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Systematic assessment of factors affecting the delivery, access and use ofinterventions to control malaria in pregnancy in sub-Saharan AfricaHill, Jenny

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Citation for published version (APA):Hill, J. A. (2014). Systematic assessment of factors affecting the delivery, access and use of interventions tocontrol malaria in pregnancy in sub-Saharan Africa Alblasserdam: Dutch University Press

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Chapter 9: Supplementary Appendix

313

Table S1. Search terms and databases used in the review.

Search terms for Pregnant WomenGlobal Health Search MiP Library Search* INRUD*

pregnant wom*AND

---- pregnant wom*AND

malaria AND

---- malaria

treat* OR treatment seeking behav* OR health seeking behav* OR care seeking behav* OR treatment seeking practice* OR health seeking practice* OR care seeking practice* OR treatment seeking decision*AND

treat* OR treatment seeking behav* OR health seeking behav* OR care seeking behav* OR treatment seeking practice* OR health seeking practice* OR care seeking practice* OR treatment seeking decision*AND

----

determinant* OR factor* OR knowledge OR attitude* OR practice* OR compliance OR adherence OR frequenc* OR symptom* OR recogn* OR perception

determinant* OR factor* OR knowledge OR attitude* OR practice* OR compliance OR adherence OR frequenc* OR symptom* OR recogn* OR perception

----

Search terms for Health ProviderGlobal Health Search MiP Library Search* INRUD

pregnan* OR pregnant wom* AND

---- pregnant wom*AND

provider* OR ANC service* OR antenatal service* OR ANC OR health provider OR health work* OR health servic* provider OR drug shop vendor OR community health worker OR licensed chemical seller OR patent medicine seller OR ADDO OR community drug dispenser OR formal service OR informal serviceAND

provider* OR ANC service* OR antenatal service* OR ANC OR health provider OR health work* OR health servic* provider OR drug shop vendor OR community health worker AND

malaria

malaria AND

---- ----

case management OR control OR management OR treat* OR diagno* OR prescrib* OR practice* OR chloroquine OR CQ OR quinine OR ACT OR artemisinin-based combination therapy OR safe* OR community case management OR refer* OR practiceAND

case management OR control OR management OR treat* OR diagno* OR prescrib* OR practice* OR safe* OR community case management OR refer* OR practiceAND

----

knowledge OR compliance OR adherence OR proportion* OR frequenc* OR symptom* OR refer*

knowledge OR compliance OR adherence OR proportion* OR frequenc* OR symptom* OR refer*

1* All material in the MiP Library contain the words malaria and pregnant women2* Terms kept very broad for INRUD search

314

Chapter 9 Supplementary Appendix

Table S2. Checklist for quality of reporting: Quantitative Studies.

We appraised the quality of reporting of each study using a checklist of criteria based on m

ethods described in a previous review [1]. Q

uantitative studies were assessed for

reporting of 10 criteria, as follows: study context, sam

pling strategy, use of randomization, m

ethodology, systematic data analysis, m

ultivariate analysis, the minim

ization of recall, social desirability and m

easurement bias, and w

hether the findings were discussed in reference to policy, program

ming or further research [2,3].

Criteria

SC

OR

E

(n/10)

Au

tho

r/Year

Descrip

tion

o

f Co

ntext

Particip

ants

and

S

amp

ling

d

escribed

Ran

do

miza-

tion

used

Meth

od

s d

escribed

System

atic D

ata A

nalysis

describ

ed

Mu

ltivariate an

alysis u

sed

Recall b

ias m

inim

ised

So

cial d

esirability

bias

min

imised

Measu

remen

t b

ias m

inim

ised

Fin

din

gs

discu

ssed

Adam

,2008 [4] 5

Enato,2009

[5]7

Ghouth, 2013 [6]

6

Harrison,2012

[7]5

Henry.2012 [8]

9

Kalilani-P

hiri,2011[9]

8

Kam

uhabwa,2011[10]

4 K

arunamoorthi,2010

[11]6

Kw

ansa-Bentum

,2011[12]

8

Luz,2013A

[13] 7

Maiga,2010

[14]4

Manirakiza, 2011 [15]

8

Mbachu,2012

[16]9

Mbonye,2010 [17]

