Characteristics and quality of reporting of cluster randomized trials in children: reporting needs improvement

Intracluster correlation coefficients from school-based cluster randomized trials of interventions for improving health outcomes in pupils

BACKGROUND AND OBJECTIVES

To summarize intracluster correlation coefficient (ICC) estimates for pupil health outcomes from school-based cluster randomized trials (CRTs) across world regions and describe their relationship with study design characteristics and context.

METHODS

School-based CRTs reporting ICCs for pupil health outcomes were identified through a literature search of MEDLINE (via Ovid). ICC estimates were summarized both overall and for different categories of study characteristics.

RESULTS

Two hundred and forty-six articles reporting ICC estimates were identified. The median (interquartile range) ICC was 0.031 (0.011 to 0.08) at the school level (N = 210) and 0.063 (0.024 to 0.1) at the class level (N = 46). The distribution of ICCs at the school level was well described by the beta and exponential distributions. Besides larger ICCs in definitive trials than feasibility studies, there were no clear associations between study characteristics and ICC estimates.

CONCLUSION

The distribution of school-level ICCs worldwide was similar to previous summaries from studies in the United States. The description of the distribution of ICCs will help to inform sample size calculations and assess their sensitivity when designing future school-based CRTs of health interventions.

Reporting quality for abstracts of randomised trials on child and adolescent depression prevention: a meta-epidemiological study on adherence to CONSORT for abstracts

OBJECTIVES

This study aimed to investigate adherence to Consolidated Standards of Reporting Trials (CONSORT) for abstracts in reports of randomised trials on child and adolescent depression prevention. Secondary objective was to examine factors associated with overall reporting quality.

DESIGN

Meta-epidemiological study.

DATA SOURCES

We searched MEDLINE, EMBASE, PsycINFO, PsycArticles and CENTRAL.

ELIGIBILITY CRITERIA

Trials were eligible if the sample consisted of children and adolescents under 18 years with or without an increased risk for depression or subthreshold depression. We included reports published from 1 January 2003 to 8 August 2020 on randomised controlled trials (RCTs) and cluster randomised trials (CRTs) assessing universal, selective and indicated interventions aiming to prevent the onset of depression or reducing depressive symptoms.

DATA EXTRACTION AND SYNTHESIS

As the primary outcome measure, we assessed for each trial abstract whether information recommended by CONSORT was adequately reported, inadequately reported or not reported. Moreover, we calculated a summative score of overall reporting quality and analysed associations with trial and journal characteristics.

RESULTS

We identified 169 eligible studies, 103 (61%) RCTs and 66 (39%) CRTs. Adequate reporting varied considerably across CONSORT items: while 9 out of 10 abstracts adequately reported the study objective, no abstract adequately provided information on blinding. Important adverse events or side effects were only adequately reported in one out of 169 abstracts. Summative scores for the abstracts' overall reporting quality ranged from 17% to 83%, with a median of 40%. Scores were associated with the number of authors, abstract word count, journal impact factor, year of publication and abstract structure.

CONCLUSIONS

Reporting quality for abstracts of trials on child and adolescent depression prevention is suboptimal. To help health professionals make informed judgements, efforts for improving adherence to reporting guidelines for abstracts are needed.

Systematic review of the characteristics of school-based feasibility cluster randomised trials of interventions for improving the health of pupils in the UK

Background

The last 20 years have seen a marked increase in the use of cluster randomised trials (CRTs) in schools to evaluate interventions for improving pupil health outcomes. Schools have limited resources and participating in full-scale trials can be challenging and costly, given their main purpose is education. Feasibility studies can be used to identify challenges with implementing interventions and delivering trials. This systematic review summarises methodological characteristics and objectives of school-based cluster randomised feasibility studies in the United Kingdom (UK).

Methods

We systematically searched MEDLINE from inception to 31 December 2020. Eligible papers were school-based feasibility CRTs that included health outcomes measured on pupils.

