The high prevalence of stigma toward mental illnesses contributes to the worsened health and quality of life for people with mental illnesses. Different stigmas (e.g., public, self) lead to social discrimination, social isolation, and reduce the likelihood that people with mental illnesses receive adequate treatment for their conditions. In response to this, numerous social interventions have been developed to help combat the spread of stigma. Subsequently, researchers have conducted meta-analyses to determine the effectiveness of different interventions for reducing stigma toward mental illness. To date, no efforts have been made to synthesize these meta-analyses to identify gaps in the stigma-reduction literature, assess the quality of extant literature, and to identify trends in programming efforts. The present study conducted a systematic meta-review of 19 meta-analyses, drawing from the Health Stigma and Discrimination Framework, to address these gaps. Results showed that the included meta-analyses were of relatively poor quality and that interventions primarily addressed either public or self-stigma, while overlooking other stigmas. Further, meta-analyses primarily assessed the effects of contact-promotion or educational intervention strategies. There was little evidence to suggest that interventions were effective longitudinally. Implications for future research and intervention development are discussed.
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BACKGROUND: Reviews of qualitative studies allow for deeper understanding of concepts and findings beyond the single qualitative studies. Concerns on study reporting quality led to the publication of the COREQ-guidelines for qualitative studies in 2007, followed by the ENTREQ-guidelines for qualitative reviews in 2012. The aim of this meta-review is to: 1) investigate the uptake of the COREQ- and ENTREQ- checklists in qualitative reviews; and 2) compare the quality of reporting of the primary qualitative studies included within these reviews prior- and post COREQ-publication.
METHODS: Reviews were searched on 02-Sept-2020 and categorized as (1) COREQ- or (2) ENTREQ-using, (3) using both, or (4) non-COREQ/ENTREQ. Proportions of usage were calculated over time. COREQ-scores of the primary studies included in these reviews were compared prior- and post COREQ-publication using T-test with Bonferroni correction.
RESULTS: 1.695 qualitative reviews were included (222 COREQ, 369 ENTREQ, 62 both COREQ/ENTREQ and 1.042 non-COREQ/ENTREQ), spanning 12 years (2007-2019) demonstrating an exponential publication rate. The uptake of the ENTREQ in reviews is higher than the COREQ (respectively 28% and 17%), and increases over time. COREQ-scores could be extracted from 139 reviews (including 2.775 appraisals). Reporting quality improved following the COREQ-publication with 13 of the 32 signalling questions showing improvement; the average total score increased from 15.15 to 17.74 (p-value < 0.001).
CONCLUSION: The number of qualitative reviews increased exponentially, but the uptake of the COREQ and ENTREQ was modest overall. Primary qualitative studies show a positive trend in reporting quality, which may have been facilitated by the publication of the COREQ.
ABSTRACT: Cannabis is the third most used psychoactive substance worldwide. The legal status of cannabis is changing in many Western countries, while we have very limited knowledge of the public health impact of cannabis-related harms. There is a need for a summary of the evidence of harms and risks attributed to cannabis use, in order to inform the definition of cannabis risky use. We have conducted a systematic review of systematic reviews, aiming to define cannabis-related harms. We included systematic reviews published until July 2018 from six different databases and following the PRISMA guidelines. To assess study quality we applied the AMSTAR 2 tool. A total of 44 systematic reviews, including 1,053 different studies, were eligible for inclusion. Harm was categorized in three dimensions: mental health, somatic harm and physical injury (including mortality). Evidence shows a clear association between cannabis use and psychosis, affective disorders, anxiety, sleep disorders, cognitive failures, respiratory adverse events, cancer, cardiovascular outcomes, and gastrointestinal disorders. Moreover, cannabis use is a risk factor for motor vehicle collision, suicidal behavior and partner and child violence. Cannabis use is a risk factor for several medical conditions and negative social consequences. There is still little data on the dose-dependency of these effects; evidence that is essential in order to define, from a public health perspective, what can be considered risky use of cannabis. This definition should be based on quantitative and qualitative criteria that informs and permits the evaluation of current approaches to a regulated cannabis market. (PsycINFO Database Record (c) 2020 APA, all rights reserved)
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BACKGROUND: Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions.