4

Mbonye,2013

[18]6

Minyaliw

a,2012 [19] 4

Obieche,2013

[20]7

Okonta,2011

[21] 8

Okoro,2012

[22]6

Om

o-Aghoja,2008 [23]

8

Onw

ujekwe,2012

[24]8

Onw

ujekwe,2013 [25]

5 P

SI C

ambodia,2007

[26]6

Sam

-Wobo, 2008 [27]

5

Sangare,2011 [28]

9

Um

ar,2011[29]

5

Wylie,2010

[30]5

Descrip

tion

of categ

ories:

ind

icates it was rep

orted

in th

e article

315


Descrip

tion

of co

ntext

Authors report an adequate description of setting (urban/rural), tim

e of study and location

Particip

ants an

d sam

plin

g d

escribed

Authors report sam

pling methods, details of participants and random

ization is discussed

Ran

do

mizatio

n u

sedA

uthors report use of randomization in sam

pling technique

Meth

od

s describ

edA

uthors use appropriate methods to address aim

s of study, provide detailed research procedures, express expertise amongst the

research team to

conduct methods, or report training of facilitators

System

atic data an

alysis describ

edA

uthors provide a detailed procedure of analysis, with justification for the m

ethod of analysis

Mu

ltivariate analysis u

sedA

uthors report use of multivariate analysis to control for confounding

Recall b

ias min

imised

Authors report using m

ethods to reduce recall bias (e.g. use of hospital records etc. rather than mem

ory)

So

cial desirab

ility bias m

inim

isedA

uthors report use of methods to reduce social desirability (e.g. stock checks, check H

CF

records, check storage of medicines, check for IT

N)

Measu

remen

t bias m

inim

isedA

uthors report on the role of researcher, the relationship of researcher to participants/context, adequate training of staff,use of standardized research tools, and the use of standardized m

easurements

Fin

din

gs d

iscussed

Authors report the findings/results in term

s of their impact on further research, program

ming and policy

316


References

1. Hill J, Hoyt J, van Eijk AM, D'Mello-Guyett L, Ter Kuile FO, et al. (2013) Factors affecting the delivery,access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis. PLoS Med 10: e1001488.

2. Sanderson S, Tatt LD, Higgins JPT (2007) Tools for assessing quality and susceptibility to bias inobservational studies in epidemiology: a systematic review and annotated bibliography. International Journal of Epidemiology 36: 666-676.

3. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, et al. (2007) The strengthening the reporting ofobservational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Bulletin of the World Health Organization 85: 867-872.

4. Adam I, Omer el sir M, Salih A, Khamis A, Malik EM (2008) Perceptions of the causes of malaria and itscomplications, treatment and prevention among midwives and pregnant women of Eastern Sudan. Journal of Public Health: 129-132.

5. Enato E. F., Mens P. F., Okhamafe A. O., Okpere E. E., Pogoson E., et al. (2009) Plasmodium falciparummalaria in pregnancy: prevalence of peripheral parasitaemia, anaemia and malaria care-seeking behaviour among pregnant women attending two antenatal clinics in Edo State, Nigeria. Journal of Obstetrics and Gynaecology 29: 301-306.

6. Bin Ghouth A.S. (2013) Availability and prescription practice of anti-malaria drugs in the private healthsector in Yemen. Journal of Infection in Developing Countries 7: 404-412.

7. Harrison N, Olufunlayo T, Agomo C (2012) Utilization of the current national antimalarial treatmentguidleines among doctors in army hospitals in Lagos, Nigeria. Open Journal of Preventive Medicine 2: 390-393.

8. Henry O J., Lagoro K D., Orach C G. (2012) Prevalence of malaria and treatment seeking behavioursamong pregnant women in postconflict internally displaced persons' camps in Gulu District. ISRN Public Health 2012: 164935. doi:10.5402/2012/164935.

9. Kalilani-Phiri LV., Lungu D., Coghlan R. (2011) Knowledge and malaria treatment practices usingartemisinin combination therapy (ACT) in Malawi: survey of health professionals. Malaria Journal 10: 279.

10. Kamuhabwa AR, Mnyusiwalla F (2011) Rational dispensing and use of artemether-lumefantrine duringpregnancy in Dar es Salaam, Tanzania. Tanzania Journal of Health Research 13.

