An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania Evaluation of community-based oral health promotion and oral disease prevention--WHO recommendations for improved evidence in public health practice. How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? Integrated health programme: a workplace randomized controlled trial. Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions Randomised trial of impact of model of integrated care and case management for older people living in the community Innovative tools for quality assessment: integrated quality criteria for review of multiple study designs (ICROMS). An integrated programme after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: effect on emotional and functional dimensions of quality of life Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings The TRANSFoRm project: Experience and lessons learned regarding functional and interoperability requirements to support primary care An intervention to stop smoking among patients suspected of TB - evaluation of an integrated approach Next steps for falls and fracture reduction. The Active plus protocol: systematic development of two theory- and evidence-based tailored physical activity interventions for the over-fifties Integrating eHealth with human services for breast cancer patients Understanding the implementation of complex interventions in health care: the normalization process model Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country. Lay health supporters aided by a mobile phone messaging system to improve care of villagers with schizophrenia in Liuyang, China: protocol for a randomised control trial Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine Operational performance of an STD control programme in Mwanza Region, Tanzania A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course
ABSTRACT Despite four decades of global experience with community-based primary health care , the strategic details of community health worker ( CHW ) recruitment , training , compensation , and deployment remain the subject of continuing discussion and debate . Responsibilities and levels of clinical expertise also vary greatly , as well as contrasting roles of public- versus private-sector organisations as organisers of CHW effort . This paper describes a programme of implementation research in Tanzania , known as the Connect Project , which aims to guide national policies with evidence on the impact and process of deploying of paid , professional CHWs . Connect is a r and omised-controlled trial of community exposure to CHW integrated primary health-care services . A qualitative appraisal of reactions to CHW implementation of community stakeholders , frontline workers , supervisors , and local managers is review ed . Results highlight the imperative to plan and implement CHW programmes as a component of a broader , integrated effort to strengthen the health system . Specifically , the introduction of a CHW programme in Tanzania should draw upon community structures and institutions and strengthen mechanisms to sustain their participation in primary health care . This should be coordinated with efforts to address poorly functioning logistics and supervisory systems and human re source and management challenges Systematic evaluation is an integral part of the organisation and delivery of community oral health care programmes , ensuring the effectiveness of these community-based interventions . As for general health promotion programmes the common problems from effectiveness review s of oral health interventions relate to the quality and validity of programme evaluations . Problems identified mostly refer to the quality of outcome measures , short-term timescales to assess change , inadequate evaluation method ologies and inappropriate evaluation of programme implementation and processes . It remains a challenge to oral health professionals to integrate community oral health programmes into a wider health agenda . Public health research focusing on the development of evaluation method ologies has identified a variety of issues including the importance of using pluralistic evaluation approaches ( quantitative and /or qualitative ) , limitations of the r and omised controlled trial ( RCT ) design for evaluation of public health interventions , the need to match evaluation methods with the nature of intervention , development of outcome measures appropriate for the nature of intervention , importance of developing workforce capacity in evaluation techniques , and the need for development of partnerships between health practitioners and academics in conducting evaluations . In June 2003 , the WHO Oral Health Programme at Headquarters organised a two-day workshop to take forward the development and documentation of the evaluation of oral health promotion and oral disease prevention programmes . The aims of the workshop were to : ( 1 ) identify common problems and challenges in evaluating community-based  oral health interventions ; ( 2 ) explore developments in the evaluation approaches in public health ; ( 3 ) share experiences in evaluating oral health intervention programmes implemented at national or community levels in developing and developed countries and ( 4 ) develop guidelines for quality evaluation of national and community oral health programmes . Twenty-two invitees from 15 countries attended in addition to WHO staff . The first day was devoted to presentations of oral health promotion and oral disease prevention programmes from around the world . During the second day , WHO staff at Headquarters in Geneva discussed aspects of evaluation of public health programmes . Two working groups were formed to discuss agreed topics , and the reports from their deliberations , together with the general discussion , result ed in the presentation of emerging key issues and recommendations . In summary , it was agreed that evaluation of oral health promotion and disease prevention programmes should integrate , whenever possible , with general health programmes . While the design and advantages of RCTs in clinical evaluations are well documented , the relevance of this design in evaluation of community oral disease preventive programmes and oral health promotion programmes are much less clearly defined . Subsequently , the conduct of such programmes may be inappropriately evaluated in systematic review s. There is a need for more research into appropriate immediate , interim and ultimate outcome measures , as well as process evaluation , an assessment that is poorly understood and practised less often than outcome evaluation . Guidance on potential design , conduct , and especially the evaluation , of community oral disease prevention programmes and oral health promotion programmes should be developed and up date d regularly . WHO Collaborating Centres could have a role in promoting good practice , training and collaboration between teams throughout the world . Centres undertaking systematic review s should consider the guidelines given in the proposed WHO document when defining their evaluation criteria Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.20 None of the studies assessed the balance of costs and benefits of ICP use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . Conclusions Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay . ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter‐professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP‐managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . OBJECTIVES • To systematic ally review all high- quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers , users and evaluators . INCLUSION CRITERIA Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services - acute care , rehabilitation and long-term support - in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes ' Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi-experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English- language abstract , where available . These were included only if an English translation was available . EXCLUSION CRITERIA This review excluded studies that : • focused only on a single aspect of stroke care ( e.g. dysphasia ) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purpose s of the review • focused exclusively on the outcomes of variance analysis SEARCH STRATEGY In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three-stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . DATA COLLECTION Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single- appraisal checklist and data - extraction tool which could be applied to all research design s.(32 ) The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.(31 ) in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . DATA SYNTHESIS Given the heterogeneity of the included studies , meta- analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . RESULTS 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . 2 ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow-up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life . 6 ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20 ) 8 None of the studies assessed the balance of costs and benefits of ICP  use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . CONCLUSIONS Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .  ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter-professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . ( ABSTRACT TRUNCATED AIM This paper is the report of a pilot study to assess if an Integrated Health Programme would reduce sick leave and subjective health complaints , and increase coping in a population of nursing personnel . BACKGROUND . The work group in Norway with most sick leave is healthcare workers . More than 50 % of the sick leave is because of subjective health complaints . Work place physical exercise interventions have a documented positive effect on sick leave . METHOD After baseline screening , employees who had agreed to participate ( n=40 ) were r and omized to an intervention or control group . The intervention group participated in an Integrated Health Programme twice weekly during working hours . The programme consisted of physical exercise , stress management training , health information and an examination of the participants ' workplace . The control group was offered the same intervention after the project was finished . This study was carried out from 2001 to 2002 . FINDINGS There were no statistically significant effects on sick leave or health-related quality of life . The intervention group reported fewer neck complaints compared to the control group , but otherwise there were no effects on subjective health complaints . However , the subjective effects were large and highly statistically significant , the intervention group reporting improvement in health , physical fitness , muscle pain , stress management , maintenance of health and work situation . CONCLUSION The Integrated Health Programme was not effective in reducing sick leave and subjective health complaints , but may be of use to employers wanting to increase employee job satisfaction and well-being At the end of a long week in the office , you sink back into your chair , reflecting on some of the more memorable patients you cared for and counseled . Through gentle history taking , you discovered that urinary incontinence is the underlying cause of an elderly patient 's increasing social isolation . During a careful physical examination , you detected bruising on the torso of a woman with chronic headaches and began to explore the longst and ing abusive relationship between the woman and her alcoholic partner . You discontinued procainamide therapy in a 72-year-old man who had asymptomatic premature ventricular contractions after myocardial infa rct ion . To prevent bleeding from esophageal varices , you started -blocker therapy in a woman with long-st and ing cryptogenic cirrhosis and portal hypertension . In couples ' therapy , discussing the future quality of life of a middle-aged gay man with human immunodeficiency virus infection , you journeyed through emotionally intense dialogue about advance directives . You presented the risk factors for major and minor bleeding to a 39-year-old woman who was considering warfarin therapy because of recently diagnosed atrial fibrillation and valvular heart disease . You listened to , made diagnoses for , treated , advised , and comforted many patients . Yet there were some hiccoughs in your practice along the way . You stumbled while debating the pros and cons of breast cancer screening with a healthy 48-year-old woman who has been staying current with information on the Internet . You question ed the merits of a personalized walking program suggested to you by a motivated 66-year-old man with severe claudication . Explaining that you wanted to review the best current evidence on these issues , you resolved to address your uncertainties before these patients made their next office visits , in a week 's time . Sighing deeply , you acknowledge that you have little time to read . You subscribe to three journals , which you browse months after they arrive-either when your journal stack becomes precariously high or when your guilt is sufficiently motivational . You sometimes find the conclusions of individual articles conflicting or confusing . You know that some of the decisions and suggestions you made this week , specifically your decisions about stopping procainamide therapy and starting -blocker therapy and your advice about bleeding risks from anticoagulant therapy , were based on the best current research evidence [ 1 - 3 ] . On the other h and , your patients ' inquiries about breast cancer screening and exercise treatment for claudication highlight your need for a concise , current , rigorous synthesis of the best available evidence on each of these topics : in brief , a systematic review [ 4 , 5 ] . Incorporating Research Evidence into Clinical Decision Making The foregoing scenario is familiar to practitioners . In a typical week , we encounter patients with diverse problems ; exercise numerous clinical , interpersonal , and technical skills ; and make many decisions . The factors that affect these decisions and their outcomes are complex . For instance , each patient has unique sociodemographic characteristics , cultural circumstances , and personal preferences . Each physician has unique knowledge , experiences , and values . Moreover , practitioners and their patients make decisions within the context of a rapidly changing health care system that influences the availability , accessibility , and cost of diagnostic tests and therapies [ 6 ] . Timely , useful evidence from the biomedical literature should be an integral component of clinical decision making . If one treatment has been shown to be better than another , we need to know , so that we can recommend the treatment to the appropriate patients . The worldwide effort to develop new tests and treatments , and to determine their usefulness , has never been stronger , and our patients and their families expect us to be fonts of the knowledge that results from this effort [ 7 ] . Unfortunately , it is easy for current best research evidence to pass us by [ 8 ] . We may lack the time , motivation , and basic skills needed to find , critically appraise , and synthesize information , all of which we must do if we are to integrate the results of original studies into our practice . Fortunately , several potent methods are emerging that can greatly enhance our ability to interpret and apply research evidence ; foremost among them is the systematic review . This article begins a series in Annals that will examine systematic review s in detail and explore their many applications . Systematic review s represent the best chance that most practitioners will have to underst and and accurately apply the key signals arising from the robust and increasingly productive search for solutions to medical problems . A properly conducted systematic review faithfully summarizes the evidence from all relevant studies on the topic of interest , and it does so concisely and transparently . What Is a Systematic Review ? Systematic review s are scientific investigations in themselves , with pre-planned methods and an assembly of original studies as their subjects . They synthesize the results of multiple primary investigations by using strategies that limit bias and r and om error [ 9 , 10 ] . These strategies include a comprehensive search of all potentially relevant articles and the use of explicit , reproducible criteria in the selection of articles for review . Primary research design s and study characteristics are appraised , data are synthesized , and results are interpreted . When the results of primary studies are summarized but not statistically combined , the review may be called a qualitative systematic review . A quantitative systematic review , or meta- analysis , is a systematic review that uses statistical methods to combine the results of two or more studies . The term overview is sometimes used to denote a systematic review , whether quantitative or qualitative . Summaries of research that lack explicit descriptions of systematic methods are often called narrative review s. Review articles are one type of integrative publication ; practice guidelines , economic evaluations , and clinical decision analyses are others . These other types of integrative articles often incorporate the results of systematic review s. For example , practice guidelines are systematic ally developed statements intended to assist practitioners and patients with decisions about appropriate health care for specific clinical circumstances [ 11 ] . Evidence -based practice guidelines are based on systematic review s of the literature , appropriately adapted to local circumstances and values . Economic evaluations compare both the costs and the consequences of different courses of action ; the knowledge of consequences that are considered in these evaluations is often generated by systematic review s of primary studies . Decision analyses quantify both the likelihood and the valuation of the expected outcomes associated with competing alternatives . Differences between Systematic and Narrative Review s All review s , narrative and systematic alike , are retrospective , observational research studies and are therefore subject to systematic and r and om error . Accordingly , the quality of a review - and thus its worth-depends on the extent to which scientific review methods have been used to minimize error and bias . This is the key feature that distinguishes traditional narrative review s from systematic review s ( Table 1 ) . If a review is prepared according to the steps outlined in the right column of Table 1 , it is more likely to be systematic and to provide unbiased conclusions . If review methods approximate those found in the middle column of Table 1 , the article is more likely to be a narrative review , and the conclusions are less likely to be based on an unbiased summary of all relevant evidence . Table 1 . Differences between Narrative Review s and Systematic Review s Systematic review s are generated to answer specific , often narrow , clinical questions in depth . These questions can be formulated explicitly according to four variables : a specific population and setting ( such as elderly out patients ) , the condition of interest ( for example , hypertension ) , an exposure to a test or treatment ( such as pharmacologic management ) , and one or more specific outcomes ( such as cardiovascular and cerebrovascular events and mortality ) [ 12 ] . Thus , an example of a well-formulated , clinical ly relevant question is , Does pharmacologic treatment of hypertension in the elderly prevent strokes and myocardial infa rct ions or delay death ? If the question that is driving the review is not clear from the title , abstract , or introduction , or if no methods section is included , the paper is more likely to be a narrative review than a systematic review [ 13 ] . Most narrative review articles deal with a broad range of issues related to a given topic rather than addressing a particular issue in depth [ 9 ] . For example , a narrative review on diabetes ( such as that which might be found in a textbook chapter ) might include sections on the physiology and pathophysiology of carbohydrate , lipid , and protein metabolism ; the epidemiology of and prognosis associated with diabetes ; diagnostic and screening approaches ; and preventive , therapeutic , rehabilitative , and palliative interventions . Thus , narrative review s may be most useful for obtaining a broad perspective on a topic ; they are less often useful in furnishing quantitative answers to specific clinical questions . Narrative review s are