The Cochrane Methods team has defined a programme of work to improve the quality and impact of Cochrane reviews in public health with the support of the Methods Executive, Methods Groups and Public Health and Health Systems Network. The programme has been designed to foster collaboration between Methods Groups and Cochrane Review Group (CRG) Networks and to support the ongoing response to COVID-19. It focuses on producing high-priority public health reviews and delivering user-friendly resources to improve the planning, conduct and reporting of methods within them.
Why focus on public health?
Public health reviews, especially those relating to COVID-19, are often highly scrutinised and have wide-ranging impacts on policy and global health outcomes. However, public health reviews typically address complex questions and use a range of complex methods that are considered non-standard in Cochrane, and existing guidance is not always being applied accurately or consistently. In the Cochrane context, public health reviews are defined as those that include diverse sources of evidence (e.g., not solely RCTs), complex interventions that are delivered at the population level (e.g., policies rather than drugs or treatments), exposures that cannot be delivered in randomized controlled trials (e.g. studying the effects of a chemical or viral exposure), and outcomes that measure something other than efficacy (e.g., harms, process outcomes, implementation or costs).
How will the programme support review production?
The programme of work is based on the premise that high-quality, timely review production requires expert methodological support and pragmatic resources that help authors and editors translate Handbook guidance into practice. The topics and approach have been designed to bring CRGs and Methods Groups together to ensure the projects and their outputs are designed with the needs of Cochrane editors and authors in mind.
Though the focus is on public health reviews, the challenges faced within them are often encountered in other topic areas, such as choosing when and how to include non-randomised studies of interventions, assessing bias in non-randomized studies of interventions, planning a useful synthesis in light of complexity and heterogeneity, incorporating qualitative evidence, and reporting results when a meta-analysis has not been possible. By tackling the challenges in a COVID-priority area, the aim will be to develop, adapt and apply the tools more widely across Cochrane. The Methods Support Unit plays an important role in bridging the gap between CRGs and Methods Groups and will be embedded in the projects to support capacity-building.
What has happened so far?
The Cochrane Methods team mapped the most frequently cited challenges from two recent methods surveys of CRGs by methodological area and listed possible projects to address them. The projects were then shortlisted considering extent of author and CRG need, potential for impact, and the anticipated time and resources required to deliver a useful output. The projects have been refined with Cochrane’s Methods Executive and project teams are now being brought together. Each has been designed to deliver a practical tool or decision aid for editors or authors by the end of 2021 that harnesses existing theory so that it can be more easily applied.
- Project 1: Preferred and accepted risk of bias tools for assessing bias in non-randomised studies of interventions
- Project 2: Practical guidance to frame public health intervention review questions, define outcomes and choose appropriate study designs
- Project 3: Standard terminology to help authors describe different study designs appropriately and consistently
- Project 4: Practical conduct and reporting guidance for assessing risk of bias in non-randomised studies of interventions and/or ROBINS-I
- Project 5: Practical tools to implement SWiM reporting guidance to improve pre-specification and presentation of findings
In addition to the projects, plans are underway to deliver a suite of learning resources around qualitative evidence synthesis, and to house a bank of exemplar reviews showcasing best practice. A Methods Symposium will also take place in October 2021 covering a range of methodological challenges relating to public health reviews and complex interventions. The symposium will be followed by a methods implementation surgery led by the Methods Support Unit and aimed at CRGs in November 2021 to discuss the outputs that were developed and how they can support editors and authors.
How can I get involved?
Each project will be encouraged to use Task Exchange to call for volunteers across the community to provide feedback on the first draft of the tools and resources being developed. Those interested in getting involved are encouraged to create a profile or contact the Methods Team directly to enquire about other ways to contribute.
- Introduction to a collection of articles in the American Journal of Public Health describing the issues in more detail, coordinated by Lisa Bero, Senior Editor of the Cochrane Public Health and Health Systems network
- Priority review topics guiding Cochrane’s ongoing response to COVID-19
World Evidence-Based Healthcare Day will take place again this year on 20 October – learn more on the website
On World Evidence-Based Healthcare (EBHC) Day, seven leaders in evidence-based healthcare spotlight the global impact of evidence on healthcare research, policy, practice and health outcomes.
Today JBI, Cochrane, Campbell Collaboration, GIN, the Institute for Evidence-Based Healthcare, the Centre for Evidence-based Health Care and NICE launch the World EBHC Day 2021 campaign, ‘the role of evidence in an infodemic’.
The 2021 campaign supports the infodemic management efforts of the World Health Organization (WHO) by exploring the role of evidence in an infodemic, in particular promoting access to trustworthy, evidence-informed health information.
“The COVID-19 pandemic has highlighted the importance of developing rapid evidence-informed responses and ensuring the best available evidence is accessible, transparent and understood. The rapid response of the global evidence community has been important and necessary. However, it has been accompanied by the exponential production of misinformation which has contributed to the creation of a global infodemic,” explains Bianca Pilla, World EBHC Day Committee Chair.
The overabundance of information and the distribution of misinformation is amplified through social media and spreads like a virus, making it hard for people to find trustworthy, evidence-based guidance when they need it.
“Never before has there been a more urgent need for a coordinated, evidence-based approach to mitigating the harm caused by an infodemic and the spread of health misinformation. COVID-19 misinformation is harming communities and individuals,” says Dr Sylvie Briand, Director of the WHO Department of Global Infectious Hazard Preparedness.
The World EBHC Day campaign in 2021 responds to the WHO’s call for action. Guided by infodemiologist Gunther Eysenbach’s work on infodemic management and the WHO’s infodemic management framework, JBI, together with the organising partners of World EBHC Day, provide a platform for the global evidence community to share their experiences, stories and collective wisdom.
WHO has produced a public health research agenda which recognises that infodemic management is an emerging and evolving field of research and practice, and that transdisciplinary synthesis is required to develop the field.
