Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. The Feasibility and Effectiveness of PASS Plus, A Lay Health Worker Delivered Comprehensive Intervention for Autism Spectrum Disorders: Pilot RCT in a Rural Low and Middle Income Country Setting Development of a Smartphone‐Enabled Hypertension and Diabetes Mellitus Management Package to Facilitate Evidence‐Based Care Delivery in Primary Healthcare Facilities in India: The mPower Heart Project A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. Multi-level support for physical activity and healthy eating. Community-Based Interventions to Promote Blood Pressure Control in a Developing Country Does free care improve adults' health? Results from a randomized controlled trial. Uterine Tonus Assessment by Midwives versus Patient self-assessment in the active management of the third stage of labor (UTAMP): study protocol for a randomized controlled trial Hypertension and Cardiovascular Risk Profile in a Middle-Income Setting: The HELISUR Study Infant-feeding patterns and cardiovascular risk factors in young adulthood: data from five cohorts in low- and middle-income countries Utilization of evidence-based therapy for acute coronary syndrome in high-income and low/middle-income countries. Economic Analyses of the Be Fit Be Well Program: A Weight Loss Program for Community Health Centers Task-sharing of psychological treatment for antenatal depression in Khayelitsha, South Africa: Effects on antenatal and postnatal outcomes in an individual randomised controlled trial. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol The Cervix Cancer Research Network: A Global Outreach Effort on Behalf of the Gynecologic Cancer InterGroup. Effectiveness of the parent-mediated intervention for children with autism spectrum disorder in south Asia in India and Pakistan (PASS): a randomised controlled trial.
The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development , borne out of powerful advocacy using public health , economic and human rights arguments . As funding comes on line for scale-up of evidence -based mental health care by task-sharing with primary care , it is time to take stock about care for people affected by severe mental illness ( SMI ) . The existing evidence base for task shared care for SMI provides an imperative to get started , but is skewed towards relatively more affluent and urban population s in middle-income countries where specialist mental health professionals provide most of the care . R and omised , controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving underst and ing of the quality , safety , effectiveness and acceptability of more widely generalisable care for people with SMI . A sub-group of people with SMI have more complex and long-term needs for care , with a high risk of homelessness , imprisonment and human rights violations as family and social supports become overwhelmed . Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation , recovery and empowerment of people with SMI , but rigorous comparative studies are needed to identify the most efficient , effective and scalable approaches to care . Health system constraints are emerging as the over-riding barriers to successful task-sharing , highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality , improving wellbeing and achieving better social outcomes . Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI OBJECTIVE Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries ( LMICs ) . Mobile health technologies may improve noncommunicable disease outcomes , but LMICs lack re sources to provide these services . We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure ( BP ) monitoring as a strategy for improving systolic BPs ( SBPs ) and other outcomes of hypertensive patients in two LMICs . SUBJECTS AND METHODS This was a r and omized trial with a 6-week follow-up . Participants with high SBPs ( ≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic ) were enrolled from clinics in Honduras and Mexico . Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States , plus a home BP monitor . At baseline , control patients received BP results , hypertension information , and usual healthcare . The primary outcome , SBP , was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs . Secondary outcomes included perceived health status and medication-related problems . RESULTS Of the 200 patients recruited , 181 ( 90 % ) completed follow-up , and 117 of 181 had low literacy or high hypertension information needs . The median annual income was $ 2,900 USD , and average educational attainment was 6.5 years . At follow-up intervention patients ' SBPs decreased 4.2 mm Hg relative to controls ( 95 % confidence interval -9.1 , 0.7 ; p=0.09 ) . In the subgroup with high information needs , intervention patients ' average SBPs decreased 8.8 mm Hg ( -14.2 , -3.4 , p=0.002 ) . Compared with controls , intervention patients at follow-up reported fewer depressive symptoms ( p=0.004 ) , fewer medication problems ( p<0.0001 ) , better general health ( p<0.0001 ) , and greater satisfaction with care ( p≤0.004 ) . CONCLUSIONS Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs . A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support The treatment gap for autism globally is high . Our previous PASS intervention , delivered by community based lay health workers , showed effectiveness . This article reports the development and evaluation of a new “ PASS ‘ Plus ’ ” intervention in a rural population in India . Using formative research methods , we supplemented the PASS intervention with additional ( Plus ) modules to address autism comorbidities . This is the first time that a rigorous methodology has been used to evaluate autism symptom outcomes in a low and middle‐income country setting . 40 parent – child dyads were recruited in a pilot r and omized controlled trial against usual care ( mean age 65 months ( 34 boys ) ; n = 19 PASS Plus , n = 21 UC ) . 89 % of intervention families partially or entirely completed the 12‐session intervention . Intention to treat analysis showed a reduction in mean scores of autism symptom severity , though the confidence interval contains zero , ( adjusted mean difference AMD −2.42 95 % CI −7.75 , 2.92 ; ES 0.22 ) ; large treatment effects on proximal outcomes of proportion of parent synchronous responses ( AMD 0.35 ; 95 % CI 0.18 , 0.52 ; effect size ES 3.97 ) and proportion of child communication initiations with parent ( AMD 0·17 ; 95 % CI 0.03 , 0.32 ; ES 1.02 ) . Confidence intervals for effects on mutual shared attention ( AMD 0.10 ; 95 % CI −0.07 , 0.27 ; ES 0.5 ) and co‐morbid symptoms ( AMD −9.0 ; 95 % CI −24.26 , 6.26 ; ES 0.32 ) contained zero . There were significant effects to improve parental mental health . PASS Plus shows good feasibility and adds to the evidence of the effectiveness of task sharing complex autism interventions to lay health workers in India . Autism Res 2019 , 12 : 328–339 © 2018 International Society for Autism Research , Wiley Periodicals , Background The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide . The mPower Heart Project aim ed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task‐sharing with the use of a mobile phone – based clinical decision support system at Community Health Centers in Himachal Pradesh , India . Methods