Quality Assessment of Meta-Analyses on Cervical Cancer.

Meta-analysis (MA) quantitatively summarizes the findings of independent studies and is considered the highest quality of evidence for evidence-based medicine. However, issues in reporting and methodological rigor of MA hamper reproducibility and create the potential for bias. By applying PRISMA reporting guideline and AMSTAR2 execution guidelines on 40 cervical cancer MA samples covering topics such as interventions and risk factors, we determined the extent to which MA execution adhered to best practice guidelines. The results show that the elements with least adherence include "review methods established before MA" and "principal summary measures defined" (each 32.5% per PRISMA) and "characteristics of included studies" (31.3% per AMSTAR2) which undermine reproducibility and increase the risk of bias. This initial work presents common pitfalls in MA and is intended to improve awareness of these issues for clinicians who are interested in conducting MA and to pave the way toward quality improvement via informatics approaches.

Are Training and Experience Adapting Evidence-Based Interventions Associated With Self-Efficacy and Attitudes? A Cross-Sectional Survey of Students and Practitioners With Varying Levels of Adaptation Experience.

Increasing use of evidence-based interventions (EBIs) in local settings will help reduce the research-practice gap and improve health equity. Because adaptation to new settings and populations is essential to effective EBI use, frameworks to guide practice are receiving more attention; most, however, only provide broad guidelines without instructions for making adaptations in practice. Therefore, practitioners may need additional training or technical assistance (TA) to implement and adapt EBIs. This study explores whether practitioners' and students' general EBI training or TA and level of adaptation experience are associated with self-efficacy in adapting EBIs and with attitudes toward EBI use. We analyzed baseline survey data of participants in an evaluation of IM-Adapt Online, a newly developed decision support tool. We asked about previous training on EBIs, general and specific adaptation behaviors, and attitudes toward EBIs and found an association between previous training or TA in using EBIs with higher self-efficacy for using and adapting EBIs. Respondents with prior EBI training were significantly more likely to have higher self-efficacy in EBI behaviors across subdomains and in total than those without training. Respondents reported lowest self-efficacy for planning adaptations (M = 3.35) and assessing fit of EBIs to their local context (M = 3.41). This study suggests the importance of EBI adaptation training and TA to increase adoption and adaptation of EBIs, subsequently. More adaptation-specific training is warranted to assist students, practitioners, and researchers undertaking the adaptation process and implement EBIs. Future training on EBI adaptation can help practitioners tailor EBIs to meet the specific needs of their populations.

Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation.

INTRODUCTION: Given homes are now a primary source of secondhand smoke (SHS) exposure in the United States, research-tested interventions that promote smoke-free homes should be evaluated in real-world settings to build the evidence base for dissemination. This study describes outcome evaluation results from a dissemination and implementation study of a research-tested program to increase smoke-free home rules through US 2-1-1 helplines. METHODS: Five 2-1-1 organizations, chosen through a competitive application process, were awarded grants of up to $70 000. 2-1-1 staff recruited participants, delivered the intervention, and evaluated the program. 2-1-1 clients who were recruited into the program allowed smoking in the home, lived in households with both a smoker and a nonsmoker or child, spoke English, and were at least 18 years old. Self-reported outcomes were assessed using a pre-post design, with follow-up at 2 months post baseline. RESULTS: A total of 2345 households (335-605 per 2-1-1 center) were enrolled by 2-1-1 staff. Most participants were female (82%) and smokers (76%), and half were African American (54%). Overall, 40.1% (n = 940) reported creating a full household smoking ban. Among the nonsmoking adults reached at follow-up (n = 389), days of SHS exposure in the past week decreased from 4.9 (SD = 2.52) to 1.2 (SD = 2.20). Among the 1148 smokers reached for follow-up, 211 people quit, an absolute reduction in smoking of 18.4% (p < .0001), with no differences by gender. CONCLUSIONS: Among those reached for 2-month follow-up, the proportion who reported establishing a smoke-free home was comparable to or higher than smoke-free home rates in the prior controlled research studies. IMPLICATIONS: Dissemination of this brief research-tested intervention via a national grants program with support from university staff to five 2-1-1 centers increased home smoking bans, decreased SHS exposure, and increased cessation rates. Although the program delivery capacity demonstrated by these competitively selected 2-1-1s may not generalize to the broader 2-1-1 network in the United States, or social service agencies outside of the United States, partnering with 2-1-1s may be a promising avenue for large-scale dissemination of this smoke-free homes program and other public health programs to low socioeconomic status populations in the United States.

