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Hall R, Taylor J, Hewitt CE, Heathcote C, Jarvis SW, Langton T, Fraser L. Impact of social transition in relation to gender for children and adolescents: a systematic review. Arch Dis Child 2024:archdischild-2023-326112. [PMID: 38594055 DOI: 10.1136/archdischild-2023-326112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/28/2023] [Indexed: 04/11/2024]
Abstract
BACKGROUND Increasing numbers of children and adolescents experiencing gender dysphoria or incongruence are being referred to specialist gender services. Historically, social transitioning prior to assessment was rare but it is becoming more common. AIM To identify and synthesise studies assessing the outcomes of social transition for children and adolescents (under 18) experiencing gender dysphoria/incongruence. METHODS A systematic review and narrative sythesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were perfomed in April 2022. Studies reporting any outcome of social transition (full or partial) for children and adolescents experiencing gender dysphoria/incongruence were included. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. RESULTS Eleven studies were included (children (n=8) and adolescents (n=3)) and most were of low quality. The majority were from the US, featured community samples and cross-sectional analyses. Different comparator groups were used, and outcomes related to mental health and gender identity reported. Overall studies consistently reported no difference in mental health outcomes for children who socially transitioned across all comparators. Studies found mixed evidence for adolescents who socially transitioned. CONCLUSIONS It is difficult to assess the impact of social transition on children/adolescents due to the small volume and low quality of research in this area. Importantly, there are no prospective longitudinal studies with appropriate comparator groups assessing the impact of social transition on mental health or gender-related outcomes for children/adolescents. Professionals working in the area of gender identity and those seeking support should be aware of the absence of robust evidence of the benefits or harms of social transition for children and adolescents. PROSPERO REGISTRATION NUMBER CRD42021289659.
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Affiliation(s)
- Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | - Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Taylor J, Hall R, Heathcote C, Hewitt CE, Langton T, Fraser L. Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations (part 2). Arch Dis Child 2024:archdischild-2023-326500. [PMID: 38594048 DOI: 10.1136/archdischild-2023-326500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/15/2023] [Indexed: 04/11/2024]
Abstract
BACKGROUND Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services and there are various published guidelines outlining approaches to clinical care. AIM To examine the recommendations about the management of children and/or adolescents (age 0-18) experiencing gender dysphoria/incongruence in published guidelines or clinical guidance. A separate paper examines the quality and development of guidelines. METHODS A systematic review and narrative synthesis. Databases (Medline, Embase, CINAHL, PsycINFO, Web of Science) were searched to April 2022 and web-based searches and contact with international experts continued to December 2022, with results assessed independently by two reviewers. The Appraisal of Guidelines for Research and Evaluation tool was used to examine guideline quality. RESULTS 23 guidelines/clinical guidance publications (1998-2022) were identified (4 international, 3 regional, 16 national). Guidelines describe a similar care pathway starting with psychosocial care for prepubertal children, puberty suppressants followed by hormones for eligible adolescents and surgical interventions as these adolescents enter adulthood. In general, there is consensus that adolescents should receive a multidisciplinary assessment, although clear guidance about the purpose or approach is lacking. There are differing recommendations about when and on what basis psychological and medical interventions should be offered. There is limited guidance about what psychological care should be provided, about the management of prepubertal children or those with a non-binary gender identity, nor about pathways between specialist gender services and other providers. CONCLUSIONS Published guidance describes a similar care pathway; however, there is no current consensus about the purpose and process of assessment for children or adolescents with gender dysphoria/incongruence, or about when psychological or hormonal interventions should be offered and on what basis. PROSPERO REGISTRATION NUMBER CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | | | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Hall R, Taylor J, Heathcote C, Langton T, Hewitt CE, Fraser L. Gender services for children and adolescents across the EU-15+ countries: an online survey. Arch Dis Child 2024:archdischild-2023-326348. [PMID: 38594051 DOI: 10.1136/archdischild-2023-326348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/25/2023] [Indexed: 04/11/2024]