Results

Of 3285 articles identified, 24 were included. School-based feasibility CRTs have been increasingly used in the UK since the first publication in 2008. Five (21%) studies provided justification for the use of the CRT design. Three (13%) studies provided details of a formal sample size calculation, with only one of these allowing for clustering. The median (IQR; range) recruited sample size was 7.5 (4.5 to 9; 2 to 37) schools and 274 (179 to 557; 29 to 1567) pupils. The most common feasibility objectives were to estimate the potential effectiveness of the intervention (n = 17; 71%), assess acceptability of the intervention (n = 16; 67%), and estimate the recruitment/retention rates (n = 15; 63%). Only one study was used to assess whether cluster randomisation was appropriate, and none of the studies that randomised clusters before recruiting pupils assessed the possibility of recruitment bias. Besides potential effectiveness, cost-effectiveness, and the intra-cluster correlation coefficient, no studies quantified the precision of the feasibility parameter estimates.

Conclusions

Feasibility CRTs are increasingly used in schools prior to definitive trials of interventions for improving health in pupils. The average sample size of studies included in this review would be large enough to estimate pupil-level feasibility parameters (e.g., percentage followed up) with reasonable precision. The review highlights the need for clearer sample size justification and better reporting of the precision with which feasibility parameters are estimated. Better use could be made of feasibility CRTs to assess challenges that are specific to the cluster design.

Trial registration

PROSPERO: CRD42020218993.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01098-w.

Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the United Kingdom: a methodological systematic review

Background

Cluster randomised trials (CRTs) are increasingly used to evaluate non-pharmacological interventions for improving child health. Although methodological challenges of CRTs are well documented, the characteristics of school-based CRTs with pupil health outcomes have not been systematically described. Our objective was to describe methodological characteristics of these studies in the United Kingdom (UK).

Methods

MEDLINE was systematically searched from inception to 30^th June 2020. Included studies used the CRT design in schools and measured primary outcomes on pupils. Study characteristics were described using descriptive statistics.

Results

Of 3138 articles identified, 64 were included. CRTs with pupil health outcomes have been increasingly used in the UK school setting since the earliest included paper was published in 1993; 37 (58%) studies were published after 2010. Of the 44 studies that reported information, 93% included state-funded schools. Thirty six (56%) were exclusively in primary schools and 24 (38%) exclusively in secondary schools. Schools were randomised in 56 studies, classrooms in 6 studies, and year groups in 2 studies. Eighty percent of studies used restricted randomisation to balance cluster-level characteristics between trial arms, but few provided justification for their choice of balancing factors. Interventions covered 11 different health areas; 53 (83%) included components that were necessarily administered to entire clusters. The median (interquartile range) number of clusters and pupils recruited was 31.5 (21 to 50) and 1308 (604 to 3201), respectively. In half the studies, at least one cluster dropped out. Only 26 (41%) studies reported the intra-cluster correlation coefficient (ICC) of the primary outcome from the analysis; this was often markedly different to the assumed ICC in the sample size calculation. The median (range) ICC for school clusters was 0.028 (0.0005 to 0.21).

Conclusions

The increasing pool of school-based CRTs examining pupil health outcomes provides methodological knowledge and highlights design challenges. Data from these studies should be used to identify the best school-level characteristics for balancing the randomisation. Better information on the ICC of pupil health outcomes is required to aid the planning of future CRTs. Improved reporting of the recruitment process will help to identify barriers to obtaining representative samples of schools.

Common Methodological Problems in Randomized Controlled Trials of Preventive Interventions

