Interventions for improving coverage of childhood immunisation in low- and middle-income countries.

BACKGROUND: Immunisation plays a major role in reducing childhood morbidity and mortality. Getting children immunised against potentially fatal and debilitating vaccine-preventable diseases remains a challenge despite the availability of efficacious vaccines, particularly in low- and middle-income countries. With the introduction of new vaccines, this becomes increasingly difficult. There is therefore a current need to synthesise the available evidence on the strategies used to bridge this gap. This is a second update of the Cochrane Review first published in 2011 and updated in 2016, and it focuses on interventions for improving childhood immunisation coverage in low- and middle-income countries. OBJECTIVES: To evaluate the effectiveness of intervention strategies to boost demand and supply of childhood vaccines, and sustain high childhood immunisation coverage in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, CINAHL, and Global Index Medicus (11 July 2022). We searched Embase, LILACS, and Sociological Abstracts (2 September 2014). We searched WHO ICTRP and ClinicalTrials.gov (11 July 2022). In addition, we screened reference lists of relevant systematic reviews for potentially eligible studies, and carried out a citation search for 14 of the included studies (19 February 2020). SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCTs), non-randomised RCTs (nRCTs), controlled before-after studies, and interrupted time series conducted in low- and middle-income countries involving children that were under five years of age, caregivers, and healthcare providers. DATA COLLECTION AND ANALYSIS: We independently screened the search output, reviewed full texts of potentially eligible articles, assessed the risk of bias, and extracted data in duplicate, resolving discrepancies by consensus. We conducted random-effects meta-analyses and used GRADE to assess the certainty of the evidence. MAIN RESULTS: Forty-one studies involving 100,747 participants are included in the review. Twenty studies were cluster-randomised and 15 studies were individually randomised controlled trials. Six studies were quasi-randomised. The studies were conducted in four upper-middle-income countries (China, Georgia, Mexico, Guatemala), 11 lower-middle-income countries (Côte d'Ivoire, Ghana, Honduras, India, Indonesia, Kenya, Nigeria, Nepal, Nicaragua, Pakistan, Zimbabwe), and three lower-income countries (Afghanistan, Mali, Rwanda). The interventions evaluated in the studies were health education (seven studies), patient reminders (13 studies), digital register (two studies), household incentives (three studies), regular immunisation outreach sessions (two studies), home visits (one study), supportive supervision (two studies), integration of immunisation services with intermittent preventive treatment of malaria (one study), payment for performance (two studies), engagement of community leaders (one study), training on interpersonal communication skills (one study), and logistic support to health facilities (one study). We judged nine of the included studies to have low risk of bias; the risk of bias in eight studies was unclear and 24 studies had high risk of bias. We found low-certainty evidence that health education (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.15 to 1.62; 6 studies, 4375 participants) and home-based records (RR 1.36, 95% CI 1.06 to 1.75; 3 studies, 4019 participants) may improve coverage with DTP3/Penta 3 vaccine. Phone calls/short messages may have little or no effect on DTP3/Penta 3 vaccine uptake (RR 1.12, 95% CI 1.00 to 1.25; 6 studies, 3869 participants; low-certainty evidence); wearable reminders probably have little or no effect on DTP3/Penta 3 uptake (RR 1.02, 95% CI 0.97 to 1.07; 2 studies, 1567 participants; moderate-certainty evidence). Use of community leaders in combination with provider intervention probably increases the uptake of DTP3/Penta 3 vaccine (RR 1.37, 95% CI 1.11 to 1.69; 1 study, 2020 participants; moderate-certainty evidence). We are uncertain about the effect of immunisation outreach on DTP3/Penta 3 vaccine uptake in children under two years of age (RR 1.32, 95% CI 1.11 to 1.56; 1 study, 541 participants; very low-certainty evidence). We are also uncertain about the following interventions improving full vaccination of children under two years of age: training of health providers on interpersonal communication skills (RR 5.65, 95% CI 3.62 to 8.83; 1 study, 420 participants; very low-certainty evidence), and home visits (RR 1.29, 95% CI 1.15 to 1.45; 1 study, 419 participants; very low-certainty evidence). The same applies to the effect of training of health providers on interpersonal communication skills on the uptake of DTP3/Penta 3 by one year of age (very low-certainty evidence). The integration of immunisation with other services may, however, improve full vaccination (RR 1.29, 95% CI 1.16 to 1.44; 1 study, 1700 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Health education, home-based records, a combination of involvement of community leaders with health provider intervention, and integration of immunisation services may improve vaccine uptake. The certainty of the evidence for the included interventions ranged from moderate to very low. Low certainty of the evidence implies that the true effect of the interventions might be markedly different from the estimated effect. Further, more rigorous RCTs are, therefore, required to generate high-certainty evidence to inform policy and practice.

Researching, co-creating and testing innovations in paper-based health information systems (PHISICC) to support health workers' decision-making: protocol of a multi-country, transdisciplinary, mixed-methods research programme in three sub-Saharan countries.