Steps Toward Scalability: Illustrations From a Smoke-Free Homes Program.

Scalable interventions remain effective across a range of real-world settings and can be modified to fit organizational and community context. "Smoke-Free Homes: Some Things are Better Outside" has been effective in promoting smoke-free home rules in low-income households in efficacy, effectiveness, generalizability, and dissemination studies. Using data from a dissemination study in collaboration with five 2-1-1 call centers in Ohio, Florida, Oklahoma, and Alabama (n = 2,345 households), this article examines key dimensions of scalability, including effectiveness by subpopulation, secondary outcomes, identification of core elements driving effectiveness, and cost-effectiveness. Evaluated by 2-1-1 staff using a pre-post design with self-reported outcomes at 2 months postbaseline, the program was equally effective for men and women, across education levels, with varying number of smokers in the home, and whether children were present in the home or not. It was more effective for nonsmokers, those who smoked fewer cigarettes per day, and African Americans. Creating a smoke-free home was associated with a new smoke-free vehicle rule (odds ratio [OR] = 3.38, confidence interval [CI 2.58, 4.42]), decreased exposure to secondhand smoke among nonsmokers (b = -2.33, p < .0001), and increased cessation among smokers (OR = 5.8, CI [3.81, 8.81]). Use of each program component was significantly associated with success in creating a smoke-free home. Using an intent-to-treat effect size of 40.1%, program benefits from 5 years of health care savings exceed program costs yielding a net savings of $9,633 for delivery to 100 households. Cost effectiveness, subpopulation analyses, and identification of core elements can help in assessing the scalability potential of research-tested interventions such as this smoke-free homes program.

Cost-Effectiveness of Herpes Zoster Vaccination: A Systematic Review.

BACKGROUND: Herpes zoster (HZ) is one of the most common diseases among adults. Its reactivation is characterized by a severe and painful complication. In addition to the existing herpes zoster vaccine (ZVL), the FDA approved a new adjuvanted subunit zoster vaccine (RZV) in 2017 for use in adults aged 50 years and older. Several studies have assessed the cost-effectiveness of ZVL, many of which were conducted before the long-term vaccine  efficacy data was available in 2014. OBJECTIVE: Our objectives were to (i) summarize and compare the cost-effectiveness analyses (CEAs) of ZVL conducted before and after 2014, (ii) summarize the CEAs of RZV, and (iii) critically assess the cost-effectiveness models and identify key parameters to consider for future CEAs of RZV. METHODS: We searched PubMed and two other databases from inception to March 2018 for original cost-effectiveness, cost-utility, or cost-benefit analyses of HZ vaccines. Three investigators independently reviewed and assessed full-text articles after screening the titles and abstracts to determine eligibility. For all included studies, we assessed study quality using the Drummond and Jefferson's checklist and extracted study characteristics, model structure, vaccine characteristics, incidence of HZ and complications, incremental cost-effectiveness ratio, and sensitivity analyses. We summarized data by type of vaccine, year of publication, and funding sources. RESULTS: Twenty-seven studies met eligibility criteria. All studies were from high-income countries and were of moderate-to-high or high quality. Twenty studies repeatedly used four cost-effectiveness models. The assumption on long-term efficacy of ZVL was not based on clinical trial data in > 50% of studies. Fifteen out of 25 studies concluded that ZVL was cost-effective compared with no vaccine at a vaccine price ranging between US$93 and US$236 per dose (2018 US$), 40% of which were published after 2014. All industry-funded studies favored the use of ZVL. The single study assessing RZV found it to be more effective and less costly than ZVL, and cost-effective compared with no vaccination. More studies conducted after 2014 included various efficacy endpoints for ZVL, adverse reactions, and productivity loss compared with those conducted before 2014. CONCLUSIONS: A majority of studies of ZVL found it to be cost-effective compared with no vaccine using the authors' chosen willingness-to-pay thresholds. RZV was dominant in the single study comparing the two vaccines, but the finding needs to be confirmed with further studies in different settings. Future studies should assume vaccine efficacy in line with clinical data, account for more efficacy endpoints for ZVL, and include other HZ long-term complications, vaccine adverse reactions, and productivity loss.