Randomized controlled trials (RCTs) are often considered the gold standard in evaluating whether intervention results are in line with causal claims of beneficial effects. However, given that poor design and incorrect analysis may lead to biased outcomes, simply employing an RCT is not enough to say an intervention "works." This paper applies a subset of the Society for Prevention Research (SPR) Standards of Evidence for Efficacy, Effectiveness, and Scale-up Research, with a focus on internal validity (making causal inferences) to determine the degree to which RCTs of preventive interventions are well-designed and analyzed, and whether authors provide a clear description of the methods used to report their study findings. We conducted a descriptive analysis of 851 RCTs published from 2010 to 2020 and reviewed by the Blueprints for Healthy Youth Development web-based registry of scientifically proven and scalable interventions. We used Blueprints' evaluation criteria that correspond to a subset of SPR's standards of evidence. Only 22% of the sample satisfied important criteria for minimizing biases that threaten internal validity. Overall, we identified an average of 1-2 methodological weaknesses per RCT. The most frequent sources of bias were problems related to baseline non-equivalence (i.e., differences between conditions at randomization) or differential attrition (i.e., differences between completers versus attritors or differences between study conditions that may compromise the randomization). Additionally, over half the sample (51%) had missing or incomplete tests to rule out these potential sources of bias. Most preventive intervention RCTs need improvement in rigor to permit causal inference claims that an intervention is effective. Researchers also must improve reporting of methods and results to fully assess methodological quality. These advancements will increase the usefulness of preventive interventions by ensuring the credibility and usability of RCT findings.

Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the UK: a systematic review protocol

INTRODUCTION

Cluster randomised trials (CRTs) are studies in which groups (clusters) of participants rather than the individuals themselves are randomised to trial arms. CRTs are becoming increasingly relevant for evaluating interventions delivered in school settings for improving the health of children. Schools are a convenient setting for health interventions targeted at children and the CRT design respects the clustered structure in schools (ie, pupils within classrooms/teachers within schools). Some of the methodological challenges of CRTs, such as ethical considerations for enrolment of children into trials and how best to handle the analysis of data from participants (pupils) that change clusters (schools), may be more salient for the school setting. A better understanding of the characteristics and methodological considerations of school-based CRTs of health interventions would inform the design of future similar studies. To our knowledge, this is the only systematic review to focus specifically on the characteristics and methodological practices of CRTs delivered in schools to evaluate interventions for improving health outcomes in pupils in the UK.

METHODS AND ANALYSIS

We will search for CRTs published from inception to 30 June 2020 inclusively indexed in MEDLINE (Ovid). We will identify relevant articles through title and abstract screening, and subsequent full-text screening for eligibility against predefined inclusion criteria. Disagreements will be resolved through discussion. Two independent reviewers will extract data for each study using a prepiloted data extraction form. Findings will be summarised using descriptive statistics and graphs.

ETHICS AND DISSEMINATION

This methodological systematic review does not require ethical approval as only secondary data extracted from papers will be analysed and the data are not linked to individual participants. After completion of the systematic review, the data will be analysed, and the findings disseminated through peer-reviewed publications and scientific meetings.

PROSPERO REGISTRATION NUMBER

CRD42020201792.

Sample Size Estimates for Cluster-Randomized Trials in Hospital Infection Control and Antimicrobial Stewardship

IMPORTANCE

An important step in designing, executing, and evaluating cluster-randomized trials (CRTs) is understanding the correlation and thus nonindependence that exists among individuals in a cluster. In hospital epidemiology, there is a shortage of CRTs that have published their intraclass correlation coefficient or coefficient of variation (CV), making prospective sample size calculations difficult for investigators.

OBJECTIVES

To estimate the number of hospitals needed to power parallel CRTs of interventions to reduce health care-associated infection outcomes and to demonstrate how different parameters such as CV and expected effect size are associated with the sample size estimates in practice.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study estimated parameters for sample size calculations using national rates developed by the Centers for Disease Control and Prevention for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, central-line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and Clostridium difficile infections (CDI) from 2016. For MRSA and vancomycin-resistant enterococci (VRE) acquisition, outcomes were estimated using data from 2012 from the Benefits of Universal Glove and Gown study. Data were collected from June 2017 through September 2018 and analyzed from September 2018 through January 2019.

MAIN OUTCOMES AND MEASURES

Calculated number of clusters needed for adequate power to detect an intervention effect using a 2-group parallel CRT.

RESULTS

To study an intervention with a 30% decrease in daily rates, 73 total clusters were needed (37 in the intervention group and 36 in the control group) for MRSA bacteremia, 82 for CAUTI, 60 for CLABSI, and 31 for CDI. If a 10% decrease in rates was expected, 768 clusters were needed for MRSA bacteremia, 875 for CAUTI, 631 for CLABSI, and 329 for CDI. For MRSA or VRE acquisition, 50 or 40 total clusters, respectively, were required to observe a 30% decrease, whereas 540 or 426 clusters, respectively, were required to detect a 10% decrease.

