr
enpa
das
it
uspe
nca
ria
nar
ti
kelda
njur
naldiPubMe
d.
b
)Ha
silpe
nca
ria
n

Pe
nca
ria
ninidi
la
kuka
npa
das
it
usPubMe
dde
nga
nka
t is
akunc ys
tema
ticr
evi
ewa
ndme
taa
nal
ysi
sofdi
arr
heai
n
c
hil
dre
n,di
dapa
tka
nha
sils
eba
nya
k125pe
nca
ria
nse
sua
ide
nga
nka
takunc
i.Se
tel
ahme
lakuka
nsc
ree
nin
g
d
enga
nme
ngguna
kanf
il
terya
ngt
ers
edi
apa
das
it
usPubMe
dde
nga
nme
mil
ihpi
li
hanya
ngt
ers
edi
atksf
e reef
ull
t
ext
,ta
hunpubl
ika
si5t
ahun,da
nbe
rba
has
ainggr
is.Ha
sils
cre
eni
ngya
ngdi
temuka
nse
sua
ifi
lt
ers
eba
nya
k20
a
rti
kelj
urna
l,ke
mudi
anka
mime
mba
cas
eti
apj
urna
lda
ndi
dapa
tka
njur
nalya
ngr
ele
vans
esua
ide
nga
ntop
ik
y
angka
miba
hass
ela
njut
nyadi
lakuka
nre
vie
w.

4
.Kr
it
ikJ
urna
l
1)Me
nil
aiva
lid
ita
sint
erna
l
Apa kaht i
njaua ns i
s t
ema tikme nga cupa dape rtanya ant erfokus( PI CO)
Pe rtanya anpe ne l
itianha r uss ecaraj elas Pe tunjuk:I nf orma siiniterdapatpa daba gi
a n
me ngungka pka npo pul as iya ngdi t el
iti
, judul ,ab s
tra k,da npa ragrafakhi rda ri
jenisi nte r
ve ns i
,ke lompokpe mba nding pe nda hulua n
(compa rator),da nha sila khi r(outc ome )
yangdi nil
a i(PI CO) .
Ma ka l
a hini:Ya Tidak TidakJ e
la s
Kome nt ar
:
Pa daba giana bstra kda rit inj
a uans is
te matike fekti
vitasme todepe ngolaha na irde sinfe ksi
ma ta hrida pa tdi ide ntifika sis emuae le me nPI CO.Ba giana bstrakme ma s uka ni nfor ma si
ber i
kut :
“Tuj ua n:unt ukme ngumpul ka nbukt iya ngt e
rse diat e
nta ngke efektifanme todepe ngol a
ha na ir
des infeks ima tahariunt ukme ngur angidi a r
ep adaa nak-ana k”( lihatabs t
ract:
obj ec t
ivesha l.1)
Se laini tupa daj ur nals iste ma ti
ki nij ugame ma suk ani nforma sime nge naiseleks ikrite
riaya itu
Pe ne li
tiani nime ngguna kanr esponde ns emuaa na kya ngt ingga ldima nas ajadiduni at anpa
me ma nda ngj e niske lami n,e tnis,da ns t
a tussosiale konomi .
Be rda sa r
ka ni nfor ma sit e rs
e buts e caraje la
sme nu njukanba hwapopul asipe nelitiannyaa dalah
ana k- anak.I nterv ensi ya ng di lakuka na da l
a h me nggol aha i
rr uma ht a ngga de nga n
me ngguna kande sinf eks ima taha r
i.

Apa kahme ngguna ka npe r

tanya anunt ukme nga rahka npe ncari
anda npe mi l
ihana rt
ikelyang
dima ksudka n?
Kriteri
ai nklusida ne ksklusidide fenisi
ka n Pe t
unj uk:I nfoma siiniterdapatpa dabag i
an
secarajelasda la
mt injauans is
te ma t
ik. me todede nga nde t
ailkrit
eri
ai nklusidan
Kriteri
ake l
ayaka nya ngdi guna kanha rus e kskl usi,terma ksudpe njel
asanme ngenai
me nentuka npa s
ien,i ntervensi,outc ame r
a nca nga npe neli
tian
yangdi cari.Jenisranc anga npe nelit
ian
peneliti
anj ugaa kanme nja
dikompone n
kri
teriake layakan
Ma ka l
ahi ni:Ya Ti dak TidakJ el
as
Kome ntar:
Padat i
njaua ns ist
ema t
iki nipe nul
ist idak me nj el
a s
ka n me ngenaikr iter
iae kskl
usi
penelitiha nyame njelaskanme ngenaikr it
eri
ai nkl usiya it
ut i
ngka tkejadiandi are(berdar
ah,
denga nde hidrasi,di sentri
),ya ngdi definis
ikans e baga ijuml ahe pisodedi are(tigaataulebih
ti
njae ncera taube r
a irselama24j ama tauti
n j
ac airya ngme ngandungda raha ta
ul endir)
.

Apa
kahpe
nca
riha
nda
patme
nemuka
nse
muabukt
iya
ngr
ele
van?
Titi
ka walpe ncar
ian komperehens
ifda n Pet
unjuk:Infor
masiiniterda
patpa d
aba gian
rele
vanme nggunakanda t
abas
ebi bl
iograf
i metode ya ng me ndeskri
psi
kan s t
rat
egi
utama(MEDLI NE,Chohrane,EMBASE) , pe
nc ar
ian,t
ermaks
udpenggunaanis
ti
lah,s
ecara
jugatermaksudpe ncar
ianrefere
nsiya ng de
tail
.
rele
van, mengguna n s
ka ci
encec i
tat
ion
index. , kont ak dengan ahli
, untuk
me nayakan pe nel
it
ian ya ng t i
dak
dipubli
ka s
ikan.Pencar
iantidak di
batas
i
dalam i nf
ormasiyang ber
bahasainggri
s
saja.Strat
egipencar
ianhar
usme masukan
denganba i
ki s
ti
lahMe SH maupuntanpa
katadalamt e
ks
Makal
ahi
ni:Ya Ti
dak Ti
dakJ
elas
Kome ntar:
pa da ba gi
an“ methods”( halama n 1)me nampi l
ka ni nfor ma s
iba hwa s t
rat
egipe nc ar
ian
me nnguna kanda tabaseMe dline/
Pubme d,Sc opus,Googl eSc hola
r ,Coc hra
neLi brary,da n
refre nsikepe ne l
it
ianlai
n.Pe ncarianlit
era t
u rdilakukanpa dabul anDe s
embe r2019.St rat
egi
pe nc ar
iandi lakukans ec
arate rbat
a spadas tudiya ngdi publikasi
ka nda l
a ml i
ter
aturba hasa
inggr is.Pe neliti
ani nij uga me ngguna kan Me nde l
ey De skt
op ya ng di gunakan unt uk
me ngga bungka nhasilpencar
ia nda nunt ukme ngha pusa r
tikeldupl i
kat.Ar t
ikel
-art
ikelya ng
dite muka n oleh pe nca
rian da l
am da taba s
ea kan di eva l
ua siuntuk di ma s
uka n padat iga
tingka tanya it
ube rdasa
rkanjudul ,abstr
a k,d ana khirnyade nga ntekslengkap.Te ksle ngkap
da ris t
udiya ngdipili
hdiambilda ndinila
is eca r
ar i
nc iberdasa r
ka nkrit
e r
iainklus
i.