Cost-Effectiveness of Competing Treatment Strategies for Clostridium difficile Infection: A Systematic Review.

BACKGROUND Clostridium difficile infection (CDI) presents a substantial economic burden and is associated with significant morbidity. While multiple treatment strategies have been evaluated, a cost-effective management strategy remains unclear. OBJECTIVE We conducted a systematic review to assess cost-effectiveness analyses of CDI treatment and to summarize key issues for clinicians and policy makers to consider. METHODS We searched PubMed and 5 other databases from inception to August 2016. These searches were not limited by study design or language of publication. Two reviewers independently screened the literature, abstracted data, and assessed methodological quality using the Drummond and Jefferson checklist. We extracted data on study characteristics, type of CDI, treatment characteristics, and model structure and inputs. RESULTS We included 14 studies, and 13 of these were from high-income countries. More than 90% of these studies were deemed moderate-to-high or high quality. Overall, 6 studies used a decision-tree model and 7 studies used a Markov model. Cost of therapy, time horizon, treatment cure rates, and recurrence rates were common influential factors in the study results. For initial CDI, fidaxomicin was a more cost-effective therapy than metronidazole or vancomycin in 2 of 3 studies. For severe initial CDI, 2 of 3 studies found fidaxomicin to be the most cost-effective therapy. For recurrent CDI, fidaxomicin was cost-effective in 3 of 5 studies, while fecal microbiota transplantation (FMT) by colonoscopy was consistently cost-effective in 4 of 4 studies. CONCLUSIONS The cost-effectiveness of fidaxomicin compared with other pharmacologic therapies was not definitive for either initial or recurrent CDI. Despite its high cost, FMT by colonoscopy may be a cost-effective therapy for recurrent CDI. A consensus on model design and assumptions are necessary for future comparison of CDI treatment. Infect Control Hosp Epidemiol 2018;39:412-424.

HIV antiretroviral medication stock-outs in Ghana: contributors and consequences.

Drug stock-outs are an unfortunate yet common reality for patients living in low and middle income countries, particularly in sub-Saharan Africa where trouble with consistent stock of antiretroviral medications (ARVs) continues. Our study takes a snapshot of this problem in Ghana. Although the country launched its antiretroviral therapy (ART) programme in 2003, progress toward realising the full benefit of ART for treated individuals has been limited, in part, because of stock-outs. In Ghana's Greater Accra region, we conducted semi-structured interviews with 40 women living with HIV (WLHIV) and 15 individuals with a history of HIV-related work in government or non-governmental organisations, or healthcare facilities. We used repeated review with coding and mapping techniques to analyse the transcripts and identify common themes. Stock-outs of ARVs result in inconsistent administration of therapy, increased indirect medical costs for WLHIV, and negative labelling of patients. Inefficiencies in drug supply, poor coordination with port authorities, inadequate government funding and dependence on international aid contribute to the stock-outs experienced in Ghana. Although using ARVs produced in-country could reduce supply problems, the domestically-manufactured product currently does not meet World Health Organization (WHO) standards. We recommend focused efforts to produce WHO standard ARVs in Ghana, and a review of current supply chain management to identify and mend pitfalls in the system.

A Minimal Intervention to Promote Smoke-Free Homes among 2-1-1 Callers: North Carolina Randomized Effectiveness Trial.

This study examined the extent to which delivery of the minimal Smoke-Free Homes intervention by trained 2-1-1 information and referral specialists had an effect on the adoption of home smoking bans in low-income households. A randomized controlled trial was conducted among 2-1-1 callers (n = 500) assigned to control or intervention conditions. 2-1-1 information and referral specialists collected baseline data and delivered the intervention consisting of 3 mailings and 1 coaching call; university-based data collectors conducted follow-up interviews at 3 and 6 months post-baseline. Data were collected from June 2013 through July 2014. Participants were mostly female (87.2%), African American (61.4%), and smokers (76.6%). Participants assigned to the intervention condition were more likely than controls to report a full ban on smoking in the home at both 3- (38.1% vs 19.3%, p = < .001) and 6-month follow-up (43.2% vs 33.2%, p = .02). The longitudinal intent-to-treat analysis showed a significant intervention effect over time (OR = 1.31, p = .001), i.e. OR = 1.72 at 6 months. This study replicates prior findings showing the effectiveness of the minimal intervention to promote smoke-free homes in low-income households, and extends those findings by demonstrating they can be achieved when 2-1-1 information and referral specialists deliver the intervention. Findings offer support for this intervention as a generalizable and scalable model for reducing secondhand smoke exposure in homes.