CONCLUSIONS AND RELEVANCE

This study suggests that large sample sizes are needed to appropriately power parallel CRTs targeting infection prevention outcomes. Sample sizes are most associated with expected effect size and CV of hospital rates.

Comparison of the Quality of Pediatric Randomized Controlled Trials Published in Both Nursing and Medical Journals: Adherence to the CONSORT Statement

BACKGROUND

Nursing care should be based on scientific evidence. However, studies must be performed rigorously with accurate reporting for their findings to be applicable to practice. Since the body of scientific nursing literature is broad, the quality and validity of its findings should be regularly controlled and verified to ensure their application and their practical impact.

PURPOSE

To compare reporting quality of pediatric randomized controlled trial (RCT) articles in nursing and medical journals.

METHODS

Randomly selected articles were reviewed and scored to assess the number of CONSORT items that were adequately reported, generating a CONSORT score. The CONSORT scores for 28 items were compared between the two journal types.

RESULTS AND DISCUSSION

The CONSORT scores by journal type were not significantly different: (19.2 [16.2; 22] for medical journals and 19.5 [16.1; 21.5] for nursing journals, p = .77). The reporting of CONSORT items was poor for both journal types. However, there were two significant differences: item 19 (Declaration of all important harm or unintended effects, p = .0006) and item 23 (Registration number of the study, p = .0003), were reported more often in medical journals. The adherence of journals to the CONSORT statement and large sample size was associated with better quality of the reporting of studies.

CONCLUSIONS

Based on reporting quality, nursing studies have the same scientific credibility and rigor as medical studies in the pediatric field.

LINKING EVIDENCE TO ACTION

The findings of this study could help researchers improve the reporting of their studies and highlight the importance of reporting quality for future knowledge transfer and practical use. The quality of research and its reporting is necessary to improve knowledge transfer into practice.

Does the medical literature remain inadequately described despite having reporting guidelines for 21 years? - A systematic review of reviews: an update

PURPOSE

Reporting guidelines (eg, Consolidated Standards of Reporting Trials [CONSORT] statement) are intended to improve reporting standards and enhance the transparency and reproducibility of research findings. Despite accessibility of such guidelines, researchers are not required to adhere to them. Our goal was to determine the current status of reporting quality in the medical literature and examine whether adherence of reporting guidelines has improved since the inception of reporting guidelines.

MATERIALS AND METHODS

Eight reporting guidelines, such as CONSORT, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), STrengthening the Reporting of OBservational studies in Epidemiology (STROBE), Quality of Reporting of Meta-analysis (QUOROM), STAndards for Reporting of Diagnostic accuracy (STARD), Animal Research: Reporting In Vivo Experiments (ARRIVE), Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and Meta-analysis of Observational Studies in Epidemiology (MOOSE) were examined. Our inclusion criteria included reviews published between January 1996 to September 2016 which investigated the adherence to reporting guidelines in the literature that addressed clinical trials, systematic reviews, observational studies, meta-analysis, diagnostic accuracy, economic evaluations, and preclinical animal studies that were in English. All reviews were found on Web of Science, Excerpta Medical Database (EMBASE), MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

RESULTS

Among the general searching of 26,819 studies by using the designed searching method, 124 studies were included post screening. We found that 87.9% of the included studies reported suboptimal adherence to reporting guidelines. Factors associated with poor adherence included non-pharmacological interventions, year of publication, and trials concluding with significant results. Improved adherence was associated with better study designs such as allocation concealment, random sequence, large sample sizes, adequately powered studies, multiple authorships, and being published in journals endorsing guidelines.

CONCLUSION

We conclude that the level of adherence to reporting guidelines remains suboptimal. Endorsement of reporting guidelines by journals is important and recommended.