Suda hka npe ne l

iti
a ndi kajis ecarakriti
s?
Ar tike lha rusme ng ga mba rka nba gaimana Pe tunjuk:Ba gianme t
odeha r
usme ngg a
mba r
ka n
kua litasda rise t
iappe nelit
ianya ngdi ka j
i, kr iteriape nilaiankua li
tasda npe nggunaa n
me ngguna ka nkr it
e riakua litasyangt elah kr iteria.Ba gianha silharusme nye diakan
ditent uka ns e suaid enga nje nispe rt
anya an i nfor ma s
ime nge na iku a
litaspe ne li
tia
npr i
me r
klinis( ya itur andomi sasi,pe nyama ran,da n
kele ngka pant indakl anjutunt ukpe rtanyaan
interve ns i
Ma ka lahi ni:Ya Tida k TidakJ ela
s
Kome nt ar
padaj ur nali niunt ukkua li
ta sme todologispe ne lit
ianda ris tudiya ngme menuhikr i
ter
ias e l
e ksi
dieva kua sis ecarai nde pende nol ehduape nulis( NESda nDOD)me ngguna ka na latrisikobi a
s
Coc hra neya ngdi re visiunt ukuj ic obaa cakya ngdi uraikanda lam BukuPe ga nganCoc hrane
untukt injaua ni nterve nsis istema t
is.Me t
od ei nime ngkl asifi
ka sikanbi asda l
ams tudia cak
seba ga ir enda h,tinggi ,a t
aut idakj elasberda s
a rka na daa taut i
da knyae na mpr os es(pembua tan
urut ana cak,pe nye mbunyi ana lokas i
,me mbut aka npe sertaa t
aupe neli
ti,dataha silya ngt idak
lengka p,pe laporans elekti
fda nbi aslainnya .
)i nidi identifi
ka sibe r
dasarkanbukt iempi risda n
pertimba nga nt eorit
is.Pe r
ingka tunt uks et
ia pkr iteriabia si ndividudi identi
f ika s
ida ndi ba has
dala mupa yaunt ukme ncapa ikons ensus.Se ti
apke tidaksepa ka t
anya ngmunc ula ntar
ape ninjau
dise leks i
ka nme laluidi skus iataukons ultaside nga npe ninjauke ti
ga .

..
dana pakahkuali
ta
snyase c
arake sel
uruhancukup?
Peneli
tianha r
usd i
nil
aisecarai ndependen Pe t
unjuk:Ba gi
an me t
ode h a
rusme nj
ela
skan
ole
h mi nimal2 pr e-
revie.Ke se
luruhan bagaima nape ni
lai
andilakukandanolehsiapa
,
kuali
tasha russedemiki
a nr upas ehingga Ba gi
anha silharusmenyediaka
ntabl
einfor
ma s
i
hasil
nyat i
dakmungki ntimbulbi assepert
it enta
ng kua l
it
asp enel
it
ian dan ke
mun gki
nan
kurang pe ngaca
kana t
aus ubyekt idak deraja
tbi a
s
dis
a markan
Ma kal
a hini:Ya Ti
dak TidakJela
s
Kome ntar:
Tinjauans is
tema t
ikinime li
batkanduape ninj
auinde pendenya ngme nil
ais e
muas tudi
yangdi perolehd arihasilpencarianme nggunakanstrat
egiya ngt el
ahdi t
etapka n.Semua
perbedaanpe ndapatdi s
elesai
kanme l
aluidi
skusiata
ube rkonsultasidenganpeni njauketi
ga.
Duape ninjauindependenme rancangformuli
runtukme ngekstrakda t
a.Apa bi
laa dada t
aya ng
ti
dakj el
as,ma kap e
ninja
ua kanme nghubungipenuli
speneliti
anpr imeruntukkonf ir
ma sil
ebih
la
njut.
Padat i
njauansist
ema t
ikinijugame nampilka
nha si
lta
belringkasa npeninj
aume nge naider
ajat
biasdaripenelit
ianpri
me rinklus
if

Suda
hka
nha
sil
nyadi
si
nte
sisda
nga
nta
belr
ingka
sanda
npl
otya
ngt
epa
t?
Hasi
l pe neli
ti
an mi nimal di
tampi
lkan Petunj
uk:Pe
tunjuk:Bagi
anhasi
lha
rus
dal
am t abelr i
ngkasan. Ji
ka hasi
lnya me nca
kupsemuat a
belri
ngka
sandanpl
ots
ert
a
se
rupa,mungki na daha s
ilmet
a-ana
lisi
s penjel
asa
ndarihasi
l.
dal
ambe ntuk“funnelplot
”
Makala
hi ni:Ya Ti
dak Ti
dakJel
as
Kome nta
r:
Ha s
ilpeneli
ti
aniniditampil
kanda lambe nt
uk“ funnelplot
”untukme mberikannil
aidan
bobotuntuks eti
appe neli
tianprimeri nklus
ifda la
mt i
njauans i
stemat
iki ni.Funne lpl
ot
ter
sebutme wa kil
i me t
a-anal
isi
s pe nel
iti
anp r
ime r untuk me nil
aike efekt
i f
an me t
ode
pengola
hana i
rde s
inf
eksima ta
haridapatme ngura
ngidi ar
eya ngter
jadipa
daa nak- a
nak.Hasi
l
akhirdia nali
sisme nggunakanf unnelpl ot ya ng me nggambarkana danyape ni
ngkat
an
hete
rogenit
asuntukusia<5da n<6t ahunsetel
ahdilakukana na
lis
issubkelompok.

I
nimenunjuk a
nme ta-
anal
is
isinime nunju
kanba hwaa dapenur
unandal
am peningkatan
ri
sikodiar
eda np enel
it
ianyangdi s
erta
kandihomoge nka
npa da6bulanmasatindakl a
njut
di
ba ndi
ngkanden ganyangdii
kutisel
ama3b ul
andan12bul an.Per
beda
andapatdias
ums ikan
bahwat i
daklanjut3bul a
nda r
ii ne
trvens
itidakcukupl a
maunt ukmendapa
tkanpe rubahan
yangs i
gni
fi
kans ecar
akompa r
ati
f.

da
…. na
pake
sama
anha
sila
nta
rpe
nel
it
iant
ers
ebut
?
Ideal
nya,ha si
lpe neli
ti
an yang be r
be da Petunj
uk: Bagia
n ha si
lh arus me nyat
aka
n
harus s er
upa a tau homoge n. J ika apakahhas
il
nyaheter
oge ndanme mba hasal
asa
n
het
e r
ogenit
asnyaa dama kapenul i
sda pat yangmungkin‘ f
ores
tpl ot’
me nunj
ukka n has
il
menghitung apakah per
be da
annya t es Cochran Q unt uk he ter
ogenita
s dan
bermakna ( tes Coc hr
an Q) , Al a
s an me mbaha
salas
anheterogeni
tasnya
ter
jadi
nyaheterog
enita
sha r
usdiekspl
orasi
Ma kal
ahini:Ya Tidak TidakJ e
las
 Kome ntar:
Sebe lum me l
akukanpe ni
la ianpa dahe te
rogenit
asp ene li
time l
akuka ns intesisna rat
ifterl
ebih
dahul u.Ke mudianme l
akuka na nalisisme tade nga nme nggunaka nCompr ehensiveMe t
a-
Ana lysis.Pe neli
time nghi tung95% CIda nni laipduas isiha s
ilnya.He terogenitasdinila
i
me ngguna ka ntheCoc hr a
neX2s t
a ti
stikuji(uji
-Q)da ni ndeksva ri
ant erba i
k.Ni l
aiujistat
ist
ik
berkisarda r
i0% s ampa i100%,di kl
a si
fikasi
kans ebagaibe ri
kut:tidaka dahe terogenita
sya ng
relevan( 0% - 25%),he teroge nit
ass eda ng(25% -50%)da nhe te
roge nitass i
gni fi
kan( >50%) .
Tingka the t
erogenitasya ng t inggidi amatiu ntuk ha sil
nya,da n de nga n de mikian,ka mi
me ngguna kanmode le feka cakunt ukme mperkirakanRR ya ngdi kumpul ka n.Pl othutan
dibua tunt uk me nya j
ikane s
tima siya ng d i
kump ulka n.Da lam pl othut an,ukur ans et
iap
li
ngka r
anme nunjukkanbobotpe neliti
an,sedangka ns eti
apga ri
sbe rs
ilangme ngacupa daCI
95%.Se laini t
u,b e
rlia
nme wa kil
ie fekke sel
uruhan,s edangka nlebarbe r l
ianme nunjukkanCI
untuke fekke s
e l
uruhanya ngdi perkirakan.Ka mime lakukana na l
isiss ubke lompokunt uk
me nye l
idiki ke mu ngkinans umbe r he t
erogeni
tas me ngguna kan pe r
iode t indakl a
njut
pene l
itia
n,us i
ape sert
aya ngdi sertakan,da nwi l
ay a
hpe ngaturan/be nuape nelit
ian.Ada nya
biaspubl ikasidiperi
ksade nga nme ngguna kanc or
ongpl otdanujiEgge r.