BACKGROUND: Health information systems are crucial to provide data for decision-making and demand for data is constantly growing. However, the link between data and decisions is not always rational or linear and the management of data ends up overloading frontline health workers, which may compromise quality of healthcare delivery. Despite limited evidence, there is an increasing push for the digitalization of health information systems, which poses enormous challenges, particularly in remote, rural settings in low- and middle-income countries. Paper-based tools will continue to be used in combination with digital solutions and this calls for efforts to make them more responsive to local needs. Paper-based Health Information Systems in Comprehensive Care (PHISICC) is a transdisciplinary, multi-country research initiative to create and test innovative paper-based health information systems in three sub-Saharan African countries. METHODS/DESIGN: The PHISICC initiative is being carried out in remote, rural settings in Côte d'Ivoire, Mozambique and Nigeria through partnership with ministries of health and research institutions. We began with research syntheses to acquire the most up-to-date knowledge on health information systems. These were coupled with fieldwork in the three countries to understand the current design, patterns and contexts of use, and healthcare worker perspectives. Frontline health workers, with designers and researchers, used co-creation methods to produce the new PHISICC tools. This suite of tools is being tested in the three countries in three cluster-randomized controlled trials. Throughout the project, we have engaged with a wide range of stakeholders and have maintained the highest scientific standards to ensure that results are relevant to the realities in the three countries. DISCUSSION: We have deployed a comprehensive research approach to ensure the robustness and future policy uptake of findings. Besides the innovative PHISICC paper-based tools, our process is in itself innovative. Rather than emphasizing the technical dimensions of data management, we focused instead on frontline health workers' data use and decision-making. By tackling the whole scope of primary healthcare areas rather than a subset of them, we have developed an entirely new design and visual language for a suite of tools across healthcare areas. The initiative is being tested in remote, rural areas where the most vulnerable live.

Vaccines for preventing invasive salmonella infections in people with sickle cell disease.

BACKGROUND: Salmonella infections are a common bacterial cause of invasive disease in people with sickle cell disease especially children, and are associated with high morbidity and mortality rates. Although available in some centres, people with sickle cell anaemia are not routinely immunized with salmonella vaccines. This is an update of a previously published Cochrane Review. OBJECTIVES: To determine whether routine administration of salmonella vaccines to people with sickle cell disease reduces the morbidity and mortality associated with infection. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.We also conducted a search of the LILACS database and the World Health Organization International Clinical Trials Registry Platform (www.who.int/trialsearch) and ClinicalTrials.gov (www.clinicaltrials.gov).Date of most recent searches: 17 October 2018. SELECTION CRITERIA: We planned to select all randomized controlled trials that compared the use of either the inactivated vaccine or an oral attenuated vaccine with a placebo among people with sickle cell disease. Equally, studies that compared the efficacy of one vaccine type over another were to be selected for the review. DATA COLLECTION AND ANALYSIS: No trials of salmonella vaccines in people with sickle cell disease were found. MAIN RESULTS: There is an absence of randomized controlled trial evidence relating to the scope of this review. AUTHORS' CONCLUSIONS: It is expected that salmonella vaccines may be useful in people with sickle cell disease, especially in resource-poor settings where the majority of those who suffer from the condition are found. Unfortunately, there are no randomized controlled trials on the efficacy and safety of the different types of salmonella vaccines in people with sickle cell disease. We conclude that there is a need for a well-designed, adequately-powered, randomized controlled trial to assess the benefits and risks of the different types of salmonella vaccines as a means of improving survival and decreasing mortality from salmonella infections in people with sickle cell disease. However, we believe that there are unlikely to be any trials published in this area, therefore, this review will no longer be regularly updated.

Honey for acute cough in children.

BACKGROUND: Cough causes concern for parents and is a major cause of outpatient visits. Cough can impact quality of life, cause anxiety, and affect sleep in children and their parents. Honey has been used to alleviate cough symptoms. This is an update of reviews previously published in 2014, 2012, and 2010. OBJECTIVES: To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. SEARCH METHODS: We searched CENTRAL (2018, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (2014 to 8 February 2018), Embase (2014 to 8 February 2018), CINAHL (2014 to 8 February 2018), EBSCO (2014 to 8 February 2018), Web of Science (2014 to 8 February 2018), and LILACS (2014 to 8 February 2018). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (WHO ICTRP) on 12 February 2018. The 2014 review included searches of AMED and CAB Abstracts, but these were not searched for this update due to lack of institutional access. SELECTION CRITERIA: Randomised controlled trials comparing honey alone, or in combination with antibiotics, versus no treatment, placebo, honey-based cough syrup, or other over-the-counter cough medications for children aged 12 months to 18 years for acute cough in ambulatory settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update.We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias.Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7-point Likert scales to measure symptomatic relief of cough; one used an unclear 5-point scale. In all studies, low score indicated better cough symptom relief.Using a 7-point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) -1.05, 95% confidence interval (CI) -1.48 to -0.62; I² = 0%; 2 studies; 154 children; moderate-certainty evidence; placebo: MD -1.62, 95% CI -3.02 to -0.22; I² = 0%; 2 studies; 402 children; moderate-certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD -0.07, 95% CI -1.07 to 0.94; I² = 87%; 2 studies; 149 children; low-certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD -0.57, 95% CI -0.90 to -0.24; 1 study; 80 children; low-certainty evidence).Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate-certainty evidence). With a 5-point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity.Adverse events included nervousness, insomnia, and hyperactivity, experienced by seven children (9.3%) treated with honey and two children (2.7%) treated with dextromethorphan (risk ratio (RR) 2.94, 95% Cl 0.74 to 11.71; I² = 0%; 2 studies; 149 children; low-certainty evidence). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14, 95% Cl 0.01 to 2.68; 1 study; 80 children; low-certainty evidence). When honey was compared with placebo, 34 children (12%) in the honey group and 13 (11%) in the placebo group complained of gastrointestinal symptoms (RR 1.91, 95% CI 1.12 to 3.24; I² = 0%; 2 studies; 402 children; moderate-certainty evidence). Four children who received salbutamol had rashes compared to one child in the honey group (RR 0.19, 95% CI 0.02 to 1.63; 1 study; 100 children; moderate-certainty evidence). No adverse events were reported in the no-treatment group. AUTHORS' CONCLUSIONS: Honey probably relieves cough symptoms to a greater extent than no treatment, diphenhydramine, and placebo, but may make little or no difference compared to dextromethorphan. Honey probably reduces cough duration better than placebo and salbutamol. There was no strong evidence for or against using honey. Most of the children received treatment for one night, which is a limitation to the results of this review. There was no difference in occurrence of adverse events between the honey and control arms.