“The infodemic has been a major challenge to achieving an evidence-informed response to COVID-19,” says Dr Karla Soares-Weiser, Editor in Chief of the Cochrane Library. “This year’s World EBHC Day will be a timely opportunity for the evidence community to come together and explore our role in the responding to the current infodemic, as well as to consider how we can prepare for future infodemics.”
World EBHC Day calls on individuals and organisations in healthcare around the world to take action as we lead up to World EBHC Day on 20 October. Visit worldebhcday.org and contribute to a global response for infodemic management.
About World Evidence-Based Healthcare Day 2021
World Evidence-Based Healthcare (EBHC) Day is held on 20 October each year. It is a global initiative that raises awareness of the need for better evidence to inform healthcare policy, practice and decision making in order to improve health outcomes globally. It is an opportunity to participate in debate about global trends and challenges, but also to celebrate the impact of individuals and organisations worldwide, recognising the work of dedicated researchers, policymakers and health professionals in improving health outcomes.
Location: De Montfort University - Faculty of Health and Life Sciences. Leicester, UK
Salary: Part-time, 0.3 FTE, 11.1 hours per week
Contract type: 13 month fixed Term Contract
Closes: 8 August
The purpose of the role is to assist the principal investigator in all phases of the NIHR-funded study: ‘Cochrane Review of Interventions for Hyperhidrosis’. Key duties will include searching and selection of studies, data extraction, assessment of risk of bias, and data analysis and interpretation. You will also contribute to study outputs.
They are looking for someone with a PhD in Bioscience or Healthcare related discipline or equivalent experience. You will have experience of conducting high quality systematic reviews and meta-analysis. The ability to explain complex knowledge to a range of audiences is essential, along with excellent verbal and written communication skills. Good organisations skills and the ability to work well in a team are also required.
Featured review: Compression bandages or stockings versus no compression for treating venous leg ulcers
The existing expectations for RoB 2 that were set out in November 2020 have been revisited and kept in place after results of a Cochrane-funded study were released. The study was initiated to underpin methods policy and implementation plans with data about the usability of RoB 2 compared with the study-based Cochrane risk of bias tool for RCTs, and its impact on efficiency and review quality. The work was led by Bernd Richter and Bianca Hemmingsen from the Cochrane Metabolic and Endocrine Disorders Group and looked at inter-reliability across domains, time-taken to perform assessments, usability issues, and consequences for analysis results and interpretation.
The decision to keep the current expectations in place means that uptake of RoB 2 to assess randomised controlled trials is encouraged but there will still be the option to use the study-based Cochrane risk of bias tool, providing it is applied in a way that allows for differences in bias across outcomes to be captured. Reviews using RoB 2 should be prepared and edited in RevMan Web to take advantage of functionality that has been designed to store and present assessments clearly. Authors wishing to adopt RoB 2 after the protocol has been published, including switching to the tool for a review update, should make the decision with editorial staff and consult the resources available in the Starter Pack for reporting guidance.
The authors of this Cochrane systematic review, published today by Cochrane Infectious Diseases Group, found no evidence to support the use of ivermectin for treating or preventing COVID-19 infection, but the evidence base is limited.
Evaluation of ivermectin is continuing in 31 ongoing studies; the authors will update this review with their results when they become available.
Main authors of the review, Maria Popp and Stephanie Weibel said: “The lack of good quality evidence on efficacy and safety of ivermectin arises from a study pool that consists mainly of small, insufficiently powered RCTs with overall limited quality regarding study design, conduct, and reporting. Current evidence does not support using ivermectin for treating or preventing of COVID-19 unless they are part of well-designed randomized trials.”What is ivermectin?
Ivermectin is a medicine used to treat parasites such as intestinal parasites in animals and scabies in humans. It is cheap and is widely used in regions of the world where parasitic infestations are common. It has few unwanted effects.
Tests in the laboratory show ivermectin can slow the reproduction of the COVID-19 (SARS-CoV-2) virus but such effects would need major doses in humans.
Medical regulators have not approved ivermectin for COVID-19. It should only be used as part of well-designed studies (called randomized controlled trials) evaluating potential effects.What did the authors want to find out?
They wanted to know if ivermectin reduces death, illness, and length of infection in people with COVID-19, or if it is useful in prevention of the disease. They included studies comparing the medicine to placebo (dummy treatment), no treatment, usual care, or treatments for COVID-19 that are known to work to some extent, such as remdesivir or dexamethasone. They excluded studies that compared ivermectin to other drugs that do not work, such as hydroxychloroquine, or that are not known to be effective against COVID-19.
They evaluated the effects of ivermectin in infected people on:
- people dying;
- whether people's COVID-19 symptoms got better or worse;
- unwanted effects;
- hospital admission or time in hospital;
- viral clearance.
For prevention, they sought the effect on preventing COVID-19 and SARS-CoV-2 infection.What did they do?
The authors searched for randomized controlled trials that investigated ivermectin to prevent or treat COVID-19 in humans. People being treated with ivermectin had to have laboratory-test confirmed COVID-19 and be receiving treatment in hospital or as outpatients.
They compared and summarized the results of the studies and rated our confidence in the evidence, based on common criteria as to how reliable the evidence is.What did they find?
The authors found 14 studies with 1678 participants that investigated ivermectin compared to no treatment, placebo, or usual care.
For treatment, there were nine studies of people with moderate COVID-19 in hospital and four of outpatients with mild COVID-19. The studies used different doses of ivermectin and different durations of treatment.
One study investigated ivermectin to prevent COVID-19.
They also found 31 ongoing studies, and there are 18 studies still requiring clarification from the authors or not yet published.Main results
Treating people in hospital with COVID-19
The authors don't know whether ivermectin compared with placebo or usual care, 28 days after treatment:
- leads to more or fewer deaths (2 studies, 185 people);
- worsens or improves patients' condition assessed by need for ventilation (2 studies, 185 people) or oxygen (1 study, 45 people);
- increases or reduces unwanted events (1 study, 152 people).