OBJECTIVE: Identify and synthesize strategies or interventions that facilitate the reduction of health inequalities.
METHODS: A systematic search strategy was carried out up until August 2019 in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, LILACS, Scopus, Scielo and Epistemonikos. In addition, a snowball strategy was used. Literature reviews (LRs) of experimental and quasi-experimental studies were included. The identified interventions and outcomes were categorized based on the recommendation by the Cochrane group in "Effective Practice and Organization of Care". The quality of the included LRs was evaluated using the AMSTAR 2 tool.
RESULTS: Four thousand ninety-five articles were identified, of which 97 were included in the synthesis of evidence. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes.
CONCLUSION: The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.
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AIM: Integrated care commonly involves provision of comprehensive community-based care for people with chronic conditions. It is anticipated that implementation of integrated care, with a proactive approach to management of chronic conditions, will reduce reliance on hospital and emergency department (ED) services. The aim of this rapid review was to summarize the best available evidence on the impact of integrated care for patients with chronic conditions on hospital and ED utilization and investigate trends in outcomes over time.
METHODS: Given the large body of literature available on this topic, this rapid review considered existing systematic reviews and meta-analyses that included adults with chronic conditions. Any model of integrated care that involved management of patients across the continuum of care, with the aim to provide more care in community settings, was considered for inclusion. A search of PubMed, CINAHL, Google Advanced, and websites of international healthcare provider organizations was conducted to locate relevant published and gray literature.
RESULTS: A total of 13 systematic reviews were included. Overall, evidence suggests that integrated care may reduce the risk of hospitalization, with reviews including patients with diverse chronic conditions showing a 19% reduction. Integrated care appears effective in reducing readmissions for patients with heart failure, with an absolute risk reduction of 8% for first and 19% for subsequent rehospitalization. For ED presentations, evidence indicates that integrated care has no effect overall but may reduce ED visits for patients aged 65 years or more. For patients with chronic obstructive pulmonary disease, integrated care was associated with reductions in length of stay ranging from 2.5 to 4 days. Studies with shorter follow-up, from 3 to 12 months, in general appeared to show a greater impact of integrated care than studies with longer follow-up of 18 months or more.
CONCLUSION: The evidence identified suggests integrated care generally reduces utilization of hospital services. In some instances, there were no differences observed between integrated care and usual care, but no included reviews reported increased utilization of these services. The impact of integrated care may be greater in the short-term, given the ultimate deterioration associated with advanced chronic disease which may negate any long-term benefits.
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ABSTRACT BACKGROUND: The therapeutic effects of cannabinoid compounds have been the center of many investigations. This study provides a synthesis on all Cochrane systematic reviews (SRs) that assessed the use of cannabinoids as a therapeutic approach. DESIGN AND SETTING: Review of SRs, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: A broad search was conducted in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed the efficacy and safety of cannabinoids as a therapeutic approach. The results and key characteristics of all reviews included were summarized and discussed. RESULTS: Eight SRs were included. They assessed the use of cannabinoids for the following types of conditions: neurological (two SRs), psychiatric (two SRs), rheumatological (one SR), infectious (one SR) and oncological (two SRs). There was moderate-quality evidence showing that the use of cannabinoids reduced nausea and vomiting among adults, compared with placebo. Additionally, there was moderate-quality evidence showing that there was no difference between cannabinoids and prochlorperazine regarding the number of participants who reported vomiting, in this same population. CONCLUSIONS: This review identified eight Cochrane systematic reviews that provided evidence of unknown to moderate quality regarding the use of cannabinoids as a therapeutic intervention. Further studies are still imperative for solid conclusions to be reached regarding practical recommendations.
