A systematic review of online interventions for mental health in low and middle income countries: a neglected field Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol Interventions for domestic violence among pregnant women in low- and middle-income countries: a systematic review protocol A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries. 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 management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. 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 Critical Role of Supervision in Retaining Staff in Obstetric Services: A Three Country Study 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 Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial Sudden cardiac death in low- and middle-income countries. Intensive Patient Education Improves Glycaemic Control in Diabetes Compared to Conventional Education: A Randomised Controlled Trial in a Nigerian Tertiary Care Hospital Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review protocol Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana The effect of electronic reminders on risk management among diabetic patients in low resourced settings. Hypothermia for encephalopathy in low and middle-income countries (HELIX): study protocol for a randomised controlled trial Screening for diabetes and hypertension in a rural low income setting in western Kenya utilizing home-based and community-based strategies Readiness of Ugandan health services for the management of outpatients with chronic diseases Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study
Background . Low and middle income countries ( LMICs ) are facing an increase of the impact of mental health problems while confronted with limited re sources and limited access to mental health care , known as the ‘ mental health gap ’ . One strategy to reduce the mental health gap would be to utilize the internet to provide more widely-distributed and low cost mental health care . We undertook this systematic review to investigate the effectiveness and efficacy of online interventions in LMICs . Methods . We systematic ally search ed the data -bases PubMed , PsycINFO , JMIR , and additional sources . MeSH terms , Thesaurus , and free text keywords were used . We included all r and omized controlled trials ( RCTs ) of online interventions in LMICs . Results . We found only three articles reported results of RCTs on  online interventions for mental health conditions in LMICs , but none of these interventions was compared with an active control condition . Also , the mental health conditions were diverse across the three studies . Conclusions . There is a dearth of studies examining the effect of online interventions  in LMICs , so we can not draw a firm conclusion on its effectiveness . However , given the effectiveness of  online interventions in high income countries and sharp increase of internet access in LMICs , online interventions may offer a potential to help reduce the ‘ mental health gap ’ . More studies are urgently needed in LMICs People living with HIV ( PLWH ) experience greater psychological distress than the general population . Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms , quality of life , and HIV care engagement . However , little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries ( LMICs ) , where the large majority of PLWH reside . This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these setting s. A systematic search strategy was undertaken to identify peer- review ed published papers of intervention trials addressing negative psychological states or disorders ( e.g. depression , anxiety ) among PLWH in LMIC setting s. Search results were assessed against pre-established inclusion and exclusion criteria . Data from papers meeting criteria were extracted for synthesis . Twenty-six papers , published between 2000 and 2014 , describing 22 unique interventions were identified . Trials were implemented in sub-Saharan Africa ( n = 13 ) , Asia ( n = 7 ) , and the Middle East ( n = 2 ) , and addressed mental health using a variety of approaches , including cognitive-behavioral ( n = 18 ) , family-level ( n = 2 ) , and pharmacological ( n = 2 ) treatments . Four r and omized controlled trials reported significant intervention effects in mental health outcomes , and 11 preliminary studies demonstrated promising findings . Among the limited mental health intervention trials with PLWH in LMICs , few demonstrated efficacy .  Mental health interventions for PLWH in LMICs must be further developed and adapted for re source -limited setting s to improve effectiveness Introduction Task shifting interventions are intended to both deliver clinical ly effective treatments to reduce disease burden and address health inequities or population vulnerability . Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting . This systematic review will address the following questions : Among  task shifting interventions in high-income setting s that have been studied using r and omised controlled trials or variants , how are health inequity or population vulnerability identified and defined ? What methods and indicators are used to describe , characterise and measure the population ’s baseline status and the intervention ’s impacts on inequity and vulnerability ? Methods and analysis Studies were identified through data base search es ( MEDLINE , Embase , CINAHL , PsycINFO and Web of Science ) . Eligible studies will be r and omised controlled trials published since 2004 , conducted in high-income countries , concerning task shifting interventions to treat any disease , in any population that may face health disadvantage as defined by the PROGRESS-Plus framework ( place of residence , race/ethnicity/culture/ language , occupation , gender/sex , religion , social capital , socioeconomic position , age , disability , sexual orientation , other vulnerable groups ) . We will conduct independent and duplicate title and abstract screening , then identify related papers from the same programme of research through further data base and manual search ing . From each programme of research , we will extract study details , and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework . Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study . A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implication s. Ethics and dissemination This review does not involve primary data collection , does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures . Dissemination will include open-access peer- review ed publication and academic conference presentations . PROSPERO Registration Number CRD42017049959 Background Violence during pregnancy is a global problem , associated with serious health risks for both the mother and baby . Evaluation of interventions targeted for reducing or controlling domestic violence ( DV ) is still in its infancy , and the majority of findings are primarily from high-income countries ( HICs ) . Therefore , there is an urgent need for generating evidence of DV interventions among pregnant women in low- and middle-income countries ( LMICs ) . Methods Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRISMA ) guidelines will be employed to structure the review . A comprehensive search will be carried out via electronic data bases including MEDLINE , CINAHL , Scopus , Embase , Web of Science , PsycINFO , and The Cochrane library . Gray literature will also be scrutinized for potential articles . An optimal search strategy has been developed following consultations with subject-matter experts and librarians . This search strategy will be adapted to the different data bases . Experimental studies evaluating DV interventions among pregnant women from LMICs will be included in the review . The review will only include literature written in English . Two review ers will independently screen and assess studies for inclusion in the review . A third author will resolve any discrepancies between the review ers . Risk of bias will be assessed based on the Cochrane risk of bias assessment tool , and overall quality of the evidence will be judged using Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) criteria . Findings will be presented with the narrative synthesis , and if applicable , they will be further quantified using r and om-effects meta- analysis . Effect size , risk ratio for dichotomous variables , and st and ardized mean differences for continuous variables will be calculated for each outcome using Review Manager 5.3 . Discussion Systematic review s to evaluate the efficacy of interventions to address DV within the perinatal context have been limited . Hence , no one intervention has emerged as substantially effective towards addressing perinatal DV and associated health consequences . The evidence generated from this systematic review will inform research ers and policy makers about the effectiveness of existing DV interventions among pregnant women in LMICs and provide recommendations for future research in this area . This in turn will contribute towards violence prevention in LMICs . Systematic review registration PROSPERO This paper describes the Common Elements Treatment Approach ( CETA ) for adults presenting with mood or anxiety problems developed specifically for use with lay counselors in low- and middle-income countries ( LMIC ) . Details of the intervention development , training , supervision , and decision-making process are presented . Case vignettes are used as examples throughout . Preliminary findings are presented on counselor/supervisor performance and client outcomes from practice cases completed prior to r and omized controlled trials ( RCT ) conducted at two sites for adult survivors of torture and /or systematic violence in ( a ) southern Iraq and ( b ) Thail and -Burma border . Data suggest that local supervisors and lay counselors with little prior mental health training or experience maintained fidelity