Abstract
BACKGROUND Over the last 10-15 years, there has been an increase in the number of children and adolescents referred to gender services, particularly among adolescent birth-registered females. This population shows a higher prevalence of co-occurring mental health difficulties and neurodevelopmental conditions. Some countries have recently restricted access to medical treatments in recognition of the uncertain evidence base. AIM To understand the current provision of gender services for children and adolescents across the EU-15+ countries that have comparable high-income healthcare systems, to inform service development in the UK. METHODS An e-survey of paediatric gender services was conducted between September 2022 and April 2023. It covered service structure, care pathways, interventions and data collection. Data were described and compared to identify similarities and differences among participating services. RESULTS 15 services in eight countries (Australia, Belgium, Denmark, Norway, Northern Ireland, The Netherlands, Spain and Finland) responded. While a multidisciplinary team was present in all services, its composition and organisation varied. Clinical practice was informed by international guidelines, with four countries following their own national guidelines. Differences were observed in referral criteria, care pathways for prepubertal children and those with co-occurring conditions. Eligibility criteria for medical interventions also varied. Psychosocial support and interventions were limited, and outcome data collection was scarce. CONCLUSIONS This survey revealed both similarities and key variations in the clinical practice of paediatric gender services across eight different countries. The study emphasises the need for service development that both considers the management of co-occurring conditions and embeds routine data collection in practice.
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Affiliation(s)
- Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | - Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | | | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Taylor J, Mitchell A, Hall R, Heathcote C, Langton T, Fraser L, Hewitt CE. Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review. Arch Dis Child 2024:archdischild-2023-326669. [PMID: 38594047 DOI: 10.1136/archdischild-2023-326669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/10/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Treatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a need to aggregate evidence as new studies are published. AIM To identify and synthesise studies assessing the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. METHODS A systematic review and narrative synthesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were used. RESULTS 11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility. CONCLUSIONS There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review. PROSPERO REGISTRATION NUMBER CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Alex Mitchell
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Taylor J, Hall R, Heathcote C, Hewitt CE, Langton T, Fraser L. Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1). Arch Dis Child 2024:archdischild-2023-326499. [PMID: 38594049 DOI: 10.1136/archdischild-2023-326499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/15/2023] [Indexed: 04/11/2024]
Abstract
BACKGROUND Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. There are various guidelines outlining approaches to the clinical care of these children and adolescents. AIM To examine the quality and development of published guidelines or clinical guidance containing recommendations for managing gender dysphoria/incongruence in children and/or adolescents (age 0-18). A separate paper reports the synthesis of guideline recommendations. METHODS A systematic review and narrative synthesis. Databases (Medline, Embase, CINAHL, PsycINFO, Web of Science) were searched to April 2022 and web-based searches and contact with international experts continued to December 2022, with results assessed independently by two reviewers. The Appraisal of Guidelines for Research and Evaluation tool was used to examine guideline quality. RESULTS Twenty-three guidelines/clinical guidance publications (1998-2022) were identified (4 international, 3 regional and 16 national). The quality and methods reporting in these varied considerably. Few guidelines systematically reviewed empirical evidence, and links between evidence and recommendations were often unclear. Although most consulted with