Models of integrated care for multi-morbidity assessed in systematic reviews: a scoping review.

BACKGROUND: The prevalence of multi-morbidity is increasing globally. Integrated models of care present a potential intervention to improve patient and health system outcomes. However, the intervention components and concepts within different models of care vary widely and their effectiveness remains unclear. We aimed to describe and map the definitions, characteristics, components, and reported effects of integrated models of care in systematic reviews (SRs). METHODS: We conducted a scoping review of SRs according to pre-specified methods (PROSPERO 2019 CRD42019119265). Eligible SRs assessed integrated models of care at primary health care level for adults and children with multi-morbidity. We searched in PubMed (MEDLINE), Embase, Cochrane Database of Systematic Reviews, Epistemonikos, and Health Systems Evidence up to 3 May 2022. Two authors independently assessed eligibility of SRs and extracted data. We identified and described common components of integrated care across SRs. We extracted findings of the SRs as presented in the conclusions and reported on these verbatim. RESULTS: We included 22 SRs, examining data from randomised controlled trials and observational studies conducted across the world. Definitions and descriptions of models of integrated care varied considerably. However, across SRs, we identified and described six common components of integrated care: (1) chronic conditions addressed, (2) where services were provided, (3) the type of services provided, (4) healthcare professionals involved in care, (5) coordination and organisation of care and (6) patient involvement in care. We observed differences in the components of integrated care according to the income setting of the included studies. Some SRs reported that integrated care was beneficial for health and process outcomes, while others found no difference in effect when comparing integrated care to other models of care. CONCLUSIONS: Integrated models of care were heterogeneous within and across SRs. Information that allows the identification of effective components of integrated care was lacking. Detailed, standardised and transparent reporting of the intervention components and their effectiveness on health and process outcomes is needed.

Developing, implementing, and monitoring tailored strategies for integrated knowledge translation in five sub-Saharan African countries.

BACKGROUND: Integrated knowledge translation (IKT) through strategic, continuous engagement with decision-makers represents an approach to bridge research, policy and practice. The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA +), comprising research institutions in Ethiopia, Malawi, Rwanda, South Africa, Uganda and Germany, developed and implemented tailored IKT strategies as part of its multifaceted research on prevention and care of non-communicable diseases and road traffic injuries. The objective of this article is to describe the CEBHA + IKT approach and report on the development, implementation and monitoring of site-specific IKT strategies. METHODS: We draw on findings derived from the mixed method IKT evaluation (conducted in 2020-2021), and undertook document analyses and a reflective survey among IKT implementers. Quantitative data were analysed descriptively and qualitative data were analysed using content analysis. The authors used the TIDieR checklist to report results in a structured manner. RESULTS: Preliminary IKT evaluation data (33 interviews with researchers and stakeholders from policy and practice, and 31 survey responses), 49 documents, and eight responses to the reflective survey informed this article. In each of the five African CEBHA + countries, a site-specific IKT strategy guided IKT implementation, tailored to the respective national context, engagement aims, research tasks, and individuals involved. IKT implementers undertook a variety of IKT activities at varying levels of engagement that targeted a broad range of decision-makers and other stakeholders, particularly during project planning, data interpretation, and output dissemination. Throughout the project, the IKT teams continued to tailor IKT strategies informally and modified the IKT approach by responding to ad hoc engagements and involving non-governmental organisations, universities, and communities. Challenges to using systematic, formalised IKT strategies arose in particular with respect to the demand on time and resources, leading to the modification of monitoring processes. CONCLUSION: Tailoring of the CEBHA + IKT approach led to the inclusion of some atypical IKT partners and to greater responsiveness to unexpected opportunities for decision-maker engagement. Benefits of using systematic IKT strategies included clarity on engagement aims, balancing of existing and new strategic partnerships, and an enhanced understanding of research context, including site-specific structures for evidence-informed decision-making.

Self-management interventions for adolescents living with HIV: a systematic review.

BACKGROUND: Self-management interventions aim to enable people living with chronic conditions to increase control over their condition in order to achieve optimal health and may be pertinent for young people with chronic illnesses such as HIV. Our aim was to evaluate the effectiveness of self-management interventions for improving health-related outcomes of adolescents living with HIV (ALHIV) and identify the components that are most effective, particularly in low-resource settings with a high HIV burden. METHODS: We considered randomised controlled trials (RCTs), cluster RCTs, non-randomised controlled trials (non-RCTs) and controlled before-after (CBA) studies. We did a comprehensive search up to 1 August 2019. Two authors independently screened titles, abstracts and full texts, extracted data and assessed the risk of bias. We synthesised results in a meta-analysis where studies were sufficiently homogenous. In case of substantial heterogeneity, we synthesised results narratively. We assessed the certainty of evidence using GRADE and presented our findings as summaries in tabulated form. RESULTS: We included 14 studies, comprising 12 RCTs and two non-RCTs. Most studies were conducted in the United States, one in Thailand and four in Africa. Interventions were diverse, addressing a variety of self-management domains and including a combination of individual, group, face-to-face, cell phone or information communication technology mediated approaches. Delivery agents varied from trained counsellors to healthcare workers and peers. Self-management interventions compared to usual care for ALHIV made little to no difference to most health-related outcomes, but the evidence is very uncertain. Self-management interventions may increase adherence and decrease HIV viral load, but the evidence is very uncertain. We could not identify any particular components of interventions that were more effective for improving certain outcomes. CONCLUSION: Existing evidence on the effectiveness of self-management interventions for improving health-related outcomes of ALHIV is very uncertain. Self-management interventions for ALHIV should take into account the individual, social and health system contexts. Intervention components need to be aligned to the desired outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019126313.

Integrated knowledge translation to advance noncommunicable disease policy and practice in South Africa: application of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework.

BACKGROUND: In response to the "know-do" gap, several initiatives have been implemented to enhance evidence-informed decision-making (EIDM). These include individual training, organizational culture change management, and legislative changes. The importance of relationships and stakeholder engagement in EIDM has led to an evolution of models and approaches including integrated knowledge translation (IKT). IKT has emerged as a key strategy for ensuring that engagement is equitable, demand-driven, and responsive. As a result, the African-German Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) incorporated an IKT approach to influence noncommunicable diseases (NCD) policy and practice. We documented the phased process of developing, implementing, and monitoring the IKT approach in South Africa; and explored the appropriateness of using the exploration, preparation, implementation, and sustainment (EPIS) framework for this purpose. METHODS: We mapped the South Africa IKT approach onto the EPIS framework using a framework analysis approach. Notes of team meetings, stakeholder matrices, and engagement strategies were analysed and purposefully plotted against the four phases of the framework in order to populate the different constructs. We discussed and finalized the analysis in a series of online iterations until consensus was reached. RESULTS: The mapping exercise revealed an IKT approach that was much more iterative, dynamic, and engaging than initially thought. Several constructs (phase-agnostic) remained important and stable across EPIS phases: stable and supportive funding; committed and competent leadership; skilled and dedicated IKT champions; diverse and established personal networks; a conducive and enabling policy environment; and boundary-spanning intermediaries. Constructs such as "innovations" constantly evolved and adapted to the changing inner and outer contexts (phase-specific). CONCLUSIONS: Using the EPIS framework to interrogate, reflect on, and document our IKT experiences proved extremely relevant and useful. Phase-agnostic constructs proved critical to ensure resilience and agility of NCD deliberations and policies in the face of highly dynamic and changing local contexts, particularly in view of the current coronavirus disease 2019 (COVID-19) pandemic. Bridging IKT with a framework from implementation science helps to reflect on this process and can guide the development and planning of similar interventions and strategies.

