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Background A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant. Methods We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as ‘rich’ or ‘sparse’, coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model. Results After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory. Conclusions Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.

ObjectivesTo assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes.DesignSystematic review.Data sourcesWe searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019.Eligibility criteriaWe included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care.Data extraction and synthesisTwo authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.ResultsOf 7568 records, we included five studies—two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty).ConclusionsCurrent evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations.PROSPERO registration numberCRD42018099314.

Systematic reviews provide a critical summary of a body of knowledge that links research to decision making, whether to inform public health, clinical medicine, medical education, system-level changes, or advocacy. Good reviews are accessed by a wide range of audiences, including health service users, health service providers, and policy decision makers. Because the topics studied, the thinking behind the review questions, the analytical plan, and the review’s interpretation in the broader policy context are often complex, diagrams can play an important role in communicating the review to the reader. Indeed, graphic design is increasingly important for researchers to communicate their work to each other and the wider world.1 Visualizing the topic under study facilitates discussion, helps understanding by making complexity more accessible, provokes deeper thinking, and makes concepts more memorable.2 Higher impact scientific articles tend to include more diagrams, possibly because diagrams improve clarity and thereby lead to more citations or because high-impact articles tend to include novel, complex ideas that require visual explanation.3\ud Merriam-Webster’s Dictionary defines a diagram as “a graphic design that explains rather than represents, especially: a drawing that shows arrangement and relations (as of parts).”4 Established standards exist for visualizing the flow of studies through a review,5 risk of bias, and individual study and meta-analysis results in forest plots; these are not the subject of this editorial. We consider diagrams that communicate the conceptual framework underpinning reviews.\ud Diagrams include “logic models,” “framework models,” or “conceptual models”—terms that are often used interchangeably and inconsistently in the literature.6 We examine how diagrams can help review authors and readers and offer guidance for presenting information diagrammatically. We based our work on a purposive search for diagrams from the Cochrane Library and sources of reviews more likely to illustrate conceptual frameworks. Drawing on the data and our own experience, we adapted rapid appraisal methods7 for analyzing documents, taking an iterative, inductive approach to understand what enhances the clarity and utility of diagrams. We then related this learning to methodological articles of systematic reviewing and science communication (Appendix A, available as a supplement to the online version of this article at http://www.ajph.org). We built on our collective experience of diagrams in reviews and helping others to develop them.\ud We first describe diagrams’ various purposes. Then we discuss what we recognized, as systematic review readers, authors, and editors, as important steps to creating a good diagram. Next, we consider how diagrams can enhance the review process for authors. We discuss these findings in relation to methodologies that routinely integrate diagrams into structure systematic reviews: framework synthesis8 and logic models of illness or treatment pathways, where principles and agreed good practice are emerging.9 Finally, we discuss theories underpinning science communication.10

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.

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.

BackgroundPeople living with human immunodeficiency virus (PLHIV) struggle with the challenges of living with a chronic disease and integrating antiretroviral treatment (ART) and care into their daily lives. The aims of this study were as follows: (1) to undertake the first mega-aggregation of qualitative evidence syntheses using the methods of framework synthesis and (2) make sense of existing qualitative evidence syntheses that explore the barriers and facilitators of adherence to antiretroviral treatment, linkage to care and retention in care for PLHIV to identify research gaps.MethodsWe conducted a comprehensive search and did all screening, data extraction and critical appraisal independently and in duplicate. We used the Kaufman HIV Behaviour Change model (Kaufman et al., 2014) as a framework to synthesise the findings using the mega-aggregative framework synthesis approach, which consists of 8 steps: (1) identify a clearly defined review question and objectives, (2) identify a theoretical framework or model, (3) decide on criteria for considering reviews for inclusion, (4) conduct searching and screening, (5) conduct quality appraisal of the included studies, (6) data extraction and categorisation, (7) present and synthesise the findings, and (8) transparent reporting. We evaluated systematic reviews up to July 2018 and assessed methodological quality, across reviews, using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews.ResultsWe included 33 systematic reviews from low, middle- and high-income countries, which reported on 1,111,964 PLHIV. The methodological quality of included reviews varied considerably. We identified 544 unique third-order concepts from the included systematic reviews, which were reclassified into 45 fourth-order themes within the individual, interpersonal, community, institutional and structural levels of the Kaufman HIV Behaviour Change model. We found that the main influencers of linkage, adherence and retention behaviours were psychosocial and personal characteristics—perceptions of ART, desires, fears, experiences of HIV and ART, coping strategies and mental health issues—interwoven with other factors on the interpersonal, community, institutional and structural level. Using this approach, we found interdependence between factors influencing ART linkage, retention and adherence and identified the need for qualitative evidence that explores, in greater depth, the complex relationships between structural factors and adherence, sociodemographic factors such as community violence and retention, and the experiences of growing up with HIV in low- and middle-income countries—specifically in children, youth, women and key populations.ConclusionsThis is the first mega-aggregation framework synthesis, or synthesis of qualitative evidence syntheses using the methods of framework synthesis at the overview level. We found the novel method to be a transparent and efficient method for assessing the quality and making sense of existing qualitative systematic reviews.Systematic review registrationThe protocol of this overview was registered on PROSPERO (CRD42017078155) on 17 December 2017.