Ke
simpul
an:
Be
rda
sar
kanha
silt
ela
h kr
it
ist
erha
dapva
lidi
ta
sint
erna
lda
ria
rti
keli
nima
kada
patdi
si
mpul
kanba
hwaa
rti
kel
t
inj
aua
nsi
st
ema
tiki
nime
mil
ikikua
lit
asya
ngs
anga
tba
ik.
2
)Me
nil
aipe
nti
ngnyaha
silpe
nel
it
ian
Pe
ngukur
ana
paya
ngdi
paka
ida
nse
ber
apabe
sare
fekpe
rla
kua
n
Pengukur a
nya ngd i
guna kan`
Effectsizeyaitup e
rbeda anke ja
diane fe
ka nta
rake lompoke ksperi
me ntalda nke lompok
dalam me ta
-analis
isme rupakane f
fectsizema s
ing-ma s
ings t
udiya ngdi lakuka nde ngan
te
kni ks t
ati
sti
kat ert
entu.Unt ukme nila
is i
gnif
ikana taut i
daknyaha silga bunga n,ki t
a
dapatme li
hat p va lue a tau pos i
siwa j
ik( perhati
kanl ebar wa ji
k/di a
mond ya ng
me nandakani nter
valke percayaan gabungan)pa da forestplot.
Ha s
i la khirt ergolong
si
gnifikanpadako ndisi
-kondi s
ibe r
ikut:pva l
ue<0, 05de nganinte
rvalke pe r
ca yaan95%,
wajikt i
dakme motongga ri
sintervalkeperca
yaansamade ngan1pa dava ri
a belt e
rgantung
nomi naldikotom,wa j
ik/diamond t idakme motongga ri
si nte
rvalke pe rcayaans ama
denga nnolpadava ri
abelt e
rgantungkont i
nyu
Berikutiniadalahanali
sispa dafunnelplot:

Ana l
is
is1: Me t
o depe ngolaha na i
rSODI Sme ngur a
ngidi arepadaa nak-anakda l
am
semuape neli
tiany angdi identi
fikasi
.Se te
lahpe nerapanme todepe ngolahanairSODI S,
ri
sikodiar
epa dama saka nak-kanakbe rkurangsecaras i
gni f
ikanda la
mde la
panpe nelit
ian
dengankisaranRR0, 16-0,70pa daCI95%.Da lamduape nelit
ian,diar
epa dama saka nak-
kanakbe rkurangt etapipe nurunannyat i
da ksignifi
ka ns eca r
as tat
is
tik.Da la
m me ta-
anali
si
sini,kamime ne mukanhe terogenit
asy angsignifi
ka ndis elur
uhstudi(I2=74, 37%,
p=0, 000).RRke seluruhanda ridiar
epa dama saka nak-kana kyangdilaporkanole h10
peneli
ti
anya ngme ngguna kanmode lefeka caka dal
a h0, 62( 95% CI0, 53hingga0, 72).
Halinime nyir
a t
kanba hwae fekdiarebe r
kurangs ecar
as ignifi
ka n(p<0,000)sebesar38%
denganme ngguna kanme t
odepe ngolahana i
rSODI S.

Ana l
is
is2:Tingkatheter
ogeni
tasme nur
uns el
ama3bulanfoll
owupda nti
daka dabukti
heter
ogenit
assel
ama6bul anfoll
owup.Ka mimenemukanRRpe nguranga
ndi a
resebesa
r
39% selama3bula n,35% s
e l
ama6bul and an41% unt
ukfoll
owup12bul an.RRya ng
dikumpulkanuntuks et
iapkelompoka dala
h0, 6
1( 95% CI0,43-
0,86)selama3bul an
ti
ndaklanjut
,0,
65( 95% CI0,48-0,
87)untukti
ndaklanj
ut6bulandan0,59(95% CI0,43
0,
80)s e
lama12b ula
nt i
nda klanj
ut.RRyangdikumpul
kanuntuka nal
isi
ssubkel
ompok
berda
sarka
nus i
apeser
tape nel
it
ianadal
ah0,
59(95% CI0,46hingga0,76)unt
ukus i
a<5
ta
hun,0,56(95% CI0,34-0,92)unt
ukusia<6t
a hundanhanyaa dasat
upe ne
lit
ianpada
kel
ompokus ia5-16dan<3t ahun.Tingka
the
te r
ogeni
tast
inggiuntukusia<5da n<6
ta
huns e
tel
ahanali
si
ssubkelompok.

Anal
isi
s3:RR ya ngdi kumpulkandaripe
ngurang
andiar
es etel
ahpe nerapanme t
ode
pe
ngolahanai
rSODI Sa dalah37% unt
ukpenel
it
iandar
iAfr
ika(RR=0, 63;95% CI0,54
hi
ngga0,74)
,16% untukpe neli
ti
andar
iAme r
ikaLat
in(RR=0, 84;95% CI0, 62menja
di
1,
13)dan52%untukst udidariAsi
a(RR=0,48;95%CI0,36hingga0,63).
Ana l
is i
s4:Ana l
isisme nunj ukkanke ef
ekti
fanme t
odepe ngola hana i
rSODI S unt uk
pence gahandiare.RRya ngdi kumpulkansecarakeseluruhanme nunj
ukka npe ngur anga n
38% di areme la
luime t
odepe ngolahanairSODI S(RR=0, 62;95% CI0, 53hi ngga0, 72).
Kajians istemat
isu ntukme ningka t
kankuali
tasa i
rint
e rvensiuntukme ncegahdia r
es tudi
yangdi l
akukano le hCl asendkkj ugame l
aporkanba hwar is
ikodi a r
ebe r
kurang38%
me ngguna kanSODI S unt uks emuaus i
a( RR = 0, 62,95% CI0, 42-0,94).Ti njaua n
si
stema tistent
angda mpa ki ntervensiai
rminu m,sanit
a si
,da ncuc itangande ngans abun
untukme ngura
ngidi arepa dama sakanak-kanak,di la
kuka nol ehWol fdkk l a por an
me nunjukka npengura nganr isikodiareyanglebihrenda hs e
besar12% ( RR=0. 88;95%
CI0. 60hi ngga1.27).