Mixed method evaluation of the CEBHA+ integrated knowledge translation approach: a protocol.

BACKGROUND: The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) is a research consortium concerned with the prevention, diagnosis and treatment of non-communicable diseases. CEBHA+ seeks to engage policymakers and practitioners throughout the research process in order to build lasting relationships, enhance evidence uptake, and create long-term capacity among partner institutions in Ethiopia, Malawi, Rwanda, South Africa and Uganda in collaboration with two German universities. This integrated knowledge translation (IKT) approach includes the formal development, implementation and evaluation of country specific IKT strategies. METHODS: We have conceptualised the CEBHA+ IKT approach as a complex intervention in a complex system. We will employ a comparative case study (CCS) design and mixed methods to facilitate an in-depth evaluation. We will use quantitative surveys, qualitative interviews, quarterly updates, and a policy document analysis to capture the process and outcomes of IKT across the African CEBHA+ partner sites. We will conduct an early stage (early 2020) and a late-stage evaluation (early 2022), triangulate the data collected with various methods at each site and subsequently compare our findings across the five sites. DISCUSSION: Evaluating a complex intervention such as the CEBHA+ IKT approach is complicated, even more so when undertaken across five diverse countries. Despite conceptual, methodological and practical challenges, our comparative case study addresses important evidence gaps: While involving decision-makers in the research process is gaining traction worldwide, we still know very little regarding (i) whether this approach really makes a difference to evidence uptake, (ii) the mechanisms that make IKT successful, and (iii) relevant differences across socio-cultural contexts. The evaluation described here is intended to provide relevant insights on all of these aspects, notably in countries in Sub-Saharan Africa, and is expected to contribute to the science of IKT overall.

Interventions for preventing postpartum constipation.

BACKGROUND: Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones, and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake are usually encouraged. Although laxatives are commonly used in relieving constipation, the effectiveness and safety of available interventions for preventing postpartum constipation should be ascertained. This is an update of a review first published in 2015. OBJECTIVES: To evaluate the effectiveness and safety of interventions for preventing postpartum constipation. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, and two trials registers ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019), and screened reference lists of retrieved trials. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo, or no intervention in postpartum women. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions). Quasi-randomised trials and cluster-RCTs were eligible for inclusion; none were identified. Trials using a cross-over design were not eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the search to select potentially relevant trials, extracted data, assessed risk of bias, and the certainty of the evidence, using the GRADE approach. We did not pool results in a meta-analysis, but reported them per study. MAIN RESULTS: We included five trials (1208 postpartum mothers); three RCTs and two quasi-RCTs. Four trials compared a laxative with placebo; one compared a laxative plus a bulking agent versus the same laxative alone, in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported, and four of the five trials were published over 40 years ago. We judged the risk of bias to be unclear for most domains. Overall, we found a high risk of selection and attrition bias. Laxative versus placebo We included four trials in this comparison. Two of the trials examined the effects of laxatives that are no longer used; one has been found to have carcinogenic properties (Danthron), and the other is not recommended for lactating women (Bisoxatin acetate); therefore, we did not include their results in our main findings. None of the trials included in this comparison assessed our primary outcomes: pain or straining on defecation, incidence of postpartum constipation, or quality of life; or many of our secondary outcomes. A laxative (senna) may increase the number of women having their first bowel movement within 24 hours after delivery (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75; 1 trial, 471 women; low-certainty evidence); may have little or no effect on the number of women having their first bowel movement on day one after delivery (RR 0.94, 95% CI 0.72 to 1.22; 1 trial, 471 women; very low-certainty evidence); may reduce the number of women having their first bowel movement on day two (RR 0.23, 95% CI 0.11 to 0.45; 1 trial, 471 women; low-certainty evidence); and day three (RR 0.05, 95% CI 0.00 to 0.89; 1 trial, 471 women; low-certainty evidence); and may have little or no effect on the number of women having their first bowel movement on day four after delivery (RR 0.22, 95% CI 0.03 to 1.87; 1 trial, 471 women; very low-certainty evidence), but some of the evidence is very uncertain. Adverse effects were poorly reported. Low-certainty evidence suggests that the laxative (senna) may increase the number of women experiencing abdominal cramps (RR 4.23, 95% CI 1.75 to 10.19; 1 trial, 471 women). Very low-certainty evidence suggests that laxatives taken by the mother may have little or no effect on loose stools in the baby (RR 0.62, 95% CI 0.16 to 2.41; 1 trial, 281 babies); or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82; 1 trial, 281 babies). Laxative plus bulking agent versus laxative only Very low-certainty evidence from one trial (147 women) suggests no evidence of a difference between these two groups of women who underwent surgical repair of third degree perineal tears; only median and range data were reported. The trial also reported no evidence of a difference in the incidence of postpartum constipation (data not reported), but did not report on quality of life. Time to first bowel movement was reported as a median (range); very low-certainty evidence suggests little or no difference between the two groups. A laxative plus bulking agent may increase the number of women having any episode of faecal incontinence during the first 10 days postpartum (RR 1.81, 95% CI 1.01 to 3.23; 1 trial, 147 women; very low-certainty evidence). The trial did not report on adverse effects of the intervention on babies, or many of our secondary outcomes. AUTHORS' CONCLUSIONS: There is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives for preventing postpartum constipation. The evidence in this review was assessed as low to very low-certainty evidence, with downgrading decisions based on limitations in study design, indirectness and imprecision. We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo, and one that examined laxatives versus laxatives plus stool bulking agents. Further, rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials should assess educational and behavioural interventions, and positions that enhance defecation. They should report on the primary outcomes from this review: pain or straining on defecation, incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention, such as: nausea or vomiting, pain, and flatus.

Strategies for optimising antenatal corticosteroid administration for women with anticipated preterm birth.