BackgroundEvidence-based healthcare (EBHC) knowledge and skills are recognised as core competencies of healthcare professionals worldwide, and teaching EBHC has been widely recommended as an integral part of their training. The objective of this overview of systematic reviews (SR) was to update evidence and assess the effects of various approaches for teaching evidence-based health care (EBHC) at undergraduate (UG) and postgraduate (PG) medical education (ME) level on changes in knowledge, skills, attitudes and behaviour.Methods and findingsThis is an update of an overview that was published in 2014. The process followed standard procedures specified for the previous version of the overview, with a modified search. Searches were conducted in Epistemonikos for SRs published from 1 January 2013 to 27 October 2020 with no language restrictions. We checked additional sources for ongoing and unpublished SRs. Eligibility criteria included: SRs which evaluated educational interventions for teaching EBHC compared to no intervention or a different strategy were eligible. Two reviewers independently selected SRs, extracted data and evaluated quality using standardised instrument (AMSTAR2). The effects of strategies to teach EBHC were synthesized using a narrative approach. Previously published version of this overview included 16 SR, while the updated search identified six additional SRs. We therefore included a total of 22 SRs (with a total of 141 primary studies) in this updated overview. The SRs evaluated different educational interventions of varying duration, frequency, and format to teach various components of EBHC at different levels of ME (UG, PG, mixed). Most SRs assessed a range of EBHC related outcomes using a variety of assessment tools. Two SRs included randomised controlled trials (RCTs) only, while 20 reviews included RCTs and various types of non-RCTs. Diversity of study designs and teaching activities as well as aggregated findings at the SR level prevented comparisons of the effects of different techniques. In general, knowledge was improved across all ME levels for interventions compared to no intervention or pre-test scores. Skills improved in UGs, but less so in PGs and were less consistent in mixed populations. There were positive changes in behaviour among UGs and PGs, but not in mixed populations, with no consistent improvement in attitudes in any of the studied groups. One SR showed improved patient outcomes (based on non-randomised studies). Main limitations included: poor quality and reporting of SRs, heterogeneity of interventions and outcome measures, and short-term follow up.ConclusionsTeaching EBHC consistently improved EBHC knowledge and skills at all levels of ME and behaviour in UGs and PGs, but with no consistent improvement in attitudes towards EBHC, and little evidence of the long term influence on processes of care and patient outcomes. EBHC teaching and learning should be interactive, multifaceted, integrated into clinical practice, and should include assessments.Study registrationThe protocol for the original overview was developed and approved by Stellenbosch University Research Ethics Committee S12/10/262.Update of the overviewYoung T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based health care (EBHC)? Overview of systematic reviews. PLoS One. 2014;9(1):e86706. doi:10.1371/journal.pone.0086706.

BackgroundThe 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.MethodsWe 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.

Postgraduate training is moving from face-to-face workshops or courses to online learning to help increase access to knowledge, expertise and skills, and save the cost of face-to-face training. However, moving from face-to-face to online learning for many of us academics is intimidating, and appears even more difficult without the help of a team of technologists. In this paper, we describe our approach, our experiences and the lessons we learnt from converting a Primer in Systematic Reviews face-to-face workshop to a 6-week online course designed for healthcare professionals in Africa. We learnt that the team needs a balance of skills and experience, including technical know-how and content knowledge; that the learning strategies needed to achieve the learning objectives must match the content delivery. The online approach should result in both building knowledge and developing skills, and include interactive and participatory approaches. Finally, the design and delivery needs to keep in mind the limited and expensive internet access in some resource-poor settings in Africa.