Seven days after treatment, we don't know if ivermectin:
- increases or reduces negative COVID-19 tests (2 studies, 159 people).
Ivermectin compared to placebo or usual care may make little or no difference to improving patients' condition 28 days after treatment (1 study, 73 people) or to length of hospital stay (1 study, 45 people).
Treating outpatients with COVID-19
The author team don't know whether ivermectin compared with placebo or usual care:
- leads to more or fewer deaths 28 days after treatment (2 studies, 422 people);
- worsens or improves patients' condition 14 days after treatment assessed by need for ventilation (1 study, 398 people);
- increases or reduces negative COVID-19 tests seven days after treatment (1 study, 24 people).
Ivermectin compared to placebo or usual care may make little or no difference to improving outpatients' condition 14 days after treatment (1 study, 398 people) or to the number of unwanted events 28 days after treatment (2 studies, 422 people).
No studies looked at hospital admissions in outpatients.
The authors don't know whether ivermectin leads to more or fewer deaths compared with no drug (1 study, 304 people); no participant died 28 days after the drug. This study reported results for development of COVID-19 symptoms (but not confirmed SARS-CoV-2 infection) and unwanted events, but in a way that we could not include in our analyses. This study did not look at hospital admissions.
Main results explained
Main authors of the review, Maria Popp and Stephanie Weibel said: “The lack of good quality evidence on efficacy and safety of ivermectin arises from a study pool that consists mainly of small, insufficiently powered RCTs with overall limited quality regarding study design, conduct, and reporting. Current evidence does not support using ivermectin for treating or preventing of COVID-19 unless they are part of well-designed randomized trials.”
What are the limitations of the evidence?
Confidence in the evidence is very low because the authors could only include 14 studies with few participants and few events, such as deaths or need for ventilation. The methods differed between studies, and they did not report everything they were interested in, such as quality of life.How up to date is this evidence?
The evidence is up to date to 26 May 2021.What’s next?
Evaluation of ivermectin is continuing in 31 ongoing studies; the authors will update this review with their results when they become available.
From this year on, 25 July marks the new UN-recognised "World Drowning Prevention Day". This global advocacy event serves as an opportunity to highlight the tragic and profound impact of drowning on families and communities and offer life-saving solutions to prevent it.
On World Drowning Prevention Day 2021, the World Health Organization launched its guideline on the provision of day-care and basic swimming and water safety skills training to prevent drowning. Cochrane Public Health and First Aid and its initiator the Centre for Evidence-Based Practice feel proud to have developed 2 systematic reviews to inform this guideline.
Cochrane has been a non-governmental organization in official relations with WHO since 2011, and a major aspect of this partnership is supporting WHO’s global health guidelines with relevant evidence synthesis.
Cochrane review on day care provision
The WHO guideline contains evidence from the review 'Day care as a strategy for drowning prevention in children under 6 years of age in low‐ and middle‐income countries'. Cochrane Public Health group have joined focuses with Cochrane First Aid to ensure a successful dissemination of review finding.
WHO guideline recommendation on daycare provision
Based on the review's findings and the overall balance between the desirable and undesirable effects of day care provision, the WHO guideline recommends day care for children under 6 years of age as a drowning prevention strategy in countries with a high burden of drowning (strong recommendation; moderate-certainty evidence).
These day care programs must be developed and regulated with a main focus on quality (e.g. safety and well-being of children, involving parents, addressing nutritional needs) and other aspects (e.g. equitable staff treatment, open during periods of high drowning risk for drowning, measures to minimize the risk of spread of infectious diseases).
Cochrane is extremely proud of this valuable work and our continued partnership with WHO and between Cochrane Groups.
Four new WHO recommendations supported by Cochrane Pregnancy and Childbirth reviews and ‘living guideline’ approach
Cochrane has been a non-governmental organization in official relations with WHO since 2011, and a major aspect of this partnership is supporting WHO’s global health guidelines with relevant evidence synthesis.
The Cochrane Pregnancy and Childbirth Group has a long-standing collaboration with WHO on the development and updating of Cochrane reviews that inform WHO’s guidelines on global maternal and perinatal health.
This relationship has led to the development of a joint ‘living guidelines’ system. The approach uses a combination of ongoing literature surveillance to inform prioritization, rapid appraisal of the potential impacts of new evidence on recommendations and accelerated updating of high-priority Cochrane systematic reviews for key questions.
The four new WHO recommendations, which relate to the prevention and treatment of maternal peripartum infections, were developed using this approach.
Read the new WHO recommendations:
- Routine antibiotic prophylaxis for women undergoing operative vaginal birth
- Prophylactic antibiotics for women undergoing caesarean section
- Choice of antiseptic agent and method of application for preoperative skin preparation for caesarean section
- Vaginal preparation with antiseptic agents for women undergoing caesarean section
Cochrane is extremely proud of this valuable work and our continued partnership with WHO. It ensures that the latest evidence in maternal and perinatal health can be translated into practice as quickly as possible.
Author interview: Diagnostic test accuracy of telehealth assessment for dementia and mild cognitive impairment
Recently Cochrane Dementia and Cognitive Improvement published 'Diagnostic test accuracy of telehealth assessment for dementia and mild cognitive impairment.' We spoke with Dr Jenny McCleery, one of the authors of this Cochrane review, a Consultant Psychiatrist at Oxford Health NHS Foundation Trust, and the Joint Coordinating Editor, of Cochrane Dementia and Cognitive Improvement Group. Find out about the findings, how it came about, and how the pandemic prompted this review.
Can you tell us about this Cochrane Review? We'd love to know how it came about and what drew to you the topic.