BACKGROUND: Preterm birth is a serious and common pregnancy complication. The burden is particularly high in low- and middle-income countries where available care is often inadequate to ensure preterm newborn survival. Administration of antenatal corticosteroids (ACS) is recommended as the standard care for the management of women at risk of imminent preterm birth but its coverage varies globally. Efforts to improve preterm newborn survival have largely been focused on optimising the coverage of ACS use. However, the benefits and harms of such strategies are unclear. OBJECTIVES: To determine the relative benefits and risks of individual patient protocols, health service policies, educational interventions or other strategies which aim to optimise the use of ACS for anticipated preterm birth. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs), randomised at individual or cluster level, and quasi-randomised trials that assessed strategies to optimise (either by increasing or restricting) the administration of ACS compared with usual care amongst women at risk of preterm birth. Our primary outcomes were perinatal death and a composite outcome of offspring mortality and early or late neurodevelopmental morbidity. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. All three review authors independently extracted data and assessed risk of bias. We used narrative synthesis to analyse results, as we were unable to pool data from the included studies. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: We included three cluster-RCTs, all assessing the effects of a multifaceted strategy aiming to promote the use of ACS among women at risk of preterm birth. We did not identify any trials assessing strategies to restrict the use of ACS versus usual care. Two of the included trials assessed use of ACS in high-resource hospital settings. The third trial, the Antenatal Corticosteroid Trial (ACT) was a multi-site trial conducted in rural and semi-urban settings of six low- and middle-income countries in South Asia, sub-Saharan Africa and Central and South America. In two trials, promoting the use of ACS resulted in increased use of ACS, whereas one trial did not find a difference in the rate of ACS administration compared to usual care. Whilst we included three studies, we were unable to pool the data in meta-analysis due to outcomes not being reported across all studies, or outcome results being reported in different ways. The main source of data in this review is from the ACT trial. We assessed the ACT trial as high risk for performance and selective reporting bias. In the protocol for this review, we planned to report all settings and subgroup by low-middle versus high-income countries; these planned analyses were not possible in this version of the review, although adding further studies in future updates may allow us to carry out planned subgroup analyses. The ACT trial was conducted in low-resource settings and reported data on appropriate ACS treatment and inappropriate ACS treatment. Although a strategy of promoting the administration of ACS compared to routine care may increase appropriate ACS treatment (RR 4.34, 95%CI 3.59 to 5.25; 1 study; n = 4389; low-certainty evidence), it may also increase inappropriate ACS treatment (RR 9.11 95%CI 8.04 to 10.33, 1 study, n = 89,237; low-certainty evidence). In low-resource settings, a strategy of promoting the administration of ACS probably increases population level perinatal death by 3 per 1000 infants (risk ratio (RR) 1.11, 95% confidence interval (CI) 1.04 to 1.19; 1 study; n = 100,705; moderate-certainty evidence); stillbirth by 2 per 1000 infants (RR 1.11, 95% CI 1.02 to 1.21; 1 study; n = 100,705; moderate-certainty evidence); and neonatal death before 28 days by 2 per 1000 infants (RR 1.12, 95% CI 1.02 to 1.23; 1 study; n = 100,705; moderate-certainty evidence); may increase the risk for 'suspected' maternal infection or inflammation (RR 1.49, 95% CI 1.32 to 1.68; 1 study; n = 99,742; low-certainty evidence); and make little or no difference to the risk of maternal mortality (RR 1.11, 95% CI 0.64 to 1.92; 1 study; n = 99,742; low-certainty evidence) compared to routine care. Included trials did not report on the composite outcomes offspring mortality, early neurodevelopmental morbidity or late neurodevelopmental morbidity; and offspring mortality or severe neonatal morbidity. AUTHORS' CONCLUSIONS: In low-resource settings, a strategy of actively promoting the use of ACS in women at risk of preterm birth may increase ACS use in the target population, but may also carry a substantial risk of unnecessary exposure of ACS to women in whom ACS is not indicated. At the population level, these effects are probably associated with increased risks of stillbirth, perinatal death, neonatal death before 28 days, and maternal infection. The findings of this review support a more conservative approach to clinical protocols and clinical decision-making particularly in low-resource settings, along the lines of the World Health Organization's ACS 2015 recommendations, which take into account both the established clinical efficacy of ACS when used in the correct situation and context, and the possibility of important adverse effects when certain conditions are not met. Given the unanticipated results of the ACT trial, further research on strategies to optimise the use of ACS in low-resource settings is justified.

Interventions to reduce ambient particulate matter air pollution and their effect on health.

BACKGROUND: Ambient air pollution is associated with a large burden of disease in both high-income countries (HICs) and low- and middle-income countries (LMICs). To date, no systematic review has assessed the effectiveness of interventions aiming to reduce ambient air pollution. OBJECTIVES: To assess the effectiveness of interventions to reduce ambient particulate matter air pollution in reducing pollutant concentrations and improving associated health outcomes. SEARCH METHODS: We searched a range of electronic databases with diverse focuses, including health and biomedical research (CENTRAL, Cochrane Public Health Group Specialised Register, MEDLINE, Embase, PsycINFO), multidisciplinary research (Scopus, Science Citation Index), social sciences (Social Science Citation Index), urban planning and environment (Greenfile), and LMICs (Global Health Library regional indexes, WHOLIS). Additionally, we searched grey literature databases, multiple online trial registries, references of included studies and the contents of relevant journals in an attempt to identify unpublished and ongoing studies, and studies not identified by our search strategy. The final search date for all databases was 31 August 2016. SELECTION CRITERIA: Eligible for inclusion were randomized and cluster randomized controlled trials, as well as several non-randomized study designs, including controlled interrupted time-series studies (cITS-EPOC), interrupted time-series studies adhering to EPOC standards (ITS-EPOC), interrupted time-series studies not adhering to EPOC standards (ITS), controlled before-after studies adhering to EPOC standards (CBA-EPOC), and controlled before-after studies not adhering to EPOC standards (CBA); these were classified as main studies. Additionally, we included uncontrolled before-after studies (UBA) as supporting studies. We included studies that evaluated interventions to reduce ambient air pollution from industrial, residential, vehicular and multiple sources, with respect to their effect on mortality, morbidity and several air pollutant concentrations. We did not restrict studies based on the population, setting or comparison. DATA COLLECTION AND ANALYSIS: After a calibration exercise among the author team, two authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We conducted data extraction, risk of bias assessment and evidence synthesis only for main studies; we mapped supporting studies with regard to the types of intervention and setting. To assess risk of bias, we used the Graphic Appraisal Tool for Epidemiological studies (GATE) for correlation studies, as modified and employed by the Centre for Public Health Excellence at the UK National Institute for Health and Care Excellence (NICE). For each intervention category, i.e. those targeting industrial, residential, vehicular and multiple sources, we synthesized evidence narratively, as well as graphically using harvest plots. MAIN RESULTS: We included 42 main studies assessing 38 unique interventions. These were heterogeneous with respect to setting; interventions were implemented in countries across the world, but most (79%) were implemented in HICs, with the remaining scattered across LMICs. Most interventions (76%) were implemented in urban or community settings.We identified a heterogeneous mix of interventions, including those aiming to address industrial (n = 5), residential (n = 7), vehicular (n = 22), and multiple sources (n = 4). Some specific interventions, such as low emission zones and stove exchanges, were assessed by several studies, whereas others, such as a wood burning ban, were only assessed by a single study.Most studies assessing health and air quality outcomes used routine monitoring data. Studies assessing health outcomes mostly investigated effects in the general population, while few studies assessed specific subgroups such as infants, children and the elderly. No identified studies assessed unintended or adverse effects.The judgements regarding the risk of bias of studies were mixed. Regarding health outcomes, we appraised eight studies (47%) as having no substantial risk of bias concerns, five studies (29%) as having some risk of bias concerns, and four studies (24%) as having serious risk of bias concerns. Regarding air quality outcomes, we judged 11 studies (31%) as having no substantial risk of bias concerns, 16 studies (46%) as having some risk of bias concerns, and eight studies (23%) as having serious risk of bias concerns.The evidence base, comprising non-randomized studies only, was of low or very low certainty for all intervention categories and primary outcomes. The narrative and graphical synthesis showed that evidence for effectiveness was mixed across the four intervention categories. For interventions targeting industrial, residential and multiple sources, a similar pattern emerged for both health and air quality outcomes, with essentially all studies observing either no clear association in either direction or a significant association favouring the intervention. The evidence base for interventions targeting vehicular sources was more heterogeneous, as a small number of studies did observe a significant association favouring the control. Overall, however, the evidence suggests that the assessed interventions do not worsen air quality or health. AUTHORS' CONCLUSIONS: Given the heterogeneity across interventions, outcomes, and methods, it was difficult to derive overall conclusions regarding the effectiveness of interventions in terms of improved air quality or health. Most included studies observed either no significant association in either direction or an association favouring the intervention, with little evidence that the assessed interventions might be harmful. The evidence base highlights the challenges related to establishing a causal relationship between specific air pollution interventions and outcomes. In light of these challenges, the results on effectiveness should be interpreted with caution; it is important to emphasize that lack of evidence of an association is not equivalent to evidence of no association.We identified limited evidence for several world regions, notably Africa, the Middle East, Eastern Europe, Central Asia and Southeast Asia; decision-makers should prioritize the development and implementation of interventions in these settings. In the future, as new policies are introduced, decision-makers should consider a built-in evaluation component, which could facilitate more systematic and comprehensive evaluations. These could assess effectiveness, but also aspects of feasibility, fidelity and acceptability.The production of higher quality and more uniform evidence would be helpful in informing decisions. Researchers should strive to sufficiently account for confounding, assess the impact of methodological decisions through the conduct and communication of sensitivity analyses, and improve the reporting of methods, and other aspects of the study, most importantly the description of the intervention and the context in which it is implemented.