Enrollment and reporting practices in pediatric general surgical randomized clinical trials: A systematic review and observational analysis

BACKGROUND

Pediatric surgical randomized clinical trials (RCTs) are labor-intensive and costly. This systematic review investigated patient accrual and estimates of study duration in RCTs by interrogating enrollment and registration practices.

METHODS

We performed a peer-review search of multiple databases from 2000 to 2016 evaluating RCTs salient to the field with inclusion mandated that a self-identified pediatric surgeon be listed as an author. Trial registries were also searched. RCTs were appraised, and predictors of success were evaluated using multivariate logistic regression, with success defined as achievement of recruitment objectives.

RESULTS

After screening, 137 RCTs were analyzed. Mean Jadad score was 1.80 (median=2). CONSORT scores ranged between 17% and 97% (median=58%). Sixty-seven studies described sample-size determination, 49 reported projected enrollment, and 26 were successful. Among 26 registered RCTs, 15 disclosed their expected completion date, which was achieved by 8. On average, protocols underwent 3.42 iterations. 9% of trials were terminated before completion, most commonly owing to poor recruitment. Trial registration and urgent cases significantly predicted success on multivariable analysis (p<0.05).

CONCLUSION

Overall quality of reporting in pediatric surgical trials is poor. Sample-size calculation and patient accrual are frequently poorly performed or underestimated, resulting in trial overrun and/or premature termination. These data may help inform subsequent study design and facilitate successful completion.

LEVEL OF EVIDENCE

Level III-Systematic Review and Observational (Case-Control) Analysis.

Reducing waste in pediatric clinical research

The importance of reducing waste and increasing value when conducting research has been emphasized by a series of articles published in the Lancet in 2014. A survey indicates that, one year later, these articles have not influenced how research is conducted. In this review, we explore four stages described by Moher et al. in research production that lead to waste. We show that all four stages including, questions relevant to users, appropriate design conduct and analysis, accessible full research, unbiased and usable reports, efficient research regulation and management of biomedical research are also producing an important waste in pediatric research. We conclude that methods to improve research quality and limit waste need to be implemented in pediatric research and recognized by authorities as a priority.

Trends in the number and the quality of trial protocols involving children submitted to a French Institutional Review Board

Background

There is a great need for high quality clinical research for children. The European Pediatric Regulation aimed to improve the quality of clinical trials in order to increase the availability of treatments for children. The main purpose of this study was to assess the evolution of both the number and the quality of pediatric trial protocols that were submitted to a French Institutional Review Board (IRB00009118) before and after the initiation of the EU Pediatric Regulation.

Methods

All protocols submitted to the IRB00009118 between 2003 and 2014 and conducting research on subjects under eighteen years of age were eligible. The quality of randomized clinical trials was assessed according to the guidelines developed by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network and ranked using the Jadad score.

Results

Out of 622 protocols submitted to the Institutional Review Board (IRB), 21% (133/622) included children. Among these 133 pediatric protocols, the number of submitted pediatric protocols doubled between the two studied periods. From 2003 to 2008, 47 protocols including 21 institutionally sponsored were submitted to the IRB and from 2009 until 2014, 86 protocols including 48 institutionally sponsored were submitted. No significant trend was observed on the quality of RCTs. The overall median score of RCTs on the Jadad scale was high (3.5), 70.0% of protocols had a Jadad score ≥ 3, and 30.0% had a score < 3.

Conclusion

Following the EU Pediatric Regulation, the number of pediatric protocols submitted to the IRB00009118 tends to increase, but no change was noticed regarding their quality.

Disease burden-research match? Registered trials in child health from low- and middle-income and high-income countries

AIM

The aim of this study was to determine whether there is a match between the health problems that children face and the clinical trials that are being conducted, especially in low- and middle-income countries (LMICs).

METHODS

All trials on the World Health Organisation International Clinical Trials Registry Platform registered from 2005 to 2013 were reviewed. The disease-specific focus of registered trials for children was compared to the global burden of disease for 2011 using World Health Organisation disability-adjusted life-year data.