appropriate for describing the history or development of a problem and its management . Narrative review s may better describe cutting-edge developments if research is scant or preliminary or if studies are very limited by flawed design or execution [ 13 ] . They may be particularly useful for discussing data in light of underlying theory and context . Narrative review s can draw analogies and can conceptually integrate two independent fields of research , such as Abstract Objective : To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community . Design : R and omised study with 1 year follow up . Setting : Town in northern Italy ( Rovereto ) . Subjects : 200 older people already receiving conventional community care services . Intervention : R and om allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care . Main outcome measures : Admission to an institution , use and costs of health services , variations in functional status . Results : Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls ( hazard ratio 0.69 ; 95 % confidence interval 0.53 to 0.91 ) . Health services were used to the same extent , but control subjects received more frequent home visits by general practitioners . In the intervention group the estimated financial savings were in the order of £ 1125 ( $ 1800 ) per year of follow up . The intervention group had improved physical function ( activities of daily living score improved by 5.1 % v 13.0 % loss in controls ; P<0.001 ) . Decline of cognitive status ( measured by the short portable mental status question naire ) was also reduced ( 3.8 % v 9.4 % ; P<0.05 ) . Conclusion : Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community . Key messages Responsibility for management of care of elderly people living in the community is poorly defined Integration of medical and social services together with care management programmes would improve such care in the community In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced OBJECTIVES With the aim to facilitate a more comprehensive review process in public health including patient safety , we established a tool that we have termed ICROMS ( Integrated quality Criteria for the Review Of Multiple Study design s ) , which unifies , integrates and refines current quality criteria for a large range of study design s including qualitative research . STUDY DESIGN Review , pilot testing and expert consensus . METHODS The tool is the result of an iterative four phase process over two years : 1 ) gathering of established criteria for assessing controlled , non-controlled and qualitative study design s ; 2 ) pilot testing of a first version in two systematic review s on behavioural change in infection prevention and control and in antibiotic prescribing ; 3 ) further refinement and adding of additional study design s in the context of the European Centre for Disease Prevention and Control funded project ' Systematic review and evidence -based guidance on organisation of hospital infection control programmes ' ( SIGHT ) ; 4 ) scrutiny by the pan-European expert panel of the SIGHT project , which had the objective of ensuring robustness of the systematic review . RESULTS ICROMS includes established quality criteria for r and omised studies , controlled before- and -after studies and interrupted time series , and incorporates criteria for non-controlled before- and -after studies , cohort studies and qualitative studies . The tool consists of two parts : 1 ) a list of quality criteria specific for each study design , as well as criteria applicable across all study design s by using a scoring system ; 2 ) a ' decision matrix ' , which specifies the robustness of the study by identifying minimum requirements according to the study type and the relevance of the study to the review question . The decision matrix directly determines inclusion or exclusion of a study in the review . ICROMS was applied to a series of systematic review s to test its feasibility and usefulness in the appraisal of multiple study design s. The tool was applicable across a wide range of study design s and outcome measures . CONCLUSION ICROMS is a comprehensive yet feasible appraisal of a large range of study design s to be included in systematic review s addressing behaviour change studies in patient safety and public health . The tool is sufficiently flexible to be applied to a variety of other domains in health-related research . Beyond its application to systematic review s , we envisage that ICROMS can have a positive effect on research ers to be more rigorous in their study design and more diligent in their reporting Objective : To assess whether a maintenance integrated health care programme is effective in improving functional and emotional dimensions of quality of life in patients with chronic obstructive pulmonary disease ( COPD ) after a first pulmonary rehabilitation . Design : Prospect i ve controlled trial . Setting : Three rehabilitation centres and three patient self-help associations within a health care network in France . Subjects : Forty patients with moderate to severe COPD . Interventions : After a first four-week inpatient pulmonary rehabilitation programme , patients took part in a maintenance integrated health care programme or usual care for 12 months . Main measures : The primary outcomes were the change in functional and emotional dimensions of quality of life measured by the St George ’s Respiratory Question naire ( SGRQ ) , the brief World Health Organization Quality of Life question naire ( Brief-WHOQOL ) and six specific questions using a 10-cm visual analogue scale . Secondary outcomes were change in exercise tolerance measured by six-minute walking test and cycle exercise . Results : At one year , the maintenance intervention ( n = 11 ) produced improvements in functional and emotional dimensions scores of quality of life and exercise tolerance . Patients in the usual aftercare group ( n = 16 ) exhibited maintenance of functional dimension scores of quality of life , but a clinical ly relevant decline in emotional scores of quality of life and in six-minute walking distance one year after the pulmonary rehabilitation . Conclusion : Patient self-help association seems to be an innovative and efficient organizational structure to support patients with COPD after pulmonary rehabilitation in real-life setting s. A distinction between emotional and functional dimensions of quality of life may improve the design and evaluation of integrated health care programmes in patients with COPD ABSTRACT Background : Cardiovascular diseases and diabetes are among the leading causes of premature adult deaths in India . Innovative approaches such as clinical decision support ( CDS ) software could play a major role in improving the quality of hypertension/diabetes care in primary care setting s. Objective : To describe the steps and processes in the development of mWellcare , a complex intervention based on mobile health ( mHealth ) technology . Methods : The Medical Research Council framework was used to develop mWellcare in four steps : ( 1 ) identify gaps in usual care through literature review and health facility assessment s ; ( 2 ) identify the components of the intervention through discussion s and consultations with experts ; ( 3 ) develop intervention ( clinical algorithms and mHealth system ) ; and ( 4 ) evaluate acceptability and feasibility through pilot testing in five community health centers . Results : Lack of evidence -based , integrated , and systematic management of chronic conditions were major gaps identified . Experts in information technology , clinical fields , and public health professionals identified intervention components to address these gaps . Thereafter , clinical algorithm context ualized to primary care setting s were prepared and the mWellcare intervention was developed . During the 2-month pilot , 631 patients diagnosed with hypertension and /or diabetes were registered , with a follow-up rate of 36.2 % . The major barrier was resistance to follow mWellcare recommended patient workflow , and to overcome it , we emphasized onsite training and orientation program to cover all health care team member in each CHC . Conclusion : A pilot-tested mWellcare intervention is an mHealth system with important components , i.e. integrated management of chronic conditions , evidence -based CDS , longitudinal health data and automated short-messaging service to reinforce compliance to drug intake and follow-up visit , which will be used by nurses at primary health care setting s in India . The effectiveness and cost-effectiveness of the intervention will be tested through a cluster r and omized trial ( trial registration number NCT02480062 ) Abstract Introduction The current model of medical knowledge production , transfer , and application suffers from serious shortcomings . Learning health systems ( LHS ) have recently emerged as a potential solution — systems in which health information generated from patients is continuously analyzed to improve knowledge that will be transferred to patient care . Method Various approaches of data integration already exist and could be considered for the implementation of a LHS . We discuss what are the possible informatics approaches to address the functional requirements of LHS , in the specific context of primary care , and present the experience and lessons learned from the TRANSFoRm project . Result Implemented in 4 countries around 5 systems , TRANSFoRm is based on a local‐as‐view data mediation approach integrating the structural and terminological models in the same framework . It clearly demonstrated that it has the potential to address the requirements for a LHS in primary care , by dealing with data fragmented across multiple points of service . Also , it has the potential to support the generation of hypotheses from the context of clinical care , retrospective and prospect i ve research , and decision support systems that improve the relevance of medical decisions . Conclusion The LHS approach embodies a shift from an institution‐centered to a patient‐centered perspective in knowledge production and transfer and can address important challenges in the primary care setting Background In many low- and middle-income countries , where tobacco use is common , tuberculosis is also a major problem . Tobacco use increases the risk of developing tuberculosis , secondary mortality , poor treatment compliance and relapses . In countries with TB epidemic , even a modest relative risk leads to a significant attributable risk . Treating tobacco dependence , therefore , is likely to have benefits for controlling tuberculosis in addition to reducing the non-communicable disease burden associated with smoking . In poorly re source d health systems which face a dual burden of disease secondary to tuberculosis and tobacco , an integrated approach to tackle tobacco dependence in TB control could be economically desirable . During TB screening , health professionals come across large numbers of patients with respiratory symptoms , a significant proportion of which are likely to be tobacco users . These clinical encounters , considered to be " teachable moments " , provide a window of opportunity to offer treatment for tobacco dependence . Methods / Design We aim to develop and trial a complex intervention to reduce  tobacco dependence among TB suspects based on the WHO ' five steps to quit ' model . This model relies on assessing personal motivation to quit tobacco use and uses it as the basis for assessing suitability for the different therapeutic options for tobacco dependence . We will use the Medical Research Council framework approach for evaluating complex interventions to : ( a ) design an evidence -based treatment package ( likely to consist of training material s for health professionals and education tools for patients ) ; ( b ) pilot the package to determine the delivery modalities in TB programme ( c ) assess the incremental cost-effectiveness of the package compared to usual care using a cluster RCT design ; ( d ) to determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes ; and ( e ) support long term implementation . The main outcomes to assess the effectiveness would be point abstinence at 4 weeks and continuous abstinence up to 6 months . Discussion This work will be carried out in Pakistan and is expected to have relevance for other low and middle income countries with high tobacco use and TB incidence . This will enhance our knowledge of the cost-effectiveness of treating tobacco dependence in patients suspected of TB.Trial Registration Trial Registration Number : IS RCT In July the Department of Health ( DH ) in Engl and published a toolkit of re sources to promote more effective services to reduce the burden of  falls and fractures in older people . Unfortunately , there is plenty of evidence that the present provision of falls services is suboptimal . The toolkit is part of a ‘ Prevention Package ’ aim ed primarily at commissioners of care , in an attempt to achieve a more consistent and integrated approach to a range of prevention issues in older people [ 1 ] . Falls are a major international public health challenge because of the myriad effects on older individuals : direct physical and psychological injury ; fear of falling and activity limitation ; reduced social participation and quality of life ; increased dependence [ 2–5 ] ; and because of the economic impact on health and social care providers [ 6 , 7 ] . Studies from various countries have shown that about one third of people aged above 65 years fall each year . In UK primary care population s , the rate rises with age to over 60 % of nonagenarians , and is generally higher in women [ 8 ] and in socio-economically deprived population s [ 9 ] . Fragility fractures are the commonest significant injury , 300,000 annually in the UK including upwards of 70,000 hip