Integration of care for hypertension and diabetes: a scoping review assessing the evidence from systematic reviews and evaluating reporting.

BACKGROUND: With the rise in pre-mature mortality rate from non-communicable disease (NCD), there is a need for evidence-based interventions. We evaluated existing systematic reviews on effectiveness of integration of healthcare services, in particular with focus on delivery of care designed to improve health and process outcomes in people with multi-morbidity, where at least one of the conditions was diabetes or hypertension. METHODS: We searched MEDLINE, EMBASE, Cochrane Library, and Health Evidence to November 8, 2016 and consulted experts. One review author screened titles, abstracts and two review authors independently screened short listed full-texts and selected reviews for inclusion. We considered systematic reviews evaluating integration of care, compared to usual care, for people with multi-morbidity. One review author extracted data and another author verified it. Two review authors independently evaluated risk of bias using ROBIS and AMSTAR. Inter-rater reliability was analysed for ROBIS and AMSTAR using Cohen's kappa and percent agreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to assess reporting. RESULTS: We identified five systematic reviews on integration of care. Four reviews focused on comorbid diabetes and depression and two covered hypertension and comorbidities of cardiovascular disease, depression, or diabetes. Interventions were poorly described. The health outcomes evaluated included risk of all-cause mortality, measures of depression, cholesterol levels, HbA1c levels, effect of depression on HbA1c levels, symptom improvement, systolic blood pressure, and hypertension control. Process outcomes included access and utilisation of healthcare services, costs, and quality of care. Overall, three reviews had a low and medium risk of bias according to ROBIS and AMSTAR respectively, while two reviews had high risk of bias as judged by both ROBIS and AMSTAR. Findings have demonstrated that collaborative care in general resulted in better health and process outcomes when compared to usual care for both depression and diabetes and hypertension and diabetes. CONCLUSIONS: Several knowledge gaps were identified on integration of care for comorbidities with diabetes and/or hypertension: limited research on this topic for hypertension, limited reviews that included primary studies based in low-middle income countries, and limited reviews on collaborative care for communicable and NCDs.

An approach for setting evidence-based and stakeholder-informed research priorities in low- and middle-income countries.

To derive evidence-based and stakeholder-informed research priorities for implementation in African settings, the international research consortium Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA+) developed and applied a pragmatic approach. First, an online survey and face-to-face consultation between CEBHA+ partners and policy-makers generated priority research areas. Second, evidence maps for these priority research areas identified gaps and related priority research questions. Finally, study protocols were developed for inclusion within a grant proposal. Policy and practice representatives were involved throughout the process. Tuberculosis, diabetes, hypertension and road traffic injuries were selected as priority research areas. Evidence maps covered screening and models of care for diabetes and hypertension, population-level prevention of diabetes and hypertension and their risk factors, and prevention and management of road traffic injuries. Analysis of these maps yielded three priority research questions on hypertension and diabetes and one on road traffic injuries. The four resulting study protocols employ a broad range of primary and secondary research methods; a fifth promotes an integrated methodological approach across all research activities. The CEBHA+ approach, in particular evidence mapping, helped to formulate research questions and study protocols that would be owned by African partners, fill gaps in the evidence base, address policy and practice needs and be feasible given the existing research infrastructure and expertise. The consortium believes that the continuous involvement of decision-makers throughout the research process is an important means of ensuring that studies are relevant to the African context and that findings are rapidly implemented.

Afin de déterminer, à partir d'éléments factuels et avec l'apport des parties prenantes, les priorités de recherche pouvant être mises en œuvre dans les pays d'Afrique, le consortium de recherche international Collaboration for Evidence-Based Health Care and Public Health in Africa (CEBHA+) a élaboré et appliqué une démarche pragmatique. Tout d'abord, une enquête en ligne et une consultation en face à face entre les partenaires du CEBHA+ et les responsables politiques ont permis de mettre en lumière les domaines de recherche prioritaires. Ensuite, des listes documentaires relatives à ces domaines de recherche prioritaires ont permis d'identifier les lacunes ainsi que des questions connexes prioritaires en matière de recherche. Enfin, des protocoles d'étude ont été mis au point en vue d'être intégrés à une proposition de subvention. Des représentants de la mise en œuvre des politiques ont participé à l'ensemble du processus. La tuberculose, le diabète, l'hypertension et les blessures de la route ont été sélectionnés comme domaines de recherche prioritaires. Les listes documentaires portaient sur le dépistage et les modèles de soins du diabète et de l'hypertension, sur la prévention de ces maladies ainsi que sur leurs facteurs de risque au niveau de la population, et sur la prévention et la prise en charge des blessures de la route. L'analyse de ces listes a permis de dégager trois questions de recherche prioritaires portant sur l'hypertension et le diabète et une sur les blessures de la route. Les quatre protocoles d'étude en découlant utilisent toute une série de méthodes de recherche primaire et secondaire; un cinquième favorise une démarche méthodologique intégrée sur l'ensemble des activités de recherche. La démarche du CEBHA+, en particulier la constitution de listes documentaires, a permis de formuler les questions de recherche et les protocoles d'étude qui reviendront aux partenaires africains, de combler les lacunes des bases de données et de répondre aux besoins en matière de politiques et de pratiques; elle s'est également révélée applicable compte tenu de l'expertise et de l'infrastructure de recherche existantes. Pour le consortium, l'implication continue des décisionnaires dans le processus de recherche est un important moyen de garantir que les études soient pertinentes pour les pays africains et que leurs résultats soient rapidement mis en œuvre.