11. Karunamoorthi K, Deboch B, Tafere Y (2010) Knowledge and practice concerning malaria, insecticide-treated net (ITN) utilization and antimalarial treatment among pregnant women attending specialist antenatal clinics. Journal of Public Health 18: 559-566.

12. Kwansa-Bentum B, Ayi I, Suzuki T, Otchere J, Kumagai T, et al. (2011) Administrative practices of healthprofessionals and use of artesunate-amodiaquine by community members for treating uncomplicated malaria in southern Ghana: implications for artemisinin-based combination therapy deployment. Tropical Medicine and International Health 16: 1215-1224.

13. Luz TCB, Miranda ES, Freitas LF, Osorio-de-Castro CGS (2013 A) Prescriptions for uncomplicated malariatreatment among pregnant women in the Brazilian Amazon: evidences from the Mafalda Project. Revista Brasileira de Epidemiologia, 16: 409 - 419 PMID PM: 24142012.

14. Maiga AS, Diakite M, Diaware A, Sango HA, Coulibaly CO (2010) Pharmacovigilance and impact ofintermittent preventive treatment with sulfadoxine-pyrimethamine for pregnant women in Selingue in Mali. Mali Medical 25: 41-48.

15. Manirakiza A, Soula G, Laganier R, Klement E, Djalle D, et al. (2011) Pattern of the antimalarialsprescription during pregnancy in Bangui, Central African Republic. Malaria Research and Treatment 2011: 414510.

16. Mbachu CO, Onwujekwe O. E., Uzochukwu B. S., Uchegbu E., Oranuba J., et al. (2012) Examining equityin access to long-lasting insecticide nets and artemisinin-based combination therapy in Anambra state, Nigeria. BMC Public Health 12: 315.

317


17. Mbonye AK, Magnussen P (2010) Symptom-based diagnosis of malaria and its implication onantimalarial drug use in pregnancy in central Uganda: results from a community trial. International Journal of Adolescent Medicine and Health 22: 257-262.

18. Mbonye AK, Birungi J, Yanow S, Magnussen P (2013) Prescription patterns and drug use amongpregnant women with febrile Illnesses in Uganda: a survey in out-patient clinics. BMC Infectious Diseases 13: 237 PMID 23702003.

19. Minyaliwa C, Bandawe C, Mwale RJ (2012) How much do Blantyre dispensers in hospital andcommunity pharmacies know about the new malaria treatment guidelines? Malawi Medical Journal 24: 1-4.

20. Obieche AO, Enato EF, Ande AB (2013) Patterns of treatment of reported malaria cases duringpregnancy in a Nigerian hospital. Scandinavian Journal of Infectious Diseases 45:849-854. PMID 23968224.

21. Okonta PI (2011) How many physicians prescribe quinine for the treatment of malaria in the firsttrimester of pregnancy? . Ebonyi Medical Journal 10: 105-111.

22. Okoro RN, Nwambu JO (2012) Evaluation of physicians' prescribing patterns of antimalarial drugsduring pregnancy at the obstetrics and gynaecology department of a teaching hospital in Maduguri, Borno State, Nigeria. International Journal of Pharmacy and BioMedical Sciences 3: 39-46.

23. Omo-Aghoja LO, Aghoja CO, Oghagbon K, Omo-Aghoja VW, Esume C (2008) Prevention and treatmentof malaria in pregnancy in Nigeria: obstetrician's knowledge of guidelines and policy changes-a call for action. Journal of Chinese Clinical Medicine 3: 114-120.

24. Onwujekwe OC, Soremekun RO, Uzochukwu B, Shu E, Onwujekwe O (2012) Patterns of casemanagement and chemoprevention for malaria-in-pregnancy by public and private sector health providers in Enugu state, Nigeria. BMC Research Notes 5: 211.

25. Onwujekwe O, Onwujekwe OO, Soremekun R (2013) Chemotherapy and chemoprophylaxis of malariain pregnancy in private and public facilities: perceptions and use by pregnant women in Enugu State, Nigeria. Gender and Behaviour 11: 5688 - 5697.

26. PSI Cambodia (2007) Cambodia 2007: TRaC Study exploring the determinants of malaria health careprovision among private providers in malaria endemic areas. First Round. Washington, District of Columbia

27. Sam-Wobo SO, Akinboroye T, Anosike JC, Adewale B (2008) Knowledge and practices on malariatreatment measures among pregnant women in Abeokuta, Nigeria. Tanzania Journal of Health Research 10: 226-231.