Berdasarka nha s i
la na li
sada tadi t
e muka nma knada r ikajiansist
ema ti
ki niadalah:
1)Ef ekme todep e ngol ahana irde s infeksima t
a harit er
ha dappe nuruna nterjadinyadi ar
e
padaa na k-ana k
a. Pva lues ignifika ns ec
a rastatistikka r
enani l
a iCIt idakme mot ongni lai1
b.Ri s kRa t
io( RR)0 ,
88( 95% CI0, 60-
1,27) ,RR <1ya ngme nunjukkanba hwa
me todepe ngol a hana irSODI Sda patme ngur angir i
sikodiareya ngbe s a
r .
c. Pe nur una n ke jadian di are ya ng s i
gni fi
ka ns ecaras t
ati
stik di ama tide ngan
pengur anga nr isiko 33% a r
tinya terdapa t33 ke j
adianl ebihs edikitda lam
kelompokpe r
la kuanda ripa dake l
omp okk on t
rolya ngme nga l
a mike jadiandiare,
sehi nggada pa tdi si
mpul ka nARRda l
amout ca mei niadalah33%.
d.Numbe rNe edt oTr eattoBe ne fit(NNTB)12( 384-502)a rt
inya12or angtuaanak-
ana kya ngme lakuka nme todepe ngolahana irde sinfeksima t
a ha r
i,pali
ngs edi
kit1
ora ngya nga ka nme nga l
a midi a
re
2)Efekme todepe ngol aha na i
rde sinfeksima taharis eca radigit
alte rhadapi nsidendi ar
e
padaa na k-ana k
a. Pva lues ignifika ns ecarasta t
istikka r
enani laiCIt idakme motongni l
ai1
b.RR0, 62( 95%CI0, 42-0, 94),RR<1me nunj ukka nba hwape r
la kuanme nurunkan
inside ndi arepa daa nak

c.Pe nggu naana i

rSODI Sda patmenurunkan38% ke jadiandi
area rti
nyater
dapat38
kej
adianl e bi
hs ediki
tdalamke l
ompokp er
l a
k uanda r
ipa dakelompokkontrolyang
menda patka npe nggunaana i
rSODI S,s ehinggada pa tdis
impul kanARR da lam
outc
omei nia dal
a h38%.
d.Numbe rNe edt oTr eattoBe nef
it(NNTB) :6( 98- 100)a r
tinyaorangt
uaya ng
melaku kanme t
odepe nggunaanai
rSODI S,ha nya1ya ngaka
nme ngala
midiare
.
Sedangkanpa daout c
a meya ngl ai
nt i
dakme nu njukanpe r
bedaani nsi
denpe nur
unan
outcamea ntarak el
ompokkont roldankelompo kpe r
lakuka nsehinggat i
dakdihit
ung
ma knadariha s
ilnya.
 Open access
To cite: Soboksa NE, Gari SR,
Hailu AB, et al. Effectiveness
of solar disinfection water
treatment method for
reducing childhood diarrhoea:
a systematic review and
meta-­analysis. BMJ Open
2020;10:e038255. doi:10.1136/
bmjopen-2020-038255
►► Prepublication history and
additional material for this paper
is available online. To view these
files, please visit the journal
online (http://​dx.​doi.​org/​10.​
1136/​bmjopen-​2020-​038255).
Received 05 March 2020
Revised 07 November 2020
Accepted 19 November 2020
© Author(s) (or their
employer(s)) 2020. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
1
Ethiopian Institute of Water
Resources, Addis Ababa
University, Addis Ababa, Ethiopia
2 determine whether solar disinfection water treatment is an
College of Public Health and
Medical Sciences, Jimma
University, Jimma, Ethiopia
3
College of Health and Medical
Sciences, Haramaya University,
Harar, Ethiopia
Correspondence to
Mr Negasa Eshete Soboksa;
​yeroosaa@​gmail.​com
Effectiveness of solar disinfection water
treatment method for reducing
childhood diarrhoea: a systematic
review and meta-­analysis
Negasa Eshete Soboksa  ‍ ‍,1 Sirak Robele Gari,1 Abebe Beyene Hailu,2
Dereje Oljira Donacho,2 Bezatu Mengistie Alemu3
ABSTRACT
Objective  This study aimed to pool out the available
evidence on the effectiveness of the solar disinfection
water treatment method for reducing childhood diarrhoea.
Design  Systematic review and meta-­analysis.
Setting  Global.
Methods  Searches were conducted in Medline/PubMed,
Scopus, Google Scholar, Cochrane Library databases
and references to other studies. The review included
all children living anywhere in the world regardless of
sex, ethnicity and socioeconomic status published in
English until December 2019. Studies that compared the
diarrhoea incidence between the intervention group who
were exposed to solar disinfection water treatment and
the control group who were not exposed to such water
treatment were included. The outcome of interest was the
change in observed diarrhoea incidence and the risk from
baseline to postintervention. Two independent reviewers
critically appraised the selected studies. Effect sizes
were expressed as risk ratios, and their 95% CIs were
calculated for analysis.
Results  We identified 10 eligible studies conducted in
Africa, Latin America and Asia that included 5795 children
aged from 1 to 15 years. In all identified studies, solar
disinfection reduced the risk of diarrhoea in children,
and the effect was statistically significant in eight of the
studies. The estimated pooled risk ratio of childhood
diarrhoea among participants that used the solar
disinfection water treatment method was 0.62 (95% CI
0.53 to 0.72). The overall pooled results indicated that
the intervention of solar disinfection water treatment had
reduced the risk of childhood diarrhoea by 38%.
Conclusions  The intervention of solar disinfection water
treatment significantly reduced the risk of childhood
diarrhoea. However, the risk of bias and marked
heterogeneity of the included studies precluded definitive
conclusions. Further high-­quality studies are needed to
important method to reduce childhood diarrhoea.
PROSPERO registration number  CRD42020159243
INTRODUCTION
Diarrhoea is the second leading cause of
death in children under 5 years of age, and
an estimated 2.5 billion cases of diarrhoea
Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255
Original research
Strengths and limitations of this study
►► Study selection, data extraction and quality assess-
ment were independently performed by two review
authors.
►► This review was the first meta-­ analysis done on
solar disinfection, water treatment methods and the
risk of childhood diarrhoea.
►► The limitations of this study were, we tried to in-
clude only published articles, excluding unpublished
articles/resources and restrictions to studies written
in English.
occur and are responsible for killing around
760 000 children every year. More than half
of these cases are in Africa and South Asia,
where the attacks of the diseases are more
likely to result in death or other severe
outcomes.1 This diarrhoea-­ related death in
low-­income andmiddle-­ income countries is
mostly attributable to inadequate water, sani-
tation and hygiene.2 The deaths of 279 000
children aged under 5 each year could be
avoided if the risk factors were addressed.3
Previous systematic review findings suggest
that point-­of-­use water treatment is one of the
most effective strategies to reduce diarrhoea
among children under 5 years of age.4–7
The importance of household water treat-
ment and safe storage (HWTS) in reducing
diarrhoeal disease has been increasingly
recognised.8 9 Solar disinfection (SODIS)
method is recognised as one viable HWTS
option.10 It is the simplest, cheapest tech-
nology, and effective water treatment method
that applies to emergencies, especially when
no chemical disinfectants are available.11
The method relies on disposable transparent
plastic or glass containers which are then
exposed to the sun and its germicidal effect
is based on the combined effect of thermal
heating of solar light and UV radiation.12–14
1
Open access
Since SODIS is simple to use and inexpensive, the method
has spread throughout the low-­ income andmiddle-­
income world and is in daily use in >50 countries in Asia,
Latin America and Africa. More than 5 million people
disinfect their drinking water with the SODIS technique
as the report of a systematic review.14
SODIS has been repeatedly shown to be effective for
eliminating microbial pathogens and reducing diarrhoea
morbidity, but its effectiveness is limited to waters of low
turbidity.12 15 Earlier cluster-­randomised controlled trial
studies showed that the SODIS of drinking water reduced
diarrhoea among under-5 children.16–18 A matched case-­
control study done in India also concludes that SODIS
of water can significantly decrease diarrhoea morbidity
in children.19 Other study findings reported from Kenya
showed that children drinking solar disinfected water had
a significantly lower risk of severe diarrhoeal disease over
8705 2 weekly follow-­up visits; the 2 weeks prevalence of
diarrhoea in the intervention group was 48.8% compared
with 58.1% in controls, corresponding to an attributable
fraction of 16.0%.17 Studies reported from Bolivia and
Peru showed that there was no statistically significant
difference in the number of diarrhoea episodes between
the SODIS and control arms of the study.18 20
Other studies showed that SODIS was essential among
household water treatment and safe storage for the
reduction of diarrhoea. However, the reported findings
revealed heterogeneous outcomes. More importantly, a
systematic review and meta-­analysis have not been done
to pool the evidence of the effectiveness of the SODIS
water treatment method for reducing diarrhoea. There-
fore, the objective of this review was to pool out the avail-
able evidence on the effectiveness of the SODIS water
treatment method for reducing diarrhoea. The research
question of this review was ‘Does solar disinfection water
treatment method improve the microbial quality of
drinking water and reduce childhood diarrhoea?’
METHODS
Protocol development
This systematic review and meta-­analysis has been written
following the Preferred Reporting Items for System-
atic Review and Meta-­ analysis (PRISMA) statement
guidelines21 (see online supplemental file 1). Before
undertaking the review, we registered the protocol in
PROSPERO (CRD42020159243) and the detail of this
systematic review and meta-­analysis protocol has been
published elsewhere.22
Data sources and search strategy
An electronic database search was carried out to identify
appropriate peer-­reviewed articles that met the inclusion
criteria. We searched PubMed/Medline, Scopus, Google
Scholar, Cochrane Library databases and references to
other studies. We used a combination of Medical Subject
Heading terms and keywords terms: (solar energy OR
sunlight) AND (water disinfection OR water purification
2 Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255
OR water treatment) AND (diarrhea OR diarrhoea OR
dysentery) AND (children OR child OR childhood). The
search of the literature was conducted in December 2019.
The search strategy was limited to studies published in
English language literature (see online supplemental file
2: full search strategy for PubMed/Medline and Cochrane
library databases). The results of the search and the full
process for selecting included the studies were reported
and presented in a PRISMA flow diagram.23
Criteria for considering studies for this review
Studies that met the following criteria were included in
this review.
Types of studies
We included only randomised controlled trials studies
that assessed the effectiveness of the SODIS water treat-
ment methods for reducing diarrhoea and published in
English until December 2019.
Participants
The review included all children living anywhere in the
world regardless of sex, ethnicity and socioeconomic
status.
Interventions and comparator
This review considered studies that evaluated the effec-
tiveness of SODIS as a water treatment method for the
reduction of diarrhoea. Studies that compared the diar-
rhoea occurrence among the intervention group chil-
dren who were exposed to SODIS water treatment and
control group children who were not exposed to such
water treatment were considered.
Types of outcome measures
This review considered studies that included the inci-
dence rates of diarrhoea (non-­bloody, with dehydration,
dysentery), defined as the number of diarrhoea (three or
more loose or watery stools during 24 hours or any loose
stool that contained blood or mucus) episodes per child
per year obtained from a daily assessment of the individual
diarrhoea occurrence. The primary outcome of this study
was the change observed in diarrhoea incidence after
SODIS was applied for the treatment of drinking water.
Data collection and analysis
Data management and selection of studies
Mendeley Desktop reference management software
V.1.19.5 (Mendeley, Elsevier, The Netherlands) was used
to combine search results and to remove duplicate articles.
Two independent reviewers (NES and DOD) conducted
the screening of included studies. The articles found by
searches in databases were evaluated for inclusion at three
levels, that is, by title, then by abstract and finally by full
text. The full text of selected studies was retrieved and
assessed in detail against the inclusion criteria. Discrepan-
cies were discussed between reviewers and agreement was
reached about whether to include the study or not. For the
screening of articles at the full-­text level, rejection of an