relevant stakeholders, including 10 which involved service users or user representatives, it was often unclear how this influenced recommendations and only two reported including children/adolescents and/or parents. Guidelines also lacked clarity about implementation. Two international guidelines (World Professional Association for Transgender Health and Endocrine Society) formed the basis for most other guidance, influencing their development and recommendations. CONCLUSIONS Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed. This should be considered when using these to inform service development and clinical practice. PROSPERO REGISTRATION NUMBER CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | | | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Taylor J, Hall R, Langton T, Fraser L, Hewitt CE. Care pathways of children and adolescents referred to specialist gender services: a systematic review. Arch Dis Child 2024:archdischild-2023-326760. [PMID: 38594052 DOI: 10.1136/archdischild-2023-326760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/17/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. However, little is currently known about the proportions accessing different types of care and treatment following referral. AIM This systematic review examines the range of care pathways of children/adolescents (under 18) referred to specialist gender or endocrinology services. METHODS Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing data for numbers of children and/or adolescents at referral/assessment and their treatment pathways were included. A narrative approach to synthesis was used and where appropriate proportions were combined in a random-effects meta-analysis. RESULTS 23 studies across nine countries were included, representing 6133 children and/or adolescents with a median age at assessment of 14-16 and overall a higher percentage of birth-registered females. Of those assessed, 36% (95% CI 27% to 45%) received puberty suppression, 51% (95% CI 40% to 62%) received masculinising or feminising hormones, 68% (95% CI 57% to 77%) received puberty suppression and/or hormones and 16% (95% CI 10% to 24%) received surgery. No study systematically reported information about the full pathway or psychological care received by children/adolescents. Follow-up in many studies was insufficient or unclear. Reasons for discontinuation were rarely provided. CONCLUSIONS Prospective studies with long-term follow-up reporting information about the full range of pathways are needed to understand what happens to children and adolescents referred to specialist gender services. Information about provision of psychological care is needed considering high rates of psychosocial difficulties in this population.PROSPERO registration number CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Heathcote C, Taylor J, Hall R, Jarvis SW, Langton T, Hewitt CE, Fraser L. Psychosocial support interventions for children and adolescents experiencing gender dysphoria or incongruence: a systematic review. Arch Dis Child 2024:archdischild-2023-326347. [PMID: 38594045 DOI: 10.1136/archdischild-2023-326347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/11/2023] [Indexed: 04/11/2024]
Abstract
BACKGROUND National and international guidelines recommend that psychosocial support should be a key component of the care offered to children and adolescents experiencing gender dysphoria/incongruence. However, specific approaches or interventions are not recommended. AIM To identify and summarise evidence on the outcomes of psychosocial support interventions for children and adolescents (age 0-18) experiencing gender dysphoria/incongruence. METHODS Systematic review and narrative synthesis. Database searches (MEDLINE; EMBASE; CINAHL; PsycINFO; Web of Science) were performed in April 2022, with results assessed independently by two reviewers. Peer-reviewed articles reporting the results of studies measuring outcomes of psychosocial support interventions were included. Quality was assessed using the Mixed Methods Appraisal Tool. RESULTS Ten studies were included. Half were conducted in the US, with others from Australia, Canada, New Zealand and the UK. Six were pre-post analyses or cohort studies, three were mixed methods, and one was a secondary analysis of intervention data from four trials. Most studies were of low quality. Most analyses of mental health and psychosocial outcomes showed either benefit or no change, with none indicating negative or adverse effects. CONCLUSIONS The small number of low-quality studies limits conclusions about the effectiveness of psychosocial interventions for children/adolescents experiencing gender dysphoria/incongruence. Clarity on the intervention approach as well as the core outcomes would support the future aggregation of evidence. More robust methodology and reporting is required. PROSPERO REGISTRATION NUMBER CRD42021289659.