28. Sangare LR, Weiss NS, Brentlinger PE, Richardson BA, Staedke SG, et al. (2011) Patterns of anti-malarialdrug treatment among pregnant women in Uganda. Malaria Journal 10: 152.

29. Umar MT, Chika A, Jimoh AO (2011) Compliance of primary health care providers to recommendationof artemesinin-based combination therapy in the treatment of uncomplicated malaria in selected primary health care centres in Sokoto, north western Nigeria. International Journal of Tropical Medicine 6: 70-72.

30. Wylie BJ, Hashmi AH, Singh N, Singh MP, Tuchman J, et al. (2010) Availability and utilization of malariaprevention strategies in pregnancy in eastern India. BMC Public Health 10: 557.

318


Table S3. Checklist for quality of reporting: Qualitative Studies.

We appraised the quality of reporting of each study using a checklist of criteria based on m

ethods described in a previous review [1]. Q

ualitative studies were assessed for

the extent to which the authors described 8 criteria: study context, sam

pling strategy, methodology, saturation of data, system

atic data analysis, the reflexivity of the researcher, the reliability and validity of findings, and the relevance of findings to policy, program

ming or further research [2,3].

Criteria

SC

OR

E

(n/8)

Au

tho

r/Year

Descrip

tion

of

Co

ntext

Particip

ants

and

Sam

plin

gM

etho

ds

describ

edS

aturatio

n

men

tion

ed

System

atic D

ata An

alysis d

escribed

Reliab

ility an

d valid

ity d

iscussed

Reflexivity o

f research

erd

ocu

men

ted

Fin

din

gs

discu

ssed

Enato,2012

[4]4

Lanuiala,2010 [5] 5

Pell,2013

[6]8

Sm

ith-Paintain,2010 [7]

7

Descrip

tion

of categ

ories:

ind

icates it was rep

orted

in th

e articleD

escriptio

n o

f con

textA

uthors report an adequate description of setting (urban/rural), time of study and location

Particip

ants an

d sam

plin

g d

escribed

Authors report sam

pling methods, details of participants and random

ization is discussed

Meth

od

s describ

edA


s of study, provide detailed research procedures, expressexpertise am

ongst the research team to

conduct methods, or report training of facilitators

Satu

ration

men

tion

edA

uthors discuss the saturation of data from using research m

ethods chosenS

ystematic d

ata analysis d

escribed

Authors provide a detailed procedure of analysis, w

ith justification for the method of analysis

Reliab

ility and

validity d

iscussed

Authors can express reliability and report steps taken to reduce m

easurement, social desirability and m

easurement biases (e.g. triangulation of

methods), and can describe validation of transcripts/data

Reflexivity o

f researcher d

ocu

men

tedA

uthors report on the effect of the researcher, role of researcher and the relationship of researcher to participants/contextF

ind

ing

s discu

ssedA

uthors report the findings/results in terms of their im

pact on further research, programm

ing and policy

319


References


2. Barbour RS (2001) Checklists for improving rigour in qualitative research: a case of the tail wagging thedog? BMJ 322: 1115-1117.

3. Mays N, Pope C (2000) Qualitative research in health care. Assessing quality in qualitative research. BMJ320: 50-52.

4. Enato EFO, Erihri RE (2012) Knowledge, perception and management of malaria in pregnancy bytraditional birth attendants in Benin City. Journal of Pharmaceutical and Allied Sciences 8: 1292-1297.

5. Launiala A, Honkasalo ML (2010) Malaria, danger, and risk perceptions among the Yao in rural Malawi.Medical Anthropology Quarterly Q24: 399-420.

6. Pell C, Menaca A, Afrah NA, Manda-Taylor L, Chatio S, et al. (2013) Prevention and management ofmalaria during pregnancy: findings from a comparative qualitative study in Ghana, Kenya and Malawi. Malaria Journal 12: 427. PMID PM:24257105.

7. Smith Paintain LA, Jones C, Adjei RO, Antwi GD, Afrah NA, et al. (2010) Intermittent screening andtreatment versus intermittent preventive treatment of malaria in pregnancy: user acceptability. Malaria Journal 9: 18.