Pathways linking socioeconomic status and postpartum smoking relapse.

BACKGROUND: Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth. PURPOSE: This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy. METHODS: Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach. RESULTS: Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models. CONCLUSIONS: Findings have implications for future interventions that aim to reduce postpartum relapse.

What is the evidence for pharmaceutical patient assistance programs? A systematic review.

Pharmaceutical patient assistance programs (PAPs) have the potential to improve prescription drug accessibility for eligible patients, but currently there is limited information regarding their effectiveness. In an attempt to provide a systematic description of primary studies on PAPs, we reviewed 33 unique studies from commercial and grey literature (e.g., government publications, conference abstracts) sources: 15 health care outcome evaluations, seven economic evaluations, seven surveys and four miscellaneous studies. Enrollment assistance for PAPs with additional medication services (e.g., counseling) was significantly associated with improved glycemic (standardized mean difference=-0.40, 95% CI=-0.59,-0.20; k=3 one-group, pre-post-test; 1 comparison-group) and lipid (standardized mean difference=-0.52, 95% CI=0.78,-0.27; k=3 one-group, pre-post-test; 1 comparison group) control. Inadequately designed economic evaluations suggest free PAP medications offset health care institutions' costs for uncompensated medications and enrollment assistance programs. More rigorous research is needed to establish the clinical and cost-effectiveness of PAPs from a patient and health care institution perspective.

Cancer control planners' perceptions and use of evidence-based programs.

The Cancer Prevention and Control Research Network surveyed 282 cancer control planners to inform its efforts to increase the use of evidence-based cancer control programs (EBPs; programs that have been scientifically tested and have successfully changed behavior). Respondents included planners from organizations in state Comprehensive Cancer Control coalitions as well as other governmental and nongovernmental organizations and community-based coalitions. Respondents provided information about personal and organizational characteristics, their cancer control programs, their attitudes toward EBPs, and their awareness and use of Web-based resources for EBPs. Although findings showed strong preferences for cancer control programs that have been shown to work, less than half of respondents (48%) had ever used EBP resources. Regardless of whether they had used EBP resources, almost all respondents (97%) indicated that further training would help them and their organizations adopt and adapt EBPs for use in their communities. The most frequently endorsed training needs were finding and securing additional resources (such as funding and technical assistance), followed by adapting EBPs for cultural appropriateness. The Cancer Prevention and Control Research Network consortium is using these findings to develop a Web-based interactive training and decision support tool that is responsive to the needs identified by the survey respondents.

Pilot study to develop a rapid assessment of tuberculosis care-seeking and adherence practices in rural Limpopo Province, South Africa.

Studies of factors influencing tuberculosis (TB) care-seeking and treatment adherence in high TB/HIV co-burden African countries have typically surveyed urban patients' sociodemographic characteristics. To understand community perceptions and guide rapid assessment interviews, we interviewed key informants (nurses, tribal leaders, n = 9) and local researchers (n = 3) in poor, rural areas of South Africa. HIV-related stigma and misperceptions about TB causes and symptoms were cited as barriers. Key informants said older people preferred traditional healers; local researchers heard a preference for "western" care and suggested supporting clinic staff travel to remote villages with health education and diagnostic services. Key informants said not understanding the consequences of incomplete treatment and reluctance to relinquish disability grants decreased adherence. All reported that nonfamily DOTS supporters provided invaluable support. Rapid assessment should include drop-outs, re-treated, and co-infected patients and ask questions examining origins of misperceptions, stigma of testing, and pre-test messages to improve community perceptions about TB care-seeking and treatment adherence.

Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review.