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Affiliation(s)
| | - Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | | | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Taylor J, Hall R, Langton T, Fraser L, Hewitt CE. Characteristics of children and adolescents referred to specialist gender services: a systematic review. Arch Dis Child 2024:archdischild-2023-326681. [PMID: 38594046 DOI: 10.1136/archdischild-2023-326681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/04/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Increasing numbers of children/adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. Services and practice guidelines are responding to these changes. AIM This systematic review examines the numbers and characteristics of children/adolescents (under 18) referred to specialist gender or endocrinology services. METHODS Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing at least birth-registered sex or age at referral were included. Demographic, gender-related, mental health, neurodevelopmental conditions and adverse childhood experience data were extracted. A narrative approach to synthesis was used and where appropriate proportions were combined in a meta-analysis. RESULTS 143 studies from 131 articles across 17 countries were included. There was a twofold to threefold increase in the number of referrals and a steady increase in birth-registered females being referred. There is inconsistent collection and reporting of key data across many of the studies. Approximately 60% of children/adolescents referred to services had made steps to present themselves in their preferred gender. Just under 50% of studies reported data on depression and/or anxiety and under 20% reported data on other mental health issues and neurodevelopmental conditions. Changes in the characteristics of referrals over time were generally not reported. CONCLUSIONS Services need to capture, assess and respond to the potentially co-occurring complexities of children/adolescents being referred to specialist gender and endocrine services. Agreement on the core characteristics for collection at referral/assessment would help to ensure services are capturing data as well as developing pathways to meet the needs of these children.PROSPERO registration number CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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Taylor J, Mitchell A, Hall R, Langton T, Fraser L, Hewitt CE. Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: a systematic review. Arch Dis Child 2024:archdischild-2023-326670. [PMID: 38594053 DOI: 10.1136/archdischild-2023-326670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/16/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Clinical guidelines outline the use of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria or incongruence. Robust evidence concerning risks and benefits is lacking. There is a need to aggregate evidence as research becomes available. AIM Identify and synthesise studies assessing the outcomes of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria/incongruence. METHODS Systematic review and narrative synthesis. Database searches (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for Cohort Studies was used to assess study quality. Moderate- and high-quality studies were synthesised. RESULTS 12 cohort, 9 cross-sectional and 32 pre-post studies were included (n=53). One cohort study was high-quality. Other studies were moderate (n=33) and low-quality (n=19). Synthesis of high and moderate-quality studies showed consistent evidence demonstrating induction of puberty, although with varying feminising/masculinising effects. There was limited evidence regarding gender dysphoria, body satisfaction, psychosocial and cognitive outcomes, and fertility. Evidence from mainly pre-post studies with 12-month follow-up showed improvements in psychological outcomes. Inconsistent results were observed for height/growth, bone health and cardiometabolic effects. Most studies included adolescents who received puberty suppression, making it difficult to determine the effects of hormones alone. CONCLUSIONS There is a lack of high-quality research assessing the use of hormones in adolescents experiencing gender dysphoria/incongruence. Moderate-quality evidence suggests mental health may be improved during treatment, but robust study is still required. For other outcomes, no conclusions can be drawn. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.PROSPERO registration number: CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Alex Mitchell
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Trilby Langton
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, YO10 5DD, UK
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Arundel CE, Clark LK, Parker A, Beard D, Coleman E, Cooper C, Devane D, Eldridge S, Galvin S, Gillies K, Hewitt CE, Sutton C, Torgerson DJ, Treweek S. Trial Forge Guidance 4: a guideline for reporting the results of randomised Studies Within A Trial (SWATs). Trials 2024; 25:183. [PMID: 38475795 PMCID: PMC10935912 DOI: 10.1186/s13063-024-08004-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Evidence to support decisions on trial processes is minimal. One way to generate this evidence is to use a Study Within A Trial (SWAT) to test trial processes or explore methodological uncertainties. SWAT evidence relies on replication to ensure sufficient power and broad applicability of findings. Prompt reporting is therefore essential; however, SWAT publications are often the first to be abandoned in the face of other time pressures. Reporting guidance for embedded methodology trials does exist but is not widely used. We sought therefore to build on these guidelines to develop a straightforward, concise reporting standard, which remains adherent to the CONSORT guideline. METHODS An iterative process was used to develop the guideline. This included initial meetings with key stakeholders, development of an initial guideline, pilot testing of draft guidelines, further iteration and pilot testing, and finalisation of the guideline. RESULTS We developed a reporting guideline applicable to randomised SWATs, including replications of previous evaluations. The guideline follows the Consolidated Standards for Reporting Trials (CONSORT) statement and provides example text to ensure ease and clarity of reporting across all domains. CONCLUSIONS The SWAT reporting guideline will aid authors, reviewers, and journal editors to produce and review clear, structured reports of randomised SWATs, whilst also adhering to the CONSORT guideline. TRIAL REGISTRATION EQUATOR Network - Guidelines Under Development ( https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-clinical-trials/#SWAT ). Registered on 25 March 2021.