RESULTS

Children account for 34% of the global disease burden, but were represented in only 15% (29 899/203 726) of registered trials. Although the number of trials in children registered annually has increased over time (from 3174 in 2005 to 3392 in 2013), the proportion of trials involving children has decreased (from 18 to 13%). LMICs account for 98% of the disease burden among children world-wide, but only 22% of trials. More trials were registered in high-income countries than in LMICs for the majority of the disease categories. There was moderate correlation between the number of trials and the burden of each disease within each region (Spearman's correlation r = 0.6, P = 0.007 and r = 0.55, P = 0.02 in LMICs and high-income countries, respectively).

CONCLUSION

Overall, children continue to be under-represented in clinical trials, particularly children from LMICs where disease burden is greatest. Clinical trial activity correlates moderately with disease burden among the world's children. A more evidence-informed approach for prioritising trials to specifically address the health-care needs of children is required.

Deficiencies of effectiveness of intervention studies in veterinary medicine: a cross-sectional survey of ten leading veterinary and medical journals

The validity of studies that assess the effectiveness of an intervention (EoI) depends on variables such as the type of study design, the quality of their methodology, and the participants enrolled. Five leading veterinary journals and 5 leading human medical journals were hand-searched for EoI studies for the year 2013. We assessed (1) the prevalence of randomized controlled trials (RCTs) among EoI studies, (2) the type of participants enrolled, and (3) the methodological quality of the selected studies. Of 1707 eligible articles, 590 were EoI articles and 435 RCTs. Random allocation to the intervention was performed in 52% (114/219; 95%CI:45.2-58.8%) of veterinary EoI articles, against 87% (321/371; 82.5-89.7%) of human EoI articles (adjusted OR:9.2; 3.4-24.8). Veterinary RCTs were smaller (median: 26 animals versus 465 humans) and less likely to enroll real patients, compared with human RCTs (OR:331; 45-2441). Only 2% of the veterinary RCTs, versus 77% of the human RCTs, reported power calculations, primary outcomes, random sequence generation, allocation concealment and estimation methods. Currently, internal and external validity of veterinary EoI studies is limited compared to human medical ones. To address these issues, veterinary interventional research needs to improve its methodology, increase the number of published RCTs and enroll real clinical patients.

The Method of Randomization for Cluster-Randomized Trials: Challenges of Including Patients with Multiple Chronic Conditions

Cluster-randomized clinical trials (CRT) are trials in which the unit of randomization is not a participant but a group (e.g. healthcare systems or community centers). They are suitable when the intervention applies naturally to the cluster (e.g. healthcare policy); when lack of independence among participants may occur (e.g. nursing home hygiene); or when it is most ethical to apply an intervention to all within a group (e.g. school-level immunization). Because participants in the same cluster receive the same intervention, CRT may approximate clinical practice, and may produce generalizable findings. However, when not properly designed or interpreted, CRT may induce biased results. CRT designs have features that add complexity to statistical estimation and inference. Chief among these is the cluster-level correlation in response measurements induced by the randomization. A critical consideration is the experimental unit of inference; often it is desirable to consider intervention effects at the level of the individual rather than the cluster. Finally, given that the number of clusters available may be limited, simple forms of randomization may not achieve balance between intervention and control arms at either the cluster- or participant-level. In non-clustered clinical trials, balance of key factors may be easier to achieve because the sample can be homogenous by exclusion of participants with multiple chronic conditions (MCC). CRTs, which are often pragmatic, may eschew such restrictions. Failure to account for imbalance may induce bias and reducing validity. This article focuses on the complexities of randomization in the design of CRTs, such as the inclusion of patients with MCC, and imbalances in covariate factors across clusters.

Recommendations and evidence for reporting items in pediatric clinical trial protocols and reports: two systematic reviews

BACKGROUND

Complete and transparent reporting of clinical trial protocols and reports ensures that these documents are useful to all stakeholders, that bias is minimized, and that the research is not wasted. However, current studies repeatedly conclude that pediatric trial protocols and reports are not appropriately reported. Guidelines like SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) may improve reporting, but do not offer guidance on issues unique to pediatric trials. This paper reports two systematic reviews conducted to build the evidence base for the development of pediatric reporting guideline extensions: 1) SPIRIT-Children (SPIRIT-C) for pediatric trial protocols, and 2) CONSORT-Children (CONSORT-C) for pediatric trial reports.