and Results The development of the intervention and mobile phone – based clinical decision support system was carried out using mixed methods in five Community Health Centers . The intervention was subsequently evaluated using pre – post evaluation design . During intervention , a nurse care coordinator screened , examined , and entered patient parameters into mobile phone – based clinical decision support system to generate a prescription , which was vetted by a physician . The change in systolic blood pressure , diastolic blood pressure , and fasting plasma glucose ( FPG ) over 18 months of intervention was quantified using generalized estimating equations models . During intervention , 6797 participants were enrolled . Six thous and sixteen participants had hypertension ( mean systolic blood pressure : 146.1 mm Hg , 95 % CI : 145.7 , 146.5 ; diastolic blood pressure : 89.52 mm Hg , 95 % CI : 89.33 , 89.72 ) , of which 3152 ( 52 % ) subjects were newly detected . Similarly , 1516 participants had diabetes mellitus ( mean FPG : 177.9 mg/dL , 95 % CI : 175.8 , 180.0 ) , of which 450 ( 30 % ) subjects were newly detected . The changes in systolic blood pressure , diastolic blood pressure , and FPG observed at 18 months of follow‐up were −14.6 mm Hg ( 95 % CI : −15.3 , −13.8 ) , −7.6 mm Hg ( CI : −8.0 , −7.2 ) , and −50.0 mg/dL ( 95 % CI : −54.6 , −45.5 ) , respectively , and were statistically significant even after adjusting for age , sex , and Community Health Center . Conclusions A nurse‐facilitated , mobile phone – based clinical decision support system‐enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale‐up in re source poor setting s. Clinical Trial Registration URL : https://www . clinical trials.gov . Unique identifiers : NCT01794052 . Clinical Trial Registry — India : CTRI/2013/02/003412 Introduction Diabetes self-management education ( DSME ) is a fundamental element of type 2 diabetes care . Although 75 % of adults with diabetes worldwide live in low-income and middle-income countries ( LMICs ) , limited DSME research has been conducted in LMICs . The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala . Methods We conducted a prospect i ve study of a DSME intervention using a quasi-experimental , single-group pretest – posttest design . We enrolled 90 participants in the intervention , which consisted of 6 home visits ( May 2014–July 2016 ) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan population s. Primary outcomes were changes in mean hemoglobin A1c ( HbA1c ) and mean systolic and diastolic blood pressure at baseline and at 12 months . Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion . Results HbA1c decreased significantly from baseline to 12 months ( absolute mean change , −1.5 % ; 95 % confidence interval [ CI ] , −1.9 % to −1.0 % ; P < .001 ) . Systolic blood pressure also improved significantly at 12 months ( −6.2 mm Hg ; 95 % CI , −10.1 to −2.2 mm Hg ; P = .002 ) ; changes in diastolic blood pressure were not significant ( −1.6 mm Hg ; 95 % CI , −3.9 to −0.7 mm Hg ; P = .17 ) . We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion . Conclusion DSME interventions can be successfully delivered in a setting with an underre source d health system , high poverty rate , and unique cultural characteristics like Mayan Guatemala . Our findings point to the need for more DSME research in re source -limited setting s globally BACKGROUND Although most cardiovascular disease occurs in low-income and middle-income countries , little is known about the use of effective secondary prevention medications in these communities . We aim ed to assess use of proven effective secondary preventive drugs ( antiplatelet drugs , β blockers , angiotensin-converting-enzyme [ ACE ] inhibitors or angiotensin-receptor blockers [ ARBs ] , and statins ) in individuals with a history of coronary heart disease or stroke . METHODS In the Prospect i ve Urban Rural Epidemiological ( PURE ) study , we recruited individuals aged 35 - 70 years from rural and urban communities in countries at various stages of economic development . We assessed rates of previous cardiovascular disease ( coronary heart disease or stroke ) and use of proven effective  secondary preventive drugs  and blood-pressure-lowering drugs with st and ardised question naires , which were completed by telephone interviews , household visits , or on patient 's presentation to clinics . We report estimates of drug use at national , community , and individual levels . FINDINGS We enrolled 153,996 adults from 628 urban and rural communities in countries with incomes classified as high ( three countries ) , upper-middle ( seven ) , lower-middle ( three ) , or low ( four ) between January , 2003 , and December , 2009 . 5650 participants had a self-reported coronary heart disease event ( median 5·0 years previously [ IQR 2·0 - 10·0 ] ) and 2292 had stroke ( 4·0 years previously [ 2·0 - 8·0 ] ) . Overall , few individuals with cardiovascular disease took antiplatelet drugs  ( 25·3 % ) , β blockers ( 17·4 % ) , ACE inhibitors or ARBs ( 19·5 % ) , or statins ( 14·6 % ) . Use was highest in high-income countries ( antiplatelet drugs 62·0 % , β blockers 40·0 % , ACE inhibitors or ARBs 49·8 % , and statins 66·5 % ) , lowest in low-income countries ( 8·8 % , 9·7 % , 5·2 % , and 3·3 % , respectively ) , and decreased in line with reduction of country economic status ( p(trend)<0·0001 for every drug type ) . Fewest patients received no drugs in high-income countries ( 11·2 % ) , compared with 45·1 % in upper middle-income countries , 69·3 % in lower middle-income countries , and 80·2 % in low-income countries . Drug use was higher in urban than rural areas ( antiplatelet drugs 28·7 % urban vs 21·3 % rural , β blockers 23·5%vs 15·6 % , ACE inhibitors or ARBs 22·8%vs 15·5 % , and statins 19·9%vs 11·6 % ; all p<0·0001 ) , with greatest variation in poorest countries ( p(interaction)<0·0001 for urban vs rural differences by country economic status ) . Country-level factors ( eg , economic status ) affected rates of drug use more than did individual-level factors ( eg , age , sex , education , smoking status , body-mass index , and hypertension and diabetes statuses ) . INTERPRETATION Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas - systematic approaches are needed to improve the long-term use of basic , inexpensive , and effective drugs . FUNDING Full funding sources listed at end of paper ( see Acknowledgments ) IMPORTANCE Hypertension is the most important preventable cause of morbidity and mortality globally , yet there are relatively few data collected using st and ardized methods . OBJECTIVE To examine hypertension prevalence , awareness , treatment , and control in participants at baseline in the Prospect i ve Urban Rural Epidemiology ( PURE ) study . DESIGN , SETTING , AND PARTICIPANTS A cross-sectional study of 153,996 adults ( complete data for this analysis on 142,042 ) aged 35 to 70 years , recruited between January 2003 and December 2009 . Participants were from 628 communities in 3 high-income countries ( HIC ) , 10 upper-middle-income and low-middle-income countries ( UMIC and LMIC ) , and 4 low-income countries ( LIC ) . MAIN OUTCOMES AND MEASURES Hypertension was defined as individuals with self-reported treated hypertension  or with an average of 2 blood