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Affiliation(s)
- C E Arundel
- York Trials Unit, Department of Health Sciences, Faculty of Science, Lower Ground Floor ARRC Building, University of York, York, YO10 5DD, UK.
| | - L K Clark
- York Trials Unit, Department of Health Sciences, Faculty of Science, Lower Ground Floor ARRC Building, University of York, York, YO10 5DD, UK
| | - A Parker
- York Trials Unit, Department of Health Sciences, Faculty of Science, Lower Ground Floor ARRC Building, University of York, York, YO10 5DD, UK
| | - D Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - E Coleman
- York Trials Unit, Department of Health Sciences, Faculty of Science, Lower Ground Floor ARRC Building, University of York, York, YO10 5DD, UK
| | - C Cooper
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - D Devane
- HRB-Trials Methodology Research Network, University of Galway, Galway, Ireland
- School of Nursing and Midwifery, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland and Cochrane Ireland, University of Galway, Galway, Ireland
| | - S Eldridge
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - S Galvin
- HRB-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - K Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - C E Hewitt
- York Trials Unit, Department of Health Sciences, Faculty of Science, Lower Ground Floor ARRC Building, University of York, York, YO10 5DD, UK
| | - C Sutton
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - D J Torgerson
- York Trials Unit, Department of Health Sciences, Faculty of Science, Lower Ground Floor ARRC Building, University of York, York, YO10 5DD, UK
| | - S Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Parker A, Arundel C, Clark L, Coleman E, Doherty L, Hewitt CE, Beard D, Bower P, Cooper C, Culliford L, Devane D, Emsley R, Eldridge S, Galvin S, Gillies K, Montgomery A, Sutton CJ, Treweek S, Torgerson DJ. Undertaking Studies Within A Trial to evaluate recruitment and retention strategies for randomised controlled trials: lessons learnt from the PROMETHEUS research programme. Health Technol Assess 2024; 28:1-114. [PMID: 38327177 PMCID: PMC11017159 DOI: 10.3310/htqw3107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Background Randomised controlled trials ('trials') are susceptible to poor participant recruitment and retention. Studies Within A Trial are the strongest methods for testing the effectiveness of strategies to improve recruitment and retention. However, relatively few of these have been conducted. Objectives PROMoting THE Use of Studies Within A Trial aimed to facilitate at least 25 Studies Within A Trial evaluating recruitment or retention strategies. We share our experience of delivering the PROMoting THE Use of Studies Within A Trial programme, and the lessons learnt for undertaking randomised Studies Within A Trial. Design A network of 10 Clinical Trials Units and 1 primary care research centre committed to conducting randomised controlled Studies Within A Trial of recruitment and/or retention strategies was established. Promising recruitment and retention strategies were identified from various sources including Cochrane systematic reviews, the Study Within A Trial Repository, and existing prioritisation exercises, which were reviewed by patient and public members to create an initial priority list of seven recruitment and eight retention interventions. Host trial teams could apply for funding and receive support from the PROMoting THE Use of Studies Within A Trial team to undertake Studies Within A Trial. We also tested the feasibility of undertaking co-ordinated Studies Within A Trial, across multiple host trials simultaneously. Setting Clinical trials unit-based trials recruiting or following up participants in any setting in the United Kingdom were eligible. Participants Clinical trials unit-based teams undertaking trials in any clinical context in the United Kingdom. Interventions Funding of up to £5000 and support from the PROMoting THE Use of Studies Within A Trial team to design, implement and report Studies Within A Trial. Main outcome measures Number of host trials funded. Results Forty-two Studies Within A Trial were funded (31 host trials), across 12 Clinical Trials Units. The mean cost of a Study Within A Trial was £3535. Twelve Studies Within A Trial tested the same strategy across multiple host trials using a co-ordinated Study Within A Trial design, and four used a factorial design. Two recruitment and five retention strategies were evaluated in more than one host trial. PROMoting THE Use of Studies Within A Trial will add 18% more Studies Within A Trial to the Cochrane systematic review of recruitment strategies, and 79% more Studies Within A Trial to the Cochrane review of retention strategies. For retention, we found that pre-notifying participants by card, letter or e-mail before sending questionnaires was effective, as was the use of pens, and sending personalised text messages to improve questionnaire response. We highlight key lessons learnt to guide others