Rapid reviews and the methodological rigor of evidence synthesis: a JBI position statement

The demand for rapid reviews has exploded in recent years. A rapid review is an approach to evidence synthesis that provides timely information to decision-makers (eg, health care planners, providers, policymakers, patients) by simplifying the evidence synthesis process. A rapid review is particularly appealing for urgent decisions. JBI is a world-renowned international collaboration for evidence synthesis and implementation methodologies. The principles for JBI evidence synthesis include comprehensiveness, rigor, transparency, and a focus on applicability to clinical practice. As such, JBI has not yet endorsed a specific approach for rapid reviews. In this paper, we compare rapid reviews versus other types of evidence synthesis, provide a range of rapid evidence products, outline how to appraise the quality of rapid reviews, and present the JBI position on rapid reviews. JBI Collaborating Centers conduct rapid reviews for decision-makers in specific circumstances, such as limited time or funding constraints. A standardized approach is not used for these cases;instead, the evidence synthesis methods are tailored to the needs of the decision-maker. The urgent need to deliver timely evidence to decision-makers poses challenges to JBI's mission to produce high-quality, trustworthy evidence. However, JBI recognizes the value of rapid reviews as part of the evidence synthesis ecosystem. As such, it is recommended that rapid reviews be conducted with the same methodological rigor and transparency expected of JBI reviews. Most importantly, transparency is essential, and the rapid review should clearly report where any simplification in the steps of the evidence synthesis process has been taken

Effectiveness of a Community-Based Breastfeeding Intervention in Ethiopia: a Cluster Randomized Controlled Trial

Peer-led breastfeeding education and support provided during the antenatal and postnatal periods are known to improve optimal breastfeeding practices; however, there is a paucity of evidence on the effectiveness of such interventions in Ethiopia. The aims of this thesis were to adapt and validate existing breastfeeding knowledge and attitudes instruments, determine the levels of breastfeeding knowledge and attitudes among low literacy women, and evaluate the effectiveness of a breastfeeding education and support intervention on early initiation and exclusive breastfeeding practices, and infant growth in a rural setting in Southwest Ethiopia. We conducted a cross-sectional study to assess validity and reliability of Breastfeeding knowledge questionnaire and Iowa infant feeding attitude scale and determined the levels of the knowledge attitudes towards breastfeeding in rural women. Then, we conducted a cluster-randomized controlled single-blind two-arm trial in the Mana district in 36 randomly selected clusters to evaluate the effectiveness of peer-led breastfeeding education and support on early initiation, exclusive breastfeeding and infant growth. We found that the translated Breastfeeding knowledge questionnaire and the Iowa infant feeding attitude scale are reliable and valid instruments for measuring maternal breastfeeding knowledge and attitudes. In addition, we found that the majority of rural women with low literacy had neutral attitudes towards breastfeeding and only half of them had adequate knowledge about breastfeeding. The peer-support intervention increased the prevalence of early initiation, exclusive breastfeeding and attitudes towards breastfeeding. Although we observed a higher maternal knowledge in the intervention group, the difference was not statistically significant. Except for a higher mid-upper arm circumference and a lower prevalence of respiratory infection, we did not find statistically significant intervention effects on other infant growth or morbidity outcomes

Effect of breastfeeding education and support intervention (BFESI) versus routine care on timely initiation and exclusive breastfeeding in Southwest Ethiopia: study protocol for a cluster randomized controlled trial