Para obtener las prioridades de investigación documentadas y comunicadas a las partes interesadas para su implementación en África, el consorcio de investigación internacional Asociación de Asistencia Médica Basada en Evidencia en África (CEBHA+, por sus siglas en inglés), desarrolló y aplicó un enfoque pragmático. En primer lugar, una encuesta en línea y una consulta presencial entre socios de la CEBHA+ y responsables políticos originó los sectores de investigación prioritarios. En segundo lugar, unos mapas documentados para estos sectores de investigación prioritarios identificaron disparidades y asuntos relativos a la investigación prioritaria. Por último, se desarrollaron protocolos de estudio para incluirlos dentro de una propuesta de subvención. Los representantes políticos y prácticos participaron durante todo el proceso. Los sectores de investigación prioritarios seleccionados fueron la tuberculosis, la diabetes, la hipertensión y los traumatismos provocados por accidentes de tráfico. Los mapas documentados abordaron el examen y los modelos de asistencia de la diabetes y la hipertensión, la prevención de la diabetes y la hipertensión a nivel de población, sus factores de riesgo y la prevención y gestión de traumatismos provocados por accidentes de tráfico. Los análisis de estos mapas generaron tres asuntos de investigación de prioridades sobre hipertensión y diabetes y uno sobre traumatismos provocados por accidentes de tráfico. Los cuatro protocolos de estudio resultantes emplean una amplia gama de métodos de investigación primarios y secundarios; un quinto presenta un enfoque metodológico integrado a través de todas las actividades de investigación. El enfoque de la CEBHA+, concretamente los mapas documentados, contribuyó a formular cuestiones y protocolos de estudio sobre la investigación que pertenecerían a socios africanos, subsanarían diferencias en la base de pruebas, abordarían las necesidades sobre políticas y prácticas y serían viables gracias a la infraestructura y experiencia de investigación existentes. El consorcio considera que la constante implicación de los responsables de la toma de decisiones a lo largo del proceso de investigación es un medio importante para garantizar que los estudios se correspondan al contexto africano y que los resultados se implementen con rapidez.

Effectiveness of interventions to reduce exposure to lead through consumer products and drinking water: A systematic review.

OBJECTIVES: The objective of this systematic review is to assess the effectiveness of regulatory, environmental and educational interventions for reducing blood lead levels (BLLs) and associated health outcomes in children, pregnant women and the general population. METHODS: Searches were run in MEDLINE, EMBASE and the Global Health Library up until August 2015. Studies were eligible for inclusion if they assessed the impact of regulatory, environmental or educational interventions, stand-alone or in combination, on BLLs among children, pregnant women or the general population through randomized controlled trials (RCT), controlled before-after (CBA), interrupted time series (ITS), uncontrolled before-after (UBA) or repeated cross-sectional studies. Studies assessing the impact of interventions to reduce exposure to lead in paint or household dust as well as studies concerned exclusively with environmental concentrations of lead were not included. As documented in a detailed protocol, screening, data extraction and quality appraisal were largely undertaken according to Cochrane standards. Harvest plots were used to graphically summarize evidence of effectiveness. RESULTS: The searches yielded 6466 unique records, of which five met our eligibility criteria; two additional eligible studies were identified by experts. We did not find any studies regarding the effectiveness of regulatory, educational or environmental interventions targeting exposure to lead in consumer products. Evidence regarding the effectiveness of interventions in reducing BLLs from exposures through drinking water is limited in both quantity and quality. Stand-alone targeted educational interventions showed no statistically significant reductions in children's BLL (two RCT) when compared to general educational interventions. Likewise, instructing women to reduce or eliminate lead-contaminated drinking water showed no effect on BLL (one RCT). Stand-alone environmental interventions appeared more promising in reducing BLL (three UBA). Combining educational and environmental interventions and targeting multiple settings may be effective in reducing BLL, as suggested by one uncontrolled before-after study. No studies examining the effectiveness of regulatory interventions were found. CONCLUSIONS: The limited quantity and quality of the evidence measuring BLL and associated health outcomes points to an urgent need for more robust research into the effectiveness of interventions to reduce lead exposure from consumer products and drinking water, especially for regulatory interventions.

Treatments for breast abscesses in breastfeeding women.