pressure measurements of at least 140/90 mm Hg using an automated digital device . Awareness was based on self-reports , treatment was based on the regular use of blood pressure-lowering medications , and control was defined as individuals with blood pressure lower than 140/90 mm Hg . RESULTS Among the 142,042 participants , 57,840 ( 40.8 % ; 95 % CI , 40.5%-41.0 % ) had hypertension and 26,877 ( 46.5 % ; 95 % CI , 46.1%-46.9 % ) were aware of the diagnosis . Of those who were aware of the diagnosis , the majority ( 23,510 [ 87.5 % ; 95 % CI , 87.1%-87.9 % ] of those who were aware ) were receiving pharmacological treatments , but only a minority of those receiving treatment were controlled ( 7634 [ 32.5 % ; 95 % CI , 31.9%-33.1 % ] ) . Overall , 30.8 % , 95 % CI , 30.2%-31.4 % of treated patients were taking 2 or more types of blood pressure-lowering medications . The percentages aware ( 49.0 % [ 95 % CI , 47.8%-50.3 % ] in HICs , 52.5 % [ 95 % CI , 51.8%-53.2 % ] in UMICs , 43.6 % [ 95 % CI , 42.9%-44.2 % ] in LMICs , and 40.8 % [ 95 % CI , 39.9%-41.8 % ] in LICs ) and treated ( 46.7 % [ 95 % CI , 45.5%-47.9 % ] in HICs , 48.3 % , [ 95 % CI , 47.6%-49.1 % ] in UMICs , 36.9 % , [ 95 % CI , 36.3%-37.6 % ] in LMICs , and 31.7 % [ 95 % CI , 30.8%-32.6 % ] in LICs ) were lower in LICs compared with all other countries for awareness ( P < .001 ) and treatment ( P < .001 ) . Awareness , treatment , and control of hypertension were higher in urban communities compared with rural ones in LICs ( urban vs rural , P < .001 ) and LMICs ( urban vs rural , P < .001 ) , but similar for other countries . Low education was associated with lower rates of awareness , treatment , and control in LICs , but not in other countries . CONCLUSIONS AND RELEVANCE Among a multinational study population , 46.5 % of participants with hypertension were aware of the diagnosis , with blood pressure control among 32.5 % of those being treated . These findings suggest substantial room for improvement in hypertension diagnosis and treatment AIM This paper reports a study evaluating the relationship between social and community level supports and  physical activity and dietary behaviours  among a low-income Latino population with multiple chronic conditions . BACKGROUND With consistently lower physical activity than whites and documented nutritional deficiencies , Latinos in the United States of America represent a disproportionate share of the population with chronic illness . This pattern of health disparities is seen across countries , where there is a struggle to raise the health status of low-income , immigrant and aboriginal communities . Social-ecological theories of health behaviour stress the importance of considering social and community support for health behaviour , and represent a useful framework for considering ways to improve physical activity and nutrition for immigrant and aboriginal groups . METHOD We report here on data from a baseline assessment of 200 patients from a health clinic in the United States of America serving a low-income , primarily Latino population . Participants were enrolled in Re sources for Health , a r and omized controlled trial to promote multi-level support for chronic illness self-management . Measures included  self-reported physical activity , dietary behaviour and multi-level support for chronic illness management  as well as demographic data . Baseline data reported on here were collected between February 2002 and September 2003 . FINDINGS Use of multi-level supports ( e.g. family , individual and healthcare provider ) was statistically significantly associated with meeting physical activity guidelines and better dietary behaviours . Being female and having multiple chronic conditions were also associated with better dietary behaviour . These variables explained 20 % of the variance in dietary behaviour . CONCLUSION Results support a social-ecological approach for promoting healthy behaviour in this low-income , primarily Latino sample with multiple chronic conditions . Addressing multiple levels of support for healthy behaviour is important in interventions to improve physical activity and diet , and nurses may be particularly well placed to address such issues for low-income , aboriginal and immigrant patients with chronic conditions Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in re source -poor setting s. Contribution Among 1341 patients living in 12 communities in Pakistan that were r and omly assigned to general practitioner education , home health visits by trained lay workers , both , or neither , patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure ( 10.8 mm Hg ) after 2 years . Improvements were similar in all other groups ( about 5 mm Hg ) . Caution Twenty-two percent of patients were lost to follow-up . Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in re source -poor setting s. The Editors Cardiovascular disease has , in just a few decades , become the leading cause of death in adults worldwide , accounting for 1 in 5 deaths . Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease ( 1 , 2 ) . Despite the demonstrated benefits of effective drug treatment ( 3 , 4 ) and the existence of many clinical practice guidelines ( 5 ) , hypertension prevention , treatment , and control rates remain suboptimal worldwide ( 6 ) . The situation is particularly acute in developing countries , such as Pakistan , India , and China , where hypertension has reached epidemic proportionsaffecting more than 20 % of the adult population (7)yet control rates are less than 6 % ( 8) . Poor health literacy and unhealthy lifestyles , compounded by lack of awareness of hypertension ( 7 ) , are part of the cause . In addition , the health systems in these countries are often dysfunctional : More than 80 % of the expenditure for chronic disease care is out-of-pocket ; private care general practitioners ( GPs ) , who primarily treat acute conditions , are the front-line service providers ; and national programs for preventing and controlling hypertension are inadequate . Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers . ( 9 ) However , evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking . We conducted the COBRA-1 ( Control of Blood Pressure and Risk Attenuation-1 ) trial in Karachi , Pakistan , to test the effectiveness of 2 community-based strategies : family-based home health education ( HHE ) , delivered by trained community health workers , to improve population -level health literacy and behaviors , and hypertension management training for GPs . We tested the effect of these interventions , alone and in combination , on blood pressure in adults with hypertension . We hypothesized that HHE would be more effective than no education , that the specially trained GPs would provide more effective care than that usually received in Karachi , and that the combined interventions would provide additional benefit . Methods Study Design and Setting We performed a cluster r and omized , controlled trial with a 22 factorial design to determine the effect of  family-based HHE and special training for GPs  on blood pressure in adults 40 years or older with hypertension . We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level , and an individual approach would be prone to contamination of interventions and biased outcomes ( 10 ) . The Aga Khan University Ethics Review Committee granted ethical approval . The sampling frame is described elsewhere ( 11 ) . In brief , we used a multistage r and om sampling technique to select 12 of 4200 low- to middle-income , geographic census-based clusters ( mean household monthly income , $ 70 ; about 250 households in each cluster ) in Karachi , the most populous city in Pakistan ( about 16 million inhabitants ) . We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention . Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits ( mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg ) were eligible for inclusion . We excluded pregnant women , persons who could not give informed consent , and bed-bound persons . R and omization and Intervention We used computer-generated codes to r and omly assign 3 clusters each to the following groups : HHE alone , GP alone , HHE and GP combined , and no intervention . Home Health Education We trained 6 community health workers ( 1 for each cluster ) over 6 weeks in methods for using behavior-changing communication strategies to convey st and ardized health education messages to all households in clusters assigned to receive HHE . The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan ( 8 or preferably 10 years of schooling ) ( 12 ) . Salary scales and assigned workload were similarly consistent . The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease , as well as advice on the importance of engaging in moderate physical activity ; maintaining normal body weight ; reducing salt intake ; consuming a diet rich in fruit , vegetables , and low-fat dairy products ; reducing intake of saturated and total fat ( including suggestions on sample recipes for culturally acceptable and economically feasible food products ) ; and smoking cessation ( Appendix 1 ) . The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized . The first HHE session , lasting 90 minutes , was held at a time when all members of the household could be present . Follow-up reinforcement visits of 30 minutes were made every 3 months . Appendix 1 . Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training , with the aim of training at least two thirds of the GPs in each area . We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training . Training was a 1-day session that focused on st and ard treatment algorithms for the stepped-care management of hypertension , which were based on the seventh report of the Joint National Committee ( 3 ) and the Fourth Working Party of the British Hypertension Society guidelines ( 4 ) and modified for the Indo-Asian population ( Appendix 2 ) . The course included components on nonpharmacologic ( diet , exercise , weight loss , and smoking cessation ) and pharmacologic interventions , prescription of low-cost and appropriate generic drugs , preferential use of single-dose drug regimens , scheduled follow-up visits guided by blood pressure , the stepped-care approach for titrating drugs to achieve target blood pressure , and satisfactory consultation sessions for patients , with explanations of treatment and use of appropriate communication strategies . For managing persons with known hypertension , GPs were advised to review medication and blood pressure ; simplify regimens ; and aim to return to a regimen that was in line , as reasonably as possible , with that recommended for those with newly diagnosed hypertension . The recommended target blood pressure was < 140/90 mm Hg for all patients . Although this diverges from recent guidelines for special subgroups ( such as diabetic persons or those with end-organ damage ) , we reasoned that we needed to keep the intervention , guidelines , and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3 % ( 7 ) . The training sessions for GPs used a case-based curriculum and were interactive . We provided a certificate of training at the end of the course . Appendix 2 . Training Manual for General Practitioner All study participants were advised to consult a local GP . If participants in the clusters r and omly assigned to a trained GP group did not already have a preferred GP , we gave them a list of trained GPs in their cluster from which to choose . However , it remained the participant 's choice whether they attended a physician on the list . We did not provide for medications or fee-for-health care services . Participants were blinded to intervention status ( training of GP ) . Neither the patients nor the GPs received reimbursement for participation . Screening and Recruitment All households in each cluster were visited , and we obtained informed consent for screening from all adults 40 years and older , whose blood pressure was then measured 3 times with a calibrated automated device ( Omron HEM-737 IntelliSense ; Omron Healthcare , Vernon Hills , Illinois ) in the sitting position after 5 minutes of rest . Those with known hypertension were invited to participate . Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit . If mean blood pressure remained elevated , these persons were also invited to participate . A routine physical examination was performed , and the following information was collected : smoking status , food frequency , and physical activity by question naire , the latter by using the international physical activity question naire ; blood pressure , measured as described above ; anthropometric characteristics ( height , weight , and waist and hip circumferences ) ; and fasting blood glucose level ( Synchron Cx-7/Delta , Beckman Coulter , Fullerton , California ) and lipid profile ( Hitachi-912 , Roche , Basel , Switzerl and ) ( 11 ) . Follow-up Procedures Trained outcomes assessors ( who were not part of and had no relationship with the community health worker team ) evaluated Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost ? In an effort to answer this question , we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been r and omly assigned to a set of insurance plans for three or five years . One plan provided free care ; the others required enrollees to pay a share of their medical bills . As previously reported , patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often . For persons with poor vision and for low-income persons with high blood pressure , free care brought an improvement ( vision better by 0.2 Snellen lines , diastolic blood pressure lower by 3 mm Hg ) ; better control of blood pressure reduced the calculated risk of early death among those at high risk . For the average participant , as well as for subgroups differing in income and initial health status , no significant effects were detected on eight other measures of health status and health habits . Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence , favorable or adverse , of free care for the average participant . For some measures of health in subgroups of the population , however , the broader confidence intervals make this conclusion less certain Background Postpartum hemorrhage ( PPH ) is the leading cause of maternal mortality worldwide and accounts for one third of maternal deaths in low-income and middle-income countries . PPH can be prevented by active management of the third stage of labor ( AMTSL ) , a series of steps recommended by the World Health Organization to be performed by skilled birth attendants ( SBAs ) . Task shifting in the AMTSL step of uterotonic drugs administration to community health workers , traditional birth attendants and self-administration has been investigated as a strategy to increase access to quality obstetric care considering persistent SBA and facility-based delivery shortages . The aim of this study is to assess task shifting in the final step of AMTSL and compare uterine tonus assessment by a SBA to self- assessment . Methods and Design The study is an individual-level two-arm non-inferiority r and omized controlled trial ( RCT ) . A total of 800 women will be recruited in Korle Bu Teaching Hospital in Accra , Ghana . Adult women in labor at term with an expected vaginal delivery who received antenatal instructions for self- assessment of uterine tonus will be eligible for inclusion . Women with an increased risk for PPH will be excluded . Women will be r and omized to uterine tone assessment by a skilled birth attendant ( midwife ) or uterine tone self- assessment ( with the safety back-up of a midwife present in case of PPH or uterine atony ) . Postpartum blood loss will be measured through weighing of disposable mats . The main study endpoints are PPH ( ≥500 ml blood loss ) , severe PPH ( ≥1000 ml blood loss ) , mean blood loss , and routine maternal and neonatal outcomes . Participants and caregivers will not be blinded given the nature of the intervention . Discussion A reduction of PPH-related maternal mortality requires full implementation of AMTSL . Task shifting of uterine tone assessment may contribute to increased AMTSL implementation in ( clinical ) setting s where SBAs capacity is constrained . Trial registration Clinical trials.gov : NCT02223806 , registration August 2014 . PACTR : PACTR201402000736158 , registration July 2014 . University of Ghana , Medical School Ethical and Protocol Review Committee : MS-Et/M.8–P4.1/2014 - BACKGROUND Hypertension is the leading risk factor responsible for premature death worldwide , but its burden has shifted to low- and middle-income countries . Therefore , we studied hypertension and cardiovascular risk in the population of Suriname , a middle-income country with a predominantly urban population of African and Asian ancestry . METHODS A r and om sample of 1,800 noninstitutionalized men and women aged 18 - 70 years was selected to be interviewed at home and examined at the local hospital for cardiovascular risk factors , asymptomatic organ damage , and cardiovascular disease . RESULTS The 1,157 participants examined ( 37 % men ) were mainly of self-defined Asian ( 43 % ) or African ( 39 % ) ancestry , mean age 43 years ( SD 14 ) . The majority of the population ( 71 % ) had  hypertension or prehypertension  , respectively , 40 % and 31 % . Furthermore , 72 % was obese or overweight , while 63 % had diabetes or prediabetes . Only 1 % of the adult population had an optimal cardiovascular risk profile . Hypertension awareness , treatment , and control were respectively 68 % , 56 % , and 20 % . In line with this , 22 % of the adult population had asymptomatic organ damage , including increased arterial stiffness , left ventricular hypertrophy , microalbuminuria , or asymptomatic chronic kidney disease . CONCLUSIONS In this first extensive cardiovascular assessment in the general population of this middle-income Caribbean country , high prevalence of hypertension with inadequate levels of treatment and control was predominant . The findings emphasize the need for collaborative effort from national and international bodies to prioritize the implementation of affordable and sustainable public health programs that combat the escalating hypertension and cardiovascular risk factor burden Background Infant-feeding patterns may influence lifelong health . This study tested the hypothesis that longer duration of breastfeeding and later introduction of complementary foods in infancy are associated with reduced adult cardiovascular risk . Methods Data were pooled from 10 912 subjects in the age range of 15–41 years from five prospect i ve birth-cohort studies in low-/middle-income countries ( Brazil , Guatemala , India , Philippines and South Africa ) . Associations were examined between infant feeding ( duration of breastfeeding and age at introduction of complementary foods ) and adult blood pressure ( BP ) , plasma glucose concentration and adiposity ( skinfolds , waist circumference , percentage body fat and overweight/obesity ) . Analyses were adjusted for maternal socio-economic status , education , age , smoking , race and urban/rural residence and infant birth weight . Results There were no differences in outcomes between adults who were ever breastfed compared with those who were never breastfed . Duration of breastfeeding was not associated with adult diabetes prevalence or adiposity . There were U-shaped associations between duration of breastfeeding and systolic BP and hypertension ; however , these were weak and inconsistent among the cohorts . Later introduction of complementary foods was associated with lower adult adiposity . Body mass index changed by −0.19 kg/m2 [ 95 % confidence interval ( CI ) −0.37 to −0.01 ] and waist circumference by −0.45 cm ( 95 % CI −0.88 to −0.02 ) per 3-month increase in age at introduction of complementary foods . Conclusions There was no evidence that longer duration of breastfeeding is protective against adult hypertension , diabetes or overweight/adiposity in these low-/middle-income population s. Further research is required to determine whether ‘ exclusive ’ breastfeeding may be protective . Delaying complementary foods until 6 months , as recommended by the World Health Organization , may reduce the risk of adult overweight/adiposity , but the effect is likely to be small Limited data exist regarding the management of patients with acute coronary syndrome ( ACS ) in high-income countries compared with low/middle-income countries . We aim ed to compare in-hospital trends of revascularization and prescription of medications  at discharge in patients with ACS from high-income ( Canada and United States ) and low/middle-income ( India , Iran , Pakistan , and Tunisia ) countries . Data from a double-blind , placebo-controlled , r and omized trial investigating the effect of bupropion on smoking cessation in patients after an enzyme-positive ACS was used for our study . A total of 392 patients , 265 and 127 from high-income and from low/middle-income countries , respectively , were enrolled . Patients from high-income countries were older , and were more likely to have diagnosed hypertension and dyslipidemia . During the index hospitalization , patients from high-income countries were more likely to be treated by  percutaneous coronary intervention  ( odds ratio [ OR ] 19.7 , 95 % confidence interval [ CI ] 10.5 to 37.0 ) . Patients with ST elevation myocardial infa rct ion from high-income countries were more often treated by  primary percutaneous coronary intervention  ( OR 16.3 , 95 % CI 6.3 to 42.3 ) in contrast with thrombolytic therapy ( OR 0.24 , 95 % CI 0.14 to 0.41 ) . Patients from high-income countries were also more likely to receive evidence -based medications at discharge ( OR 2.32 , 95 % CI 1.19 to 4.52 , a composite of aspirin , clopidogrel , and statin ) . In conclusion , patients with ACS in low/middle-income countries