Background Infant mortality rates are still high in Ethiopia. Breastfeeding is regarded as the simplest and least expensive strategy for reduction of infant mortality rates. Community-based educational and support interventions provided prenatally and postnatally are effective in increasing breastfeeding rates. However, such interventions are not widely implemented in Ethiopia. This study aims to assess the effect of breastfeeding education and support on timely initiation and duration of exclusive breastfeeding. Methods A cluster-randomized controlled trial at the community level will be conducted to compare the effect of breastfeeding education and support versus routine care. The intervention will be provided by Women Development Army leaders who are already in the country’s health system using a 40-h WHO breastfeeding counseling course, “Infant and Young Child Feeding Counseling: an integrated course” and the “Training of Trainers Manual for Counseling on Maternal, Infant and Young Child Nutrition” in the local language. Culturally appropriate operational packages of information will be developed for them. Using preset criteria at least 432 pregnant women in their third trimester will be recruited from 36 zones. Visits in the intervention arm include two prenatal visits and 8 postnatal visits. Supervisory visits will be conducted monthly to each intervention zone. Data will be entered into Epi-data version 3.1 and analyzed using STATA version 13.0. All analysis will be done by intention to treat analysis. We will fit mixed-effects linear regression models for the continuous outcomes and mixed-effects linear probability models for the binary outcomes with study zone as random intercept to estimate study arm difference (intervention vs. routine education) adjusted for baseline value of the outcome and additional relevant covariates. The protocol was developed in collaboration with the Jimma Zone and Mana district Health office. Ethical clearance was obtained from the Institutional Review Board of University of Oslo and Jimma University. This study is partly funded by NORAD’s NORHED programme. Discussion We expect that the trial will generate findings that can inform breastfeeding policies and practices in Ethiopia. Trial registration ClinicalTrials.gov NCT 03030651 January 25, 2017 version 3 dated 16 July 2018

Breastfeeding education and support to improve early initiation and exclusive breastfeeding practices and infant growth : a cluster randomized controlled trial from a rural Ethiopian setting

Although peer-led education and support may improve breastfeeding practices, there is a paucity of evidence on the effectiveness of such interventions in the Ethiopian context. We designed a cluster-randomized trial to evaluate the efficacy of a breastfeeding education and support intervention (BFESI) on infant growth, early initiation (EI), and exclusive breastfeeding (EBF) practices. We randomly assigned 36 clusters into either an intervention group (n = 249) receiving BFESI by trained Women's Development Army (WDA) leaders or a control group (n = 219) receiving routine care. The intervention was provided from the third trimester of pregnancy until five months postpartum. Primary study outcomes were EI, EBF, and infant growth; secondary outcomes included maternal breastfeeding knowledge and attitude, and child morbidity. The intervention effect was analysed using linear regression models for the continuous outcomes, and linear probability or logistic regression models for the categorical outcomes. Compared to the control, BFESI significantly increased EI by 25.9% (95% CI: 14.5, 37.3%; p = 0.001) and EBF by 14.6% (95% CI: 3.77, 25.5%; p = 0.010). Similarly, the intervention gave higher breastfeeding attitude scores (Effect size (ES): 0.85SD; 95% CI: 0.70, 0.99SD; p < 0.001), but not higher knowledge scores (ES: 0.15SD; 95% CI: -0.10, 0.41SD; p = 0.173). From the several growth and morbidity outcomes evaluated, the only outcomes with significant intervention effect were a higher mid-upper arm circumference (ES: 0.25cm; 95% CI: 0.01, 0.49cm; p = 0.041) and a lower prevalence of respiratory infection (ES: -6.90%; 95% CI: -13.3, -0.61%; p = 0.033). Training WDA leaders to provide BFESI substantially improves EI and EBF practices and attitude towards breastfeeding

Adaptation and validation of the Iowa infant feeding attitude scale and the breastfeeding knowledge questionnaire for use in an Ethiopian setting

Background Validated instruments to assess breastfeeding knowledge and attitude are non-existent in Africa including Ethiopia. We aimed to adapt and validate the Breastfeeding Knowledge Questionnaire (BFKQ) and the Iowa Infant Feeding Attitude Scale (IIFAS) for use in Afan Oromo (AO), the most widely spoken language in Ethiopia. Methods After forward-backward translation into Afan Oromo, the instruments were reviewed for content validity by a panel of a nutritionist and pediatricians, and pretested on a sample of 30 mothers. Then, a cross-sectional study involving 468 pregnant women in their second and third trimester was conducted between May and August 2017 in the Manna district, Southwest Ethiopia, using the final versions of the adapted questionnaires. We used exploratory and confirmatory factor analysis to assess the construct validity, receiver operating characteristic (ROC) curves to determine the predictive validity and Cronbach’s alpha coefficients to assess internal consistency. Results Using exploratory factor analysis (EFA), nine domains containing 34 items were extracted from the BFKQ-AO. A confirmatory factor analysis of the constructs from EFA confirmed construct validity of the instrument (χ2/df = 2.11, RMSEA = 0.049, CFI = 0.845, TLI = 0.823). In factor analysis of the IIFAS, the first factor explained 19.7% of the total variance and the factor loadings and scree plot test suggested unidimensionality of the tool. Cronbach’s alpha was 0.79 for the BFKQ-AO and 0.72 for IIFAS-AO suggesting an acceptable internal consistency of both instruments. For the sensitivity and specificity in predicting intention of breastfeeding for ≥24 months, the area under the curve (AUC) was 82% for IIFAS score and 79% for BFKQ score. Conclusions Here we present the first study that reported the use of the BFKQ and the IIFAS in Ethiopia. Our results showed that both BFKQ-AO and IIFAS-AO can be reliable and valid tools for measuring maternal breastfeeding knowledge and attitude in the study population, showing the potential for adapting these tools for application in a wider Ethiopian context

