In her editorial reflecting on Cochrane's 30th year, Cochrane's Editor in Chief, Karla Soares-Weiser, observed that "the shape and output of our organization continues to adapt to the needs of the times, while together we continue to deliver the evidence the world needs at this critical juncture for humanity."[1] To keep pace with the global demand for health evidence, throughout its 30-year history Cochrane has embraced change. This was initially through methodological development and latterly through technological change, including automation and artificial intelligence. Evolution of methods and process have enabled Cochrane to remain fixed on informing decision making across health and social care through evidence synthesis.To mark Cochrane's 30th year, we are assembling a collection of reviews as they publish. The reviews reflect both the permanence of the mission, and the innovative ways in which we are achieving it. The reviews that feature in this collection address important questions and use methodological approaches that Cochrane has developed and built on. Reviews in this collection will tackle health inequality, global health and non-communicable diseases among other things. Some will compare multiple interventions in a single network meta-analysis, others will focus on implementation, or have had to adapt established and familiar approaches to intervention questions. All show that the clues to Cochrane's future lie in its history of methodological diversity and commitment to meeting user needs.
This review found that quality improvement programmes can improve diabetes care, especially when multiple strategies are used in combination. Strategies used in these programmes that lead to the largest improvements in key outcomes in people with diabetes are case management, team changes, patient education and promotion of self‐management. The goal of this work was not to provide a single answer about the effects for a given component (or combination of components) in a complex quality improvement intervention, but to provide a rich set of data for decision makers and researchers to enable them to match programme components to the specific determinants (i.e. barriers and enablers) of the targeted behaviour of the health professionals involved in diabetes care and patients living with diabetes, and local context and resources. Read the Review
Physical exercise for people with Parkinson’s disease: a systematic review and network meta‐analysis
This review investigates which type of exercise works best in people with Parkinson’s disease. It found that many types of physical exercise worked well for improving movement and quality of life, and that there was not much difference between any of them. Read the review, the news story, and the associated Cochrane Clinical Answer. Key results from the network meta‐analysis are also available as an interactive summary of findings table, produced in collaboration with MAGIC.
Interventions to improve sanitation for preventing diarrhoea
Diarrhoea is a major contributor to the global disease burden, particularly among children aged under five years in low‐ and middle‐income countries. This review found that sanitation interventions are effective at preventing diarrhoea, across different age groups. Read the review and the associated Cochrane Clinical Answer.
Vitamin D for the management of asthma
Since the previous Cochrane Review on this topic in 2016, debate has continued surrounding a potential role for vitamin D in reducing risk of asthma exacerbation and improving asthma control. Including data from new trials in this updated meta‐analysis changed the results and conclusions. Having previously shown a reduction in exacerbations of asthma, the review now concludes that there is little benefit of vitamin D or its hydroxylated metabolites in reducing the risk of severe asthma exacerbations and improving asthma symptom control. Read the review and the associated Cochrane Clinical Answer.
Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person‐centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). The review found that some consumers and health providers believed that partnerships improved the culture and environment of the health service, as well as how health services were planned and developed. This qualitative evidence synthesis was co‐produced with a Stakeholder Panel of consumers and health providers. Read the review, the associated Cochrane Clinical Answer, and listen to an interview with the authors.
Environmental interventions for preventing falls in older people living in the community
Approximately one‐third of people aged 65 years and older fall each year. Most falls occur in the home, and more than 30% of all falls are caused by environmental hazards. This review found that for older adults at a higher risk of having a fall, such as having had a fall in the past year and being recently hospitalised or needing support with daily activities, removing environmental fall hazards in the home can reduce the number of falls by 38%. Examples of environmental fall hazards are a stairway without railings, a slippery pathway, or poor lighting. Read the review and the editorial.
Zinc deficiency is prevalent in low‐ and middle‐income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The review found that zinc supplementation in children aged 6 months to 12 years makes little to no difference to all-cause mortality, but probably has an effect on death due to lower respiratory tract infections and malaria. Zinc might prevent illness due to diarrhoea, but might lead to vomiting after supplementation. It might lead to a small increase in height gain. Read the review and the associated Cochrane Clinical Answer.