QUESTION: Network meta-analyses (NMAs) of treatment efficacy across different pharmacological treatments help inform clinical decision-making, but their methodological quality may vary a lot depending also on the quality of the included primary studies. We therefore conducted a systematic review of NMAs of pharmacological treatment for common mental disorders in order to assess the methodological quality of these NMAs, and to relate study characteristics to the rankings of efficacy and tolerability.
STUDY SELECTION AND ANALYSIS: We searched three databases for NMAs of pharmacological treatment used in major depression, generalised anxiety disorder (GAD), social anxiety disorder (SAD), post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and specific phobia.Studies were appraised using the International Society for Pharmacoeconomics and Outcomes Research checklist of good research practices for indirect-treatment-comparison and network-meta-analysis studies.
FINDINGS: Twenty NMAs were eligible for inclusion. The number of randomised controlled trials per NMA ranged from 11 to 234, and included between 801 to more than 26 000 participants. Overall, antidepressants were found to be efficacious and tolerable agents for several disorders based on rankings (45%) or statistical significance (55%). The majority of NMAs in this review adhered to guidelines by including a network diagram (70%), assessing consistency (75%), making use of a random effects model (75%), providing information on the model used to fit the data (75%) and adjusting for covariates (75%).
CONCLUSIONS: The 20 NMAs of depression and anxiety disorders, PTSD and/or OCD included in this review demonstrate some methodological strengths in comparison with the larger body of published NMAs for medical disorders, support current treatment guidelines and help inform clinical decision-making.
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BACKGROUND: A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.
OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories – strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.
AUTHORS' CONCLUSIONS: Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.
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BACKGROUND: One target of the Sustainable Development Goals is to achieve "universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". A fundamental concern of governments in striving for this goal is how to finance such a health system. This concern is very relevant for low-income countries.
OBJECTIVES: To provide an overview of the evidence from up-to-date systematic reviews about the effects of financial arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on financial arrangements, and informing refinements in the framework for financial arrangements presented in the overview.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language, or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of financial arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment, or financial burden of patients, e.g. out-of-pocket payment, catastrophic disease expenditure) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 reviews and included 15 in this overview, on: collection of funds (2 reviews), insurance schemes (1 review), purchasing of services (1 review), recipient incentives (6 reviews), and provider incentives (5 reviews). The reviews were published between 2008 and 2015; focused on 13 subcategories; and reported results from 276 studies: 115 (42%) randomised trials, 11 (4%) non-randomised trials, 23 (8%) controlled before-after studies, 51 (19%) interrupted time series, 9 (3%) repeated measures, and 67 (24%) other non-randomised studies. Forty-three per cent (119/276) of the studies included in the reviews took place in low- and middle-income countries. Collection of funds: the effects of changes in user fees on utilisation and equity are uncertain (very low-certainty evidence). It is also uncertain whether aid delivered under the Paris Principles (ownership, alignment, harmonisation, managing for results, and mutual accountability) improves health outcomes compared to aid delivered without conforming to those principles (very low-certainty evidence). Insurance schemes: community-based health insurance may increase service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). It is uncertain whether social health insurance improves utilisation of health services or health outcomes (very low-certainty evidence). Purchasing of services: it is uncertain whether increasing salaries of public sector healthcare workers improves the quantity or quality of their work (very low-certainty evidence). Recipient incentives: recipient incentives may improve adherence to long-term treatments (low-certainty evidence), but it is uncertain whether they improve patient outcomes. One-time recipient incentives probably improve patient return for start or continuation of treatment (moderate-certainty evidence) and may improve return for tuberculosis test readings (low-certainty evidence). However, incentives may not improve completion of tuberculosis prophylaxis, and it is uncertain whether they improve completion of treatment for active tuberculosis. Conditional cash transfer programmes probably lead to an increase in service utilisation (moderate-certainty evidence), but their effects on health outcomes are uncertain. Vouchers may improve health service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). Introducing a restrictive cap may decrease use of medicines for symptomatic conditions and overall use of medicines, may decrease insurers' expenditures on medicines (low-certainty evidence), and has uncertain effects on emergency department use, hospitalisations, and use of outpatient care (very low-certainty evidence). Reference pricing, maximum pricing, and index pricing for drugs have mixed effects on drug expenditures by patients and insurers as well as the use of brand and generic drugs. Provider incentives: the effects of provider incentives are uncertain (very low-certainty evidence), including: the effects of provider incentives on the quality of care provided by primary care physicians or outpatient referrals from primary to secondary care, incentives for recruiting and retaining health professionals to serve in remote areas, and the effects of pay-for-performance on provider performance, the utilisation of services, patient outcomes, or resource use in low-income countries.
