Community-led strategies for communicable disease prevention and management in low- and middle- income countries: A mixed-methods systematic review of health, social, and economic impact.

Control of infectious diseases is a global health priority and a target of the 2015-2030 Sustainable Development Goals (SDGs). Community participation is fundamental to advancing primary health care and meeting SDGs. We conducted a mixed-methods systematic literature review of quantitative and qualitative evidence to understand the health, social, and economic impact of community-led strategies for communicable disease prevention and management in low- and middle- income countries. We searched seven electronic databases through 31 December, 2023 for cluster-randomised trials and economic evaluations of community-led communicable disease control. Reference searches identified additional studies associated with eligible database records. Data extraction and narrative synthesis summarised evidence on impact, costs, and cost-effectiveness, described the nature and extent of community participation, and examined implementation, mechanisms of impact, and contexts. Risk of bias of was assessed using the Cochrane Risk-of-Bias Tool and the Drummond checklist. Our database search yielded 14,269 records. Following database and reference screening, we included 49 records across 16 unique cluster-randomised trials, mostly from sub-Saharan Africa. Communicable disease strategies included provision of biomedical products, environmental modifications, and education and outreach. Based on evidence with moderate risk of bias, we found that community-led strategies can improve health behaviours for diarrhoeal diseases, HIV, malaria, and neglected tropical diseases. Evidence for impact on mortality and morbidity, health care access and utilisation, and community and social outcomes was less conclusive. Impact depended on the intensity of implementation by community actors. Factors facilitating implementation included motivation, trust, and health systems engagement. Contextual influences included attitudes and norms around communicable diseases. Economic studies were few and many omitted societal costs and consequences. This review supports community-led communicable disease control as a potentially effective strategy to improve health behaviours and contribute to SDGs. Operational guidance for implementation and evaluation is critical to support rapid evidence generation in this important area.