METHOD

MEDLINE, the Cochrane Methodology Register, and reference lists of included studies were searched. Publications of any type were eligible if they included explicit recommendations or empirical evidence for the reporting of potential items in a pediatric protocol (SPIRIT-C systematic review) or trial report (CONSORT-C systematic review). Study characteristics, recommendations and evidence for pediatric extension items were extracted. Recurrent themes in the recommendations and evidence were identified and synthesized. All steps were conducted by two reviewers.

RESULTS

For the SPIRIT-C and CONSORT-C systematic reviews 366 and 429 publications were included, respectively. Recommendations were identified for 48 of 50 original reporting items and sub-items from SPIRIT, 15 of 20 potential SPIRIT-C reporting items, all 37 original CONSORT items and sub-items, and 16 of 22 potential CONSORT-C reporting items. The following overarching themes of evidence to support or refute the utility of reporting items were identified: transparency; reproducibility; interpretability; usefulness; internal validity; external validity; reporting bias; publication bias; accountability; scientific soundness; and research ethics.

CONCLUSION

These systematic reviews are the first to systematically gather evidence and recommendations for the reporting of specific items in pediatric protocols and trials. They provide useful and translatable evidence on which to build pediatric extensions to the SPIRIT and CONSORT reporting guidelines. The resulting SPIRIT-C and CONSORT-C will provide guidance to the authors of pediatric protocols and reports, respectively, helping to alleviate concerns of inappropriate and inconsistent reporting, and reduce research waste.

A systematic review of factors affecting children's right to health in cluster randomized trials in Kenya

Following the South African case, Treatment Action Campaign and Others v Minister of Health and Others, the use of 'pilot' studies to investigate interventions already proven efficacious, offered free of charge to government, but confined by the government to a small part of the population, may violate children's right to health, and the negative duty on governments not to prevent access to treatment. The applicants challenged a government decision to offer Nevirapine in a few pilot sites when evidence showed Nevirapine significantly reduced HIV transmission rates and despite donor offers of a free supply. The government refused to expand access, arguing they needed to collect more information, and citing concerns about long-term hazards, side effects, resistance and inadequate infrastructure. The court ruled this violated children's right to health and asked the government to immediately expand access. Cluster randomized trials involving children are increasingly popular, and are often used to reduce 'contamination': the possibility that members of a cluster adopt behavior of other clusters. However, they raise unique issues insufficiently addressed in literature and ethical guidelines. This case provides additional crucial guidance, based on a common human rights framework, for the Kenyan government and other involved stakeholders. Children possess special rights, often represent a 'captive' group, and so motivate extra consideration. In a systematic review, we therefore investigated whether cluster trial designs are used to prevent or delay children's access to treatment in Kenya or otherwise inconsistently with children's right to health as outlined in the above case. Although we did not find state sponsored cluster trials, most had significant public sector involvement. Core obligations under children's right to health were inadequately addressed across trials. Few cluster trials reported rationale for cluster randomization, offered post- trial access or planned to implement successful interventions. A small number of trials may have unnecessarily evaluated proven interventions, offered their control arm trial conditions worse than local standards of care or evaluated interventions ostensibly worse than local standards of care. Further research is required to establish if children's right to health in cluster trials is well understood and to explain why some obligations are unmet.

A systematic scoping review of adherence to reporting guidelines in health care literature

Background

Reporting guidelines have been available for the past 17 years since the inception of the Consolidated Standards of Reporting Trials statement in 1996. These guidelines were developed to improve the quality of reporting of studies in medical literature. Despite the widespread availability of these guidelines, the quality of reporting of medical literature remained suboptimal. In this study, we assess the current adherence practice to reporting guidelines; determine key factors associated with better adherence to these guidelines; and provide recommendations to enhance adherence to reporting guidelines for future studies.