AUTHORS' CONCLUSIONS: Research based on sound systematic review methods has evaluated numerous financial arrangements relevant to low-income countries, targeting different levels of the health systems and assessing diverse outcomes. However, included reviews rarely reported social outcomes, resource use, equity impacts, or undesirable effects. We also identified gaps in primary research because of uncertainty about applicability of the evidence to low-income countries. Financial arrangements for which the effects are uncertain include external funding (aid), caps and co-payments, pay-for-performance, and provider incentives. Further studies evaluating the effects of these arrangements are needed in low-income countries. Systematic reviews should include all outcomes that are relevant to decision-makers and to people affected by changes in financial arrangements.
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Motivation is a well-established predictor of recovery for addictive behaviors. Treatments aimed at changing substance use and gambling frequently employ motivational enhancing strategies, based in the principles of Motivational Interviewing (MI). Evidence for these approaches across addictive behaviors does not always paint a clear picture. The purpose of this review was to examine existing reviews of motivational-based interventions for various substances of abuse and gambling in the last decade to gain a deeper understanding of the current evidence and implications for future research and clinical practice. Literature searches were conducted to identify review articles from January 1, 2007 to January 30, 2017 for motivational enhancing interventions for alcohol, tobacco, drugs, marijuana, cocaine, opioids, methamphetamines, and gambling. Of the 144 articles assessed we included a total of 34 review articles in our review, including 6 Cochrane reviews. This review supports use of motivationally enhancing interventions across addictive behaviors with strongest evidence supporting use in alcohol and tobacco, with brief interventions showing strong efficacy. There is strong support for MI with marijuana and some support for gambling. Insufficient evidence is available for methamphetamine or opiate use. There are important caveats. In most cases, MI is more effective than no treatment and as effective (but not necessarily more effective) than other active treatments. Findings for effectiveness of more intensive motivational interventions or combinations are mixed. Treatment fidelity assessments, limited subpopulation analyses, and differences in dose, outcomes, and protocol specification continue to pose significant problems for reviews. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
The high prevalence of stigma toward mental illnesses contributes to the worsened health and quality of life for people with mental illnesses. Different stigmas (e.g., public, self) lead to social discrimination, social isolation, and reduce the likelihood that people with mental illnesses receive adequate treatment for their conditions. In response to this, numerous social interventions have been developed to help combat the spread of stigma. Subsequently, researchers have conducted meta-analyses to determine the effectiveness of different interventions for reducing stigma toward mental illness. To date, no efforts have been made to synthesize these meta-analyses to identify gaps in the stigma-reduction literature, assess the quality of extant literature, and to identify trends in programming efforts. The present study conducted a systematic meta-review of 19 meta-analyses, drawing from the Health Stigma and Discrimination Framework, to address these gaps. Results showed that the included meta-analyses were of relatively poor quality and that interventions primarily addressed either public or self-stigma, while overlooking other stigmas. Further, meta-analyses primarily assessed the effects of contact-promotion or educational intervention strategies. There was little evidence to suggest that interventions were effective longitudinally. Implications for future research and intervention development are discussed.
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