We chose to write this review when we did because of the COVID-19 pandemic. All the authors work in NHS clinical services. Some of my regular work is in a community memory clinic, where we assess older people with suspected dementia. Of course, not every patient gets a diagnosis, but most commonly we diagnose dementia or mild cognitive impairment (MCI), which is a less severe condition in which the patient has some problems with thinking and/or remembering, but can still manage all their daily activities independently. In our service, a patient usually has some investigations before the appointment (blood tests and often a brain scan), and then spends 1-2 hours in clinic being interviewed and examined before a doctor makes a diagnosis.
Once the pandemic hit, there was an immediate suspension of all non-urgent face-to-face contacts and memory clinics were left scrabbling to find alternative ways to keep their services going. One way to do this was to offer telehealth assessments, that is assessments conducted using telephone or videoconferencing systems where the patient and the doctor making the diagnosis did not meet in person. Although it was clear that this would not be an ideal solution for many older people with suspected dementia, some patients were willing to try this approach.
This brought up lots of questions. One of these was whether patients could be confident that we would be able to make accurate diagnoses of dementia or mild cognitive impairment using telehealth methods. We knew there was some literature about this, mainly from higher income countries where there is an interest in providing services to remote and rural areas. We thought it would be important to look at the work that had been done in those areas to see what was known about accuracy of telehealth diagnoses.
Although we were motivated chiefly by the pandemic, there are other very good reasons to be interested in the use of telemedicine in dementia services. Worldwide, a large majority of people with dementia have not had a formal diagnosis. This affects not only their own and their families’ knowledge about the cause of their symptoms, but also their access to support services and treatments. It also means that governments and health and social care providers lack essential information to plan services for their populations. The World Health Organization (WHO) has set a target that by 2025 at least 50% of the estimated number of people with dementia in 50% of countries should have had a diagnosis. This target will be challenging in many countries, and innovative ways to increase access to assessment will be needed, particularly for older people living outside urban centres. Telehealth might be one part of a solution.
What is included in the review?
We looked for studies in which participants had two assessments for dementia within four weeks of each other - one assessment using telehealth methods and one standard face-to-face assessment. The face-to-face assessment was the ‘reference standard’, that is, it was assumed to give the correct result, and we then looked to see how well the telehealth assessment (the index test) agreed with it. These kinds of studies are known as cross-sectional diagnostic test accuracy studies.
We knew that in remote and rural services, the telehealth models used are not necessarily very ‘pure’. Even if the specialist making the diagnosis does not meet the patient in person, it is quite common for local healthcare professionals, e.g. nurses, to meet the patient to gather some information or do some of the examination in advance. Although these models might not be very useful in a pandemic situation, we included them because of the wider importance of telemedicine for dementia care in future.
We only found three studies with 136 participants to include in the review. Two studies (20 and 100 participants) took place in community settings in Australia and one study (16 participants) was conducted in veterans' care homes in the USA. All the telehealth assessments were done using videoconferencing systems. Only the smaller Australian study (20 participants) used a pure telehealth model in which all aspects of the assessment were done remotely. In the other two studies, quite a lot of information was gathered in person by nurses and used in both diagnostic assessments; this could make it more likely for the researchers to find close agreement between the in-person and telehealth diagnoses.
How can people with dementia, their carers and clinicians use the review to help them with their decision making?
The conclusions we could draw were limited by the very small amount of evidence and the application of our results to the pandemic situation was limited by the type of telehealth model used in the included studies.
In as far as they went, the results were reassuring for the accuracy of telehealth assessment. We found that telehealth assessment correctly identified 80% to 100% of the people who were diagnosed with dementia at face-to-face assessment and also correctly identified 80% to 100% of people who did not have dementia. Only one study (100 participants) attempted to diagnose MCI. In this study, 71% of participants who had MCI were correctly identified using telehealth assessment, as were 97% of those who had any cognitive diagnosis (either MCI or dementia), but only 22% of those who had no cognitive diagnosis at face-to-face assessment. However, the latter result was especially uncertain because there were so few patients in this category.
It is important to note that diagnoses of dementia and MCI made by two specialists seeing patients face-to-face will not show 100% agreement. Therefore, perfect agreement between telehealth and face-to-face assessments cannot be expected. The larger Australian study was interesting because it also included a group who had two face-to-face assessments; the authors found that agreement between telehealth and face-to-face assessments was no worse than agreement between two face-to-face assessments.
Therefore, although there was less evidence than we would like to have found, we did not find any reason to think that dementia diagnoses made by clinicians using videoconference assessments were likely to be inaccurate.
What would you like to see happen next to build on this study?
There are many more questions to be answered. We have not touched so far on the diagnosis of different subtypes of dementia, which is something else clinicians in memory clinics are usually trying to achieve. Although we intended to study accuracy of subtype diagnosis, we did not find any data on this at all. That would be something very important to study if telehealth were to remain in widespread use.
A few established telehealth dementia services, again mainly in remote and rural areas, have published data on the acceptability of the telehealth model to their populations. The factors affecting acceptability are likely to vary a lot from place to place, so local research on acceptability, equity and barriers to use is really important to inform service developments.
There is also clearly a need to compare different telehealth models on accuracy, acceptability, cost effectiveness and sustainability measures.
Although we were only looking at the accuracy of diagnosis in this review, patients and carers are of course also interested in the quality of ongoing support after a dementia diagnosis. Whether telehealth support services are effective is another whole area for interesting research.
Featured review: Non‐pharmacological interventions for preventing delirium in hospitalised non‐ICU patients
Cochrane Convenes is an online event hosted by Cochrane and co-organized with the World Health Organization and the COVID-19 Evidence Network to support Decision making (COVID-END) in October 2021.
Drawing on experiences of the COVID-19 pandemic, the inaugural Cochrane Convenes will bring together leaders across the world to explore and then recommend the changes needed in evidence synthesis to prepare for and respond to future global health emergencies. It will also engage a larger global community of evidence producers and users in conversation via social media and other parallel activities.