fractures . Many falls go unreported , but nevertheless they account for 40 % of UK ambulance call-outs , with the variable proportion being conveyed to hospital accounting for one in ten Emergency Department ( ED ) attendances of the over 75s [ 6 ] , a third of whom are admitted , thus comprising about 14 % of emergency admissions . Identifying all falls related activity is challenging but recent estimates suggest that it accounts for between 10 % and 25 % of all local health and social care spending on older people [ 10 ] . Care of fragility fractures is particularly expensive , total health and social care costs in the UK being around £ 2 billion , most of which relates to hip fractures [ 11 ] . Current population and incidence projections suggest that by 2020 , this figure will rise by 50 % . Early in the development of geriatric medicine , falls were identified as a ‘ geriatric giant’—adverse in their own right but also a non-specific indicator of functional decompensation . Building on clarification of falls risk factors [ 12 ] , r and omised controlled trials demonstrated the effectiveness of risk factor based multi-factorial interventions [ 13 , 14 ] . This led to the notion of ‘ falls prevention services ’ . Based on international consensus about what constituted best clinical practice [ 15 ] , broadly similar policies have been developed by the responsible government departments of the four UK nations , and in Irel and [ 16 ] . The National Service Framework for Older People in Engl and ( NSF , 2001 ) [ 17 ] required health services and their local council partners to develop integrated services by April 2005 , incorporating case finding , assessment and referral systems and specialist falls and fragility fracture services . The NSF was launched without earmarked implementation funding , but there was plenty of activity , some enabled and directed by various government initiatives , encouraging community engagement . An independent postal question naire survey to health and social care agencies about their falls services in 2004 [ 18 ] reported most having made plans for an integrated service but implementation was patchy and focused on widely differing priorities . Only 30 % included systems for identifying high risk individuals and only 13 % of falls prevention programmes included exercise classes , the most effective prevention strategy [ 19 ] whilst interventions with little or no evidence base were promoted [ 20 ] . Implementation of these policies across Engl and , Wales and Northern Irel and has been monitored in a series of government funded national audits run by the Royal College of Physicians of London ( RCP ) . The first of these confirmed major gaps at the organisational level , particularly in case finding and referrals for secondary prevention [ 21 ] . A subsequent patient level clinical care audit of fragility fracture patients showed that most returning home from the Emergency Department were not offered a falls risk assessment and only one third were on appropriate treatment for osteoporosis 3 months later [ 22 ] . Despite intense interest among clinicians in the UK and appointment of many geriatricians with a focus on falls , syncope and orthogeriatrics , a repeat organisational audit showed that by 2008 there had been little improvement in service structure , capacity or processes [ 23 ] . Meanwhile the picture was clouded by the negative results of a DH funded systematic review with meta-analyses [ 24 ] . This suggested that the variable outcomes of clinical trials might be associated with the way that the multifactorial approach was organised . There are now several negative outcome trials employing the strategy of nurse led case finding linked to interventions intended to be provided by a range of unconnected professions acting on referral [ 25 ] . In clinical practice , it is likely that there is even more differential effectiveness depending on case finding and referral practice s and context ual differences in service delivery . Research evidence is still lacking on how to achieve much that the NSF aspired to , but there is sufficient evidence and examples of successful implementation to do much better than most are currently doing . So how will the latest government action help ? A key step is to clarify priorities and to put available re sources into the activities likely to make Background Limited data are available on the development , implementation and evaluation processes of physical activity promotion programmes among older adults . More integrative insights into interventions describing the planned systematic development , implementation and evaluation are needed . Methods and design The purpose of this study is to give an integrative insight into the development of the Active plus programme applying the six-step Intervention Mapping protocol . The Active plus programme consisted of two theory- and evidence -based tailored physical activity promotion interventions , both comprising three tailored letters delivered over four months and aim ed at raising awareness of insufficient physical activity , and stimulating physical activity initiation and maintenance among the over-fifties . The first intervention , the basic tailored intervention , provided tailored letters that intervened on the psychosocial determinants of physical activity . The second intervention , the intervention plus , provided the same tailored information but additionally provided tailored information about physical activity opportunities in the specific environment in which the older adults lived . This environment-based component also provided access to a forum and e-buddy system on a website . A plan for implementation and evaluation is also described . Discussion The planned development of the Active plus programme result ed in two theory- and evidence -based tailored physical activity interventions targeted at the over-fifties . Trial Registration Dutch Trial Register NTR Following demonstrations of success of interactive cancer communication systems ( ICCS ) for patients , the challenge and opportunity are to integrate such systems with human re sources . A r and omized trial explored relative benefits of an ICCS , a human cancer information mentor , and a condition combining both . Women with breast cancer ( N = 434 ) were r and omized to have access to a tested  ICCS ( CHESS , the Comprehensive Health Enhancement Support System ) , a human cancer information mentor , both interventions , or a control condition providing a computer , training , and Internet access . Both a human mentor and an ICCS version improved health information competence and emotional processing over the Internet control , and the combined condition exceeded either alone . Integrating human and computer-based re sources for breast cancer patients benefits them more than either alone Background The Normalization Process Model is a theoretical model that assists in explaining the