article was decided by the review team on the suggestion
of the first reader. The details regarding the final decision
of inclusion of articles were clarified and archived in a
database. In case of uncertainty in the decision, whether
to include the study or not, the reviewer included this
article for the next level of screening. The documents
without abstracts were screened at the full-­text level. A list
of articles excluded at the full-­text level was provided in the
systematic review, accompanied by reasons for exclusion.
Data extraction
The data were extracted from studies included in the
review using the prepared data extraction tool form
by two independent review authors (NES and DOD).
For each study, the authors’ name, place and year of
publication, data on sample size and characteristics,
characteristics of interventions performed, results
of included studies, and follow-­up of the study were
extracted. The data extraction form was pretested
with three randomised controlled trials similar to
those eligible in this review. Any disagreements that
arise between the reviewers were resolved through
discussion or with a third reviewer (BMA).
Risk of bias of included studies
The methodological quality of the studies that met the
selection criteria were evaluated independently by two
authors (NES and DOD) using the revised Cochrane
risk-­o f-­b ias tool for randomised trials outlined in the
Cochrane Handbook for Systematic Reviews of Inter-
ventions.24 This method classifies bias in randomised
studies as ‘low’, ‘high’ or ‘unclear’ based on the pres-
ence or absence of six processes (random sequence
generation, allocation concealment, blinding partic-
ipants or investigators, incomplete outcome data,
selective reporting and other biases). These were
identified based on both empirical evidence and theo-
retical considerations. The rating for each bias crite-
rion of the two authors was compared. Disagreements
between the two authors on individual bias criteria
were identified and discussed in an attempt to reach
a consensus. Any disagreements that arose between
the reviewers were resolved through discussion or in
consultation with a third reviewer.
Measures of treatment effect
It is expected that SODIS water treatment intervention
reduces the risk of diarrhoea, and we used the risk ratio
(RR). RR was estimated by using the following data: the
number of participants who experienced diarrhoea and
the total number of participants in each group. RR <1
indicated that SODIS water treatment results in a greater
chance of decreasing diarrhoea.
Dealing with missing data
We contacted the authors for missing data and clarity of
primary studies if required; such inclusions were reported
in the review.
Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255
Open access
Data synthesis and assessment of heterogeneity
We conducted a narrative synthesis first to describe the
study details, participant and intervention characteristics
and outcomes of the included studies. Then meta-­analysis
was conducted using Comprehensive Meta-­Analysis V.3.3
(Biostat, USA). We calculated 95% CIs and two-­sided p
values for the outcome. Heterogeneity was assessed using
the Cochrane χ2 test (Q-­test) statistics and inverse variance
index (I2) statistics. An I2 value, a measure that ranges from
0% to 100%, was classified as follows: no relevant hetero-
geneity (0%–25%), moderate heterogeneity (25%–50%)
and significant heterogeneity (>50%).25 A high degree of
heterogeneity was observed for the outcome, and thus, we
used a random-­effects model to estimate the pooled RR.
Forest plots were generated to present the pooled esti-
mates. In the forest plot, the size of each circle revealed
the weight of the study, while each crossed line refers to
a 95% CI. Moreover, the diamond represents the overall
effect, whereas the width of the diamond shows the CIs
for the overall effect estimated. We performed subgroup
analyses to investigate the possible sources of heteroge-
neity using follow-­up periods of the studies, the age of the
included participants and the region of study settings/
continent. The presence of publication bias was exam-
ined using a funnel plot and Egger’s test. A sensitivity
analysis was repeated 10 times after excluding one study
using a random-­effects model to observe the impact of
the individual study on the overall RR.
Patient and public involvement
No patient involved.
RESULTS
Study selection
The search strategy resulted in 1678 records from elec-
tronic databases and hand searches. Out of these records,
we identified 1527 records after duplicates removed. After
reviewing the titles/abstracts, 1482 records were excluded
and 45 full-­text articles assessed for eligibility. Of the 45
articles selected for potential eligibility, 32 were excluded
as they did not relate to our study question. The other
three articles were excluded due to their study design
and study participants.26–28 A list of articles excluded at
the full-­text level and reasons for exclusion are illustrated
in online supplemental file 3. The remaining 10 studies
were included in the present systematic review and meta-­
analysis16–20 29–33 (figure 1).
Study characteristics
Table 1 summarises the characteristics of the studies
included in this meta-­analysis. All the included studies
were intervention-­ based studies that were conducted
from 1996 to 2018 in seven low-­ income andmiddle-­
income countries. Among the 10 studies, 6 studies were
conducted in Africa,16 17 29–32 2 studies were conducted
in Latin America18 20 and the remaining 2 studies
3
Open access
Figure 1  Flow diagram of included relevance studies identified by the systematic search strategy. RCT, randomised controlled
trial; SODIS, solar disinfection.
were conducted in Asia.19 33 Regarding the included
studies setting, seven studies were conducted in a rural
area.16–18 20 30–33 The total study participants were 5795
children aged 1–15 years live in households using SODIS
and no intervention (table 1).
Risk of bias in individual studies
Risk of bias assessment is presented in figure 2. Based on
the results of the study’s risk of bias assessment, we have
judged seven studies as having a low risk, two studies were
judged as having some concerns and the remaining one
study was judged as having a higher risk of bias (figure 2).
Childhood diarrhoea
SODIS water treatment method reduced diarrhoea in chil-
dren in all studies identified. After the implementation of
the SODIS water treatment method, the risk of childhood
diarrhoea was significantly reduced in eight studies with
a RR range of 0.16–0.70 at 95% CI. In two studies, child-
hood diarrhoea was reduced but the reduction was not
statistically significant. In this meta-­analysis, we found a
significant heterogeneity across the studies (I2=74.37%,
p=0.000). As presented in figure 3, the overall pooled RR
of childhood diarrhoea reported by the 10 studies using
4 Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255
the random-­effects model was 0.62 (95% CI 0.53 to 0.72).
These imply that the effect of diarrhoea was significantly
(p<0.000) reduced by 38% using the SODIS water treat-
ment method (figure 3).
Subgroup analysis
The results from subgroup analysis are summarised in
figures 4–6. In the figures, the presence of heterogeneity
was assessed by subgroup analysis. In figure 4, the level
of heterogeneity was decreased for 3 months follow-­up
and there is no evidence of heterogeneity for 6 months
follow-­up. We found a RR of diarrhoea reduction by 39%
for 3 months, 35% for 6 months and 41% for 12 months
follow-­up. The pooled RRs for each group were 0.61 (95%
CI 0.43 to 0.86) for 3 months follow-­up, 0.65 (95% CI 0.48
to 0.87) for 6 months follow-­up and 0.59 (95% CI 0.43 to
0.80) for 12 months follow-­up (figure 4). The pooled RRs
for the subgroup analysis based on the age of study partic-
ipants were 0.59 (95% CI 0.46 to 0.76) for age <5 years,
0.56 (95% CI 0.34 to 0.92) for age <6 years and there was
only one study in the 5–16 and <3 years age groups. In
figure 5, the level of heterogeneity was high for ages <5
and <6 years after subgroup analysis (figure 5). Moreover,
 Table 1  Detailed characteristics of study populations
Number of participants
Follow-­up
enrolled in the trail
Study setting, Age groups periods Effect size (95%
Study country Intervention Control (years) (months) Intervention CI) Study design Findings
16
Bitew et al Rural, Ethiopia 384 394 <5 6 POU, solar 0.60 (0.52 to 0.70) Community-­based High risk for faecal contamination of
treatment cluster randomised drinking water was brought to low-­
controlled trial risk levels.
The incidence of diarrhoea was
reduced in the intervention group
compared with the control.
Conroy et al31 Rural, Kenya 155 144 <6 3 POU, solar 0.16 (0.05 to 0.52) Household The odds of having cholera was
treatment randomised reduced in the intervention group
controlled trial compared with controls.
Conroy et al32 Rural, Kenya 108 98 5–16 3 POU, solar 0.66 (0.50 to 0.87) Household Solar treatment of drinking water
treatment randomised was associated with a reduction in
controlled trial all diarrhoea episodes.
Conroy et al17 Rural, Kenya 175 174 <6 3 POU, solar 0.69 (0.63 to 0.75) Household The odds of having childhood
treatment randomised diarrhoea was significantly reduced
controlled trial among children using solar
disinfected water.
du Preez et al30 Mixed, Kenya 555 534 <5 6 POU, solar 0.70 (0.59 to 0.84) Household Escherichia coli concentrations did

Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255

treatment randomised not differ over the follow-­up period
controlled trial between control and intervention
households. However, E. coli
concentrations in SODIS bottles
were significantly lower than those in
storage containers.
IRR for both number of days
and episodes of dysentery and
non-­dysentery diarrhoea were
significantly (p<0.001) reduced by
use of SODIS.
Du Preez et al29 Peri-­urban, 383 335 <5 12 POU, solar 0.36 (0.16 to 0.81) Unblinded No significant difference in
South Africa treatment randomised geometric mean values of
controlled trial thermotolerant coliforms per 100 mL
of water between intervention and
control.
Dysentery was significantly reduced
only in households with higher
motivation showing but not for non-­
dysentery.
Mäusezahl et Rural, Bolivia 376 349 <5 12 POU, solar 0.91 (0.64 to 1.30) Cluster randomised No strong evidence for a practical
al18 treatment, controlled trial reduction in diarrhoea was observed
hygiene among children in the intervention
education groups.

Continued
Open access

5
6
Open access

Table 1  Continued
Number of participants
Follow-­up
enrolled in the trail
Study setting, Age groups periods Effect size (95%
Study country Intervention Control (years) (months) Intervention CI) Study design Findings
McGuigan et Rural, Cambodia 426 502 <5 12 POU, solar 0.37 (0.29 to 0.48) Randomised Significant difference in faecal
al33 treatment controlled trial coliform levels was observed
between intervention and controls
(48 CFU per 100 mL in the control
and 6.8 CFU per 100 mL in the
SODIS group).
The childhood incidence of
dysentery and incidence of non-­
dysentery diarrhoea were reduced
among the intervention group.
Rose et al19 Urban, India 100 100 <5 6 POU, solar 0.64 (0.48 to 0.86) Randomised The risk of diarrhoea was reduced
treatment, controlled trial by using SODIS.
health
education
Hartinger et al20 Rural, Peru 250 253 <3 12 POU, solar 0.78 (0.58 to 1.05) Village level cluster The E. coli geometric mean
treatment, randomised trial observed was declined both in
hygiene intervention and control households
education The odds of developing diarrhoea
were decreased in the intervention
group.

POU, Point-­of-­use; SODIS, solar disinfection.

Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255


Figure 2  Tabular representation of risk of bias in individual studies.
subgroup analysis was computed based on the region of
study settings/continent and presented in figure 6. In the
analysis, there is no evidence of heterogeneity for studies
from Latin America. The pooled RR of diarrhoea reduc-
tion after implementation of the SODIS water treatment
method was 37% for studies from Africa (RR=0.63; 95%
CI 0.54 to 0.74), 16% for studies from Latin America
(RR=0.84; 95% CI 0.62 to 1.13) and 52% for studies from
Asia (RR=0.48; 95% CI 0.36 to 0.63) (figure 6).
Figure 3  Forest plot showing pooled risk ratio and corresponding 95% CIs of solar disinfection water treatment to reduce
childhood diarrhoea.
Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255
Open access
Sensitivity analysis
To identify a single study influence on the overall analysis,
a sensitivity analysis was computed using a random-­effects
model and the results showed that there is evidence for
the effect of a single study on the overall meta-­analysis.
In table 2, the absence of a study done by McGuigan et
al33 slightly increased the overall RR to estimate the effec-
tiveness of SODIS on the reduction of childhood diar-
rhoea. After removing the study by McGuigan et al, the
7
Open access

Figure 4  Forest plot showing subgroup analysis: comparing by the length of the follow-­up period in months.