The comprehensive 'Communicate to Vaccinate' taxonomy of communication interventions for childhood vaccination in routine and campaign contexts.

BACKGROUND: Communication can be used to generate demand for vaccination or address vaccine hesitancy, and is crucial to successful childhood vaccination programmes. Research efforts have primarily focused on communication for routine vaccination. However, vaccination campaigns, particularly in low- or middle-income countries (LMICs), also use communication in diverse ways. Without a comprehensive framework integrating communication interventions from routine and campaign contexts, it is not possible to conceptualise the full range of possible vaccination communication interventions. Therefore, vaccine programme managers may be unaware of potential communication options and researchers may not focus on building evidence for interventions used in practice. In this paper, we broaden the scope of our existing taxonomy of communication interventions for routine vaccination to include communication used in campaigns, and integrate these into a comprehensive taxonomy of vaccination communication interventions. METHODS: Building on our taxonomy of communication for routine vaccination, we identified communication interventions used in vaccination campaigns through a targeted literature search; observation of vaccination activities in Cameroon, Mozambique and Nigeria; and stakeholder consultations. We added these interventions to descriptions of routine vaccination communication and categorised the interventions according to their intended purposes, building from an earlier taxonomy of communication related to routine vaccination. RESULTS: The comprehensive taxonomy groups communication used in campaigns and routine childhood vaccination into seven purpose categories: 'Inform or Educate'; 'Remind or Recall'; 'Enhance Community Ownership'; 'Teach Skills'; 'Provide Support'; 'Facilitate Decision Making' and 'Enable Communication'. Consultations with LMIC stakeholders and experts informed the taxonomy's definitions and structure and established its potential uses. CONCLUSIONS: This taxonomy provides a standardised way to think and speak about vaccination communication. It is categorised by purpose to help conceptualise communication interventions as potential solutions to address needs or problems. It can be utilised by programme planners, implementers, researchers and funders to see the range of communication interventions used in practice, facilitate evidence synthesis and identify evidence gaps.

Factors affecting the implementation of childhood vaccination communication strategies in Nigeria: a qualitative study.

BACKGROUND: The role of health communication in vaccination programmes cannot be overemphasized: it has contributed significantly to creating and sustaining demand for vaccination services and improving vaccination coverage. In Nigeria, numerous communication approaches have been deployed but these interventions are not without challenges. We therefore aimed to explore factors affecting the delivery of vaccination communication in Nigeria. METHODS: We used a qualitative approach and conducted the study in two states: Bauchi and Cross River States in northern and southern Nigeria respectively. We identified factors affecting the implementation of communication interventions through interviews with relevant stakeholders involved in vaccination communication in the health services. We also reviewed relevant documents. Data generated were transcribed verbatim and analysed using thematic analysis. RESULTS: We used the SURE framework to organise the identified factors (barriers and facilitators) affecting vaccination communication delivery. We then grouped these into health systems and community level factors. Some of the commonly reported health system barriers amongst stakeholders interviewed included: funding constraints, human resource factors (health worker shortages, training deficiencies, poor attitude of health workers and vaccination teams), inadequate infrastructure and equipment and weak political will. Community level factors included the attitudes of community stakeholders and of parents and caregivers. We also identified factors that appeared to facilitate communication activities. These included political support, engagement of traditional and religious institutions and the use of organised communication committees. CONCLUSIONS: Communication activities are a crucial element of immunization programmes. It is therefore important for policy makers and programme managers to understand the barriers and facilitators affecting the delivery of vaccination communication so as to be able to implement communication interventions more effectively.

Interventions for improving coverage of childhood immunisation in low- and middle-income countries.

BACKGROUND: Immunisation is a powerful public health strategy for improving child survival, not only by directly combating key diseases that kill children but also by providing a platform for other health services. However, each year millions of children worldwide, mostly from low- and middle-income countries (LMICs), do not receive the full series of vaccines on their national routine immunisation schedule. This is an update of the Cochrane review published in 2011 and focuses on interventions for improving childhood immunisation coverage in LMICs. OBJECTIVES: To evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunisation coverage in LMICs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 4, part of The Cochrane Library. www.cochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 12 May 2016); MEDLINE In-Process and Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 12 May 2016); CINAHL 1981 to present, EbscoHost (searched 12 May 2016); Embase 1980 to 2014 Week 34, OvidSP (searched 2 September 2014); LILACS, VHL (searched 2 September 2014); Sociological Abstracts 1952 - current, ProQuest (searched 2 September 2014). We did a citation search for all included studies in Science Citation Index and Social Sciences Citation Index, 1975 to present; Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 2 July 2016). We also searched the two Trials Registries: ICTRP and ClinicalTrials.gov (searched 5 July 2016) SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT), non-RCTs, controlled before-after studies, and interrupted time series conducted in LMICs involving children aged from birth to four years, caregivers, and healthcare providers. DATA COLLECTION AND ANALYSIS: We independently screened the search output, reviewed full texts of potentially eligible articles, assessed risk of bias, and extracted data in duplicate; resolving discrepancies by consensus. We then conducted random-effects meta-analyses and used GRADE to assess the certainty of evidence. MAIN RESULTS: Fourteen studies (10 cluster RCTs and four individual RCTs) met our inclusion criteria. These were conducted in Georgia (one study), Ghana (one study), Honduras (one study), India (two studies), Mali (one study), Mexico (one study), Nicaragua (one study), Nepal (one study), Pakistan (four studies), and Zimbabwe (one study). One study had an unclear risk of bias, and 13 had high risk of bias. The interventions evaluated in the studies included community-based health education (three studies), facility-based health education (three studies), household incentives (three studies), regular immunisation outreach sessions (one study), home visits (one study), supportive supervision (one study), information campaigns (one study), and integration of immunisation services with intermittent preventive treatment of malaria (one study).We found moderate-certainty evidence that health education at village meetings or at home probably improves coverage with three doses of diphtheria-tetanus-pertussis vaccines (DTP3: risk ratio (RR) 1.68, 95% confidence interval (CI) 1.09 to 2.59). We also found low-certainty evidence that facility-based health education plus redesigned vaccination reminder cards may improve DTP3 coverage (RR 1.50, 95% CI 1.21 to 1.87). Household monetary incentives may have little or no effect on full immunisation coverage (RR 1.05, 95% CI 0.90 to 1.23, low-certainty evidence). Regular immunisation outreach may improve full immunisation coverage (RR 3.09, 95% CI 1.69 to 5.67, low-certainty evidence) which may substantially improve if combined with household incentives (RR 6.66, 95% CI 3.93 to 11.28, low-certainty evidence). Home visits to identify non-vaccinated children and refer them to health clinics may improve uptake of three doses of oral polio vaccine (RR 1.22, 95% CI 1.07 to 1.39, low-certainty evidence). There was low-certainty evidence that integration of immunisation with other services may improve DTP3 coverage (RR 1.92, 95% CI 1.42 to 2.59). AUTHORS' CONCLUSIONS: Providing parents and other community members with information on immunisation, health education at facilities in combination with redesigned immunisation reminder cards, regular immunisation outreach with and without household incentives, home visits, and integration of immunisation with other services may improve childhood immunisation coverage in LMIC. Most of the evidence was of low certainty, which implies a high likelihood that the true effect of the interventions will be substantially different. There is thus a need for further well-conducted RCTs to assess the effects of interventions for improving childhood immunisation coverage in LMICs.