In order to help us plan the programme, we want to learn from your experiences over the past 18 months. Please can we ask you to respond to this short questionnaire by 9 August. It will take about 10 minutes. You will remain anonymous.
We will share responses and more information on how you can get involved in this opportunity in due course.
The ABC’s recent documentary series Old people’s home for 4 year olds surprised many by becoming a runaway ratings success. It attracted more viewers than Masterchef and took out an international Emmy Award to boot. It’s the first time the lives of lonely older Australians struggling with isolation, health and mental health issues have been the subject of so much public interest and attention. For Cochrane author Dr Paul Gardiner, this represents a welcome development.
‘One of the great public health successes of the twentieth century was increasing people’s lifespan,’ Paul says, ‘Now we really need a greater focus on the health and quality of life of older people throughout those additional years. To date, in many ways, they’ve been a largely forgotten population.’
Paul has long been interested in the well-being of older people, and believes understanding and addressing the impact of sedentary behaviour is one of the keys to delivering better health outcomes. As part of his broader research program, he recently co-authored a new Cochrane review on interventions for reducing sedentary behaviour in community‐dwelling older adults.
‘This is the first review of interventions specifically targeting older people living in the community,’ he explains. ‘This is especially important because while we often hear concerns about children’s screen time or office workers sitting for too long at their desks, older adults are actually the most sedentary segment of society—they spend over 80 percent of their waking day sitting. At the same time, increasing evidence is telling us that sedentary behaviour is detrimental to their physical and mental health. Among other things, it’s linked with depression, chronic diseases, frailty, social isolation and premature death.’
It’s worth noting that sedentary behaviour is often confused with inactivity but is actually distinctly different. The former involves sitting or reclining while awake—think watching TV for long periods—while inactivity is regarded as too little exercise/not meeting physical activity guidelines. So for example, you might meet physical activity guidelines by doing an hour of moderate intensity activity each day, but you could still be sitting for very long periods as well.
Key findings reflect lack of research, data and diversity
‘Having weighed up the latest evidence for this review, our main finding was disappointing but not unexpected,’ Paul says. ‘In a nutshell, our conclusion was that we simply don’t have enough research in this area, and need more and better studies to build our evidence base.’
‘Overall I think this reflects that research in this area has often focused on younger populations, and that older people have largely been a neglected part of the population until recently, and that’s compounded by the fact the data we have on sitting time has only been gathered from as recently as 2000 onwards. So when we think about some of those big population cohort studies that have data from across 50 or 60 years, none of them ask about sitting time or sedentary behaviours across lifetimes and we don’t know if there are critical periods when it matters more how sedentary we are or if the impacts on health are accumulated. We’ll have to wait another few decades to get the kind of cumulative data we really need.’
‘For this latest review, we identified only seven relevant studies with 397 adults aged over 60—predominantly white, female and all from high-income countries. We really need to see future studies recruiting much larger and more varied global samples in terms of age, gender, ethnicity, and socioeconomic background. And within high-income countries, we need to recruit people from different cultural groups.’
Intervention-wise, the majority of studies looked at ways to help change sedentary behaviour through a combination of behaviour change techniques and strategies that included information, education, counselling and goal setting. Some used wearable technology and apps that record behaviour, others included prompts, text messages and phone calls. None of the studies looked at changes to the natural, built, home or social environment, or making changes at policy level.
‘Given the various limitations in terms of the size and quality of the studies, we can’t draw any definitive conclusions about whether these interventions are effective in changing sedentary behaviour at this stage,’ Paul says. ‘The evidence suggests they may reduce sedentary time slightly, but it’s unclear whether they have an impact on physical and mental health.’
So what’s next?
‘The need for higher-quality randomised controlled trials assessing the impact of interventions is clear,’ Paul says. ‘We recommend that future studies use more device-based measures, with devices that recognise posture and can distinguish between sitting, standing or lying down. There needs to be greater consistency and accuracy around what’s measured, recorded and assessed. We also need accurate assessments of individual behaviours like TV viewing time as there is some evidence that not all behaviours have the same impacts on health.’
‘Throughout Covid lockdowns we’ve seen older people embracing FaceTime, Zoom and other apps to communicate with family and friends, and research suggests that older people will embrace technology if they're trained and understand how to use it. If we can encourage this and address access and equity considerations, hopefully technology will provide new avenues for effective interventions, research and data collection.’
‘With these developments on the horizon and more relevant studies currently underway, hopefully we'll be in a much better position to make more conclusive recommendations when it’s time to update this latest Cochrane review. In the meantime, here’s hoping the next series of Old people’s home for 4 year olds will provide top tips and information on the importance of reducing sitting time—for all the young and old alike.'
Approaches sedentary behaviour interventions take to decreasing or breaking-up prolonged sitting time include:
- Providing information: interventions could be used to educate people on the benefits of decreasing their overall sedentary time and breaking up prolonged sedentary periods, by using consultations/interviews, reviewing their own behaviour (self-monitoring by diary), or using a monitor to detect sedentary behaviour that provides feedback to identify times when prolonged sitting could be reduced.
- Prompting: real-time behaviour prompts using wearable sensor and mobile technology that detects prolonged sedentary periods and prompts the individual to rise and move. Less frequent reminders by email and phone messages may act as a less regular prompt system.
- Environmental restructuring: interventions may alter indoor or outdoor spaces to attempt to decrease individuals’ sedentary time. More specifically, home or care setting layout changes might be considered in order to encourage individuals to sit less. Standing tables and perching stools rather than comfortable seats are some other potential examples of this.
- Challenge to cultural and social norms: it’s culturally and socially acceptable in many places to expect older adults to sit. It’s considered important to offer seats to older adults, such as on public transport. Friends and family often start doing household jobs and tasks for older people rather than them being encouraged to be active and continue doing these activities. There is also a tendency for a risk-averse culture around older adults, with a perception that sitting is safe and that standing might lead to a fall. Some interventions might challenge these cultural norms by educating older adults, family members or carers, or changing the perception of the place of older adults and active ageing in society.