Methods

We undertook a systematic scoping review of systematic reviews of adherence to reporting guidelines across different clinical areas and study designs. We searched four electronic databases (Cumulative Index to Nursing and Allied Health Literature, Web of Science, Embase, and Medline) from January 1996 to September 2012. Studies were included if they addressed adherence to one of the following guidelines: Consolidated Standards of Reporting Trials (CONSORT), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Quality of Reporting of Meta-analysis (QUOROM), Transparent Reporting of Evaluations with Nonrandomized Designs (TREND), Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). A protocol for this study was devised. A literature search, data extraction, and quality assessment were performed independently by two authors in duplicate. This study reporting follows the PRISMA guidelines.

Results

Our search retrieved 5159 titles, of which 50 were eligible. Overall, 86.0% of studies reported suboptimal levels of adherence to reporting guidelines. Factors associated with better adherence included journal impact factor and endorsement of guidelines, publication date, funding source, multisite studies, pharmacological interventions and larger studies.

Conclusion

Reporting guidelines in the clinical literature are important to improve the standards of reporting of clinical studies; however, adherence to these guidelines remains suboptimal. Action is therefore needed to enhance the adherence to these standards. Strategies to enhance adherence include journal editorial policies endorsing these guidelines.

Changes in adolescents' oral health status following oral health promotion activities in Tanzania

OBJECTIVE

To assess the impact of oral health promotion integrated with a health promoting school (HPS) initiative on the oral health outcomes of secondary school students.

MATERIALS AND METHOD

Using an urban-rural stratified cluster randomized approach, the intervention was applied to secondary school students in Arusha, Tanzania. In the urban, three control (n = 315) and two intervention (n = 214) schools performed oral clinical examination and questionnaires at baseline. In rural the corresponding figures at baseline were two (n = 188) and three (n = 360) schools. After 2 years, 374 and 358 students remained in the intervention and control arms.

RESULTS

Mean number of decayed teeth (DT) increased in the intervention (mean score 1.0 vs 1.7, p < 0.001) and control schools (mean score 1.2 vs 1.7, p < 0.001). Mean number of teeth with plaque decreased significantly in intervention and control schools. No significant difference in caries increment and plaque decline scores was observed between groups. Mean number of teeth with bleeding decreased (0.5 vs 0.3, p < 0.05) in intervention schools, whereas no change was observed in the control schools (0.4 vs 0.5, p = 0.051). Increment in mean number of DT between baseline and follow-up was largest and smallest in students who, respectively, deteriorated and improved their plaque and bleeding scores.

CONCLUSION

The intervention activities did not show any effect with respect to dental caries, calculus and plaque status among the students investigated. Compared with the control group, more favorable changes in the intervention group occurred with respect to bleeding on probing, suggesting a weak but positive effect on students' oral hygiene status.

Illustrating Problems Faced by Stroke Researchers: A Review of Cluster-Randomized Controlled Trials

The cluster-randomized controlled trial is a design increasingly used in prevention and health care evaluation studies and is highly relevant to stroke research. However, there are methodological issues that make it complex to implement. These are not always fully appreciated, with reviews continuing to reveal deficiencies. We searched PUBMED and CENTRAL databases to March 31, 2011 for cluster-randomized controlled trials in stroke. Two investigators independently reviewed citations for eligibility and extracted data on key aspects of each trial. Fifteen trials met the eligibility criteria. No trial fully met CONSORT cluster-randomized controlled trial guidelines, although good design and reporting practice were usually present. Twelve trials included the term ‘cluster-randomized’ (or ‘group-randomized’) in the title, and 12 trials stated the intraclass correlation coefficient used to plan the number of clusters and cluster size. However, few provided a clear, evidence-based justification for the choice of intraclass correlation coefficient, and only two-thirds reported the intraclass correlation coefficient for primary outcomes. Several trials appeared underpowered because of problems in determining an appropriate sample size, defining appropriate clusters, and recruiting and retaining clusters and patients. Cluster-randomized controlled trials are difficult to design and perform due to the combination of methodological and practical difficulties. It is important that further improvements are made to reporting cluster-randomized trials and intraclass correlation coefficients should be estimated using a standardized approach and reported consistently; this would be beneficial for stroke researchers when designing future cluster-randomized trials.