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.

Contains fulltext : 190759.pdf (Publisher’s version ) (Closed access) The complexity associated with how interventions result-or fail to result-in outcomes and how context matters is increasingly recognised. Logic models provide an important tool for handling complexity, with contrasting uses in programme evaluation and evidence synthesis. To reconcile these, we developed an approach that combines the strengths of both traditions, propose a taxonomy of logic models, and provide guidance on how to choose between approaches and types of logic models in systematic reviews and health technology assessments (HTA). The taxonomy distinguishes 3 approaches (a priori, staged, and iterative) and 2 types (systems-based and process-orientated) of logic models. An a priori logic model is specified at the start of the systematic review/HTA and remains unchanged. With a staged logic model, the reviewer prespecifies several points, at which major data inputs require a subsequent version. An iterative logic model is continuously modified throughout the systematic review/HTA process. System-based logic models describe the system, in which the interaction between participants, intervention, and context takes place; process-orientated models display the causal pathways leading from the intervention to multiple outcomes. The proposed taxonomy of logic models offers an improved understanding of the advantages and limitations of logic models across the spectrum from a priori to fully iterative approaches. Choice of logic model should be informed by scope of evidence synthesis, presence/absence of clearly defined population, intervention, comparison, outcome (PICO) elements, and feasibility considerations. Applications across distinct interventions and methodological approaches will deliver good practice case studies and offer further insights on the choice and implementation of logic modelling approaches.

Background A broad range of interventions have been implemented to improve ambient air quality, and many of these have been evaluated. Yet to date no systematic review has been conducted to identify and synthesize these studies. In this systematic review, we assess the effectiveness of interventions in reducing ambient particulate matter air pollution and improving adverse health outcomes. Methods We searched a range of electronic databases across multiple disciplines, as well as grey literature databases, trial registries, reference lists of included studies and the contents of relevant journals, through August 2016. Eligible for inclusion were randomized and cluster randomized controlled trials, as well as several non-randomized study designs often used for evaluating air quality interventions. We included studies that evaluated interventions targeting industrial, residential, vehicular and multiple sources, with respect to their effect on mortality, morbidity and the concentrations of particulate matter (PM – including PM10, PM2.5, coarse particulate matter and combustion-related PM), as well as several criteria pollutants, including ozone, carbon monoxide, nitrogen oxides, nitrogen dioxide, nitric oxide and sulphur dioxide. We did not restrict studies based on the population, setting or comparison. Two authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We assessed risk of bias using the Graphic Appraisal Tool for Epidemiological studies (GATE) for correlation studies, as modified and employed by the UK National Institute for Health and Care Excellence. We synthesized evidence narratively, as well as graphically using harvest plots. We assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results We included 42 studies assessing 38 unique interventions. These comprised a heterogeneous mix of interventions, including those aiming to address industrial sources (n = 5; e.g. the closure of a factory), residential sources (n = 7; e.g. coal ban), vehicular sources (n = 22; e.g. low emission zones), and multiple sources (n = 4; e.g. tailored measures that target both local traffic and industrial polluters). Evidence for effectiveness was mixed. Most included studies observed either no significant association or an association favoring the intervention, with little evidence that the assessed interventions might be harmful. 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. Some evidence suggests that interventions are associated with improvements in air quality and human health, with very little evidence suggesting interventions were harmful. The evidence base highlights the challenges related to establishing the effectiveness of specific air pollution interventions on outcomes. It also points to the need for improved study design and analysis methods, as well as more uniform evaluations. The prospective planning of evaluations and an evaluation component built into the design and implementation of interventions may also be particularly beneficial.

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.

BACKGROUND: Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS: We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS: We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION: This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives. ispartof: PLOS ONE vol:14 issue:1 ispartof: location:United States status: published

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. (C) 2016 ELSEVIER. All rights reserved.

Interest in assessing the health effects of air quality interventions has grown in response to questions about the benefit of further tightening air pollution regulations. No systematic review has ...

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. Electronic supplementary material The online version of this article (10.1186/s12913-018-3290-8) contains supplementary material, which is available to authorized users.

ObjectivesTo examine whether regional biomedical journals in Africa had policies on plagiarism and procedures to detect it; and to measure the extent of plagiarism in their original research articles and reviews.DesignCross sectional survey.Setting and participantsWe selected journals with an editor-in-chief in Africa, a publisher based in a low or middle income country and with author guidelines in English, and systematically searched the African Journals Online database. From each of the 100 journals identified, we randomly selected five original research articles or reviews published in 2016.OutcomesFor included journals, we examined the presence of plagiarism policies and whether they referred to text matching software. We submitted articles to Turnitin and measured the extent of plagiarism (copying of someone else’s work) or redundancy (copying of one’s own work) against a set of criteria we had developed and piloted.ResultsOf the 100 journals, 26 had a policy on plagiarism and 16 referred to text matching software. Of 495 articles, 313 (63%; 95% CI 58 to 68) had evidence of plagiarism: 17% (83) had at least four linked copied or more than six individual copied sentences; 19% (96) had three to six copied sentences; and the remainder had one or two copied sentences. Plagiarism was more common in the introduction and discussion, and uncommon in the results.ConclusionPlagiarism is common in biomedical research articles and reviews published in Africa. While wholesale plagiarism was uncommon, moderate text plagiarism was extensive. This could rapidly be eliminated if journal editors implemented screening strategies, including text matching software.

Healthcare decisions need to be informed by reliable research. This requires practitioners to phrase clear questions when being faced with a knowledge gap, find the evidence that will best answer the question, critically appraise the evidence for validity and reliability and apply the findings to the unique setting. Systematic reviews are often the first point of reference when seeking healthcare answers. This article provides a short guide on finding, reading and interpreting systematic reviews, as well as applying the results, illustrated by a clinical scenario (multiple micronutrient powders for health and nutrition in children under two years of age).

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 placebo None 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 agent Only 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.

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 antibiotics One 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.

OBJECTIVE To describe the development and application of logic model templates for systematic reviews and health technology assessments (HTAs) of complex interventions. STUDY DESIGN AND SETTING This study demonstrates the development of a method to conceptualize complexity and make underlying assumptions transparent. Examples from systematic reviews with specific relevance to Sub-Saharan Africa (SSA) and other low- and middle-income countries (LMICs) illustrate its usefulness. RESULTS Two distinct templates are presented: the system-based logic model, describing the system in which the interaction between participants, intervention, and context takes place; and the process-orientated logic model, which displays the processes and causal pathways that lead from the intervention to multiple outcomes. CONCLUSION Logic models can help authors of systematic reviews and HTAs to explicitly address and make sense of complexity, adding value by achieving a better understanding of the interactions between the intervention, its implementation, and its multiple outcomes among a given population and context. They thus have the potential to help build systematic review capacity-in SSA and other LMICs-at an individual level, by equipping authors with a tool that facilitates the review process; and at a system-level, by improving communication between producers and potential users of research evidence.

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. Plain Language Summary Antimalarial drugs as a treatment of anaemia in children living in malaria-endemic areas Children living in malaria areas may develop severe anaemia, often caused by malaria infection, and this can cause death if not treated properly. Intermittent preventive treatment (IPT) is a course of malaria treatment given regularly to these children in order to prevent infection and malaria illness. It has been suggested that IPT could be used to treat children with anaemia in these areas. We aimed to find all the studies looking at treating anaemic children with IPT in order to see what the overall effect is. We examined the evidence available up to 4 December 2014. We included six trials in this review, with a total number of 3847 participants. In all the trials, one group received IPT and the control group received placebo. Three trials were done in low malaria endemicity areas and the other three in high endemicity areas. In some trials, iron supplements were also given to children, which is also a treatment for anaemia, and we took this into consideration when analysing the data. Our results did not find that the number of children who died or were admitted to hospital was lower in the group receiving IPT, irrespective of whether they received iron (moderate quality evidence); and there was no difference in the number of children with anaemia at the end of follow-up (moderate quality evidence). Average haemoglobin levels were higher in the IPT group compared to the placebo group, but the effect was modest (low quality evidence). Although our results show that there are small benefits in haemoglobin levels when treating anaemic children with IPT, we did not detect an effect on death or hospital admissions. However, three of the six included trials were conducted in low endemicity areas where malaria transmission is low and thus any protective effect is likely to be modest.