It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. The review found that people appreciate cash transfers and see them as necessary for their basic needs. However, cash transfers can influence people’s relationships in positive and negative ways. Not all people want to receive cash and some recipients do not perceive that cash alone will be enough to change their health behaviour. Read the review.
Antidepressants for pain management in adults with chronic pain: a network meta‐analysis
Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well‐being, and quality of life. This review compares different antidepressants to see how effective they are in treating chronic pain. The review found that there was reasonable evidence for the effectiveness of one antidepressant, duloxetine, when given at a dose of 60 mg, and that there is no benefit to using a higher dose. Read the review, the news story, and the associated Cochrane Clinical Answer.
Topical repellents for malaria prevention
Malaria is a disease spread by the bite of mosquitoes. It regularly affects people in tropical areas of Central and South America, South and Southeast Asia, and particularly, Africa. Certain things that prevent mosquito bites, like nets treated with insecticides, can protect people from getting it. Although effective, most of these approaches target mosquitoes that feed indoors and on humans. They are less effective against species that can feed outside, so do not really eliminate the disease. Topical repellents are substances applied to the skin to prevent mosquito bites. The review found evidence suggesting that topical repellents may slightly reduce the incidence and prevalence of malaria cases in settings where other tools to prevent mosquito bites are not available, although repellents probably make little or no difference in places where these tools are already widely used. Read the review.
Recruitment to vaccine trials is particularly challenging as it involves healthy volunteers who may have concerns around the potential risks and benefits associated with rapidly developed vaccines. This review summarised studies that looked at what influences a person's decision to take part in a vaccine trial in the context of a pandemic or epidemic. It found that many factors influence a person's decision to take part in a vaccine trial during a pandemic or epidemic. People are influenced by the way in which the trial is set up and how information about the trial is communicated. People are also influenced by what they think the possible risks and side effects are. Friends and family may also have influenced their decision. A fear of stigma and distrust in governments may prevent people from taking part in a vaccine trial. People may often see the chance to help others and prevent the spread of disease as a reason to take part in a vaccine trial. Read the review.
Chronic non‐cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non‐cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children’s chronic non‐cancer pain, with many services being inadequate. This review synthesized evidence from 43 studies to understand how children with chronic non‐cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them. The authors found that poorly managed chronic non‐cancer pain impacted on family life and relationships. It also affected children’s education and future employment prospects as well as parental employment. Families had difficulty getting support from health services to manage their child’s pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Read the review
Many children under five years of age who live in low- and middle-income countries are not receiving adequate nutrition. This can lead to increased illnesses, impaired mental development (which diminishes school and work performance later in life) and death. Growth monitoring and promotion (GMP) is a complex intervention that comprises regular measurement and charting of growth combined with nutrition promotion activities. There are currently no standard guidelines explaining how to implement GMP or how to design the promotion activities; and policymakers, particularly in international aid agencies, have differing and changeable interpretations and perceptions of the purpose and value of GMP. Based on evidence from six studies conducted in children under five years of age in resource-poor rural settings with high levels of malnutrition, the review found limited and uncertain evidence on the effectiveness of GMP.
Many people, especially in low‐ and middle‐income countries, are unable to access mental health support due to a lack of specialized mental healthcare staff. To overcome this barrier, primary workers such as nurses or teachers, without a professional background in mental health, can be trained to deliver some mental health services. This review investigated whether this strategy helps to promote mental health and prevent mental disorders amongst adults and children. It also assessed costs. The review found that mental health outcomes may be improved by using primary workers to deliver interventions aimed at preventing mental health disorders.
Thermal stability and storage of human insulin
Insulin is needed to help control blood sugar; it is made naturally by the human body. People with diabetes cannot naturally make enough insulin or their bodies do not use it effectively. Some have to obtain and inject insulin that is manufactured. Reliable refrigeration is needed to store insulin in line with current recommendations at temperatures between 2 °C and 8 °C. Many people with diabetes live in places with little access to healthcare facilities and refrigeration. Refrigeration can also be affected by unstable power supply during natural disasters, periods of extreme heat or war. This review looked at how stable insulin is when it is stored at different temperatures. The review included different types of studies, from studies in humans to those carried out in laboratories. The review found that it is possible to store unopened insulin vials or cartridges at up to 25 °C for a maximum of six months and at up to 37 °C for a maximum of two months without a meaningful loss of insulin potency. There was also some evidence that storing insulin at temperatures varying between 25 °C and 37 °C, similar to daytime and night-time fluctuations in some countries, for up to three months, does not result in a meaningful loss of insulin activity of short-acting, intermediate-acting and mixed human insulin. Using clay pots or other ways of keeping insulin out of direct sunlight may help to store insulin in many high-temperature regions of the world.