processes by which complex interventions become routinely embedded in health care practice . It offers a framework for process evaluation and also for comparative studies of complex interventions . It focuses on the factors that promote or inhibit the routine embedding of complex interventions in health care practice . Methods A formal theory structure is used to define the model , and its internal causal relations and mechanisms . The model is broken down to show that it is consistent and adequate in generating accurate description , systematic explanation , and the production of rational knowledge cl aims about the workability and integration of complex interventions . Results The model explains the normalization of complex interventions by reference to four factors demonstrated to promote or inhibit the operationalization and embedding of complex interventions ( interactional workability , relational integration , skill-set workability , and context ual integration ) . Conclusion The model is consistent and adequate . Repeated calls for theoretically sound process evaluations in r and omized controlled trials of complex interventions , and policy-makers who call for a proper underst and ing of implementation processes , emphasize the value of conceptual tools like the Normalization Process Model Objective To evaluate the cost effectiveness , cost utility , and cost-benefit of an integrated care programme compared with usual care for sick listed patients with chronic low back pain . Design Economic evaluation alongside a r and omised controlled trial with 12 months ’ follow-up . Setting Primary care ( 10 physiotherapy practice s , one occupational health service , one occupational therapy practice ) and secondary care ( five hospitals ) in the Netherl and s , 2005 - 9 . Participants 134 adults aged 18 - 65 sick listed because of chronic low back pain : 66 were r and omised to integrated care and 68 to usual care . Interventions Integrated care consisted of a workplace intervention based on participatory ergonomics , with involvement of a supervisor , and a grade d activity programme based on cognitive behavioural principles . Usual care was provided by general practitioners and occupational physicians according to Dutch guidelines . Main outcome measures The primary outcome was duration until sustainable return to work . The secondary outcome was quality adjusted life years ( QALYs ) , measured using EuroQol . Results Total costs in the integrated care group ( £ 13 165 , SD £ 13 600 ) were significantly lower than in the usual care group ( £ 18 475 , SD £ 13 616 ) . Cost effectiveness planes and acceptability curves showed that integrated care was cost effective compared with usual care for return to work and QALYs gained . The cost-benefit analyses showed that every £ 1 invested in integrated care would return an estimated £ 26 . The net societal benefit of integrated care compared with usual care was £ 5744 . Conclusions Implementation of an integrated care programme for patients sick listed with chronic low back pain has a large potential to significantly reduce societal costs , increase effectiveness of care , improve quality of life , and improve function on a broad scale . Integrated care therefore has large gains for patients and society as well as for employers Background Many promising technological innovations in health and social care are characterized by nonadoption or ab and onment by individuals or by failed attempts to scale up locally , spread distantly , or sustain the innovation long term at the organization or system level . Objective Our objective was to produce an evidence -based , theory-informed , and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program . Methods The study had 2 parallel components : ( 1 ) secondary research ( hermeneutic systematic review ) to identify key domains , and ( 2 ) empirical case studies of technology implementation to explore , test , and refine these domains . We studied 6 technology-supported programs — video outpatient consultations , global positioning system tracking for cognitive impairment , pendant alarm services , remote biomarker monitoring for heart failure , care organizing software , and integrated case management via data sharing — using longitudinal ethnography and action research for up to 3 years across more than 20 organizations . Data were collected at micro level ( individual technology users ) , meso level ( organizational processes and systems ) , and macro level ( national policy and wider context ) . Analysis and synthesis was aided by sociotechnically informed theories of individual , organizational , and system change . The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback . Results The literature review identified 28 previous technology implementation frameworks , of which 14 had taken a dynamic systems approach ( including 2 integrative review s of previous work ) . Our empirical data set consisted of over 400 hours of ethnographic observation , 165 semistructured interviews , and 200 documents . The final nonadoption , ab and onment , scale-up , spread , and sustainability ( NASSS ) framework included questions in 7 domains : the condition or illness , the technology , the value proposition , the adopter system ( comprising professional staff , patient , and lay caregivers ) , the organization(s ) , the wider ( institutional and societal ) context , and the interaction and mutual adaptation between all these domains over time . Our empirical case studies raised a variety of challenges across all 7 domains , each classified as simple ( straightforward , predictable , few components ) , complicated ( multiple interacting components or issues ) , or complex ( dynamic , unpredictable , not easily disaggregated into constituent components ) . Programs characterized by complicatedness proved difficult but not impossible to implement . Those characterized by complexity in multiple NASSS domains rarely , if ever , became mainstreamed . The framework showed promise when applied ( both prospect ively and retrospectively ) to other programs . Conclusions Subject to further empirical testing , NASSS could be applied across a range of technological innovations in health and social care . It has several potential uses : ( 1 ) to inform the design of a new technology ; ( 2 ) to identify technological solutions that ( perhaps despite policy or industry enthusiasm ) have a limited chance of achieving large-scale , sustained adoption ; ( 3 ) to plan the implementation , scale-up , or rollout of a technology program ; and ( 4 ) to explain and learn from program failures BACKGROUND Programmes that promote early psychological development of children in the developed world have been found to be beneficial . However , such programmes are rare in underprivileged parts of the developing world . We adapted one such parent-based programme ( Learning Through Play ) for a rural Pakistani population and