Barriers to and determinants of the use of intermittent preventive treatment of malaria in pregnancy in Cross River State, Nigeria: a cross-sectional study.

BACKGROUND: Malaria in pregnancy (MIP) has serious consequences for the woman, unborn child and newborn. The use of sulfadoxine-pyrimethamine for the intermittent preventive treatment of malaria in pregnancy (SP-IPTp) is low in malaria endemic areas, including some regions of Nigeria. However, little is known about pregnant women's compliance with the SP-IPTp national guidelines in primary health care (PHC) facilities in the south-south region of Nigeria. The aim of this study was to identify the barriers to and determinants of the use of SP-IPTp among pregnant women attending ANC in PHC facilities in Cross River State, south-south region of Nigeria. METHODS: A cross-sectional survey was conducted in 2011 among 400 ANC attendees aged 15-49 years recruited through multistage sampling. Binary logistic regression was used to determine the factors associated with the use of SP-IPTp in the study population. RESULTS: Use of SP-IPTp was self-reported by 41% of the total respondents. Lack of autonomy in the households to receive sulfadoxine-pyrimethamine (SP) during ANC was the main barrier to use of IPTp (83%). Other barriers were stock-outs of free SP (33%) and poor supervision of SP ingestion by directly observed treatment among those who obtained SP from ANC clinics (36/110 = 33%). In the multivariate logistic regression, the odds of using SP-IPTp was increased by the knowledge of the use of insecticide treated nets (ITNs) (OR = 2.13, 95% CI: 1.70-3.73) and SP (OR = 22.13, 95% CI: 8.10-43.20) for the prevention of MIP. Use of ITNs also increased the odds of using SP-IPTp (OR = 2.38, 95% CI: 1.24-12.31). CONCLUSIONS: Use of SP-IPTp was low and was associated with knowledge of the use of ITNs and SP as well as the use of ITNs for the prevention of MIP. There is a need to strengthen PHC systems and address barriers to the usage of SP-IPTp in order to reduce the burden of MIP.

Surgical versus non-surgical management of abdominal injury.

BACKGROUND: Injury to the abdomen can be blunt or penetrating. Abdominal injury can damage internal organs such as the liver, spleen, kidneys, intestine, and large blood vessels. There are controversies about the best approach to manage abdominal injuries. OBJECTIVES: To assess the effects of surgical and non-surgical interventions in the management of abdominal trauma in a haemodynamically stable and non-peritonitic abdomen. SEARCH METHODS: We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic+EMBASE (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), and clinical trials registers, and screened reference lists. We ran the most recent search on 17 September 2015. SELECTION CRITERIA: Randomised controlled trials of surgical interventions and non-surgical interventions involving people with abdominal injury who were haemodynamically stable with no signs of peritonitis. The abdominal injury could be blunt or penetrating. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the selection criteria. Data were extracted by two authors using a standard data extraction form, and are reported narratively. MAIN RESULTS: Two studies are included, which involved a total of 114 people with penetrating abdominal injuries. Both studies are at moderate risk of bias because the randomisation methods are not fully described, and the original study protocols are no longer available. The studies were undertaken in Finland between 1992 and 2002, by the same two researchers.In one study, 51 people were randomised to surgery or an observation protocol. None of the participants in the study died. Seven people had complications: 5 (18.5%) in the surgical group and 2 (8.3%) in the observation group; the difference was not statistically significant (P = 0.42; Fischer's exact). Among the 27 people who had surgery, 6 (22.2%) surgeries were negative laparotomies, and 15 (55.6%) were non-therapeutic.In the other study, 63 people were randomised to diagnostic laparoscopy (surgery) or an observation protocol. There were no deaths and no unnecessary surgeries in either group. Four people did not receive the intervention they were assigned. There was no difference in therapeutic operations between the two groups: 3 of 28 in the diagnostic laparoscopy group versus 1 of 31 in the observation protocol group (P = 0.337). AUTHORS' CONCLUSIONS: Based on the findings of 2 studies involving a total of 114 people, there is no evidence to support the use of surgery over an observation protocol for people with penetrating abdominal trauma who have no signs of peritonitis and are stable.