planning Studies Within A Trial, including involving patient and public involvement partners; prioritising and selecting strategies to evaluate and elements to consider when designing a Study Within A Trial; obtaining governance approvals; implementing Studies Within A Trial, including individual and co-ordinated Studies Within A Trials; and reporting Study Within A Trials. Limitations The COVID-19 pandemic negatively impacted five Studies Within A Trial, being either delayed (n = 2) or prematurely terminated (n = 3). Conclusions PROMoting THE Use of Studies Within A Trial significantly increased the evidence base for recruitment and retention strategies. When provided with both funding and practical support, host trial teams successfully implemented Studies Within A Trial. Future work Future research should identify and target gaps in the evidence base, including widening Study Within A Trial uptake, undertaking more complex Studies Within A Trial and translating Study Within A Trial evidence into practice. Study registration All Studies Within A Trial in the PROMoting THE Use of Studies Within A Trial programme had to be registered with the Northern Ireland Network for Trials Methodology Research Study Within A Trial Repository. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/55/80) and is published in full in Health Technology Assessment; Vol. 28, No. 2. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Adwoa Parker
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catherine Arundel
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Clark
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Elizabeth Coleman
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Doherty
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, NIHR Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Cindy Cooper
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lucy Culliford
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Declan Devane
- School of Nursing and Midwifery, University of Galway, Galway, Republic of Ireland
- Health Research Board-Trials Methodology Research Network, Galway, Republic of Ireland
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sandra Eldridge
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Sandra Galvin
- School of Nursing and Midwifery, University of Galway, Galway, Republic of Ireland
- Health Research Board-Trials Methodology Research Network, Galway, Republic of Ireland
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Foresthill, Aberdeen, UK
| | - Alan Montgomery
- University of Nottingham, Nottingham Clinical Trials Unit, University Park Nottingham, Nottinghamshire, UK
| | | | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Foresthill, Aberdeen, UK
| | - David J Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
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Fraser LK, Bedendo A, O'Neill M, Taylor J, Hackett J, Horridge KA, Cade J, Richardson G, Phung H, McCarter A, Hewitt CE. Safety, resource use and nutritional content of home-blended diets in children who are gastrostomy fed: findings from 'YourTube' - a prospective cohort study. Arch Dis Child 2023:archdischild-2023-326393. [PMID: 38129118 DOI: 10.1136/archdischild-2023-326393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To assess the risks, benefits and resource implications of using home-blended food in children with gastrostomy tubes compared with currently recommended formula feeds. DESIGN This is a cohort study. Data were collected at months 0, 12 and 18 from parents and clinicians using standardised measures. SETTING 32 sites across England: 28 National Health Service trusts and 4 children's hospices. PATIENTS Children aged 6 months-18 years who were gastrostomy fed. MAIN OUTCOME MEASURE The main outcome measure was the PedsQL Gastrointestinal Symptoms Scales score. Secondary outcomes included quality of life, sleep (child, parent), dietary intake, anthropometry, healthcare usage, safety outcomes and resource use. RESULTS 180 children and families completed the baseline data collection, with 134 (74%) and 105 (58%) providing follow-up data at 12 and 18 months. There were fewer gastrointestinal (GI) symptoms at all time points in the home-blended diet group, but there was no difference in change over time within or between the groups. The nutritional intake of those on a home-blended diet had higher calories per kilogram and fibre, and both home-blended and formula-fed children have values above the dietary reference values for most micronutrients. Safety outcomes were similar between groups and over time. The total costs to the statutory sector were higher among children who were formula fed, but the costs of purchasing special equipment for home-blended food and the total time spent on childcare were higher for families with home-blended diet. CONCLUSIONS Children who are gastrostomy fed a home-blended diet have similar safety profile, adequate nutritional intake and lower burden of GI symptoms than formula-fed children.Trial registration number ISRCTN13977361.