320


Table S4. Checklist for quality of reporting: Mixed M

ethods. W

e appraised the quality of reporting of each study using a checklist of criteria based on methods described in a previous review

[1]. Mixed m

ethods studies were assessed

for the reporting of 11 criteria: study context, sampling strategy, m

ethodology, justification of mixed m

ethods, systematic data analysis, m

ultivariate analysis, minim

ization of bias, the integration of qualitative and quantitative findings and the extent to w

hich the findings were discussed in reference to policy, program

ming or further research

[2-4].

Criteria

SC

OR

E

(n/11)

Au

tho

r/Year

Descrip

tion

o

f Co

ntext

Particip

ants an

d

Sam

plin

g

describ

ed

Meth

od

s d

escribed

Justificatio

n

of m

ixed

meth

od

s

System

atic Data

An

alysis d

escribed

Mu

ltivariate an

alysis u

sed

Min

imizatio

n

of b

ias d

iscussed

Integ

ration

o

f Q

UA

N/Q

UA

L

com

po

nen

ts

Fin

din

gs

discu

ssed

QU

AN

QU

AL

QU

AN

QU

AL

Kiningu,2013 [5]

10

Luz,2013 B [6]

9

Sabin,2010 [7]

10S

mith-P

aintain,2011[8]

10

Stangeland,2011 [9]

9

Taw

fik,2006[10]

9

Descrip

tion

of categ

ories:

ind

icates it was rep

orted

in th

e article

Descrip

tion

of co

ntext

Authors report an adequate description of setting (urban/rural), tim

e of study and location

Particip

ants an

d sam

plin

g

describ

edA

uthorsreport sam

pling methods, justify use of sam

pling methods and provide details of participants

Meth

od

s describ

edA


s of study, provide detailed research procedures, express expertise amongst the

research team

to conduct methods, or report training of facilitators

Justificatio

n o

f mixed

meth

od

sA

uthors discuss and justify the purpose, priority and sequence of methods used.

System

atic data an

alysis describ

edA

uthors provide a detailed procedure of analysis, with justification for the m

ethod of analysis

Mu

ltivariate analysis u

sedA

uthors report use of multivariate analysis to control for confounding

Min

imizatio

n o

f bias d

iscussed

Authors report steps taken to reduce m

easurement, social desirability, recall, and m

easurement biases.

Integ

ration

of Q

UA

N/Q

UA

L

com

po

nen

tsA

uthors report the integration of QU

AN

/QU

AL m

ethods and results

Fin

din

gs d

iscussed

Authors report the findings/results in term

s of their impact on further research, program

ming and policy

321


References


2. O'Cathain A, Murphy E, Nicholl J (2008) The quality of mixed methods studies in health servicesresearch. Journal of Health Services Research & Policy 13: 92-98.

3. Pluye P, Gagnon MP, Griffiths F, Johnson-Lafleur J (2009) A scoring system for appraising mixed methodsresearch, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in Mixed Studies Reviews. International Journal Of Nursing Studies 46: 529-546.

4. Sale JEM, Brazil K (2004) A strategy to identify critical appraisal criteria for primary mixed-methodstudies. Quality & Quantity 38: 351-365.

5. Kiningu D.K. (2013) Factors influencing the use of evidence based guidelines in the management ofmalaria in pregnancy among health workers at Garissa provincial hospital, Kenya. [Master’s thesis]. Nairobi: School of Public Health, University of Nairobi. Available: http://erepository.uonbi.ac.ke:8080/xmlui/bitstream/handle/11295/59598/Factors%20Influencing%20The%20Use%20Of%20Evidence%20Based%20Guidelines%20in%20the%20Management%20of%20Malaria%20in%20Pregnancy%20Among%20Health%20Workers%20at%20Garissa%20Provincial%20Hospital%20Kenya.pdf?sequence=3. Accessed 7 July 2014

6. Luz TC, Suarez-Mutis C, Miranda S, Moritz F, Freitas F, et al. (2013 B) Uncomplicated malaria amongpregnant women in the Brazilian Amazon: Local barriers to prompt and effective case management. Acta Tropica 125: 137-142.