Determinants of knowledge and attitude towards breastfeeding in rural pregnant women using validated instruments in Ethiopia

Understanding the underlying determinants of maternal knowledge and attitude towards breastfeeding guides the development of context-specific interventions to improve breastfeeding practices. This study aimed to assess the level and determinants of breastfeeding knowledge and attitude using validated instruments in pregnant women in rural Ethiopia. In total, 468 pregnant women were interviewed using the Afan Oromo versions of the Breastfeeding Knowledge Questionnaire (BFKQ-AO) and the Iowa Infant Feeding Attitude Scale (IIFAS-AO). We standardized the breastfeeding knowledge and attitude scores and fitted multiple linear regression models to identify the determinants of knowledge and attitude. 52.4% of the women had adequate knowledge, while 60.9% of the women had a neutral attitude towards breastfeeding. In a multiple linear regression model, maternal occupation was the only predictor of the BFKQ-AO score (0.56SD; 95%CI, 1.28, 4.59SD; p = 0.009). Age (0.57SD; 95%CI, 0.24, 0.90SD; p = 0.001), parity (−0.24SD; 95%CI, −0.47, −0.02SD; p = 0.034), antenatal care visits (0.41SD; 95%CI, 0.07, 0.74SD; p = 0.017) and the BFKQ-AO score (0.08SD; 95% CI, 0.06, 0.09SD; p < 0.000) were predictors of the IIFAS-AO score. Nearly half of the respondents had inadequate knowledge and most women had a neutral attitude towards breastfeeding. Policymakers and managers could address these factors when planning educational interventions to improve breastfeeding practices

Determinants of knowledge and attitude towards breastfeeding in rural pregnant women using validated instruments in Ethiopia

Understanding the underlying determinants of maternal knowledge and attitude towards breastfeeding guides the development of context-specific interventions to improve breastfeeding practices. This study aimed to assess the level and determinants of breastfeeding knowledge and attitude using validated instruments in pregnant women in rural Ethiopia. In total, 468 pregnant women were interviewed using the Afan Oromo versions of the Breastfeeding Knowledge Questionnaire (BFKQ-AO) and the Iowa Infant Feeding Attitude Scale (IIFAS-AO). We standardized the breastfeeding knowledge and attitude scores and fitted multiple linear regression models to identify the determinants of knowledge and attitude. 52.4% of the women had adequate knowledge, while 60.9% of the women had a neutral attitude towards breastfeeding. In a multiple linear regression model, maternal occupation was the only predictor of the BFKQ-AO score (0.56SD; 95%CI, 1.28, 4.59SD; p = 0.009). Age (0.57SD; 95%CI, 0.24, 0.90SD; p = 0.001), parity (−0.24SD; 95%CI, −0.47, −0.02SD; p = 0.034), antenatal care visits (0.41SD; 95%CI, 0.07, 0.74SD; p = 0.017) and the BFKQ-AO score (0.08SD; 95% CI, 0.06, 0.09SD; p &lt; 0.000) were predictors of the IIFAS-AO score. Nearly half of the respondents had inadequate knowledge and most women had a neutral attitude towards breastfeeding. Policymakers and managers could address these factors when planning educational interventions to improve breastfeeding practices