BACKGROUND: Although numerous studies have examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES, findings have been inconsistent. A systematic review of existing studies is timely to identify conceptual and methodologic limitations and to provide a basis for future research directions and policy. OBJECTIVE: The objectives were to (a) describe the study designs, constructs, methods, and measures; (b) describe the independent association of area SES and cancer screening; and (c) identify neglected areas of research. METHODS: We searched six electronic databases and manually searched cited and citing articles. Eligible studies were published before 2008 in peer-reviewed journals in English, represented primary data on individuals ages > or = 18 years from developed countries, and measured the association of area and individual SES with breast, cervical, or colorectal cancer screening. RESULTS: Of 19 eligible studies, most measured breast cancer screening. Studies varied widely in research design, definitions, and measures of SES, cancer screening behaviors, and covariates. Eight employed multilevel logistic regression, whereas the remainder analyzed data with standard single-level logistic regression. The majority measured one or two indicators of area and individual SES; common indicators at both levels were poverty, income, and education. There was no consistent pattern in the association between area SES and cancer screening. DISCUSSION: The gaps and conceptual and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between area SES and cancer screening. We identify five areas of research deserving greater attention in the literature.

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review.

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

The promise and pitfalls of systematic reviews.

The systematic review "movement" that has transformed medical journal reports of clinical trials and reviews of clinical trials has taken hold in public health, with the most recent milestone, the publication of the first edition of The Guide to Community Health Services in 2005. In this paper we define and distinguish current terms, point out important resources for systematic reviews, describe the impact of systematic review on the quality of primary studies and summaries of the evidence, and provide perspectives on the promise of systematic reviews for shaping the agenda for public health research. Several pitfalls are discussed, including a false sense of rigor implied by the terms "systematic review" and "meta-analysis" and substantial variation in the validity of claims that a particular intervention is "evidence based," and the difficulty of translating conclusions from systematic reviews into public health advocacy and practice.

Correlates of mammography screening among Hispanic women living in lower Rio Grande Valley farmworker communities.

Factors contributing to the underuse of mammography screening by female Hispanic farmworkers aged 50 years and older in the Lower Rio Grande Valley were determined through home-based, Spanish-language personal interviews (N = 200). Questions covered adherence to screening mammography guidelines (mammogram within 2 years), healthcare access, sociodemographic characteristics, and theoretical constructs related to breast cancer screening in the literature. Multivariate findings indicated that adherent women were 3.6 times more likely to have health insurance. Self-efficacy for obtaining a mammogram and decisional balance were also significantly related to adherence; age, income, and education variables were not associated, perhaps because of restricted variation. Results indicate continuing efforts are needed to ensure that medically underserved migrant farmworker women have access to health care services. In addition, efforts to increase their self-efficacy in obtaining a mammogram and to counter negative attitudes and opinions by stressing the positive prognosis associated with early detection are warranted.

How can more smoking suspension during pregnancy become lifelong abstinence? Lessons learned about predictors, interventions, and gaps in our accumulated knowledge.

UNLABELLED: Maintenance of abstinence from cigarettes during pregnancy yields important benefits for both women and children, yet only 20%-30% of pregnancy cessation lasts 1 year postpartum. This paper reviews accumulated knowledge about factors that influence restarting smoking and the effectiveness of interventions to decrease it. Evidence from six trials and six multivariate predictor studies is provided, supplemented by qualitative and more focused quantitative studies. Studies were international, with diverse candidate predictors, intensity and timing of interventions, theory, designs, and measures of quitting and of maintenance postpartum. RECOMMENDATIONS: (a). Partner smoking must be addressed in interventions with cessation messages. (b). Intervention studies should include women of lower socioeconomic status and Black women. (c). Program developers and researchers should adopt a consistent standard for cessation. (d). Communication laboratory methods should test ways to increase intrinsic reasons for abstinence and success attributions to stable, internal causes. (e). Staging for postpartum smoking should supplant relapse prevention alone. (f). Among those whose intention it is to maintain nonsmoking postpartum, standard relapse prevention treatment is insufficient to combat environmental cues that also have been suspended for the pregnancy and typical problems of sleeplessness, stress, depression, and weight concern. (g). Interventions ideally should begin in late pregnancy, when postpartum smoking goals can be revised and plans made to manage postpartum issues. (h). Innovative methods for reducing postpartum problems should be tested. (i). Study of incentives for pregnancy cessation should include varying patterns, carryover to early postpartum months, and focus on their impact on long-term change.