Vaccines for preventing invasive salmonella infections in people with sickle cell disease.

BACKGROUND: Salmonella infections are a common bacterial cause of invasive disease in people with sickle cell disease especially children, and are associated with high morbidity and mortality rates. Although available in some centres, people with sickle cell anaemia are not routinely immunized with salmonella vaccines. This is an update of a previously published Cochrane Review. OBJECTIVES: To determine whether routine administration of salmonella vaccines to people with sickle cell disease reduces the morbidity and mortality associated with infection. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.We also conducted a search of the LILACS database.Date of most recent searches: 05 May 2015. SELECTION CRITERIA: We planned to select all randomized controlled trials that compared the use of either the inactivated vaccine or an oral attenuated vaccine with a placebo among people with sickle cell disease. Equally, studies that compared the efficacy of one vaccine type over another were to be selected for the review. DATA COLLECTION AND ANALYSIS: No trials of salmonella vaccines in people with sickle cell disease were found. MAIN RESULTS: There is an absence of randomized controlled trial evidence relating to the scope of this review. AUTHORS' CONCLUSIONS: It is expected that salmonella vaccines may be useful in people with sickle cell disease, especially in resource-poor settings where the majority of those who suffer from the condition are found. Unfortunately, there are no randomized controlled trials on the efficacy and safety of the different types of salmonella vaccines in people with sickle cell disease. We conclude that there is a need for a well-designed, adequately-powered, randomized controlled trial to assess the benefits and risks of the different types of salmonella vaccines as a means of improving survival and decreasing mortality from salmonella infections in people with sickle cell disease.

Factors associated with appropriate home management of uncomplicated malaria in children in Kassena-Nankana district of Ghana and implications for community case management of childhood illness: a cross-sectional study.

BACKGROUND: Home management of uncomplicated malaria (HMM) is now integrated into the community case management of childhood illness (CCM), an approach that requires parasitological diagnosis before treatment. The success of CCM in resource-constrained settings without access to parasitological testing significantly depends on the caregiver's ability to recognise malaria in children under five years (U5), assess its severity, and initiate early treatment with the use of effective antimalarial drugs in the appropriate regimen at home. Little is known about factors that influence effective presumptive treatment of malaria in U5 by caregivers in resource-constrained malaria endemic areas. This study examined the factors associated with appropriate HMM in U5 by caregivers in rural Kassena-Nankana district, northern Ghana. METHODS: A cross-sectional household survey was conducted among 811 caregivers recruited through multistage sampling. A caregiver was reported to have practiced appropriate HMM if an antimalarial drug was administered to a febrile child in the recommended regimen (correct dose and duration for the child's age). Binary logistic regression was used to determine factors associated with appropriate HMM. RESULTS: Of the 811 caregivers, 87% recognised the symptoms of uncomplicated malaria in U5, and 49% (n = 395) used antimalarial drugs for the HMM. Fifty percent (n = 197) of caregivers who administered antimalarial drugs used the appropriate regimen. In the multivariate logistic regression, caregivers with secondary (OR = 1.71, 95% CI: 1.03, 2.83) and tertiary (OR = 3.58, 95% CI: 1.08, 11.87) education had increased odds of practicing appropriate HMM compared with those with no formal education. Those who sought treatment in the hospital for previous febrile illness in U5 had increased odds of practicing appropriate HMM (OR = 2.24, 95% CI: 1.12, 4.60) compared with those who visited the health centres. CONCLUSIONS: Half of caregivers who used antimalarial drugs practiced appropriate HMM. Educational status and utilisation of hospitals in previous illness were associated with appropriate HMM. Health education programmes that promote the use of the current first line antimalarial drugs in the appropriate regimen should be targeted at caregivers with no education in order to improve HMM in communities where parasitological diagnosis of malaria may not be feasible.

Mapping how information about childhood vaccination is communicated in two regions of Cameroon: What is done and where are the gaps?

BACKGROUND: The 'Communicate to vaccinate' (COMMVAC) project builds research evidence for improving communication with parents and communities about childhood vaccinations in low- and middle-income countries. Understanding and mapping the range of vaccination communication strategies used in different settings is an important component of this work. In this part of the COMMVAC project, our objectives were: (1) to identify the vaccination communication interventions used in two regions of Cameroon; (2) to apply the COMMVAC taxonomy, a global taxonomy of vaccination communication interventions, to these communication interventions to help us classify these interventions, including their purposes and target audiences; and identify whether gaps in purpose or target audiences exist; (3) to assess the COMMVAC taxonomy as a research tool for data collection and analysis. METHODS: We used the following qualitative methods to identify communication strategies in the Central and North West Regions of Cameroon in the first half of 2014: interviews with program managers, non-governmental organizations, vaccinators, parents and community members; observations and informal conversations during routine immunization clinics and three rounds of the National Polio Immunization Campaign; and document analysis of reports and mass media communications about vaccination. A survey of parents and caregivers was also done. We organised the strategies using the COMMVAC taxonomy and produced a map of Cameroon-specific interventions, which we presented to local stakeholders for feedback. RESULTS: Our map of the interventions used in Cameroon suggests that most childhood vaccination communication interventions focus on national campaigns against polio rather than routine immunisation. The map also indicates that most communication interventions target communities more broadly, rather than parents, and that very few interventions target health workers. The majority of the communication interventions aimed to inform or educate or remind or recall members of the community about vaccination. The COMMVAC taxonomy provided a useful framework for quickly and simply mapping existing vaccination communication strategies. CONCLUSIONS: By identifying the interventions used in Cameroon and developing an intervention map, we allowed stakeholders to see where they were concentrating their communication efforts and where gaps exist, allowing them to reflect on whether changes are needed to the communication strategies they are using.