to the model . The majority of pilot clients were retained in treatment , suggesting acceptability . Using the Reliable Change Index ( RCI ) for each individual we examined the number of clients above a minimal threshold ( z > 1.96 ) for each outcome . In Iraq 100 % of clients had RCIs above the threshold for depression and posttraumatic stress , and 81.8 % for impaired function . In Thail and , 81.3 % of clients had RCIs above minimum threshold for depression , 68.8 % for posttraumatic stress , and 37.5 % for impaired function . Implementation of CETA is discussed in relation to cultural issues within LMIC . These findings , combined with US-based evidence , suggest that a common elements approach warrants further development and testing as a means for addressing the treatment gap for mental health problems in LMIC 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 - 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 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 Millennium Development Goal ( MDG ) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015 . In order to reach these goals , greater access to basic emergency obstetric care ( EmOC ) as well as comprehensive EmOC which includes safe Caesarean section , is needed .. The limited capacity of health systems to meet dem and for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers . Although this does provide greater capacity for service delivery , concern about the performance and motivation of these workers is emerging . We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally . To investigate this , we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers ( health workers trained for shorter periods to perform specific tasks e.g. clinical officers ) delivering obstetric care in Malawi , Tanzania , and Mozambique . Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace . In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave . We find no evidence that facility level factors modify the link between supervisory methods and key outcomes . We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision . This will promote better job satisfaction and improve the retention and performance of obstetric care workers , something which has the potential to improve maternal and neonatal outcomes in the countdown to 2015 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 Background In many low-income countries , care for patients with non-communicable diseases ( NCDs ) and mental health conditions is provided by nurses . The benefits of nurse substitution and supplementation in NCD care in high-income setting s are well recognised , but evidence from low- and middle-income countries is limited . Primary Care 101 ( PC101 ) is a programme design ed to support and exp and nurses ’ role in NCD care , comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions . We evaluated the effect of the programme on primary care nurses ’ capacity to manage NCDs . Methods and Findings In a cluster r and omised controlled trial design , 38 public sector primary care clinics in the Western Cape Province , South Africa , were r and omised . Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an exp and ed range of drugs for several NCDs . Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa ( PALSA PLUS ) management tool and usual training . Patients attending these clinics with one or more of hypertension ( 3,227 ) , diabetes ( 1,842 ) , chronic respiratory disease ( 1,157 ) or who screened positive for depression ( 2,466 ) , totalling 4,393 patients , were enrolled between 28 March 2011 and 10 November 2011 . Primary outcomes were treatment intensification in the hypertension , diabetes , and chronic respiratory disease cohorts , defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo , and case detection in the depression cohort . Primary outcome data were analysed for 2,110 ( 97 % ) intervention and 2,170 ( 97 % ) control group patients . Treatment intensification rates in intervention clinics were not superior to those in the control clinics ( hypertension : 44 % in the intervention group versus 40 % in the control group , risk ratio [ RR ] 1.08 [ 95 % CI 0.94 to 1.24 ; p = 0.252 ] ; diabetes : 57 % versus 50 % , RR 1.10 [ 0.97 to 1.24 ; p = 0.126 ] ; chronic respiratory disease : 14 % versus 12 % , RR 1.08 [ 0.75 to 1.55 ; p = 0.674 ] ) , nor was case detection of depression ( 18 % versus 24 % , RR 0.76 [ 0.53 to 1.10 ; p = 0.142 ] ) . No adverse effects of the nurses ’ exp and ed scope of practice were observed . Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts , limited data on uptake of PC101 by users , reliance on process outcomes , and insufficient re sources to measure important health outcomes , such as HbA1c , at follow-up . Conclusions Educational outreach to primary care nurses to train them in the use of a management tool involving an exp and ed role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases . This notwithst and ing , the intervention , with adjustments to improve its effectiveness , has been adopted for implementation in primary care clinics throughout South Africa . Trial Registration The trial is registered with Current Controlled Trials ( IS RCT N20283604 Cardiovascular disease , and the incidence of sudden cardiac death ( SCD ) , will increase significantly in low- and middle-income countries ( LMIC ) . Thus , SCD threatens to become a global public health problem . We present a summary of the current research that has investigated the epidemiology of SCD in LMIC . Few studies of SCD in LMIC exist , and they are of variable method ological quality . Risk factors for SCD are described , taking into account recent global burden of disease and risk factor statistics . We describe 1 proposal for a community-based , prospect i ve , multiple- source methodology for SCD monitoring and surveillance that can be implemented in LMIC . Further research into the epidemiology of SCD in LMIC , using st and ardized methodology , would allow investigators and policy makers to determine the regions , communities , and individuals most at need for SCD prevention . Focusing on SCD and its prevention in LMIC should be a priority for the global health community Background Diabetes is now a global epidemic , but most cases are now in low- and middle-income countries . Diabetes self-management education ( DSME ) is key to enabling patients to manage their chronic condition and can reduce the occurrence of costly and devastating complications . However , there is limited evidence on the effectiveness of different DSME programmes in re source limited setting s. Methods We conducted an unblinded , parallel-group , individually-r and omised controlled trial at the University of Calabar Teaching Hospital ( Nigeria ) to evaluate whether an intensive and systematic DSME programme , using structured guidelines , improved glycaemic control compared to the existing ad hoc patient education ( clinical practice was unchanged ) . Eligible patients ( ≥18 years , HbA1c > 8.5 % and physically able to participate ) were r and omly allocated by permuted block r and omisation to participate for six months in either an intensive or conventional education group . The primary outcome was HbA1c ( % ) at six-months . Results We r and omised 59 participants to each group and obtained six-month HbA1c outcomes from 53 and 51 participants in the intensive and conventional education groups , respectively . Intensive group participants had a mean six-month HbA1c ( % ) of 8.4 ( 95 % CI : 8 to 8.9 ) , while participants in the conventional education group had a mean six-month HbA1c ( % ) of 10.2 ( 95 % CI : 9.8 to 10.7 ) . The difference was statistically ( P < 0.0001 ) and clinical ly significant , with intensive group participants having HbA1c outcomes on average -1.8 ( 95 % CI : -2.4 to -1.2 ) percentage points lower than conventional group participants . Results were robust to adjustment for a range of covariates and multiple imputation of missing outcome data . Conclusions This study demonstrates the effectiveness of a structured , guideline -based DSME intervention in a LMIC setting versus a pragmatic comparator . The intervention is potentially replicable at other levels of the Nigerian healthcare system and in other LMICs , where nurses/diabetes educators can run the programme . Trial Registration Pan African Clinical Trial Registry Background Task shifting and the integration of human immunodeficiency virus ( HIV ) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment ( ART ) . This paper describes the development and content of an intervention involving these two strategies , as part of the Streamlining Tasks and Roles to Exp and Treatment and Care for HIV ( STRETCH ) pragmatic r and omised controlled trial . Methods : Developing the interventionThe intervention was developed following discussion s with senior management , clinicians , and clinic staff . These discussion s revealed that the establishment of separate antiretroviral treatment services for HIV had result ed in problems in accessing care due to the large number of patients at ART clinics . The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals ( ARVs ) for uncomplicated patients and the stepwise integration of HIV care into primary care services . Results : Components of the interventionThe intervention consisted of regulatory changes , training , and guidelines to support nurse ART prescription , local management teams , an implementation toolkit , and a flexible , phased introduction . Nurse supervisors were equipped to train  intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline . Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process . Discussion Three important processes were used in developing and implementing this intervention : active participation of clinic staff and local and provincial management , educational outreach to train nurses in intervention sites , and an external facilitator to support all stages of the intervention rollout . The STRETCH trial is registered with Current Control Trials IS RCT N46836853 Background Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe . Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths ; many of these in sub-Saharan countries . Many of these deaths are preventable . Countries , like Malawi , do not have the re sources nor highly trained medical specialists using complex technologies within their healthcare system . Much of the burden falls on healthcare staff other than doctors including non-physician clinicians ( NPCs ) such as clinical officers , midwives and community health-workers . The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care . Training that will hopefully be cascaded to their colleagues ( other NPCs , midwives , nurses ) . Methods / design This is a cluster r and omised controlled trial with the unit of r and omisation being the 14 districts of central and northern Malawi ( one large district was divided into two giving an overall total of 15 ) . Eight districts will be r and omly allocated the intervention . Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme ( the intervention ) . Primary outcome will be maternal and perinatal ( defined as until discharge from health facility ) mortality . Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project ( 3–4 years ) and comparisons made . In addition a process evaluation using both quantitative and qualitative ( e.g. interviews ) will be undertaken to evaluate the intervention implementation . Discussion Education and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi . Some of the challenges faced are discussed as are the potential limitations . It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training . Trial registration IS RCT Background Cluster r and omised trials ( CRTs ) are a key instrument to evaluate public health interventions , particularly in low- and middle-income countries ( LMICs ) . Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned . Evaluation of implementation fidelity ( IF ) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions . Current CRT reporting guidelines offer no guidance on IF assessment . We will systematic ally review the scientific literature to study current practice s concerning the assessment of IF in CRTs of public health interventions in LMICs . Methods We will include  CRTs of public health interventions in LMICs that planned or assessed IF in either the trial protocol or the main trial report ( or an associated document ) . Search strategies use Medical Subject Headings ( MESH ) and text words related to CRTs , developing countries , and public health interventions . The electronic data base search was developed first for MEDLINE and adapted for the following data bases : EMBASE , CINAHL , PubMed , and EMB Review s , to identify CRT reports in English , Spanish , or French published on or after January 1 , 2012 . To ensure availability of a study protocol , we will include CRTs reporting a registration number in the abstract . For each included study , we will compare planned versus reported assessment of IF , and consider the dimensions of IF studied , and data collection methods used to evaluate each dimension . Data will be synthesis ed using quantitative and narrative techniques . Risk of bias for individual studies will be assessed using the Cochrane Collaboration Risk of Bias Tool criteria and additional criteria related to CRT methods . We will investigate possible sources of heterogeneity by performing subgroup analysis . This review was not eligible for inclusion in the PROSPERO registry . Discussion Fidelity assessment may be a key tool for making studies more reliable , internally valid , and externally generalizable . This review will provide a portrait of current practice s related to the assessment of intervention fidelity in CRTs and offer suggestions for improvement . Results will be relevant to research ers , those who finance health interventions , and for decision-makers who seek the best evidence on public health interventions IMPORTANCE Little is known about adoption of healthy lifestyle behaviors among individuals with a coronary heart disease ( CHD ) or stroke event in communities across a range of countries worldwide . OBJECTIVE To examine the prevalence of avoidance or cessation of smoking , eating a healthy diet  , and undertaking regular physical activities  by individuals with a CHD or stroke event . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve Urban Rural Epidemiology ( PURE ) was a large , prospect i ve cohort study that used an epidemiological survey of 153,996 adults , aged 35 to 70 years , from 628 urban and rural communities in 3 high-income countries ( HIC ) , 7 upper-middle-income countries ( UMIC ) , 3 lower-middle-income countries ( LMIC ) , and 4 low-income countries ( LIC ) , who were enrolled between January 2003 and December 2009 . MAIN OUTCOME MEASURES Smoking status ( current , former , never ) , level of exercise ( low , < 600 metabolic equivalent task [MET]-min/wk ; moderate , 600 - 3000 MET-min/wk ; high , > 3000 MET-min/wk ) , and diet ( classified by the Food Frequency Question naire and defined using the Alternative Healthy Eating Index ) . RESULTS Among 7519 individuals with self-reported CHD ( past event : median , 5.0 [ interquartile range { IQR } , 2.0 - 10.0 ] years ago ) or stroke ( past event : median , 4.0 [ IQR , 2.0 - 8.0 ] years ago ) , 18.5 % ( 95 % CI , 17.6%-19.4 % ) continued to smoke ; only 35.1 % ( 95 % CI , 29.6%-41.0 % ) undertook high levels of work- or leisure-related physical activity , and 39.0 % ( 95 % CI , 30.0%-48.7 % ) had healthy diets ; 14.3 % ( 95 % CI , 11.7%-17.3 % ) did not undertake any of the 3 healthy lifestyle behaviors and 4.3 % ( 95 % CI , 3.1%-5.8 % ) had all 3 . Overall , 52.5 % ( 95 % CI , 50.7%-54.3 % ) quit smoking ( by income country classification : 74.9 % [ 95 % CI , 71.1%-78.6 % ] in HIC ; 56.5 % [ 95 % CI , 53.4%-58.6 % ] in UMIC ; 42.6 % [ 95 % CI , 39.6%-45.6 % ] in LMIC ; and 38.1 % [ 95 % CI , 33.1%-43.2 % ] in LIC ) . Levels of physical activity increased with increasing country income but this trend was not statistically significant . The lowest prevalence of eating healthy diets was in LIC ( 25.8 % ; 95 % CI , 13.0%-44.8 % ) compared with LMIC ( 43.2 % ; 95 % CI , 30.0%-57.4 % ) , UMIC ( 45.1 % , 95 % CI , 30.9%-60.1 % ) , and HIC ( 43.4 % , 95 % CI , 21.0%-68.7 % ) . CONCLUSION AND RELEVANCE Among a sample of patients with a CHD or stroke event from countries with varying income levels , the prevalence  of healthy lifestyle behaviors  was low , with even lower levels in poorer countries Background Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa . Implementation of evidence -based systems-level strategies targeted at these barriers are lacking . We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage ( HIC ) alone versus a nurse-led task shifting strategy for hypertension control ( TASSH ) plus HIC on systolic blood pressure ( SBP ) reduction among patients with uncontrolled hypertension in Ghana . Methods and findings Using a pragmatic cluster r and omized trial , 32 community health centers within Ghana ’s public healthcare system were r and omly assigned to either HIC alone or TASSH + HIC .  A total of 757 patients with uncontrolled hypertension were recruited between November 28 , 2012 , and June 11 , 2014 , and followed up to October 7 , 2016 . Both intervention groups received health insurance coverage plus scheduled nurse visits , while TASSH + HIC comprised cardiovascular risk assessment , lifestyle counseling , and initiation/titration of antihypertensive medications for 12 months , delivered by trained nurses within the healthcare system . The primary outcome was change in SBP from baseline to 12 months . Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months . Of the 757 patients ( 389 in the HIC group and 368 in the TASSH + HIC group ) , 85 % had 12-month data available ( 60 % women , mean BP 155.9/89.6 mm Hg ) . In intention-to-treat analyses adjusted for clustering , the TASSH + HIC group had a greater SBP reduction ( −20.4 mm Hg ; 95 % CI −25.2 to −15.6 ) than the HIC group ( −16.8 mm Hg ; 95 % CI −19.2 to −15.6 ) , with a statistically significant between-group difference of −3.6 mm Hg ( 95 % CI −6.1 to −0.5 ; p = 0.021 ) . Blood pressure control improved significantly in both groups ( 55.2 % , 95 % CI 50.0 % to 60.3 % , for the TASSH + HIC group versus 49.9 % , 95 % CI 44.9 % to 54.9 % , for the HIC group ) , with a non-significant between-group difference of 5.2 % ( 95 % CI −1.8 % to 12.4 % ; p = 0.29 ) . Lifestyle behaviors did not change appreciably in either group . Twenty-one adverse events were reported ( 9 and 12 in the TASSH + HIC and HIC groups , respectively ) . The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits , if any , of the TASSH + HIC group . Conclusions Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone , among patients with uncontrolled hypertension in Ghana . Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost – benefit analysis . Trial registration Clinical Trials.gov BACKGROUND Information technology has potential to improve health care delivery particularly among individuals with chronic diseases such as diabetes in low and middle-income countries ( LMIC ) . Research on the usefulness of information technology to manage persons living with chronic diseases is scarce in LMIC . We sought to evaluate the effect of an electronic reminder system on cardiovascular risk factors ( blood pressure , heart rate , and fasting plasma glucose ) and adherence to clinical appointments among persons living with diabetes . RESEARCH DESIGN AND METHODS A r and omized controlled design was used to recruit 200 diabetic patients ( intervention n=100 , control n=100 ) from the National Diabetes Management Research Centre , Accra . All patients received usual diabetes care . The intervention group was given electronic reminders for their clinical appointments and their physicians were prompted with abnormal laboratory results for six months . RESULTS Baseline characteristics were largely similar for both groups . At six months follow up , the mean reductions of all the cardiovascular risk factors in the intervention group were significantly greater than in the control group : -1.7 kg/m(2 ) versus -1.1 kg/m(2)(p=0.002 ) for BMI ; -4.7 mmHg versus -2.8 mmHg ( p=0.002 ) for SBP ; -5.3 mmH versus -3.1 mmHg ( p=0.001 ) for DBP ; -1.7 bpm versus -0.1 bpm ( p=0.001 ) for heart rate and -2.3 mmol/L versus -1.6 mmol/L ( p=0.001 ) for fasting plasma glucose , respectively . Adherence to appointment schedules was also significantly higher in the intervention group compared with the control group ( 97.8 % versus 89.4 % , p=0.010 ) . CONCLUSIONS Locally developed electronic initiatives such as this result ed in improved cardiovascular risk factors and effective compliance to clinical practice s and improved quality of care for persons living with diabetes Background Therapeutic hypothermia reduces death and disability after moderate or severe neonatal encephalopathy in high-income countries and is used as st and ard therapy in these setting s. However , the safety and efficacy of cooling therapy in low- and middle-income countries ( LMICs ) , where 99 % of the disease burden occurs , remains unclear . We will examine whether whole body cooling reduces death or neurodisability at 18–22 months after neonatal encephalopathy , in LMICs . Methods We will r and omly allocate 408 term or near-term babies ( aged ≤ 6 h ) with moderate or severe neonatal encephalopathy admitted to public sector neonatal units in LMIC countries ( India , Bangladesh or Sri Lanka ) , to either usual care alone or whole-body cooling with usual care . Babies allocated to the cooling arm will have core body temperature maintained at 33.5 ° C using a servo-controlled cooling device for 72 h , followed by re-warming at 0.5 ° C per hour . All babies will have detailed infection screening at the time of recruitment and 3 Telsa cerebral magnetic resonance imaging and spectroscopy at 1–2 weeks after birth . Our primary endpoint is death or moderate or severe disability at the age of 18 months . Discussion Upon completion , HELIX will be the largest cooling trial in neonatal encephalopathy and will provide a definitive answer regarding the safety and efficacy of cooling therapy for neonatal encephalopathy in LMICs . The trial will also provide important data about the influence of co-existent perinatal infection on the efficacy of hypothermic neuroprotection . Trial registration Clinical Trials.gov , NCT02387385 . Registered on 27 February 2015 Background The burdens of hypertension and diabetes are increasing in low- and middle-income countries ( LMICs ) . It is important to identify patients with these conditions early in the disease process . The goal of this study , therefore , is to compare community- versus home-based screening for hypertension and diabetes in Kenya . Methods This was a feasibility study conducted by the Academic Model Providing Access to Healthcare ( AMPATH ) program in Webuye , a town in western Kenya .  Home-based ( door-to-door ) screening occurred in March 2010 and community-based screening in November 2011 . HIV counselors were trained to screen for diabetes and hypertension in the home-based screening with local district hospital based staff conducting the community-based screening . Participants > 18 years old qualified for screening in both groups . Counselors referred all participants with a systolic blood pressure (  SBP  )  ≥160 mmHg and /or a r and om blood glucose ≥7 mmol/L ( 126 mg/dL ) to a local clinic for follow-up . Differences in likelihood of screening positive between the two strategies were compared using Fischer ’s Exact Test . Logistic regression models were used to identify factors associated with the likelihood of following-up after a positive screening . Results There were 236 participants in home-based screening : 13 ( 6 % ) had a SBP ≥160 mmHg , and 54 ( 23 % ) had a r and om glucose ≥ 7 mmol/L. There were 346 participants in community-based screening : 35 ( 10 % ) had a SBP ≥160 mmHg , and 27 ( 8 % ) had a r and om glucose ≥ 7 mmol/L. Participants in community-based screening were twice as likely to screen positive for hypertension compared to home-based screening ( OR=1.93 , P=0.06 ) . In contrast , participants were 3.5 times more likely to screen positive for a r and om blood glucose ≥7 mmol/L with home-based screening ( OR=3.51 , P<0.01 ) . Rates for following-up at the clinic after a positive screen were low for both groups with 31 % of patients with an elevated SBP returning for confirmation in both the community-based and home-based group ( P=1.0 ) . Follow-up after a r and om glucose was also low with 23 % returning in the home-based group and 22 % in the community-based group ( P=1.0 ) . Conclusion Community- or home-based screening for diabetes and hypertension in LMICs is feasible . Due to low rates of follow-up , screening efforts in rural setting s should focus on linking cases to care Abstract Objective Traditionally , health systems in sub‐Saharan Africa have focused on acute conditions . Few data exist on the readiness of African health facilities ( HFs ) to address the growing burden of chronic diseases ( CDs ) , specifically chronic , non‐communicable diseases ( NCDs ) . Methods A stratified r and om sample of 28 urban and rural Ug and an HFs was surveyed to document the burden of selected CDs by analysing the service statistics , service availability and service readiness using a modified WHO Service Availability and Readiness Assessment question naire . Knowledge , skills and practice in the management of CDs of 222 health workers were assessed through a self‐completed question naire . Results Among adult outpatient visits at hospitals , 33 % were for CDs including HIV vs. 14 % and 4 % at medium‐sized and small health centres , respectively . Many HFs lacked guidelines , diagnostic equipment and essential medicines for the primary management of CDs ; training and reporting systems were weak . Lower‐level facilities routinely referred patients with hypertension and diabetes . HIV services accounted for most CD visits and were stronger than NCD services . Systems were weaker in lower‐level HFs . Non‐doctor clinicians and nurses lacked knowledge and experience in NCD care . Conclusion Compared with higher level HFs , lower‐level ones are less prepared and little used for CD care . Health systems in Ug and a , particularly lower‐level HFs , urgently need improvement in managing common NCDs to cope with the growing burden . This should include the provision of st and ard guidelines , essential diagnostic equipment and drugs , training of health workers , supportive supervision and improved referral systems . Substantially better HIV basic service readiness demonstrates that improved NCD care is feasible Asthma is a common cause of emergency care attendance in low- and middle-income countries ( LMICs ) . While few prospect i ve studies of predictors for emergency care attendance have been undertaken in high-income countries , none have been performed in a LMIC . We followed a cohort of 5–15-year-old children treated for asthma attacks in emergency rooms of public health facilities in Esmeraldas City , Ecuador . We collected blood and nasal wash sample s , and performed spirometry and exhaled nitric oxide fraction measurements . We explored potential predictors for recurrence of severe asthma attacks requiring emergency care over 6 months ’ follow-up . We recruited 283 children of whom 264 ( 93 % ) were followed-up for ≥6 months or until their next asthma attack . Almost half ( 46 % ) had a subsequent severe asthma attack requiring emergency care . Predictors of recurrence in adjusted analyses were ( adjusted OR , 95 % CI ) younger age ( 0.87 , 0.79–0.96 per year ) , previous asthma diagnosis ( 2.2 , 1.2–3.9 ) , number of parenteral corticosteroid courses in previous year ( 1.3 , 1.1–1.5 ) , food triggers ( 2.0 , 1.1–3.6 ) and eczema diagnosis ( 4.2 , 1.02–17.6 ) . A parsimonious Cox regression model included the first three predictors plus urban residence as a protective factor ( adjusted hazard ratio 0.69 , 95 % CI 0.50–0.95 ) . Laboratory and lung function tests did not predict recurrence . Factors independently associated with recurrent emergency attendance for asthma attacks were identified in a low-re source LMIC setting . This study suggests that a simple risk- assessment tool could potentially be created for emergency rooms in similar setting s to identify higher-risk children on whom limited re sources might be better focused . Among children in a low-re source setting in Latin America , younger age , an established asthma diagnosis and history of severe asthma attacks in the previous year were associated with recurrence of severe asthma attacks , irrespective of biomarkers
The majority of studies showed improved health outcomes when compared with usual healthcare , including reductions in blood pressure , increased uptake of medications and lower depression scores .
Factors such as training of NPHWs , provision of algorithms and protocol s for screening , treatment and drug titration were the main enablers of the task-shifting intervention .
The main barriers identified were restrictions on prescribing medications and availability of medicines .
CONCLUSIONS Task-shifting from physicians to NPHWs , if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs .
BACKGROUND One potential solution to limited healthcare access in low and middle income countries ( LMIC ) is task-shifting- the training of  non-physician healthcare workers ( NPHWs ) to perform tasks traditionally undertaken by physicians .
The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease ( NCD ) in LMIC .