BACKGROUND: The benefits of breastfeeding are well known, and the World Health Organization recommends exclusive breastfeeding for the first six months of life and continuing breastfeeding to age two. However, many women stop breastfeeding due to lactational breast abscesses. A breast abscess is a localised accumulation of infected fluid in breast tissue. Abscesses are commonly treated with antibiotics, incision and drainage (I&D) or ultrasound-guided needle aspiration, but there is no consensus on the optimal treatment. OBJECTIVES: To assess the effects of different treatments for the management of breast abscesses in breastfeeding women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trial Register (27 February 2015). In addition we searched African Journals Online (27 February 2015), Google Scholar (27 February 2015), ProQuest Dissertations and Theses Databases (27 February 2015) and the WHO International Clinical Trials Registry Platform (ICTRP) search portal (27 February 2015). We also checked reference lists of retrieved studies and contacted experts in the field as well as relevant pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials (RCTs) investigating any intervention for treating lactational breast abscesses compared with any other intervention. Studies published in abstract form, quasi-RCTs and cluster-RCTs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. MAIN RESULTS: We included six studies. Overall, trials had an unclear risk of bias for most domains due to poor reporting. Two studies did not stratify data for lactational and non-lactational breast abscesses, and these studies do not contribute to the results. This review is based on data from four studies involving 325 women. Needle aspiration (with and without ultrasound guidance) versus incision and drainage (I&D) Mean time (days) to complete resolution of breast abscess (three studies) - there was substantial heterogeneity among these data (Tau(2) = 47.63, I(2) = 97%) and a clear difference between subgroups (with or without ultrasound guidance; Chi(2) = 56.88, I(2) = 98.2%, P = < 0.00001). We did not pool these data in a meta-analysis. Two studies excluded women who had treatment failure when they calculated the mean time to complete resolution. One study found that the time to complete resolution of breast abscess favoured needle aspiration over I&D (mean difference (MD) -6.07; 95% confidence interval (CI) -7.81 to -4.33; n = 36), but excluded 9/22 (41%) women in the needle aspiration group due to treatment failure. Another study reported faster resolution in the needle aspiration group (MD -17.80; 95% CI -21.27 to -14.33; n = 64) but excluded 6/35 (17%) women in the needle aspiration group due to treatment failure. A third study also reported that needle aspiration was associated with a shorter time to complete resolution of breast abscess (MD -16.00; 95%CI -18.73 to -13.27; n = 60); however, the authors did not indicate the number of women who were lost to follow-up for either group, and it is unclear how many women contributed to this result. Considering the limitations of the available data, we do not consider the results to be informative. Continuation of breastfeeding, after treatment (success): results favoured the needle aspiration group, but we did not pool data from the two studies because of substantial unexplained heterogeneity (I(2) = 97%). One study reported that women in the needle aspiration group were more likely to continue breastfeeding (risk ratio (RR) 2.89; 95% CI 1.64 to 5.08; n = 60), whereas the other study found no clear difference (RR 1.09; 95% CI 0.97 to 1.22 n = 70). Treatment failure was more common among women treated with needle aspiration compared to those who underwent I&D (RR 16.12; 95% CI 2.21 to 117.73; two studies, n = 115, low quality evidence). In one study, treatment with needle aspiration failed in 9/22 women who subsequently underwent I&D to treat their breast abscess. In another study, treatment with needle aspiration failed in 6/35 women, who subsequently underwent I&D. All abscesses in the I&D group were successfully treated.The included studies provided limited data for the review's secondary outcomes. No data were reported for adverse events. One study (60 women) reported that women in the needle aspiration group were more satisfied with their treatment than women who received I&D to treat their breast abscesses. Incision and drainage (I&D) with or without antibioticsOne study (150 women) compared the value of adding a broad-spectrum cephalosporin (single dose or a course of treatment) to women who underwent I&D for breast abscesses.The mean time to resolution of breast abscess was reported as being similar in all groups (although women with infection were excluded). Mean time to resolution for women who received a course of antibiotics was reported as 7.3 days, 6.9 days for women who received a single dose of antibiotics and 7.4 days for women who did not receive antibiotics. Standard deviations, P values and CIs were not reported and prevented further analysis. No data were reported for any continuation of breastfeeding after treatment (success). For treatment failure, there was no clear difference between the groups of women who received antibiotics (either a single dose or a course of antibiotics) and those who did not (RR 1.00; 95% CI 0.36 to 2.76).Included studies rarely reported this review's secondary outcomes (including adverse events). For post-operative complications/morbidity, there was no difference in the risk of wound infections between the antibiotics and no antibiotics groups (RR 0.58; 95% CI 0.29 to 1.17), irrespective of whether women received a single dose or a course of antibiotics. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine whether needle aspiration is a more effective option to I&D for lactational breast abscesses, or whether an antibiotic should be routinely added to women undergoing I&D for lactational breast abscesses. We graded the evidence for the primary outcome of treatment failure as low quality, with downgrading based on including small studies with few events and unclear risk of bias.

Interventions for preventing postpartum constipation.

BACKGROUND: Postpartum constipation, with symptoms such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake is usually encouraged, although laxatives are commonly used in relieving constipation. The effectiveness and safety of available interventions for preventing postpartum constipation needs to be ascertained. OBJECTIVES: To evaluate the effectiveness and safety of interventions for preventing postpartum constipation. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), Stellenbosch University database, ProQuest Dissertation and Theses database, World Health Organization International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov (30 April 2015) and reference lists of included studies. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo or no intervention. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions).We included quasi-randomised trials. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the search to select potentially relevant studies, extracted data and assessed risk of bias. Results were pooled in a meta-analysis only where there was no substantial statistical heterogeneity. MAIN RESULTS: We included five trials (1208 postpartum mothers); four compared a laxative with placebo and one compared a laxative alone versus the same laxative plus a bulking agent in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported and risk of bias was unclear for most domains. Overall, there was a high risk of selection and attrition bias. Laxative versus placeboNone of the four trials included in this comparison assessed any of our pre-specified primary outcomes (pain or straining on defecation, incidence of postpartum constipation or changes in quality of life).All four trials reported time to first bowel movement (not pre-specified in our protocol). In one trial, more women in the laxative group had their first bowel movement less than 24 hours after delivery compared to women in the placebo group (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75, 471 women). Individual trials also reported inconsistent results for days one, two and three after delivery. Pooled results of two trials showed that fewer women in the laxative group were having their first bowel movement at day four compared with controls (average RR 0.36, 95% CI 0.21 to 0.61, 671 women).Regarding secondary outcomes, no trials reported on stool consistency using the Bristol stool form scale orrelief of abdominal pain/discomfort . One trial reported the number of women having loose or watery stools and there were more women who experienced this in the laxative group compared to the placebo group (RR 26.96, 95% CI 3.81 to 191.03, 106 women). One trial found no clear difference in the number of enemas between groups (RR 0.63, 95% CI 0.38 to 1.05, 244 women). One trial reported more women having more than two bowel movements per day in the laxative compared to the placebo group (RR 26.02, 95% CI 1.59 to 426.73, 106 women). Adverse effects were poorly reported; two trials reported the number of women having abdominal cramps, but their results could not be pooled in a meta-analysis due to substantial statistical heterogeneity. In one trial, more women in the laxative group had abdominal cramps compared to the placebo group (RR 4.23, 95% CI 1.75 to 10.19, 471 women), while the other trial showed no difference between groups (RR 0.25, 95% CI 0.03 to 2.20, 200 women). With regards to adverse effects of the intervention on the baby , one trial found no difference in the incidence of loose stools (RR 0.62, 95% CI 0.16 to 2.41, 281 women) or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82, 281 women) between the two groups. Laxative versus laxative plus bulking agentOnly one trial was included in this comparison and reported on pain or straining on defecation in women who underwent surgical repair of third degree perineal tears; there was no reported difference between groups (median (range) data only). No difference was reported in the incidence of postpartum constipation (data not reported) and the outcome changes in quality of life was not mentioned.Time to first bowel movement was reported as a median (range) with no difference between the two groups. In terms of adverse effects , women in the laxative plus stool-bulking group were reported to be at a greater risk of faecal incontinence during the immediate postpartum period (median (range) data only). However the number of women having any episode of faecal incontinence during first 10 days postpartum was reported with no clear difference between the two groups (14/77 (18.2%) versus 23/70 (32.9%), RR 0.55, 95% CI 0.31 to 0.99, 147 women). The trial did not report on adverse effects of the intervention on the babies.The trial reported none of the following pre-specified secondary outcomes: stool consistency using Bristol stool form scale , use of alternative products , laxative agents , enemas , relief of abdominal pain/discomfort and stool frequency . AUTHORS' CONCLUSIONS: We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo and one that examined laxatives versus laxatives plus stool bulking agents. Results from trials were inconsistent and there is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives.Further rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials assessing educational and behavioural interventions and positions that enhance defecation are also needed. Future trials should report on the following important outcomes: pain or straining on defecation; incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention such as: nausea or vomiting, pain and flatus.

Intermittent preventive antimalarial treatment for children with anaemia.