were less likely to be revascularized and to receive evidence -based medications at discharge . Further studies are needed to underst and the underutilization of procedures and evidence -based medications in low/middle-income countries ABSTRACT BACKGROUND The U.S. Preventive Services Task Force has released new guidelines on obesity , urging primary care physicians to provide obese patients with intensive , multi-component behavioral interventions . However , there are few studies of weight loss in real world nonacademic primary care , and even fewer in largely racial/ethnic minority , low-income sample s. OBJECTIVE To evaluate the recruitment , intervention and replications costs of a 2-year , moderate intensity weight loss and blood pressure control intervention . DESIGN A comprehensive cost analysis was conducted , associated with a weight loss and hypertension management program delivered in three community health centers as part of a pragmatic r and omized trial . PARTICIPANTS Three hundred and sixty-five high risk , low-income , inner city , minority ( 71 % were Black/African American and 13 % were Hispanic ) patients who were both hypertensive and obese . MAIN MEASURES Measures included total recruitment costs and intervention costs , cost per participant , and incremental costs per unit reduction in weight and blood pressure . KEY RESULTS Recruitment and intervention costs were estimated $ 2,359 per participant for the 2-year program . Compared to the control intervention , the cost per additional kilogram lost was $ 2,204 /kg , and for blood pressure , $ 621 /mmHg . Sensitivity analyses suggest that if the program was offered to a larger sample and minor modifications were made , the cost per participant could be reduced to the levels of many commercially available products . CONCLUSIONS The costs associated with the Be Fit Be Well program were found to be significantly more expensive than many commercially available products , and much higher than the amount that the Centers for Medicare and Medicaid reimburse physicians for obesity counseling . However , given the serious and costly health consequences associated with obesity in high risk , multimorbid and socioeconomically disadvantaged patients , the re sources needed to provide interventions like those described here may still prove to be cost-effective with respect to producing long-term behavior change The study 's objective was to determine the effectiveness of a task-sharing psychological treatment for  perinatal depression  using non-specialist community health workers . A double-blind individual r and omised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha , Cape Town . Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale ( EPDS ) were r and omised into the intervention arm ( structured six-session psychological treatment ) or the control arm ( routine antenatal health care and three monthly phone calls ) . The primary outcome was response on the Hamilton Depression Rating Scale ( HDRS ) at three months postpartum ( minimum 40 % score reduction from baseline ) among participants who did not experience pregnancy or infant loss ( modified intention-to-treat population ) ( registered on Clinical Trials : NCT01977326 ) . Of 2187 eligible women approached , 425 ( 19.4 % ) screened positive on the EPDS and were r and omised ; 384 were included in the modified intention-to-treat analysis ( control : n = 200 ; intervention : n = 184 ) . There were no significant differences in response on the HDRS at three months postpartum between the intervention and control arm . A task-sharing psychological treatment was not effective in treating  depression among women living in Khayelitsha , South Africa . The findings give cause for reflection on the strategy of task-sharing in low-re source setting INTRODUCTION Elevated blood pressure greatly contributes to cardiovascular deaths in low-income and middle-income countries . We aim ed to investigate the effectiveness of a population -level intervention led by existing community health workers in reducing the burden of hypertension in a low-income population . METHODS We did a community-based , open-label , two-group , cluster-r and omised controlled trial in Nepal . Using computer-generated codes , we r and omly assigned ( 1:1 ) 14 clusters to a lifestyle intervention led by female community health volunteers ( FCHVs ) or usual care ( control group )  . In the intervention group , 43 FCHVs provided  home visits  every 4 months for lifestyle counselling and blood pressure monitoring .  Eligible participants had been involved in a previous population -based survey , were aged 25 - 65 years , did not have plans to migrate outside the study area , and were not severely ill or pregnant . The primary outcome was mean systolic blood pressure at 1 year . We included all participants who remained in the trial at 1 year in the primary analysis . This trial is registered with Clinical Trials.gov , number NCT02428075 . FINDINGS Between April 1 , 2015 , and Dec 31 , 2015 , we recruited 1638 participants ( 939 assigned to intervention ; 699 assigned to control ) . At 1 year , 855 participants remained in the intervention group ( 425 were normotensive , 175 were prehypertensive , and 255 had hypertension ) and 613 remained in the control group ( 305 were normotensive , 128 were prehypertensive , and 180 had hypertension ) . The mean systolic blood pressure at 1 year was significantly lower in the intervention group than in the control group for all cohorts : the difference was -2·28 mm Hg ( 95 % CI -3·77 to -0·79 , p=0·003 ) for participants who were normotensive , -3·08 mm Hg ( -5·58 to -0·59 , p=0·015 ) for participants who were prehypertensive , and -4·90 mm Hg ( -7·78 to -2·00 , p=0·001 ) for participants who were hypertensive . INTERPRETATION A simple , FCHV-led lifestyle intervention coupled with monitoring of blood pressure is effective for reduction of blood pressure in individuals with hypertension and ameliorates age-related increases in blood pressure in adults without hypertension in the general population of Nepal . FUNDING Aarhus University , Jayanti Memorial Trust Background Blood Pressure related disease affected 118 million people in India in the year 2000 ; this figure will double by 2025 . Around one in four adults in rural India have hypertension , and of those , only a minority are accessing appropriate care . Health systems in India face substantial challenges to meet these gaps in care , and innovative solutions are needed . Methods We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare . This intervention will be implemented as a stepped wedge , cluster r and omised controlled trial in 18 primary health centres and 54 villages in rural And hra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk ( approximately 15,000 people ) . Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension ’s region-specific risk charts . Cluster r and omisation will occur at the level of the primary health centres . Outcome analyses will be conducted blinded to intervention allocation . Expected outcomes The primary study outcome is the difference in the proportion of people meeting guideline -recommended blood pressure targets in the intervention period vs. the control period . Secondary outcomes include mean reduction in blood pressure levels ; change in other cardiovascular disease risk factors , including body mass index , current smoking , reported healthy eating habits , and reported physical activity levels ; self-reported use of blood pressure and other cardiovascular medicines ; quality of life ( using the EQ-5D ) ; and cardiovascular disease events ( using hospitalisation data ) . Trial outcomes will be accompanied by detailed process and economic evaluations . Significance The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served population s in low and middle income country setting s . Trial registration Clinical Trial Registry India CTRI/2013/06/003753 Introduction In low/middle-income countries with substantial HIV and tuberculosis epidemics , health services often neglect other highly prevalent chronic conditions , such as hypertension , which as a result are poorly managed . This paper reports on a study to assess the effect on hypertension management of lay health workers ( LHW ) working in South African rural primary healthcare clinics to support the provision of integrated chronic care . Methods A pragmatic cluster r and omised trial with a process evaluation in eight rural clinics assessed the effect of adding  two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months . Control clinics continued with usual care . The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure ( BP ) before and after the intervention , as measured by two cross-sectional population surveys . Results There was no improvement in BP control among users of intervention clinics as compared with control clinics . However , the LHWs improved clinic functioning , including overall attendance , and attendance on the correct day . All clinics faced numerous challenges , including rapidly increasing number of users of chronic care , unreliable BP machines and cuffs , intermittent drug shortages and insufficient space . Conclusion LHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients , the dominance of the vertically funded HIV programme and the poor st and ards of equipment in clinics . Trial registration number IS RCT N12128227 BACKGROUND WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80 % of communities and used by 50 % of eligible individuals by 2025 . We have previously reported that use of these medicines is very low , but now aim to assess how such low use relates to their lack of availability or poor affordability . METHODS We analysed information about availability and costs of cardiovascular disease medicines ( aspirin , β blockers , angiotensin-converting enzyme inhibitors , and statins ) in pharmacies gathered from 596 communities in 18 countries participating in the Prospect i ve Urban Rural Epidemiology ( PURE ) study . Medicines were considered available if present at the pharmacy when surveyed , and affordable if their combined cost was less than 20 % of household capacity-to-pay . We compared results from high-income , upper middle-income , lower middle-income , and low-income countries . Data from India were presented separately given its large , generic pharmaceutical industry . FINDINGS Communities were recruited between Jan 1 , 2003 , and Dec 31 , 2013 . All four cardiovascular disease medicines were available in 61 ( 95 % ) of 64 urban and 27 ( 90 % ) of 30 rural communities in high-income countries , 53 ( 80 % ) of 66 urban and 43 ( 73 % ) of 59 rural communities in upper middle-income countries , 69 ( 62 % ) of 111 urban and 42 ( 37 % ) of 114 rural communities in lower middle-income countries , eight ( 25 % ) of 32 urban and one ( 3 % ) of 30 rural communities in low-income countries ( excluding India ) , and 34 ( 89 % ) of 38 urban and 42 ( 81 % ) of 52 rural communities in India . The four cardiovascular disease medicines were potentially unaffordable for 0·14 % of households in high-income countries ( 14 of 9934 households ) , 25 % of upper middle-income countries ( 6299 of 24,776 ) , 33 % of lower middle-income countries ( 13,253 of 40,023 ) , 60 % of low-income countries ( excluding India ; 1976 of 3312 ) , and 59 % households in India ( 9939 of 16,874 ) . In low-income and middle-income countries , patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available ( odds ratio [ OR ] 0·16 , 95 % CI 0·04 - 0·57 ) . In communities in which all four medicines were available , patients were less likely to use medicines if the household potentially could not afford them ( 0·16 , 0·04 - 0·55 ) . INTERPRETATION Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income , lower middle-income , and low-income countries , which have very low use of these medicines . Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO 's targets of 50 % use of key medicines by 2025 . FUNDING Population Health Research Institute , the Canadian Institutes of Health Research , Heart and Stroke Foundation of Ontario , AstraZeneca ( Canada ) , Sanofi-Aventis ( France and Canada ) , Boehringer Ingelheim ( Germany and Canada ) , Servier , GlaxoSmithKline , Novartis , King Pharma , and national or local organisations in participating countries Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Cervix cancer is a worldwide scourge . It is the second leading cause of cancer deaths in women worldwide with a rate of 728 deaths per day . 87 % of cervix cancer deaths occur in low- and middle-income countries , with mortality rates varying 18-fold.1 Even in high-income nations , there has been little improvement in survival rates.2 The last major improvement in cervix cancer was published 15 years ago with the superiority of cisplatin-based chemoradiotherapy to radiotherapy alone.3,4 The Cervix Cancer Research Network ( CCRN ) developed within the Gynecologic Cancer Intergroup ( GCIG ) out of a realisation that cervical cancer trials were becoming scarce . While cervical cancer rates are declining in GCIG countries , low- and middle-income countries are coping with large disease burdens . This led to extending trial development beyond GCIG borders to involve a network of accredited , capable centres in other areas of the world . It was envisaged that this could harness local enthusiasm to raise st and ards of care . The CCRN would provide the infrastructure and support for high quality trials . The CCRN recognized that many low- and middle-income countries would not be eligible to participate in trials since the degree of infrastructure required to participate would be lacking . The literature was evaluated for best practice s for clinical trials within gynecologic cancers.5 The CCRN developed st and ard operating procedures to ensure adequate infrastructure . A pre-qualifying question naire was developed to evaluate potential sites addressing clinical activity , site re sources , trials operation , radiation records , quality assurance , and clinical management information . Participation in a beam measurement program is required every two years to determine the stability of linear accelerators . The Imaging and Radiation Oncology Imaging Core ( IROC ) in Houston , Texas has partnered with CCRN to provide regular quality assurance . Site visits are performed by an audit team , including a physician and clinical trial manager , to evaluate the appropriateness to participate in CCRN trials . The GCIG has grown to include 28 member groups , and worldwide interest in the CCRN is shown in Figure 1 . To date , 17 different CCRN site visits have been performed . There are ten approved CCRN sites including Tata Memorial Hospital ; Bangalore , India ; Ramathibodi , Thail and ; Triv and rum , India ; Siriaj , Thail and ; Pramongkutklao , Thail and ; Ho Chi Minh , Vietnam ; Blokhin Russian Cancer Research Center , the Hertzen Moscow Cancer Research Institute , and the Russian Scientific Center of Roentgenoradiology . Several additional sites have been approved with contingencies , including Cluj , Romania and Minsk , Belarus . Figure 1 Worldwide GCIG and CCRN participation . CCRN currently has four multinational publicly funded clinical trials that are open for enrollment in low- , middle- , and high-income countries . The TACO Trial , which was developed by investigators from the Korean Gynecologic Oncology Group ( KGOG ) and the Thai Cooperative Group , is comparing weekly cisplatin cancer to every-three-week chemotherapy for locally advanced cervical cancer .  