Honey for acute cough in children.

BACKGROUND: Cough causes concern for parents and is a major cause of outpatient visits. It can impact on quality of life, cause anxiety and affect sleep in parents and children. Several remedies, including honey, have been used to alleviate cough symptoms. OBJECTIVES: To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. SEARCH METHODS: We searched CENTRAL (2014, Issue 10), MEDLINE (1950 to October week 4, 2014), EMBASE (1990 to November 2014), CINAHL (1981 to November 2014), Web of Science (2000 to November 2014), AMED (1985 to November 2014), LILACS (1982 to November 2014) and CAB abstracts (2009 to January 2014). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing honey given alone, or in combination with antibiotics, versus nothing, placebo or other over-the-counter (OTC) cough medications to participants aged from one to 18 years for acute cough in ambulatory settings. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results for eligible studies and extracted data on reported outcomes. MAIN RESULTS: We included three RCTs, two at high risk of bias and one at low risk of bias, involving 568 children. The studies compared honey with dextromethorphan, diphenhydramine, 'no treatment' and placebo for the effect on symptomatic relief of cough using a seven-point Likert scale. The lower the score, the better the cough symptom being assessed.Moderate quality evidence showed that honey may be better than 'no treatment' in reducing the frequency of cough (mean difference (MD) -1.05; 95% confidence interval (CI) -1.48 to -0.62; I(2) statistic 23%; two studies, 154 participants). High quality evidence also suggests that honey may be better than placebo for reduction of cough frequency (MD -1.85; 95% Cl -3.36 to -0.33; one study, 300 participants). Moderate quality evidence suggests that honey does not differ significantly from dextromethorphan in reducing cough frequency (MD -0.07; 95% CI -1.07 to 0.94; two studies, 149 participants). Low quality evidence suggests that honey may be slightly better than diphenhydramine in reducing cough frequency (MD -0.57; 95% CI -0.90 to -0.24; one study, 80 participants).Adverse events included mild reactions (nervousness, insomnia and hyperactivity) experienced by seven children (9.3%) from the honey group and two (2.7%) from the dextromethorphan group; the difference was not significant (risk ratio (RR) 2.94; 95% Cl 0.74 to 11.71; two studies, 149 participants). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14; 95% Cl 0.01 to 2.68; one study, 80 participants). When honey was compared with placebo, four children (1.8%) in the honey group and one (1.3%) from the placebo group complained of gastrointestinal symptoms (RR 1.33; 95% Cl 0.15 to 11.74). However, there was no significant difference between honey versus dextromethorphan, honey versus diphenhydramine or honey versus placebo. No adverse event was reported in the 'no treatment' group. AUTHORS' CONCLUSIONS: Honey may be better than 'no treatment', diphenhydramine and placebo for the symptomatic relief of cough, but it is not better than dextromethorphan. None of the included studies assessed the effect of honey on 'cough duration' because intervention and follow-up were for one night only. There is no strong evidence for or against the use of honey.

Seeking evidence to support efforts to increase use of antenatal care: a cross-sectional study in two states of Nigeria.

BACKGROUND: Antenatal care (ANC) attendance is a strong predictor of maternal outcomes. In Nigeria, government health planners at state level and below have limited access to population-based estimates of ANC coverage and factors associated with its use. A mixed methods study examined factors associated with the use of government ANC services in two states of Nigeria, and shared the findings with stakeholders. METHODS: A quantitative household survey in Bauchi and Cross River states of Nigeria collected data from women aged 15-49 years on ANC use during their last completed pregnancy and potentially associated factors including socio-economic conditions, exposure to domestic violence and local availability of services. Bivariate and multivariate analysis examined associations with having at least four government ANC visits. We collected qualitative data from 180 focus groups of women who discussed the survey findings and recommended solutions. We shared the findings with state, Local Government Authority, and community stakeholders to support evidence-based planning. RESULTS: 40% of 7870 women in Bauchi and 46% of 7759 in Cross River had at least four government ANC visits. Women's education, urban residence, information from heath workers, help from family members, and household owning motorized transport were associated with ANC use in both states. Additional factors for women in Cross River included age above 18 years, being married or cohabiting, being less poor (having enough food during the last week), not experiencing intimate partner violence during the last year, and education of the household head. Factors for women in Bauchi were presence of government ANC services within their community and more than two previous pregnancies. Focus groups cited costly, poor quality, and inaccessible government services, and uncooperative partners as reasons for not attending ANC. Government and other stakeholders planned evidence-based interventions to increase ANC uptake. CONCLUSION: Use of ANC services remains low in both states. The factors related to use of ANC services are consistent with those reported previously. Efforts to increase uptake of ANC should focus particularly on poor and uneducated women. Local solutions generated by discussion of the evidence with stakeholders could be more effective and sustainable than externally driven interventions.

Prevalence and determinants of adherence to HAART amongst PLHIV in a tertiary health facility in south-south Nigeria.

BACKGROUND: Adherence to Highly active antiretroviral therapy (HAART) is a major predictor of the success of HIV/AIDS treatment. Good adherence to HAART is necessary to achieve the best virologic response, lower the risk of drug resistance and reduce morbidity and mortality. This study therefore aimed to determine the prevalence and determinants of adherence to HAART amongst PLHIV accessing treatment in a tertiary location in Cross River State, Nigeria. METHODS: A cross-sectional study was conducted among patients on HAART attending the Presidential Emergency plan for AIDS relief (PEPFAR) clinic of the University of Calabar Teaching Hospital between October-December 2011. A total of 411 PLHIV visiting the study site during the study period were interviewed. PLHIV who met the inclusion criteria were consecutively recruited into the study till the desired sample size was attained. Information was obtained from participants using a semi-structured, pretested, interviewer administered questionnaire. Adherence was measured via patients self report and were termed adherent if they took at least 95% of prescribed medication in the previous week prior to the study. Data were summarized using proportions, and χ2 test was used to explore associations between categorical variables. Predictors of adherence to HAART were determined by binary logistic regression. Level of significance was set at p < 0.05. RESULTS: The mean age of PLHIV who accessed treatment was 35.7 ± 9.32 years. Females constituted 68.6% of all participants. The self reported adherence rate based on a one week recall prior to the study was 59.9%. The major reasons cited by respondents for skipping doses were operating a busy schedule, simply forgot medications, felt depressed, and travelling out of town. On logistic regression analysis, perceived improved health status [OR 3.11; CI: 1.58-6.11], reduced pill load [OR 1.25; 95% CI: 0.46-2.72] and non-use of herbal remedies [OR 1.83; 95% CI: 1.22-2.72] were the major predictors for adherence to HAART. However, payment for ART services significantly decreased the likelihood of adherence to HAART. [OR 0.46; 95% CI: 0.25-0.87.]. CONCLUSIONS: The adherence rate reported in this study was quite low. Appropriate adherence enhancing intervention strategies targeted at reducing pill load and ensuring an uninterrupted access to free services regimen is strongly recommended.

Open-label trial of three dosage regimens of fixed-dose combination of artemisinin and naphthoquine for treating uncomplicated falciparum malaria in Calabar, Nigeria.

BACKGROUND: The use of anti-malarial drug combinations with artemisinin, or with one of its derivatives, is now widely recommended to overcome drug resistance in falciparum malaria. Fixed-dose combination of artemisinin and naphthoquine is a new generation artemisinin combination therapy (ACT) offered as a single dose therapy. The aim of the study was to assess the therapeutic efficacy, safety and tolerability of three dosage schedules of fixed-dose combination of artemisinin (125 mg) and naphthoquine (50 mg) for treating uncomplicated Plasmodium falciparum malaria among adolescents and adults in Calabar, South-east Nigeria. METHOD: A total of 121 patients aged ≥15 years with uncomplicated P. falciparum malaria were enrolled and randomly assigned to three dosage schedules: (A) 700 mg (four tablets) single dose; (B) 700 mg 12-hourly x two doses; and (C) 1,400 mg (eight tablets) single dose. Patients were observed for 28 days, with clinical, parasitological, and haematological assessments. RESULTS: A total of 108 patients completed the study. The overall 28-day cure rate was 88.9%. Day 28-cure rates of the three dosage schedules were 85.3%, 93.1% and 88.9% for Group A, B and C respectively. Adverse events were few and mild, the commonest being weakness and headache; there was no serious adverse event. CONCLUSION: Concerns for emergence of parasite resistance due to the use of artemisinin-naphthoquine as single dose regimen is likely to compromise the usefulness of this potentially important combination treatment. A robust multi-centre trial is recommended to evaluate a three-day regimen with potentials to achieve high cure rates while minimizing the risk of emergence of resistant parasite strains.

Surgical versus non-surgical management of abdominal injury.

BACKGROUND: Injury to the abdomen can be blunt or penetrating. Abdominal injury can damage internal organs such as the liver, spleen, kidneys, and intestine. There are controversies about the best approach to manage abdominal injuries. OBJECTIVES: To assess the effects of surgical and non-surgical interventions in the management of abdominal trauma. SEARCH METHODS: We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library 2012, issue 1), MEDLINE, PubMed, EMBASE, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), and ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) all until January 2012; CINAHL until January 2009. We also searched the reference lists of all eligible studies and the trial registers www.controlled-trials.com and www.clinicaltrials.gov in January 2012. SELECTION CRITERIA: Randomised controlled trials of surgical and non surgical interventions among patients with abdominal injury who are haemodynamically stable and with no signs of peritonitis. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the search criteria. One study involving participants with penetrating abdominal injury met the inclusion criteria. Data were extracted by two authors using a standard data extraction form. MAIN RESULTS: One study including 51 participants with moderate risk of bias was included. Participants were randomised to surgery or an observation protocol. There were no deaths among the participants. Seven participants had complications; 5 (18.5%) in the surgical group and 2 (8.3%) in the non-surgical group; the difference was not statistically significant (p = 0.42; Fischer's exact). Among the 27 who had surgery six (22.2%) surgeries were negative laparotomies, and 15 (55.6%) were non-therapeutic. AUTHORS' CONCLUSIONS: Based on the findings of one study involving 51 participants, which was at moderate risk of bias, there is no evidence to support the use of surgery over observation for people with abdominal trauma.

Honey for acute cough in children.

BACKGROUND: Cough causes concern for parents and is a major cause of outpatient visits. It can impact on quality of life, cause anxiety and affect sleep in parents and children. Several remedies, including honey, have been used to alleviate cough symptoms. OBJECTIVES: To evaluate the effectiveness of honey for acute cough in children in ambulatory settings. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2011) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1950 to December week 4, 2011); EMBASE (1990 to January 2012); CINAHL (1981 to January 2012); Web of Science (2000 to January 2012); AMED (1985 to January 2012); LILACS (1982 to January 2012); and CAB abstracts (2009 to January 2012). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing honey given alone, or in combination with antibiotics, versus nothing, placebo or other over-the-counter (OTC) cough medications to participants aged from two to 18 years for acute cough in ambulatory settings. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results for eligible studies and extracted data on reported outcomes. MAIN RESULTS: We included two RCTs of high risk of bias involving 265 children. The studies compared the effect of honey with dextromethorphan, diphenhydramine and 'no treatment' on symptomatic relief of cough using the 7-point Likert scale.Honey was better than 'no treatment' in reducing frequency of cough (mean difference (MD) -1.07; 95% confidence interval (CI) -1.53 to -0.60; two studies; 154 participants). Moderate quality evidence suggests honey did not differ significantly from dextromethorphan in reducing cough frequency (MD -0.07; 95% CI -1.07 to 0.94; two studies; 149 participants). Low quality evidence suggests honey may be slightly better than diphenhydramine in reducing cough frequency (MD -0.57; 95% CI -0.90 to -0.24; one study; 80 participants).Adverse events included mild reactions (nervousness, insomnia and hyperactivity) experienced by seven children (9.3%) from the honey group and two (2.7%) from the dextromethorphan group; the difference was not significant (risk ratio (RR) 2.94; 95% Cl 0.74 to 11.71; two studies; 149 participants). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14; 95% Cl 0.01 to 2.68; one study; 80 participants) but there was no significant difference between honey versus dextromethorphan or honey versus diphenhydramine. No adverse event was reported in the 'no treatment' group. AUTHORS' CONCLUSIONS: Honey may be better than 'no treatment' and diphenhydramine in the symptomatic relief of cough but not better than dextromethorphan. There is no strong evidence for or against the use of honey.

Using and improving the PHISICC paper-based tools in the health facility laboratories: Examples of Human Centered Design taking systems thinking into practice, in Côte d'Ivoire and Nigeria.

Background: Health workers in low- and middle-income countries are increasingly demanded to collect more and more data to report them to higher levels of the health information system (HIS), in detriment of useful data for clinical and public health decision-making, potentially compromising the quality of their health care provison. In order to support health workers' decision-making, we engaged with partners in Côte d'Ivoire, Mozambique and Nigeria in a research project to conceive, design, produce, implement and test paper-based health information tools: the PHISICC tools. Our aim was to understand the use of PHISICC tools by health workers and to improve them based on their feedback. Methods: The design Health Facility Laboratories (HF Labs) in Côte d'Ivoire and in Nigeria were set up after months of use of PHISICC tools. Activities were structured in three phases or 'sprints' of co-creative research. We used a transdisciplinary approach, including anthropology and Human Centered Design (HCD), observations, shadowing, structured interviews and co-creation. Results: Health workers appreciated the standardization of the tools across different health care areas, with a common visual language that optimized use. Several design issues were raised, in terms of formats and contents. They strongly appreciated how the PHISICC registers guided their clinical decision-making and how it facilitated tallying and counting for monthly reporting. However, adherence to new procedures was not universal. The co-creation sessions resulted in modifications to the PHISICC tools of out-patient care and postnatal care. Discussion: Although health systems and systemic thinking allowed the teams to embrace complexity, it was the HCD approach that actually produced a shift in researchers' mind-set: from HIS as data management tools to HIS as quality of care instruments. HCD allowed navigating the complexity of health systems interventions due to its capacity to operate change: it not only allowed us to understand how the PHISICC tools were used but also how to further improve them. In the absence of (or even with) an analytical health systems framework, HCD approaches can work in real-life situations for the ideation, testing and implementation of interventions to improve health systems and health status outcomes.

Interventions for improving coverage of child immunization in low- and middle-income countries.

BACKGROUND: Immunization coverage remains low, particularly in low- and middle-income countries (LMIC), despite its proven effectiveness in reducing the burden of childhood infectious diseases. A Cochrane review has shown that patient reminder recall is effective in improving coverage of immunization but technologies to support this strategy are lacking in LMIC. OBJECTIVES: To evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunization coverage in LMIC. SEARCH STRATEGY: We searched the following databases for primary studies: Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 1, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 8 July 2010); MEDLINE, Ovid (1948 to March Week 3 2011) (searched 30 March 2011); EMBASE, Ovid (1980 to 2010 Week 26) (searched 8 July 2010); CINAHL, EBSCO (1981 to present ) (searched 8 July 2010); LILACS, VHL (1982 to present) (searched 8 July 2010); Sociological Abstracts, CSA Illumnia (1952 to current) (searched 8 July 2010). Reference lists of all papers and relevant reviews were identified and searched for additional studies. SELECTION CRITERIA: Included studies were randomized controlled trials (RCTs), non-randomized controlled trials (NRCTs), and interrupted-time-series (ITS) studies. Study participants were children aged 0 to 4 years, caregivers, and health providers. Interventions included patient and community-oriented interventions, provider-oriented interventions, health system interventions, multi-faceted (any combination of the above categories of interventions), and any other single or multifaceted intervention intended to improve childhood immunisation coverage The primary outcome was the proportion of the target population fully immunized with recommended vaccines by age. DATA COLLECTION AND ANALYSIS: Two authors independently screened full articles of selected studies, extracted data, and assessed study quality. MAIN RESULTS: Six studies were included in the review; four were at high risk of bias. There was low quality evidence that: facility based health education may improve the uptake of combined vaccine against diphtheria, pertussis, and tetanus (DPT3) coverage (risk ratio (RR) 1.18; 95% CI 1.05 to 1.33); and also that a combination of facility based health education and redesigned immunization cards may improve DPT3 coverage (RR 1.36; 95% CI 1.22 to 1.51). There was also moderate quality evidence that: evidence-based discussions probably improve DPT3 coverage (RR 2.17; 95% CI 1.80 to 2.61), and that information campaigns probably increase uptake of at least a dose of a vaccine (RR 1.43; 95% CI 1.01 to 2.02). AUTHORS' CONCLUSIONS: Home visits and health education may improve immunization coverage but the quality of evidence is low.