This review looked at the experiences of women who survived significant blood loss after giving birth (postpartum haemorrhage), and of health workers involved in childbirth. Managing this condition with timely detection and initiation of appropriate, evidence-based treatments is possible but can be challenging. This is especially true in low- and middle-income countries where there is unequal access to hospitals and limited access to effective medicines. The review included 43 studies from 26 countries. Most studies were from low- and middle-income countries and included the perspectives of women and health workers. The review found that cultural beliefs around postpartum bleeding influence individual and community perspectives on postpartum haemorrhage. When women give birth at home or in communities, cultural beliefs lead to delays in seeking care. In health facilities, health workers have difficulty estimating blood loss after birth. Common challenges in managing postpartum haemorrhage include insufficient staffing, stressful working conditions, insufficient training, and lack of medication and supplies. Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with postpartum haemorrhage.
Interventions for improving coverage of childhood immunisation in low‐ and middle‐income countries
In many low- and middle-income countries, immunisation coverage is low. While 129 countries achieved 90% coverage target for DTP3 vaccine by 2014, the 10 countries with the largest numbers of unimmunised children are all low-income or lower- to middle-income countries.
Making well-informed decisions about how best to achieve and sustain high and equitable immunisation coverage in these countries will depend partly on decision makers accessing the best scientific evidence about what interventions work, and integrating this evidence into their national health systems. Increasing internet penetration of remote communities, has enabled rollout of technologies and approaches currently used in high-income countries. This review explores client-oriented interventions, provider-oriented interventions, and health system interventions, with the aim of improving immunisation coverage.
Education, incentive, and engineering‐based interventions to promote the use of seat belts
Over 1.3 million people die each year as a result of traffic collisions, and hundreds of thousands of others are permanently and seriously injured. Most of these deaths occur in low‐ and middle‐income countries, where mortality rates can be up to 10 times higher than those of some high‐income countries. This review looks at interventions that aim to increase use of one of the most simple ways to reduce the impact of traffic collisions: seat belts. The review looked at education, incentives, or engineering‐based interventions rather than law enforcement, to encourage seat belt use. Fifteen studies were included, most of which were done in the USA and mainly focused on educational interventions. The review found some limited evidence that education‐based and engineering‐based interventions may promote seat belt use in early and late adolescents and adults. However, more evidence is needed to investigate the effect of incentives (alone or combined with other interventions) as well as other types of interventions.
Decision aids for people facing health treatment or screening decisions
Patient decision aids are pamphlets, videos, or web-based resources that help people who are considering a treatment or screening decision to decide whether to proceed or not. The aids state the decision, describe the options, and help people think about what matters most to them. The team of review authors wanted to find out if patient decision aids are better than the usual care for helping people to choose an option that reflects what is most important to them. The review summarises evidence from 209 studies involving 107,698 adults. Most of the studies looked at aids that helped people to make decisions about surgery, screening, genetic testing, and long-term medication. The review found moderate-certainty evidence that adults given patient decision aids were more likely to choose an option that reflected what features of the options were most important to them. There is high-certainty evidence that when adults used patient decision aids, they had large increases in their knowledge, expectations of benefits and harms, and participation in making the decision. There is also high-certainty evidence that patient decision aids did not cause any unwanted effects such as regret about the decision.
About this Special Collection
References
1. Soares-Weiser K. Looking back, looking forward: Cochrane at 30 and beyond. Cochrane Database of Systematic Reviews 2022;(12):ED000161. https://doi.org/10.1002/14651858.ED000161
Acknowledgements
This collection was curated and introduced by Toby Lasserson, Deputy Editor in Chief, Cochrane.
Translation
This Special Collection was translated into [language] by [name of Cochrane Group and optionally translators] on [date of the latest translation update].
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