BACKGROUND: Anaemia is a global public health problem. Children under five years of age living in developing countries (mostly Africa and South-East Asia) are highly affected. Although the causes for anaemia are multifactorial, malaria has been linked to anaemia in children living in malaria-endemic areas. Administering intermittent preventive antimalarial treatment (IPT) to children might reduce anaemia, since it could protect children from new Plasmodium parasite infection (the parasites that cause malaria) and allow their haemoglobin levels to recover. OBJECTIVES: To assess the effect of IPT for children with anaemia living in malaria-endemic areas. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, Cochrane Central of Controlled Trials (CENTRAL), published in The Cochrane Library; MEDLINE; EMBASE; and LILACS. We also searched the World Health Organization (WHO) International Clinical Trial Registry Platform and metaRegister of Controlled Trials (mRCT) for ongoing trials up to 4 December 2014. SELECTION CRITERIA: Randomized controlled trials (RCTs) evaluating the effect of IPT on children with anaemia. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias. We analysed data by conducting meta-analyses, stratifying data according to whether participants received iron supplements or not. We used GRADE to assess the quality of evidence. MAIN RESULTS: Six trials with 3847 participants met our inclusion criteria. Trials were conducted in areas of low malaria endemicity (three trials), and moderate to high endemicity (three trials). Four trials were in areas of seasonal malaria transmission. Iron was given to all children in two trials, and evaluated in a factorial design in a further two trials.IPT for children with anaemia probably has little or no effect on the proportion anaemic at 12 weeks follow-up (four trials, 2237 participants, (moderate quality evidence).IPT in anaemic children probably increases the mean change in haemoglobin levels from baseline to follow-up at 12 weeks on average by 0.32 g/dL (MD 0.32, 95% CI 0.19 to 0.45; four trials, 1672 participants, moderate quality evidence); and may improve haemoglobin levels at 12 weeks (MD 0.35, 95% CI 0.06 to 0.64; four trials, 1672 participants, low quality evidence). For both of these outcomes, subgroup analysis did not demonstrate a difference between children receiving iron and those that did not.IPT for children with anaemia probably has little or no effect on mortality or hospital admissions at six months (three trials, 3160 participants moderate quality evidence). Subgroup analysis did not show a difference between those children receiving iron supplements and those that did not. AUTHORS' CONCLUSIONS: Trials did show a small effect on average haemoglobin levels but this did not appear to translate into an effect on mortality and hospital admissions. Three of the six trials were conducted in low endemicity areas where transmission is low and thus any protective effect is likely to be modest.

Interventions for treating postpartum constipation.

BACKGROUND: Constipation is a functional bowel disorder that can reduce quality of life in the puerperium period. The diagnosis of postpartum constipation is both subjective and objective. It is characterised by symptoms such as pain or discomfort, straining, hard lumpy stools and a sense of incomplete bowel evacuation. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones and hematinics used in pregnancy can increase the risk of postpartum constipation. Although a high fibre diet and increased fluid intake is encouraged to assist defecation in the puerperium, pain-relieving drugs and laxatives are common drugs of choice to alleviate constipation. However, the effectiveness and safety of laxatives on the nursing mother need to be ascertained. OBJECTIVES: To evaluate the effectiveness of interventions for treating postpartum constipation. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 March 2014), the metaRegister of Controlled Trials, the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov), the Australian New Zealand Clinical Trials Registry (ANZCTR), the World Health Organization International Clinical Trials Registry platform (ICTRP), the ProQuest database, Stellenbosch University database and Google Scholar (28 March 2014). We also searched the reference lists of potentially relevant studies identified by the search, reviewed articles for relevant trials and contacted experts to identify any additional published or unpublished trials (10 April 2014). SELECTION CRITERIA: All randomised controlled trials comparing any intervention for the treatment of postpartum constipation to another intervention, placebo or no intervention.Interventions could include laxatives, surgery, as well as educational and behavioural interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the search to select potentially relevant studies using pre-designed eligibility inclusion criteria. Discrepancies were resolved through discussion. We did not identify any studies for inclusion. MAIN RESULTS: We did not identify any studies that met our inclusion criteria. We excluded nine studies. AUTHORS' CONCLUSIONS: We could not make explicit conclusions on interventions for treating postpartum constipation because we found no studies for inclusion in this review. Rigorous and well-conducted large randomised controlled trials aimed at treating postpartum women diagnosed with constipation would be beneficial. These trials should also address the criteria for administering the intervention (time and stage of a diagnosis of postpartum constipation), and the safety and effectiveness of such interventions.

Methods used and lessons learnt in conducting document reviews of medical and allied health curricula - a key step in curriculum evaluation.

BACKGROUND: This paper describes the process, our experience and the lessons learnt in doing document reviews of health science curricula. Since we could not find relevant literature to guide us on how to approach these reviews, we feel that sharing our experience would benefit researchers embarking on similar projects. METHODS: We followed a rigorous, transparent, pre-specified approach that included the preparation of a protocol, a pre-piloted data extraction form and coding schedule. Data were extracted, analysed and synthesised. Quality checks were included at all stages of the process. RESULTS: The main lessons we learnt related to time and project management, continuous quality assurance, selecting the software that meets the needs of the project, involving experts as needed and disseminating the findings to relevant stakeholders. CONCLUSION: A complete curriculum evaluation comprises, apart from a document review, interviews with students and lecturers to assess the learnt and taught curricula respectively. Rigorous methods must be used to ensure an objective assessment.

Building capacity for network meta-analysis in Sub-Saharan Africa: reflections and future direction.

Robust, relevant, comprehensive, and up-to-date evidence syntheses are the cornerstone for evidence-informed healthcare decisions. When considering multiple treatment options, network meta-analysis (NMA) systematic reviews play a key role in informing impactful decisions and clinical practice guidelines. However, the capacity and literacy to conduct NMA systematic reviews and interpret its results remains out of reach for many clinicians and review authors, especially in low-to-middle-income countries. Despite ample resources and guides, NMA capacity and training opportunities remain limited to non-existent in Sub-Saharan Africa. Towards solutions and strengthening evidence synthesis and NMA capacity in the Sub-Saharan African region, we describe and reflect on two courses that build NMA capacity and aim to address NMA literacy in Sub-Saharan Africa.The Primer in NMA systematic reviews aimed for participants to be able to find, appraise, interpret, and consider the use of NMA SRs of intervention effects. It is a 6-week online course for clinicians, policy-makers, and researchers wanting to learn more about using NMA systematic reviews. The Global NMA Masterclass workshop aimed for participants to be able to understand and apply pairwise and NMA in STATA and R, evaluate NMA assumptions and confidence in NMA results, and appropriately report NMA results. This course was offered over 5 weeks to clinicians, biostatisticians, and researchers with basic knowledge of epidemiology and biostatics. Although the bulk of learning occurred through self-study, we had weekly, synchronous question-and-answer sessions for both courses. Using relevant examples throughout the courses helped to enable an authentic learning environment.This was the first NMA training developed in Africa for Africa. Development of the courses was a collaborative effort from a multi-disciplinary team. Both NMA courses were well received and attended by a diverse group of participants spread across Sub-Saharan African countries. Participants felt the courses were applicable to their setting. Although most participants appreciated the benefits of online learning, we also experienced some challenges. There is great potential to conduct NMA systematic reviews in Sub-Saharan Africa. The NMA Primer and NMA workshop can play an essential role in expanding and developing NMA SR capacity and literacy in SSA.