overall pooled RR is slightly increased (0.67 (95% CI 0.60 DISCUSSION

to 0.75)) and there is no heterogeneity across studies. A
statistically significant reduction of diarrhoea occurrence
was observed with a risk reduction of 33% after the study
by McGuigan et al33 was removed (table 2).
Publication bias
Funnel plot and Egger’s statistical test at 95% CI were used
to examine the presence of publication bias. The funnel
plot was asymmetrical when visually inspected. The likeli-
hood of this funnel plot asymmetry may be related to true
heterogeneity or poor methodological quality that led in
smaller studies to spuriously inflated effects (figure 7).
However, the Egger’s test was not statistically significant at
a p value of 0.13. This indicated that there was no statis-
tical evidence of publication bias.
The analysis demonstrates the effectiveness of the SODIS
water treatment method for the prevention of diarrhoea.
The overall pooled RR indicated a 38% reduction of
diarrhoea through SODIS water treatment methods
(RR=0.62; 95% CI 0.53 to 0.72). A systematic review of
improving water quality intervention for preventing diar-
rhoea study done by Clasen et al also reported that the risk
of diarrhoea was reduced by 38% using SODIS for all ages
(RR=0.62, 95% CI 0.42 to 0.94).34 A systematic review of
the impact of drinking water, sanitation and handwashing
with soap interventions to reduce childhood diarrhoea,
done by Wolf et al report showed a lower reduction of
diarrhoeal risk of 12% (RR=0.88; 95% CI 0.60 to 1.27)
after adjusting for non-­binding using the point-­ of-­
use

Figure 5  Forest plot showing subgroup analysis: comparing by age of study participants.

8 Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255

 Open access

Figure 6  Forest plot showing subgroup analysis: comparing by the region of study settings.

solar treatment for the community depending on the
unimproved source.35
A systematic review of improving water quality interven-
tion for preventing diarrhoea study done by Clasen et al
also reported that the risk of diarrhoea among children
aged <5 years of age was reduced by 45% using point-­of-­use
SODIS.34 A review of point-­of-­use drinking water filtration
done by Sobsey et al also reported that SODIS treatment
significantly decreased diarrhoeal disease in children in
Africa and India, with reductions of 26%–37%.36 Simi-
larly, in our study subgroup analysis of children aged <5
years of age, the risk of diarrhoea was reduced by 41%
using the SODIS water treatment method. The simi-
larity of the results might be the overlap of the included
studies, that is, 6 out of 10 studies included in the pooled
estimate calculated by Clasen et al were also included in
this analysis.17 18 29 30 32 33
The results of our meta-­analysis are nearly consistent
with a systematic review of water, sanitation and hygiene
interventions to reduce diarrhoea in low-­income coun-
tries, done by Fewtrell et al, where a pooled effect for house-
hold water treatment only improved the risk of diarrhoea
by 35%.6 However, this study finding showed a stronger
effect of SODIS than the pooled meta-­analysis results of
the study done to demonstrate the effect of point-­of-­use
chlorine treatment on child diarrhoea, which indicated
the effect of diarrhoea was reduced by 29% after the
intervention.37 Our study findings also showed a stronger
effect of SODIS than other methods of water disinfection
reports which showed point-­ of-­
use chlorine treatment

Table 2  Sensitivity analysis of the effectiveness of SODIS water treatment method for the reduction of childhood diarrhoea
Article removed in the Number of studies Random-­effects pooled
analysis included risk ratio (95% CI) Q-­value Q-­test p value I2 (%)
Bitew et al (2018) 9 0.62 (0.52 to 0.74) 33.69 <0.0001 76.26
Conroy et al (1996) 9 0.61 (0.52 to 0.73) 35.10 <0.0001 77.21
Conroy et al (1999) 9 0.60 (0.49 to 0.73) 31.87 <0.0001 74.89
Conroy et al (2001) 9 0.63 (0.55 to 0.73) 29.75 <0.0001 73.11
du Preez et al (2011) 9 0.61 (0.51 to 0.72) 34.39 <0.0001 76.74
Du Preez et al (2010) 9 0.63 (0.54 to 0.73) 33.04 <0.0001 75.79
Mäusezahl et al (2009) 9 0.59 (0.51 to 0.70) 31.59 <0.0001 74.67
McGuigan et al (2011) 9 0.67 (0.60 to 0.75) 14.55 0.0690 45.01
Rose et al (2006) 9 0.62 (0.52 to 0.73) 35.09 <0.0001 77.21
Hartinger et al (2016) 9 0.60 (0.51 to 0.71) 33.63 <0.0001 76.21
SODIS, solar disinfection.

Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255 9

Open access
Figure 7  Funnel plot of studies included in the analysis of the effectiveness of solar disinfection on the reduction of childhood
diarrhoea.
to have reduced the risk of diarrhoea by 9% among the
community using the unimproved source water supply.35
The discrepancy could be due to the difference in the
study sample size or the length of the follow-­up period of
the interventions or study design.
However, compared with a review of point-­ of-­
use
drinking water filtration done by Sobsey et al where the
risk of diarrhoea reduced by 46%–63% using different
types of filtration drinking water treatment methods,36
our finding was less. A systematic review and meta-­analysis
done by Cohen and Colford showed boiling the drinking
water before consumption also affects childhood diar-
rhoea.38 Our findings are also consistent with these
results, although a direct comparison is difficult because
they report results ranked by the measure of ORs rather
than the RRs.
The evidence from this meta-­analysis shows that there
is a reduction in improvement in the risk of diarrhoea
and the studies included were homogenised at 6 months
follow-­up compared16 19 30 with those followed for 3
months and 12 months.17 18 20 29 31–33 The difference could
be assumed that the 3 months follow-­up of the inter-
ventions was not long enough to get any great signifi-
cant changes comparatively. The use of SODIS for water
treatment has a limitation as it requires safe storage after
disinfection since the intervention provides no residual
disinfectant.38 39 Similarly, in the 12 months of follow-­up,
the motivation of participants for safe storage might be
lowered over time.
This meta-­analysis has some limitations. First, we tried
to include only published articles, excluding unpublished
articles/resources. The restriction to studies written in
the English language was another limitation of this meta-­
analysis. In addition, the differences in the study settings
10
(urban or rural) or the environments under which the
intervention was carried out were also a limitation of this
study. The other limitation of this analysis was that we
used a limited number of studies.
In conclusion, the results of this systematic review and
meta-­analysis showed that the intervention of SODIS water
treatment had significantly reduced the risk of childhood
diarrhoea. There was some bias, but after sensitivity anal-
ysis, the effect was still apparent. The exclusion of one
study reduced the heterogeneity. Further high-­ quality
studies are needed to definitively determine whether
SODIS water treatment is an important method to reduce
childhood diarrhoea. Our meta-­analysis will need to be
updated as the results of future studies become available.
Acknowledgements  The authors would like to thank the authors of the studies
they used to conduct this study.
Contributors  NES developed the research question, methods and wrote the first
draft of the manuscript. NES, BMA, SRG, ABH and DOD assisted with the analysis
and interpretation of the data and critically reviewed the manuscript. All authors
have read and approved the final manuscript.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data availability statement  Data are available on reasonable request. Not
applicable.
Supplemental material  This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255

terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
ORCID iD
Negasa Eshete Soboksa http://​orcid.​org/​0000-​0003-​3451-​175X
REFERENCES
1 UNICEF/ WHO. Diarrhea: why children are still dying and what can be
done, 2009.
2 Prüss-­Ustün A, Bartram J, Clasen T, et al. Burden of disease from
inadequate water, sanitation and hygiene in low- and middle-­income
settings: a retrospective analysis of data from 145 countries. Trop
Med Int Health 2014;19:894–905.
3 WHO. Drinking-­Water. Geneva, Switzerland: WHO, 2019. https://
www.​who.​int/​news-​room/​fact-​sheets/​detail/​drinking-​water
4 Semenza JC, Roberts L, Henderson A, et al. Water distribution
system and diarrheal disease transmission: a case study in
Uzbekistan. Am J Trop Med Hyg 1998;59:941–6.
5 Waddington H, Snilstveit B, White H, et al. Water, sanitation, and
hygiene interventions to combat childhood diarrhoea in developing
countries. International Initiative for Impact Evaluation 2009;2014
https://www.​researchgate.​net/​publication/​228378510
6 Fewtrell L, Kaufmann RB, Kay D, et al. Water, sanitation, and
hygiene interventions to reduce diarrhoea in less developed
countries: a systematic review and meta-­analysis. Lancet Infect Dis
2005;5:42–52.
7 Clasen T, Schmidt W-­P, Rabie T, et al. Interventions to improve
water quality for preventing diarrhoea: systematic review and meta-­
analysis. BMJ 2007;334:782–10.
8 Schmidt W-­P, Cairncross S. Household water treatment in poor
populations: is there enough evidence for scaling up now? Environ
Sci Technol 2009;43:986–92.
9 Clasen TF, Cairncross S. Household water management: Refining the
dominant paradigm. Trop Med Int Health 2004;9:187–91.
10 Luzi S, Tobler M, Suter F. Sandec: Sanitation, Water, and Solid Waste
for Development SODIS manual, 2016. Available: www.​sodis.​ch
11 World Health Organization. Water treatment at the household level
and on a large scale, 2016. World Health Organization. Available:
https://www.​who.​int/​water_​sanitation_​health/​emergencies/​qa/​
emergencies_​qa16/​en/ [Accessed June 1, 2019].
12 McGuigan KG, Joyce TM, Conroy RM, et al. Solar disinfection of
drinking water contained in transparent plastic bottles: characterizing
the bacterial inactivation process. J Appl Microbiol 1998;84:1138–48.
doi:10.1046/j.1365-2672.1998.00455.x
13 Wegelin M, Canonica S, Mechsner K, et al. Solar water disinfection :
scope of the process and analysis of radiation experiments. Journal
of Water Supply Research and Technology 1994:43–169 http://www.​
irc.​nl/​docsearch/​title/​107952
14 McGuigan KG, Conroy RM, Mosler H-­J, et al. Solar water disinfection
(SODIS): a review from bench-­top to roof-­top. J Hazard Mater
2012;235-236:29–46.
15 Dawney B, Cheng C, Winkler R, et al. Evaluating the geographic
viability of the solar water disinfection (SODIS) method by decreasing
turbidity with NaCl: a case study of South Sudan. Appl Clay Sci
2014;99:194–200.
16 Bitew BD, Gete YK, Biks GA, et al. The effect of SODIS water
treatment intervention at the household level in reducing diarrheal
incidence among children under 5 years of age: a cluster randomized
controlled trial in Dabat district, Northwest Ethiopia. Trials
2018;19:1–15.
17 Conroy RM, Meegan ME, Joyce T, et al. Solar disinfection of
water reduces diarrhoeal disease: an update. Arch Dis Child
1999;81:337–8.
18 Mäusezahl D, Christen A, Pacheco GD, et al. Solar drinking water
disinfection (SODIS) to reduce childhood diarrhoea in rural Bolivia: a
cluster-­randomized, controlled trial. PLoS Med 2009;6:e1000125–13.
Soboksa NE, et al. BMJ Open 2020;10:e038255. doi:10.1136/bmjopen-2020-038255
Open access
19 Rose A, Roy S, Abraham V, et al. Solar disinfection of water
for diarrhoeal prevention in southern India. Arch Dis Child
2006;91:139–41.
20 Hartinger SM, Lanata CF, Hattendorf J, et al. Improving household
air, drinking water and hygiene in rural Peru: a community-­
randomized-­controlled trial of an integrated environmental home-­
based intervention package to improve child health. Int J Epidemiol
2016;45:dyw242–99.
21 Beller EM, Glasziou PP, Altman DG, et al. PRISMA for Abstracts:
reporting systematic reviews in Journal and conference Abstracts.
PLoS Med 2013;10:e1001419.
22 Soboksa NE, Gari SR, Hailu AB, et al. The effectiveness of solar
disinfection water treatment method for reducing childhood
diarrhea: a systematic review and meta-­analysis protocol. Syst Rev
2020;9:1–5.
23 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for
systematic reviews and meta-­analyses: the PRISMA statement. PLoS
Med 2009;7:889–96.
24 Sterne JAC, Savović J, Page MJ, et al. Rob 2: a revised Cochrane
risk-­of-­bias tool for randomized trials. BMJ. In Press 2019 https://​
methods.​cochrane.​org/
25 Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-­
analysis. Stat Med 2002;21:1539–58.
26 Ariff S, Khan U, Turab A, et al. Evaluation of solar disinfection of
water intervention delivered through lady health workers in the
reduction of diarrheal episodes in under-­five children. International
Journal of Pediatrics & Child Care 2016;1:1–10.
27 Gruber JS, Reygadas F, Arnold BF, et al. A stepped wedge, cluster-­
randomized trial of a household UV-­disinfection and safe storage
drinking water intervention in rural Baja California sur, Mexico. Am J
Trop Med Hyg 2013;89:238–45.
28 Rai B, Pal R, Kar S, et al. Solar disinfection improves drinking water
quality to prevent diarrhea in under-­five children in sikkim, India. J
Glob Infect Dis 2010;2:221.
29 Du Preez M, Mcguigan KG, Conroy RM. Solar disinfection of drinking
water in the prevention of dysentery in South African children aged
under 5 years: the role of participant motivation. Environ Sci Technol
2010;44:8744–9.
30 du Preez M, Conroy RM, Ligondo S, et al. Randomized intervention
study of solar disinfection of drinking water in the prevention of
dysentery in Kenyan children aged under 5 years. Environ Sci
Technol 2011;45:9315–23.
31 Conroy RM, Meegan ME, Joyce T, et al. Solar disinfection of drinking
water protects against cholera in children under 6 years of age. Arch
Dis Child 2001;85:293–5.
32 Conroy RM, Elmore-­Meegan M, Joyce T, et al. Solar disinfection of
drinking water and diarrhoea in Maasai children: a controlled field
trial. Lancet 1996;348:1695–7.
33 McGuigan KG, Samaiyar P, du Preez M, et al. High compliance
randomized controlled field trial of solar disinfection of drinking water
and its impact on childhood diarrhea in rural Cambodia. Environ Sci
Technol 2011;45:7862–7.
34 Clasen TF, Alexander KT, Sinclair D, et al. Interventions to improve
water quality for preventing diarrhea. Cochrane Database of
Systematic Reviews Interventions 2015;10:1–178.
35 Wolf J, Hunter PR, Freeman MC, et al. Impact of drinking water,
sanitation and handwashing with soap on childhood diarrhoeal
disease: updated meta-­analysis and meta-­regression. Trop Med Int
Health 2018;23:508–25.
36 Sobsey MD, Stauber CE, Casanova LM, et al. Point of use household
drinking water filtration: a practical, effective solution for providing
sustained access to safe drinking water in the developing world.
Environ Sci Technol 2008;42:4261–7.
37 Arnold BF, Colford JM. Treating water with chlorine at point-­of-­use
to improve water quality and reduce child diarrhea in developing
countries: a systematic review and meta-­analysis. Am J Trop Med
Hyg 2007;76:354–64.
38 Cohen A, Colford JM. Effects of boiling drinking water on diarrhea
and pathogen-­specific infections in low- and middle-­income
countries: a systematic review and meta-­analysis. Am J Trop Med
Hyg 2017;97:1362–77.
39 Wright J, Gundry S, Conroy R. Household drinking water in
developing countries: a systematic review of microbiological
contamination between source and point-­of-­use. Trop Med Int Health
2004;9:106–17.
11