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Affiliation(s)
- Lorna K Fraser
- Cicely Saunders Institute, King's College London, London, UK
- Health Sciences, University of York, York, UK
| | | | | | - Jo Taylor
- Health Sciences, University of York, York, UK
| | | | | | | | | | - Han Phung
- University of York Centre for Health Economics, York, UK
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13
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Zainab R, Kandasamy A, Bhat NA, Dsouza CV, Jennings H, Jackson C, Mazumdar P, Hewitt CE, Ekers D, Narayanan G, Rao GN, Coales K, Muliyala KP, Chaturvedi SK, Murthy P, Siddiqi N. Behavioral Activation for Comorbid Depression in People With Noncommunicable Disease in India: Protocol for a Randomized Controlled Feasibility Trial. JMIR Res Protoc 2023; 12:e41127. [PMID: 37971791 PMCID: PMC10690525 DOI: 10.2196/41127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 03/23/2023] [Accepted: 04/18/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated. OBJECTIVE Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care. METHODS Following well-established frameworks for intervention adaptation, we first adapted BA (to fit the linguistic, cultural, and resource context) for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters (eg, recruitment and retention rates and completeness of follow-up) needed to design a future definitive trial. RESULTS Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation (qualitative data) collection is ongoing. Both the qualitative and quantitative data analyses are ongoing. CONCLUSIONS This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program. TRIAL REGISTRATION Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41127.
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Affiliation(s)
- Rayeesa Zainab
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Arun Kandasamy
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Naseer Ahmad Bhat
- Jindal School of Psychology and Counselling, O P Jindal Global University, Sonipat, India
| | | | - Hannah Jennings
- Department of Health Sciences, University of York & Hull York Medical School, Heslington, United Kingdom
| | - Cath Jackson
- Valid Research LTD, West Yorkshire, United Kingdom
| | - Papiya Mazumdar
- School of Politics and International Studies, Faculty of Social Science, University of Leeds, Leeds, United Kingdom
| | | | - David Ekers
- Tees Esk and Wear Valleys NHS Foundation Trust, North Yorkshire, United Kingdom
- Department of Medicine, Pharmacy, and Health, Durham University, North Yorkshire, United Kingdom
| | | | - Girish N Rao
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Karen Coales
- Department of Health Sciences, University of York & Hull York Medical School, Heslington, United Kingdom
| | | | | | - Pratima Murthy
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Najma Siddiqi
- Department of Health Sciences, University of York & Hull York Medical School, Heslington, United Kingdom
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14
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Darling AL, Manders RJF, Sahni S, Zhu K, Hewitt CE, Prince RL, Millward DJ, Lanham-New SA. Dietary protein and bone health across the life-course: an updated systematic review and meta-analysis over 40 years. Osteoporos Int 2019; 30:741-761. [PMID: 30903209 DOI: 10.1007/s00198-019-04933-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 03/04/2019] [Indexed: 12/31/2022]
Abstract
We undertook a systematic review and meta-analysis of published papers assessing dietary protein and bone health. We found little benefit of increasing protein intake for bone health in healthy adults but no indication of any detrimental effect, at least within the protein intakes of the populations studied. This systematic review and meta-analysis analysed the relationship between dietary protein and bone health across the life-course. The PubMed database was searched for all relevant human studies from the 1st January 1976 to 22nd January 2016, including all bone outcomes except calcium metabolism. The searches identified 127 papers for inclusion, including 74 correlational studies, 23 fracture or osteoporosis risk studies and 30 supplementation trials. Protein intake accounted for 0-4% of areal BMC and areal