Adherence to the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) of studies on evidence-based healthcare e-learning: a cross-sectional study.

OBJECTIVES: The objectives of this study are to assess reporting of evidence-based healthcare (EBHC) e-learning interventions using the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) checklist and explore factors associated with compliant reporting. DESIGN: Methodological cross-sectional study. METHODS: Based on the criteria used in an earlier systematic review, we included studies comparing EBHC e-learning and any other form of EBHC training or no EBHC training. We searched Medline, Embase, ERIC, CINAHL, CENTRAL, SCOPUS, Web of Knowledge, PsycInfo, ProQuest and Best Evidence Medical Education up to 4 January 2023. Screening of titles, abstracts, full-text articles and data extraction was done independently by two authors. For each study, we assessed adherence to each of the 17 GREET items and extracted information on possible predictors. Adequacy of reporting for each item of the GREET checklist was judged with yes (provided complete information), no (provided no information), unclear (when insufficient information was provided), or not applicable, when the item was clearly of no relevance to the intervention described (such as for item 8-details about the instructors-in the studies which used electronic, self-paced intervention, without any tutoring). Studies' adherence to the GREET checklist was presented as percentages and absolute numbers. We performed univariate analysis to assess the association of potential adherence predictors with the GREET checklist. We summarised results descriptively. RESULTS: We included 40 studies, the majority of which assessed e-learning or blended learning and mostly involved medical and other healthcare students. None of the studies fully reported all the GREET items. Overall, the median number of GREET items met (received yes) per study was 8 and third quartile (Q3) of GREET items met per study was 9 (min. 4 max. 14). When we used Q3 of the number of items met as cut-off point, adherence to the GREET reporting checklist was poor with 7 out of 40 studies (17.5%) reporting items of the checklist on acceptable level (adhered to at least 10 items out of 17). None of the studies reported on all 17 GREET items. For 3 items, 80% of included studies well reported information (received yes for these items): item 1 (brief description of intervention), item 4 (evidence-based practice content) and item 6 (educational strategies). Items for which 50% of included studies reported complete information (received yes for these items) included: item 9 (modes of delivery), item 11 (schedule) and 12 (time spent on learning). The items for which 70% or more of included studies did not provide information (received no for these items) included: item 7 (incentives) and item 13 (adaptations; for both items 70% of studies received no for them), item 14 (modifications of educational interventions-95% of studies received no for this item), item 16 (any processes to determine whether the materials and the educational strategies used in the educational intervention were delivered as originally planned-93% of studies received no for this item) and 17 (intervention delivery according to schedule-100% of studies received no for this item). Studies published after September 2016 showed slight improvements in nine reporting items. In the logistic regression models, using the cut-off point of Q3 (10 points or above) the odds of acceptable adherence to GREET guidelines were 7.5 times higher if adherence to other guideline (Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, etc) was reported for a given study type (p=0.039), also higher number of study authors increased the odds of adherence to GREET guidance by 18% (p=0.037). CONCLUSIONS: Studies assessing educational interventions on EBHC e-learning still poorly adhere to the GREET checklist. Using other reporting guidelines increased the odds of better GREET reporting. Journals should call for the use of appropriate use of reporting guidelines of future studies on teaching EBHC to increase transparency of reporting, decrease unnecessary research duplication and facilitate uptake of research evidence or result. STUDY REGISTRATION NUMBER: The Open Science Framework (https://doi.org/10.17605/OSF.IO/V86FR).

Antispasmodics for labour.

BACKGROUND: Prolonged labour can lead to increased maternal and neonatal mortality and morbidity due to increased risks of maternal exhaustion, postpartum haemorrhage and sepsis, fetal distress and asphyxia and requires early detection and appropriate clinical response. The risks for complications of prolonged labour are much greater in poor resource settings. Active management of labour versus physiological, expectant management, has shown to decrease the occurrence of prolonged labour. Administering antispasmodics during labour could also lead to faster and more effective dilatation of the cervix. Interventions to shorten labour, such as antispasmodics, can be used as a preventative or a treatment strategy in order to decrease the incidence of prolonged labour. As the evidence to support this is still largely anecdotal around the world, there is a need to systematically review the available evidence to obtain a valid answer. OBJECTIVES: To assess the effects of antispasmodics on labour in term pregnancies. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013), the ProQuest dissertation and thesis database, the dissertation database of the University of Stellenbosch and Google Scholar (28 February 2013) and reference lists of articles. We also contacted pharmaceutical companies and experts in the field. We did not apply language restrictions. SELECTION CRITERIA: Randomised controlled trials comparing antispasmodics with placebo or no medication in women with term pregnancies. DATA COLLECTION AND ANALYSIS: Two review authors independently screened abstracts and selected studies for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. We contacted trial authors when data were missing. MAIN RESULTS: Twenty-one trials (n = 3286) were included in the review. Seventeen trials (n = 2617) were included in the meta-analysis. Antispasmodics used included valethamate bromide, hyoscine butyl-bromide, drotaverine hydrochloride, rociverine and camylofin dihydrochloride. Most studies included antispasmodics as part of their package of active management of labour. Overall, the quality of studies was poor, as only four trials were assessed as low risk of bias. Thirteen trials (n = 1995) reported on the duration of first stage of labour, which was significantly reduced by an average of 74.34 minutes when antispasmodics were administered (mean difference (MD) -74.34 minutes; 95% confidence Interval (CI) -98.76 to -49.93). Seven studies (n = 797) reported on the total duration of labour, which was significantly reduced by an average of 85.51 minutes (MD -85.51 minutes; 95% CI -121.81 to -49.20). Six studies (n = 820) had data for the outcome: rate of cervical dilatation. Administration of antispasmodics significantly increased the rate of cervical dilatation by an average of 0.61 cm/hour (MD 0.61 cm/hour; 95% CI 0.34 to 0.88). Antispasmodics did not affect the duration of second and third stage of labour. The rate of normal vertex deliveries was not affected either. Only one study explored pain relief following administration of antispasmodics and no conclusions can be drawn on this outcome. There was significant heterogeneity for most outcomes and therefore, we undertook random-effects meta-analysis. Subgroup analysis was undertaken to explore heterogeneity, but remained largely unexplained. Maternal and neonatal adverse events were reported inconsistently. The main maternal adverse event reported was tachycardia. No serious neonatal adverse events were reported. AUTHORS' CONCLUSIONS: There is low quality evidence that antispasmodics reduce the duration of first stage of labour and increase the cervical dilatation rate. There is very low quality evidence that antispasmodics reduce the total duration of labour. There is moderate quality evidence that antispasmodics do not affect the rate of normal vertex deliveries. There is insufficient evidence to make any conclusions regarding the safety of these drugs for both mother and baby. Large, rigorous randomised controlled trials are needed to evaluate the effect of antispasmodics on prolonged labour and to evaluate their effect on labour in a context of expectant management of labour.