7. Sabin LL, Rizal A, Brooks MI, Singh MP, Tuchman J, et al. (2010) Attitudes, knowledge, and practicesregarding malaria prevention and treatment among pregnant women in Eastern India. American Journal of Tropical Medicine and Hygiene 82: 1010-1016.

8. Smith Paintain L, Antwi GD, Jones C, Amoako E, Adjei RO, et al. (2011) Intermittent Screening andTreatment versus Intermittent Preventive Treatment of Malaria in Pregnancy: Provider Knowledge and Acceptability. Plos One 6: e24035.

9. Stangeland T, Alele PE, Katuura E, Lye KA (2011) Plants used to treat malaria in Nyakayojo sub-county,western Uganda. Journal of Ethnopharmacology 137: 154-166.

10. Tawfik L (2006) Mosquitoes, Malaria and Malarine: A Qualitative Study on Malaria Drug Use inCambodia. Arlington, Virginia, USA: U. S. Agency for International Development.

322


Table S5. Sub-group analysis for source of treatment among pregnant women.

N* Pooled effect estimate (95% CI)

N Pooled effect estimate (95% CI)

p-value†

Type of question PW with fever If PW would have fever Doctor 3 0.84 (0.65-0.94) 1 0.82 (0.75-0.87) 0.7Health facility or ANC 4 0.60 (0.33-0.82) 2 0.46 (0.01-0.98) 0.8 Self-Medication 5 0.14 (0.06-0.32) 2 0.08 (0.06-0.12) 0.3 Traditional healer/herbs 5 0.03 (0.01-0.17) 2 0.24 (0.01-0.93) 0.3

Site of enrolment PW Antenatal clinic Community Doctor 3 0.84 (0.65-0.94) 1 0.82 (0.75-0.87) 0.7 Health facility or ANC 3 0.70 (0.30-0.92) 3 0.40 (0.10-0.80) 0.3 Self-Medication 6 0.13 (0.05-0.27) 1 0.10 (0.06-0.15) 0.5Traditional healer/herbs 5 0.05 (0.01-0.20) 2 0.06 (0.0-0.99) 1.0

Country of study Nigeria Not NigeriaDoctor 2 0.90 (0.75-0.96) 2 0.74 (0.53-0.88) 0.1 Health facility or ANC 2 0.62 (0.26-0.88) 4 0.52 (0.17-0.85) 0.7 Self-Medication 3 0.09 (0.03-0.25) 4 0.16 (0.05-0.40) 0.5 Traditional healer/herbs 3 0.04 (0.00-0.78) 4 0.08 (0.02-0.27) 0.8

Location of residence Rural UrbanDoctor 2 0.74 (0.53-0.88) 2 0.90 (0.75-0.96) 0.1 Health facility or ANC 4 0.38 (0.14-0.70) 2 0.84 (0.71-0.91) 0.006 Self-Medication 3 0.20 (0.06-0.51) 4 0.08 (0.04-0.19) 0.2 Traditional healer/herbs 4 0.21 (0.06-0.52) 3 0.02 (0.00-0.07) 0.008 “Private clinic” and “Retail/pharmacy” not examined; only 1 and 3 studies in total, respectively *N: indicates number of studies in subgroup†Sub-group analysis was conducted with the program “Comprehensive Meta-Analysis”

323


Table S6. Sub-group analysis for adherence to treatment policy among health care providers.

Factor N* Pooled effect estimate (95% CI) p-value† Trimester First trimester 9 0.45 (0.19-0.75) 0.067 Other trimesters 5 0.28 (0.14-0.47) Trimester not specified 7 0.72 (0.39-0.91)

First trimester 9 0.28 (0.14-0.47) 0.021 Other trimesters 5 0.72 (0.39-0.91)

Level of prescriber Doctors only 3 0.11 (0.04-0.23) <0.001 Other staff or mixed cadres 18 0.52 (0.35-0.67)

Method of study Self-administered questionnaires 6 0.14 (0.07-0.28) 0.001 Interviews 7 0.50 (0.27-0.73)Record reviews 8 0.66 (0.39-0.86)

Country of study Nigeria 10 0.25 (0.12-0.46) 0.018Not Nigeria 11 0.58 (0.40-0.75) *N: indicates number of studies in subgroup†Sub-group analysis was conducted with the program “Comprehensive Meta-Analysis”

324


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