Cisplatin delivered every three weeks may be more effective by achieving a higher peak concentration.6 The OUTBACK Trial , sponsored by the Australia New Zeal and Gynaecology Oncology Group ( ANZGOG ) with participation from NRG Oncology and other cooperative groups , is evaluating the efficacy of extended adjuvant chemotherapy compared to the st and ard weekly cisplatin chemoradiotherapy . The extended adjuvant chemotherapy consists of four cycles of carboplatin and paclitaxel . The INTERLACE Trial is headed by the National Cancer Research Institute ( NCRI ) from the United Kingdom . This trial is evaluating neoadjuvant chemotherapy prior to definitive chemoradiotherapy . Compliance with chemotherapy may be higher in a neoadjuvant approach than in an extended adjuvant approach . In the meta- analysis for neoadjuvant chemotherapy in locally advanced cervix cancer , a benefit was observed when the dose intensity of cisplatin was greater than 25 mg/m2 per week.8 The SHAPE Trial , led by the NCIC Clinical Trials Group in Canada , is a r and omized trial evaluating radical hysterectomy  versus  simple hysterectomy  in low risk , early-stage cervix cancer ( lesions < 2 cm ) . The primary endpoint is pelvic relapse-free survival with secondary endpoints of quality of life , sexual health , and cost-effectiveness.9 The greatest burden of cervix cancer resides in low- and middle-income countries , most notably in Central and South America , sub-Saharan Africa , Eastern Europe , India , and parts of Asia . Simultaneously , the incidence of cervix cancer is declining in the high-income countries . Clinical research is an ongoing challenge , and requires collaboration amongst physicians , hospitals , and patients . In many countries , there are governmental barriers to trial participation and data sharing . The legislation and bureaucracy involved in clinical trials means there is significant cost associated with participation . Physicians and hospitals frequently donate their time to these important efforts , but even in developed nations governmental funding is not sufficient to cover all costs . As technology improves , the information sharing and data collection are easier , but rigorous quality assurance is necessary to maintain the validity of the research question and the credibility of the results . Radiotherapy quality assurance in these trials is done via an internet-based approach . Many areas of the world have experienced relatively rapid economic growth and investment in health systems , which will provide more opportunity for conducting trials . The mission of the CCRN is to promote high quality research performed in locations where there is significant need . In three years we have met with success in this endeavor : there are four fully funded cervix cancer trials ; st and ard operating procedures ; a large cadre of expert volunteer site visitors ; 8 sites have been opened in 6 countries ; and 50 patients have been accrued . The cost of clinical research is small compared with the cost of clinical care . Through these efforts , CCRN hopes to improve the care of women with cervical cancer worldwide . As CCRN exp and s , an additional goal is to provide formalized training to physicians , study staff , and patient navigators to ensure high quality care delivery and follow-up . This can be a motivational aspect for international collaboration and development of country-specific , comprehensive healthcare programs . The goal , to save more lives from cervical cancer , is one that must be achieved BACKGROUND Autism spectrum disorder affects more than 5 million children in south Asia . Although early interventions have been used for the treatment of children in high-income countries , no substantive trials have been done of the interventions adapted for use in low-income and middle-income countries ( LMICs ) . We therefore assessed the feasibility and acceptability of the parent-mediated intervention for autism spectrum disorder in south Asia ( PASS ) in India and Pakistan . METHODS A single-blind r and omised trial of the comparison of 12 sessions of PASS ( plus treatment as usual ) with treatment as usual alone delivered by non-specialist health workers was done at two centres in Goa , India , and Rawalpindi , Pakistan . Children aged 2 - 9 years with autism spectrum disorder were r and omly assigned ( 1:1 ) by use of probabilistic minimisation , controlling for treatment centre ( Goa or Rawalpindi ) , age ( < 6 years or ≥6 years ) , and functional impairment ( Vinel and Adaptive Behaviour Scale Composite score < 65 or ≥65 ) . The primary outcome was quality of parent-child interaction on the Dyadic Communication Measure for Autism at 8 months . Analysis was by intention to treat . The study is registered with IS RCT N , number IS RCT N79675498 . FINDINGS From Jan 1 to July 30 , 2013 , 65 children were r and omly allocated , 32 to the PASS group ( 15 in Goa and 17 in Rawalpindi ) and 33 to the treatment-as-usual group ( 15 in Goa and 18 in Rawalpindi ) . 26 ( 81 % ) of 32 participants completed the intervention . After adjustment for minimisation factors and baseline outcome , the primary outcome showed a treatment effect in favour of PASS in parental synchrony ( adjusted mean difference 0·25 [ 95 % CI 0·14 to 0·36 ] ; effect size 1·61 [ 95 % CI 0·90 to 2·32 ] ) and initiation of communication by the child with the parent ( 0·15 [ 0·04 to 0·26 ] ; effect size 0·99 [ 0·29 to 1·68 ] ) , but time in mutual shared attention was reduced ( -0·16 [ -0·26 to -0·05 ] ; effect size -0·70 [ -1·16 to -0·23 ] ) . INTERPRETATION Our results show the feasibility of adapting and task-shifting an intervention used in a high-income context to LMICs . The findings also replicate the positive primary outcome treatment effects of a parent-mediated communication-focused intervention in the original UK Preschool Autism Communication Trial , with one negative effect not reported previously . FUNDING Autism Speaks , USA
The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure , but low for diastolic blood pressure .
INTERPRETATION Task-sharing interventions are effective in reducing blood pressure .
BACKGROUND Task sharing for the management of hypertension could be useful for understaffed and re source -poor health systems .
We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries .