A systematic review of online interventions for mental health in low and middle income countries: a neglected field Sudden cardiac death in low- and middle-income countries. Improving mental health among people living with HIV: a review of intervention trials 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. 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 Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study Interventions for domestic violence among pregnant women in low- and middle-income countries: a systematic review protocol A complex breastfeeding promotion and support intervention in a developing country: study protocol for a randomized clinical trial A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala Hypothermia for encephalopathy in low and middle-income countries (HELIX): study protocol for a randomised controlled trial A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries. What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts The Cervix Cancer Research Network: A Global Outreach Effort on Behalf of the Gynecologic Cancer InterGroup. A cluster randomized clinical trial of a stepped care intervention for depression in primary care (STEPCARE)- study protocol Panic disorder in public sector primary care: clinical characteristics and illness severity compared with "mainstream" primary care panic disorder. Stress, social support and problem drinking among women in poverty. Paying the price: the cost and consequences of emergency obstetric care in Burkina Faso. Therapeutic use of humor to improve social support in an institutionalized schizophrenic inpatient community. Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the global network's EmONC trial) Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries. Reducing child conduct problems and promoting social skills in a middle-income country: cluster randomised controlled trial† Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country.
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 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 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 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 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 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 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 Background Breastfeeding has countless benefits to mothers , children and community at large , especially in developing countries . Studies from Lebanon report disappointingly low breastfeeding exclusivity and continuation rates . Evidence reveals that antenatal breastfeeding education , professional lactation support , and peer lay support are individually effective at increasing breastfeeding duration and exclusivity , particularly in low-income setting s. Given the complex nature of the breastfeeding ecosystem and its barriers in Lebanon , we hypothesize that a complex breastfeeding support intervention , which is centered on the three components mentioned above , would significantly increase breastfeeding rates . Methods / Design A multi-center r and omized controlled trial . Study population : 443 healthy pregnant women in their first trimester will be r and omized to control or intervention group . Intervention : A “ prenatal/postnatal ” professional and peer breastfeeding support package continuing till 6 months postpartum , guided by the Social Network and Social Support Theory . Control group will receive st and ard prenatal and postnatal care . Mothers will be followed up from early pregnancy till five years after delivery . Outcome measures : Total and exclusive breastfeeding rates , quality of life at 1 , 3 and 6 months postpartum , maternal breastfeeding knowledge and attitudes at 6 months postpartum , maternal exclusive breastfeeding rates of future infants up to five years from baseline , cost-benefit and cost-effectiveness analyses of the intervention . Statistical analysis : Descriptive and regression analysis will be conducted under the intention to treat basis using the most recent version of SPSS . Discussion Exclusive breastfeeding is a cost-effective public health measure that has a significant impact on infant morbidity and mortality . In a country with limited healthcare re sources like Lebanon , developing an effective breastfeeding promotion and support intervention that is easily replicated across various setting s becomes a priority . If positive , the results of this study would provide a generalizable model to bolster breastfeeding promotion efforts and contribute to improved child health in Lebanon and the Middle East and North Africa ( MENA ) region . Trial registration Current Controlled Trials IS RCT 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 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 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 A novel approach is explored for improving causal inference in observational studies by comparing cohorts from high-income with low- or middle-income countries ( LMIC ) , where confounding structures differ . This is applied to assessing causal effects of  breastfeeding  on child blood pressure ( BP ) , body mass index ( BMI ) and intelligence quotient ( IQ ) . Methods St and ardized approaches for assessing the confounding structure of breastfeeding by socio-economic position were applied to the British Avon Longitudinal Study of Parents and Children ( ALSPAC ) ( N ≃ 5000 ) and Brazilian Pelotas 1993 cohorts ( N ≃ 1000 ) . This was used to improve causal inference regarding associations of breastfeeding with child BP , BMI and IQ . Analyses were extended to include results from a meta- analysis of five LMICs ( N ≃ 10 000 ) and compared with a r and omized trial of breastfeeding promotion . Findings Although higher socio-economic position was strongly associated with breastfeeding in ALSPAC , there was little such patterning in Pelotas . In ALSPAC , breastfeeding was associated with lower BP , lower BMI and higher IQ , adjusted for confounders , but in the directions expected if due to socioeconomic patterning . In contrast , in Pelotas , breastfeeding was not strongly associated with BP or BMI but was associated with higher IQ . Differences in associations observed between ALSPAC and the LMIC meta- analysis were in line with those observed between ALSPAC and Pelotas , but with robust evidence of heterogeneity detected between ALSPAC and the LMIC meta- analysis associations . Trial data supported the conclusions inferred by the cross-cohort comparisons , which provided evidence for causal effects on IQ but not for BP or BMI . Conclusion While reported associations of breastfeeding with child BP and BMI are likely to reflect residual confounding , breastfeeding may have causal effects on IQ . Comparing associations between population s with differing confounding structures can be used to improve causal inference in observational studies 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 Depression constitutes a significant public health burden and is associated is with high level of individual suffering . Insufficient human and material re sources impede the provision of adequate care for persons with the condition in low- and middle-income countries . It is commonly recognized that , to bridge this treatment gap , it is essential to integrate the treatment of depression into primary health care system . Methods / Design STEPCARE is a two-arm parallel cluster r and omized controlled trial to compare a stepped-care intervention package for depression in primary health care with care as usual in Nigeria . R and omization was conducted at the level of the participating primary health care clinics , while interventions are delivered to consenting individual participants who screen positive on the 9-item patient health question naire ( PHQ-9 score ≥ 11 ) and fulfil the DSM-IV criteria for major depression . Intervention delivered by trained primary health care workers ( PHCW ) supported by general physicians and psychiatrists as needed is in 3 steps determined by response to treatment . Each step consists of psychological interventions ( including psychoeducation , activity scheduling , social network reactivation and problem solving treatment ) offered to all participants and , depending on severity and response , medication . Primary outcome , assessed at 12 months following recruitment into the trial , is recovery from depression as shown by a PHQ-9 score of less than 6 . Secondary outcomes include changes in disability , quality of life and service utilization assessed at 6 and 12 months . Discussion The stepped care model examines the effectiveness of an intervention package for depression in which the intensity of treatment is determined by the clinical need of the patients . This approach is design ed to make the most efficient use of available re sources .Trial registration IS RCT N46754188 ( ISRTCN registry at isrtcn.com ; registered 23 September 2013 The prevalence of anxiety disorders is increased among low-income individuals , who are more likely to seek mental health care in medical as opposed to specialty setting s because of limited insurance access and restricted availability of public sector mental health re sources . However , little is known about the clinical characteristics and illness severity of anxiety disorders in this setting . We studied the clinical characteristics of  low-income compared with middle-income primary care panic patients .  Clinical , functional , and service use measures obtained at baseline interview in 39 panic disorder patients seen in one public sector medical clinic were compared with 76 patients seen in two middle-income clinics . All patients were participants in a r and omized effectiveness pharmacotherapy trial [ Roy Byrne et al. , Arch Gen Psychiatry 2001;58:869 - 876 ] . Public sector patients were more often older , male , single , unemployed , of lower income , and non-Caucasian ethnicity . They had more severe clinical symptoms , more medical comorbidity , worse physical and role health status , and more emergency room visits . Low income and unemployment accounted for most of the differences in non-anxiety-related measures . However , type of clinic still contributed independently to the greater severity of specific measures of panic/anxiety ( Panic Disorder Severity Scale and Marks Fear Scale scores ) , suggesting that the increased stress and limited social re sources associated with low-income and disadvantaged status may have more specific effects on anxiety than other aspects of psychopathology AIMS Previous studies have found that stress contributes to problem drinking , while social support can buffer its effects . However , these studies are confined largely to middle-class and general population s. We extend what is known by examining how the unique stressors and forms of social support experienced by women in poverty impact  alcohol problems over a 4-year time-period . DESIGN , SETTING AND PARTICIPANTS This prospect i ve study used generalized estimating equations ( GEE ) transition modeling and four annual waves of survey data from 392 American mothers receiving Temporary Assistance for Needy Families ( TANF ) in a large Northern California county . MEASUREMENTS We examined the effects of neighborhood disorder , stressful life events and economic hardship on psychological distress and problem drinking over time , and whether social support moderated these relationships for women in poverty . FINDINGS Neighborhood disorder and stressful life events increased significantly the risk for problem drinking , largely through their effect on psychological distress . We found little evidence , however , that social support buffers poor women from the effects of these stressors . CONCLUSIONS Women in poverty are exposed to severe , chronic stressors within their communities and immediate social networks which increase vulnerability to psychological distress and problem drinking . The finding that social support does not buffer stress among these women may reflect their high level of exposure to stressors , as well as the hardships and scarce re sources within their networks . If the ' private safety net ' of the social network fails to provide a strong buffer , more effective environmental interventions that reduce exposure to stressors may be needed to prevent alcohol problems in poor women 's lives Substantial healthcare expenses can impoverish households or push them further into poverty . In this paper , we examine the cost of obstetric care  and the social and economic consequences associated with exposure to economic shocks up to a year following the end of pregnancy in Burkina Faso . Burkina Faso is a low-income country with poor health outcomes and a poorly functioning health system . We present an inter-disciplinary analysis of an ethnographic study of 82 women nested in a prospect i ve cohort study of 1013 women . We compare the experiences of women who survived life-threatening obstetric complications ( ' near-miss ' events ) with women who delivered without complications in hospitals . The cost of emergency obstetric care  was significantly higher than the cost of care for uncomplicated delivery . Compared with women who had uncomplicated deliveries , women who survived near-miss events experienced substantial difficulties meeting the costs of care , reflecting the high cost of emergency obstetric care and the low socioeconomic status of their households . They reported more frequent sale of assets , borrowing and slower repayment of debt in the year following the expenditure . Healthcare costs consumed a large part of households ' re sources and women who survived near-miss events continued to spend significantly more on healthcare in the year following the event , while at the same time experiencing continued cost barriers to accessing healthcare . In-depth interviews confirm that the economic burden of emergency obstetric care  contributed to severe and long-lasting consequences for women and their households . The necessity of meeting unexpectedly high costs challenged social expectations and patterns of reciprocity between husb and s , wives and wider social networks , placed enormous strain on everyday survival and shaped physical , social and economic well-being in the year that followed the event . In conclusion , we consider the implication s of our findings for financing mechanisms for maternity care in low-income setting We attempted to use passive communal laughter to improve social support within a chronic schizophrenic inpatient population . Two identical wards were compared on classical measures of social support ( emotional and functional ) , social network ( size and dispersion ) , satisfaction , and the nature of the social relationships ( source ) . The experimental group was exposed to video projection of humorous movies four times daily for 3 months , and the control group to video projections of other , assorted movies at the same rate . In the experimental ward a significant improvement was manifest in the category of " distinct individuals supporting each patient . " The difference may have been due to an improvement in the relationship with the staff . No improvement was found on any of the other measures . We concluded that the positive atmosphere that humor creates affects the therapeutic alliance between staff and patients but does not affect other social networks because of the regressed nature of the schizophrenics ' social relationships Background Maternal and newborn mortality rates remain unacceptably high , especially where the majority of births occur in home setting s or in facilities with inadequate re sources . The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes . However , the effectiveness of emergency obstetric and neonatal care services has never been proven . Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes . Methods / Design We have developed a cluster-r and omized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization , birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities . This trial will take place in 106 clusters ( 300 - 500 deliveries per year each ) across 7 sites of the Global Network for Women 's and Children 's Health Research in Argentina , Guatemala , India , Kenya , Pakistan and Zambia . The trial intervention has three key elements , community mobilization , home-based life saving skills for communities and birth attendants , and training of providers at obstetric facilities to improve quality of care . The primary outcome of the trial is perinatal mortality . Secondary outcomes include rates of stillbirth , 7-day neonatal mortality , maternal death or severe morbidity ( including obstetric fistula , eclampsia and obstetrical sepsis ) and 28-day neonatal mortality . Discussion In this trial , we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes . If successful , the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries . Trial Registration Clinical Trials.gov OBJECTIVES To analyze data from recent Demographic and Health Surveys ( DHS ) conducted in 21 low- and middle-income countries ( LMICs ) to examine patterns of interpregnancy intervals , unmet need , pregnancy risk and family planning method use and method mix among women 0 - 23 months postpartum . STUDY DESIGN Secondary analysis of postpartum women aged 15 - 49 years in 22 DHS surveys from 21 LMICs conducted between 2005 and 2012 . We applied an adapted unmet need definition for postpartum women to look at prospect i ve fertility preferences . We also constructed a new composite pregnancy risk indicator for postpartum women who have been sexually active since their last birth . RESULTS In 9 of 22 surveys , 50 % or more of nonfirst births occur at interpregnancy intervals that are too short . Overall prospect i ve unmet need for family planning by postpartum women has not changed demonstrably since a 2001 analysis and is universally high : 61 % of all postpartum women across the 21 countries have an unmet need for family planning . In 10 of 22 surveys , pregnancy risk rises steadily throughout the 2 years after birth . In the remaining 12 surveys , the risk of pregnancy peaks at 6 - 11 months after birth . Even when postpartum women are using family planning , they rely overwhelmingly on short-acting methods ( 51 - 96 % in 21 of 22 surveys ) . CONCLUSION Our approach of estimating pregnancy risk by postpartum timing confirms a high probability for pregnancies to be less than optimally spaced within 2 years of a prior birth and suggests that special consideration is needed to effectively reach this population with the right messages and services . IMPLICATION S Using recent , multicountry data for women within 2 years postpartum in LMICs , this paper up date s existing estimates of high prospect i ve unmet need for family planning and presents a new composite pregnancy risk analysis based on postpartum women 's actual practice s to demonstrate the magnitude of missed opportunities for programmatic intervention for the postpartum population Background There is an urgent need for effective , affordable interventions to prevent child mental health problems in low- and middle-income countries . Aims To determine the effects of a universal pre-school-based intervention on child conduct problems and social skills at school and at home . Method In a cluster r and omised design , 24 community pre-schools in inner-city areas of Kingston , Jamaica , were r and omly assigned to receive the Incredible Years Teacher Training intervention ( n = 12 ) or to a control group ( n = 12 ) . Three children from each class with the highest levels of teacher-reported conduct problems were selected for evaluation , giving 225 children aged 3–6 years . The primary outcome was observed child behaviour at school . Secondary outcomes were child behaviour by parent and teacher report , child attendance and parents ’ attitude to school . The study is registered as IS RCT N35476268 . Results Children in intervention schools showed significantly reduced conduct problems ( effect size ( ES ) = 0.42 ) and increased friendship skills ( ES = 0.74 ) through observation , significant reductions to teacher-reported ( ES = 0.47 ) and parent-reported ( ES = 0.22 ) behaviour difficulties and increases in teacher-reported social skills ( ES = 0.59 ) and child attendance ( ES = 0.30 ) . Benefits to parents ’ attitude to school were not significant . Conclusions A low-cost , school-based intervention in a middle-income country substantially reduces child conduct problems and increases child social skills at home and at school 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 BACKGROUND Patients ' engagement in mobile health ( m-health ) interventions using interactive voice response ( IVR ) calls is less in low- and middle-income countries ( LMICs ) than in industrialized ones . We conducted a study to determine whether automated telephone feedback to informal caregivers ( " CarePartners " ) increased engagement in m-health support among diabetes and hypertension patients in Bolivia . MATERIAL S AND METHODS Patients with diabetes and /or hypertension were identified through ambulatory clinics affiliated with four hospitals . All patients enrolled with a CarePartner . Patients were r and omized to weekly IVR calls including self-management questions and self-care education either alone ( " st and ard m-health " ) or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ( " m-health+CP " ) . RESULTS The 72 participants included 39 with diabetes and 53 with hypertension , of whom 19 had ≤6 years of education . After 1,225 patient-weeks of attempted IVR assessment s , the call completion rate was higher among patients r and omized to m-health+CP compared with st and ard m-health ( 62.0 % versus 44.9 % ; p < 0.047 ) . CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy ( p < 0.001 for both ) . M-health+CP patients were more likely to report excellent health via IVR ( adjusted odds ratio [ AOR ] = 2.60 ; 95 % confidence interval [ CI ] , 1.07 , 6.32 ) and less likely to report days in bed due to illness ( AOR = 0.42 ; 95 % CI , 0.19 , 0.91 ) . CONCLUSIONS In this study we found that caregiver feedback increased engagement in m-health and may improve patients ' health status relative to st and ard approaches . M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs
Second , we show that network composition , individual network central ity , and network structure are associated with important health behaviors and health and development outcomes in different context s across multiple levels of analysis and across distinct network types .
Lastly , we highlight the opportunities for health research ers and practitioners in LMICs to 1 ) design effective studies and interventions in LMICs that account for the sociocentric network positions of certain individuals and overall network structure , 2 ) measure the spread of outcomes or intervention externalities , and 3 ) enhance the effectiveness and efficiency of aid based on knowledge of social structure .
In low- and middle-income countries ( LMICs ) , naturally occurring social networks may be particularly vital to health outcomes as extended webs of social ties often are the principal source of various re sources .