Images: Old People's Home for 4 Year Olds courtesy of the ABC (home page feature photo), Paul Gardiner (pictured above)
The launch of Cochrane Cameroon was officially celebrated on 30 June from its base at the Hôpital Central de Yaoundé.
At the launch Cochrane Cameroon highlighted its commitment to promoting evidence-based healthcare policy and practice; translation of research to policy and practice; advocating for evidence to promote access and equity to healthcare; effective collaboration, and, strengthening capacity for conducting and using systematic reviews.
"Cochrane Cameroon will play an important role in developing a critical mass of those who understand the role of evidence in improving healthcare," said Co-Director Pierre Ongolo-Zogo.
Cochrane activities in Cameroon have been underway for a number of years with collaborations working to produce high-quality, Africa-relevant reviews (particularly in HIV/AIDS, Tuberculosis and Malaria) and to support their use in policy and practice through stakeholder engagement and capacity building.
“There have been Cochrane activities in Cameroon for a long time especially in author training and development,” said Lawrence Mbuagbaw Co-Director of Cochrane Cameroon. "Reviews by Cameroonian authors especially on HIV/AIDS have informed national and international guidelines, and impacted on the lives of people living with HIV. This launch is a huge step forward in our commitment to developing the evidence ecosystem in Cameroon."
Cochrane Cameroon has also been part of Cochrane Africa since its inception. This was initially an informal network established in 2007, created to build on the strong track record and to enhance and expand activities. Cochrane Africa was officially launched at the Global Evidence Summit in Cape Town in 2017 with a vision to increase the use of best evidence to inform healthcare decision making in sub-Saharan Africa.
Cochrane Africa consists of regional centres including a Southern and Eastern Africa Hub, West Africa Hub and Francophone Africa Hub, and co-ordinating centre at Cochrane South Africa. Cochrane Cameroon focuses on Francophone African countries.
The launch of Cochrane Cameroon follows on the launch of Cochrane Kenya on 8 June. The increased presence of Cochrane in sub-Saharan Africa means the increased conduct of relevant reviews based on priority setting, identification of research gaps, and regional needs with the overall aim of improving health outcomes in Africa.
"Cochrane Cameroon will build on an important Cochrane goal of ensuring far more representation in Africa," said Charles Shey Wiysonge, Cochrane South Africa Director.
Preparing for and responding to global health emergencies: what have we learnt from COVID-19?
In this interview, Dr Karla Soares-Weiser introduces Cochrane Convenes, a virtual event that Cochrane is organizing from 5-8 October 2021. Cochrane Convenes will bring together key thought leaders from around the world to discuss the COVID-19 evidence response and develop recommendations to help prepare for and respond to future global health emergencies.
Tell us about Cochrane Convenes.
Cochrane is co-organizing this event with the World Health Organization (WHO) and the COVID-19 Evidence Network to support Decision making (COVID-End). Our objective is to bring together leaders from a diversity of disciplines and perspectives from across the world to explore and recommend the changes needed in evidence synthesis to prepare for and respond to future global health emergencies.
One of the outputs will be an Action Plan with recommendations to be presented to policy makers at the next World Health Assembly. Cochrane will also use the Action Plan to inform our own strategy and response to global health priorities and to advocate for change within the wider evidence synthesis community.
“If not now, when?” The last 18 months have shown us the importance of collaboration, but we have also seen an increase in the amount of published research and how this may have contributed to misinformation and the politicization of health decision making as part of the infodemic. Evidence synthesis is more important than ever, but we need to understand the challenges to identify opportunities to respond better in the future. We know that the next pandemic is not a hundred years away. There are also longer-term crises to address, which have major impacts on people’s health, including climate change and inequity. The COVID-19 pandemic has highlighted the importance of challenging global inequality.
The response to COVID-19 has emphasized the need for evidence to support decisions in health and social care. Cochrane has a wealth of expertise in preparing and maintaining evidence syntheses and our global community was central in our ability to respond to this crisis. Our unique perspective places us well to host these discussions. As a global community of evidence producers, we know we need to support WHO and its member states with the best possible evidence and guidance, to ultimately ensure that local decision-makers and frontline healthcare professionals have the information they need. Our collective challenge is to find the best way to do this.
What themes will Cochrane Convenes address?
It will be an opportunity to reflect on how the evidence community responded to the pandemic, and how evidence was shared and used in decision making. Perhaps most importantly, we will also discuss what worked and did not work - relating to both primary and secondary research - and what we should keep or change to make sure the world is better prepared to respond to future health emergencies.
Who is Cochrane Convenes for?
The inaugural event will be organized into a series of invitation-only thematic roundtables, where recommendations will be discussed and developed, with some plenary sessions and personal experiences and stories from senior health professionals working on the frontline during the pandemic. We aim to include researchers; policy makers; and funders of research, primarily – because we hope the learnings and reflections bought about by this event will influence their decisions and ways of working in the future. We will also involve civil society and the public as the ultimate beneficiaries of good research and policy making – they will also help shape the agenda of this event and, in time, help hold the professionals to account.
What do you hope to achieve?
We want to create an environment for collaboration and the sharing of ideas on how we can be better prepared and aligned for future health emergencies. This support and advocacy will help build on strategic priorities but also identify ways that we can practically prepare – for example, identifying evidence gaps to inform future research as well as maintaining a database of evidence syntheses that can be available when needed . Awareness, advocacy and availability of high-quality and timely evidence will support a better response worldwide to inform improved health outcomes for all people. From Cochrane’s perspective, we will embed what we learn in our future organizational strategy.
Featured review: How well does botulinum toxin (type A; often called ‘Botox’) treat wrinkles on the face?
Communicating to the public about vaccines and using digital strategies to promote vaccine uptake: information for planners and implementers
Based on evidence from systematic reviews, Cochrane Effective Practice and Organisation of Care (EPOC) has prepared three information leaflets for health systems planners and implementers involved in developing vaccine communication strategies. The leaflets are underpinned by systematic reviews from Cochrane and other sources and include this qualitative evidence synthesis: Healthcare worker's perceptions and experiences of communicating with people over 50 years of age about vaccination, which published today in the Cochrane Library.
The reviews underlying these leaflets include studies carried out prior to the COVID-19 pandemic. However, they include important information that has relevance for implementers rolling out vaccines for COVID-19. With countries at different stages of the COVID-19 vaccine rollout, the leaflets provide timely guidance for decision making.
The first leaflet provides prompts and questions for planners implementing strategies to improve vaccination communication between healthcare workers and older adults. The leaflet is based on the findings of a review of qualitative research published today by Cochrane EPOC, and produced within the VITAL (Vaccines, Infectious Diseases in the Ageing Population) consortium. “The review suggests a number of issues that implementers should consider, including the potential tension between the public health goal of increasing vaccine uptake and the goal of supporting informing vaccination choices by individuals,” says Claire Glenton, review author and EPOC editor at the Norwegian Institute of Public Health.
EPOC staff have also prepared two additional leaflets for the OECD’s COVID-19 Global Evaluation Coalition. One of these leaflets presents prompts and questions for planners implementing communication strategies for all target groups, including parents, older adults and healthcare workers and is based on four systematic reviews of qualitative research. The leaflet encourages planners to consider a range of factors, including people’s concerns and misconceptions about the disease and the vaccine; and the extent to which the information they are providing is transparent, timely and understandable, and accessible to hard-to-reach groups.
The third leaflet presents what we know about the effectiveness of digital strategies to promote vaccine uptake and summarises evidence from four systematic reviews on this topic. This leaflet illustrates that despite these strategies being used widely, the evidence is fragmented and shows mixed results.
Governments worldwide are currently undertaking or planning the rollout of COVID-19 vaccines, and some are starting to review their progress and refine their communication efforts to promote vaccine uptake.
Communication to the public is an important part of these and other vaccination strategies. Simon Lewin, review author and Joint Coordinating Editor of EPOC at the Norwegian Institute of Public Health and the South African Medical Research Council noted that, “Cochrane has been systematically assessing evidence about vaccine communication for a number of years. This remains a topic area that does not receive the attention it deserves from implementers or researchers. We hope that these leaflets will help implementers to better plan vaccination communication strategies in their setting”.
One of the contributing reviews was undertaken within the Vaccines, Infectious Diseases in the Ageing Population (VITAL) consortium. For more information, see https://vital-imi.eu/
Two of the briefs were commissioned and funded by the Evaluation Department of the Norwegian Agency for Development Cooperation (Norad).
The 2020 Journal Citation Report (JCR) has just been released by Clarivate Analytics, and we are delighted to announce that Cochrane Database of Systematic Reviews (CDSR) Journal Impact Factor is now 9.266. This is an increase on the 2019Journal Impact Factor, which was 7.890.
The CDSR Journal Impact Factor is calculated by taking the total number of citations in a given year to all Cochrane Reviews published in the past 2 years and dividing that number by the total number of Reviews published in the past 2 years. It is a useful metric for measuring the strength of a journal by how often its publications are cited in scholarly articles.
Some highlights of the CDSR 2020 Journal Impact Factor include:
- The CDSR is ranked 11th of the 169 journals in the Medicine, General & Internal category
- The CDSR received 81,212 cites in the 2020 Journal Impact Factor period, compared with 67,763 in 2019
- The 5-Year Journal Impact Factor is 9.871 compared with 7.974 in 2019
Cochrane Library’s Editor in Chief, Karla Soares-Weiser, commented: “I am delighted to see a rise in Impact Factor for the Cochrane Database of Systematic Reviews. We are pleased to see a rise in total citations and the five year impact factor is consistently strong. All of these data demonstrate the usage and impact of Cochrane reviews, and reflect enormous credit on our many thousands of contributors and groups.”
The main Journal Impact Factor report and the Cochrane Review Group reports will be delivered in August 2021.
Wednesday, June 30, 2021
Science in the Break is a communication platform to make research more accessible to everyone and give more visibility to young researchers, which will potentially enhance their network and future collaborations. They focuses on health sciences and rehabilitation, touching on methods like musculoskeletal imaging, movement analysis, brain imaging, and brain stimulation techniques. Led by Tea Lulic-Kuryllo, Cristina Simon-Martinez, and Francesco Cenni, guests chat about their work, explain methods, and share academic and funding experiences.
In their most recent episode they provide overview about Cochrane Rehabilitation (Carlotte Kiekens), practical information on how to learn/contribute (Chiara Arienti), and a young researcher's perspective on their experience (Vanessa Young).
- 1:18 - What is Cochrane?
- 2:15 - What is Cochrane Rehabilitation? What other groups are there?
- 4:55 - How can clinicians use Cochrane evidence?
- 7:53 - What is a good level of knowledge to write a systematic review?
- 10:15 - How can early career professionals get involved in Cochrane Rehabilitation?
- 10:58 - Cochrane International Mobility Programme and Cochrane Rehabilitation opportunities
- 13:38 - Students 4 Best Evidence blog
- 17:17 - Citizen Scientist platform, Cochrane Crowd
- 17:33 - Cochrane TaskExchange
- 19:06 - Cochrane community is a very welcoming environment for entry-level researchers
- 22:43 - 3 top points
Learn more about Science in the Break:
- @SciInTheBreak on Twitter
- @scienceinthebreak on Instagram
- Science in the Break on Youtube
- Science in the Break on Spotify
Learn more about Cochrane Rehabilitation:
Wednesday, July 7, 2021
First author of this new Cochrane Review, 'Low‐dose oral misoprostol for induction of labour', Robert Kerr explains, “Our review found that Misoprostol given orally outperforms the ‘gold-standard’ drug which is much more expensive, and used in preference in many countries. This review has the potential to impact millions of women and babies who have inductions of labour through its comparison of oral misoprostol with other commonly used induction techniques."
Labour inductions are common around the world. Induction rates vary worldwide, but for example in the UK, 1 in 3 women will have labour induced. Induction of labour may be a life-saving intervention and identifying effective and safe methods will help achieve greater positive birth experiences for mothers and their babies.
In this recently published Cochrane review, authors explored the evidence from randomised controlled trials to see if low-dose misoprostol given by mouth is effective in starting labour in women in their third trimester with a live baby. They compared misoprostol with other commonly used methods of inducing labour.
What is the issue?
Artificially starting labour, or induction, is common in pregnancy. Reasons include the mother having high blood pressure in pregnancy or the baby being past the due date. Misoprostol is a type of prostaglandin that can be taken in low doses by mouth to induce labour. Prostaglandins are hormone-like compounds that are made by the body for various functions (including the natural onset of labour). Unlike other prostaglandins such as vaginal dinoprostone, misoprostol does not need to be stored in the refrigerator. Taking a tablet is convenient to mothers and the low-dose tablet sizes are now available (25 µg).
Why is this important?
A good induction method achieves a safe birth for mother and baby. It is effective, results in a relatively low number of caesarean sections, has few side effects, and is highly acceptable to mothers. Some methods of inducing labour may cause more caesarean sections by being ineffective at bringing on labour, other methods may lead to more caesareans as they cause too many contractions (hyperstimulation) that result in the baby becoming distressed (foetal heart rate changes).
What evidence did we find?
We searched for evidence on 14 February 2021 and identified 61 trials involving 20,026 women for inclusion in this review. Not all trials were high quality.
Starting with oral misoprostol immediately may have a similar effect on rates of caesarean section (4 trials, 594 women; low-certainty evidence) to giving no treatment for 12 to 24 hours then starting oxytocin, while the effects of misoprostol on uterine hyperstimulation with foetal heart rate changes are unclear (3 trials, 495 women; very low-quality evidence). All women in theses trials had ruptured membranes.
Oral misoprostol was compared to vaginal dinoprostone in 13 trials (9676 women). Misoprostol use probably decreased the risk of caesarean section (moderate-certainty evidence). When studies were divided by their initial dose of misoprostol, there was evidence that use of 10 µg to 25 µg may be effective in reducing the risk of a caesarean section (9 trials, 8652 women), while the higher 50 µg dose might not reduce the risk (4 trials, 1024 women). There may be very small or no differences between misoprostol and dinoprostone in rates of vaginal births within 24 hours (10 trials, 8983 women; low-certainty evidence) but may be fewer cases of hyperstimulation with foetal heart rate changes with oral misoprostol (11 trials, 9084 women; low-certainty evidence).
Oral misoprostol was compared with vaginal misoprostol in 33 trials (6110 women). Oral use may have resulted in fewer vaginal births within 24 hours (16 trials, 3451 women; low-certainty evidence). Oral use may have caused less hyperstimulation with foetal heart rate changes (25 trials, 4857 women; low-certainty evidence), especially with a dose of 10 µg to 25 µg. There was no clear difference in the number of caesarean sections overall (32 trials, 5914 women; low-certainty evidence) but oral use likely resulted in fewer caesareans being performed because of concerns of the baby being in distress (24 trials, 4775 women).
When oral misoprostol was compared to oxytocin for induction, misoprostol use probably resulted in fewer caesarean sections (6 trials, 737 women). We found no clear difference in vaginal birth within 24 hours (3 trials, 466 women; moderate-certainty evidence) or hyperstimulation with foetal heart rate changes (3 trials, 331 women; very low-certainty evidence).
Oral misoprostol was compared to a balloon catheter inserted in the cervix to mechanically induce labour. The number of vaginal births within 24 hours may have increased with misoprostol (4 trials, 1044 women; low-certainty evidence). Misoprostol probably reduced the risk of caesarean section (6 trials, 2993 women; moderate-certainty evidence) with no difference in risk of hyperstimulation with foetal heart rate changes (4 trials, 1044 women; low-certainty evidence).
Different doses and timings of giving oral misoprostol were explored in three small trials. The certainty of the findings from these trials was either low or very low so we cannot draw any meaningful conclusions from this data.
What does this mean?
Using low-dose (50 µg or less) oral misoprostol to induce labour likely leads to fewer caesarean sections and so more vaginal births than vaginal dinoprostone, oxytocin, and a transcervical Foley catheter. Rates of hyperstimulation with foetal heart rate changes were comparable with these methods. Misoprostol taken by mouth causes less hyperstimulation with foetal heart changes compared to when taken vaginally.
More trials are needed to establish the most effective misoprostol regimen for labour induction, but for now the findings of this review support oral rather than vaginal use, and suggest that commencing oral misoprostol at a dose of 25 µg or less may be safe and effective.
Low-dose oral misoprostol is probably associated with fewer caesarean sections (and therefore more vaginal births) than vaginal dinoprostone, and lower rates of hyperstimulation with foetal heart rate changes. However, time to birth may be increased, as seen by a reduced number of vaginal births within 24 hours.
Compared to transcervical Foley catheter, low-dose oral misoprostol is associated with fewer caesarean sections, but equivalent rates of hyperstimulation.
Low-dose misoprostol given orally rather than vaginally is probably associated with similar rates of vaginal birth, although rates may be lower within the first 24 hours. However, there is likely less hyperstimulation with foetal heart changes, and fewer caesarean sections performed due to foetal distress.
The best available evidence suggests that low-dose oral misoprostol probably has many benefits over other methods for labour induction. This review supports the use of low-dose oral misoprostol for induction of labour, and demonstrates the lower risks of hyperstimulation than when misoprostol is given vaginally. More trials are needed to establish the optimum oral misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good balance of efficacy and safety.