BMD variance in adults and 0-14% of areal BMC variance in children and adolescents. However, when confounder adjusted (5 studies) adult lumbar spine and femoral neck BMD associations were not statistically significant. There was no association between protein intake and relative risk (RR) of osteoporotic fractures for total (RR(random) = 0.94; 0.72 to 1.23, I2 = 32%), animal (RR (random) = 0.98; 0.76 to 1.27, I2 = 46%) or vegetable protein (RR (fixed) = 0.97 (0.89 to 1.09, I2 = 15%). In total protein supplementation studies, pooled effect sizes were not statistically significant for LSBMD (total n = 255, MD(fixed) = 0.04 g/cm2 (0.00 to 0.08, P = 0.07), I2 = 0%) or FNBMD (total n = 435, MD(random) = 0.01 g/cm2 (-0.03 to 0.05, P = 0.59), I2 = 68%). There appears to be little benefit of increasing protein intake for bone health in healthy adults but there is also clearly no indication of any detrimental effect, at least within the protein intakes of the populations studied (around 0.8-1.3 g/Kg/day). More studies are urgently required on the association between protein intake and bone health in children and adolescents.
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Affiliation(s)
- A L Darling
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK.
| | - R J F Manders
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - S Sahni
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - K Zhu
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - C E Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - R L Prince
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - D J Millward
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - S A Lanham-New
- Department of Nutritional Sciences, School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
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15
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Abstract
OBJECTIVE Cochlear implantation in one ear (unilateral implantation) has been the standard treatment for severe-profound childhood deafness. We assessed whether cochlear implantation in both ears (bilateral implantation) is associated with better listening skills, higher health-related quality of life (health utility) and higher general quality of life (QOL) than unilateral implantation. DESIGN Cross-sectional observational study. SETTING University of York. PARTICIPANTS Fifty severely-profoundly deaf and 56 normally-hearing children recruited via a charity, the UK National Health Service and schools. INTERVENTIONS Thirty of the deaf children had received bilateral cochlear implants; 20 had unilateral cochlear implants. MAIN OUTCOME MEASURES Performance measures of children's listening skills; parental-proxy valuations of the deaf children's health utility obtained with the Health Utilities Index Mark 3 and of their QOL obtained with a visual analogue scale. RESULTS On average, bilaterally-implanted children performed significantly better than unilaterally implanted children on tests of sound localisation and speech perception in noise. After conservative imputation of missing data and while controlling for confounds, bilateral implantation was associated with increases of 18.5% in accuracy of sound localisation (95% CI 5.9 to 31.1) and of 3.7 dB in speech perception in noise (95% CI 0.9 to 6.5). Bilaterally-implanted children did not perform as well as normally-hearing children, on average. Bilaterally- and unilaterally-implanted children did not differ significantly in parental ratings of health utility (difference in medians 0.05, p>0.05) or QOL (difference in medians 0.01, p>0.05). CONCLUSIONS Compared with unilateral cochlear implantation, bilateral implantation is associated with better listening skills in severely-profoundly deaf children.
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Affiliation(s)
- R E S Lovett
- Department of Psychology, University of York, Heslington, York YO10 5DD, UK
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Hewitt CE, Gilbody SM. Is it clinically and cost effective to screen for postnatal depression: a systematic review of controlled clinical trials and economic evidence. BJOG 2009; 116:1019-27. [DOI: 10.1111/j.1471-0528.2009.02148.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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