aim ed to study if : ( 1 ) it was acceptable to community health workers ; ( 2 ) the programme led to an improvement , after a period of 6 months , in mothers ' knowledge and attitudes about early infant development ; ( 3 ) it led to a reduction in the levels of maternal mental distress in the post-natal period . METHODS Using a cluster r and omized design with villages as unit of r and omization , 163 mothers from 24 villages in a rural sub-district of Rawalpindi , Pakistan , received the ' Learning Through Play ' programme , whereas 146 mothers from 24 villages acted as controls . Twenty-four community health workers were trained to carry out the programme . Assessment s were conducted using a specially developed 15-item Infant Development Question naire and the 20-item Self-Reporting Question naire ( SRQ ) . RESULTS Over 80 % of the community health workers trained found the programme to be relevant and were able to integrate it into their routine work . There was a significant increase in mothers ' knowledge and positive attitudes about infant development in the intervention group , compared with the control group . Women in the intervention group answered correctly 4.3 ( 95 % CI 3.7 - 14.9 , P < 0.001 ) more questions than the control group . There was no difference in levels of mental distress measured by the SRQ . CONCLUSIONS The ' Learning Through Play ' programme was successfully integrated into the existing health system and accepted by community health workers . The programme succeeded in improving the knowledge and attitudes of mothers about infant development Introduction Schizophrenia is a severe , chronic and disabling mental illness . Non-adherence to medication and relapse may lead to poorer patient function . This r and omised controlled study , under the acronym LEAN ( Lay health supporter , e-platform , award , and iNtegration ) , is design ed to improve medication adherence and high relapse among people with schizophrenia in re source poor setting s. Methods / analysis The community-based LEAN has four parts : ( 1 ) Lay health supporters ( LHSs ) , mostly family members who will help supervise patient medication , monitor relapse and side effects , and facilitate access to care , ( 2 ) an E-platform to support two-way mobile text and voice messaging to remind patients to take medication ; and alert LHSs when patients are non-adherent , ( 3 ) an Award system to motivate patients and strengthen LHS support , and ( 4 ) iNtegration of the efforts of patients and LHSs with those of village doctors , township mental health administrators and psychiatrists via the e-platform . A r and om sample of 258 villagers with schizophrenia will be drawn from the schizophrenic ‘ 686 ’ Program registry for the 9 Xiang dialect towns of the Liuyang municipality in China . The sample will be further r and omised into a control group and a treatment group of equal sizes , and each group will be followed for 6 months after launch of the intervention . The primary outcome will be medication adherence as measured by pill counts and supplemented by pharmacy records . Other outcomes include symptoms and level of function . Outcomes will be assessed primarily when patients present for medication refill visits scheduled every 2 months over the 6-month follow-up period . Data from the study will be analysed using analysis of covariance for the programme effect and an intent-to-treat approach . Ethics and dissemination University of Washington : 49464 G ; Central South University : CTXY-150002 - 6 . Results will be published in peer- review ed journals with deidentified data made available on FigShare . Trial registration number ChiCTR-ICR-15006053 ; Pre- results Abstract During the recent years improved operation techniques and administrative procedures have been developed for early rehabilitation . At the same time preoperative lifestyle intervention ( prehabilitation ) has revealed a large potential for additional risk reduction . The aim was to assess the quality of life and to estimate the cost-effectiveness of st and ard care versus an integrated programme including prehabilitation and early rehabilitation . Methods The analyses were based on the results from 60 patients undergoing lumbar fusion for degenerative lumbar disease ; 28 patients were r and omised to the integrated programme and 32 to the st and ard care programme .  Data on cost and health related quality of life was collected preoperatively , during hospitalisation and postoperatively . The cost was estimated from multiplication of the re source consumption and price per unit . Results Overall there was no difference in health related quality of life scores . The patients from the integrated programme obtained their postoperative milestones sooner , returned to work and soaked less primary care after discharge . The integrated programme was 1,625 € ( direct costs 494 € + indirect costs 1,131 € ) less costly per patient compared to the st and ard care programme . Conclusion The integrated programme of prehabilitation and early rehabilitation in spine surgery is more cost-effective compared to st and ard care programme alone Objectives : To describe important details of the design and operational features of the Mwanza sexually transmitted diseases ( STD ) control programme . To assess the feasibility of the intervention , the distribution of STD syndromes observed , the clinical effectiveness of syndromic STD case management , the utilisation of STD services by the population , and the quality of syndromic STD services delivered at rural health units . Methods : The intervention was integrated into rural primary healthcare ( PHC ) units . It comprised improved STD case management using the syndromic approach , facilitated by a regional programme office which ensured the training of health workers , a reliable supply of effective drugs , and regular support supervision . Five studies were performed to evaluate operational performance : ( i ) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections ( RTIs ) to rural health units with improved STD services , ( ii ) a survey of register books from health units in communities without improved services , ( iii ) a survey of register books from referral clinics , ( iv ) a home based cross sectional study of STD patients who did not return to the intervention health units for follow up  , ( v ) a cross sectional survey of reported STD treatment seeking behaviour in a r and om cohort of 8845 adults served by rural health units . Results : During the 2 years of the Mwanza trial , 12 895 STD syndromes were treated at the 25 intervention health units . The most common syndromes were urethral discharge ( 67 % ) and genital ulcers ( 26 % ) in men and  vaginal discharge ( 50 % ) , lower abdominal tenderness ( 33 % ) , and genital ulcers ( 13 % ) in women . Clinical treatment effectiveness was high in patients from whom complete follow up data were available , reaching between 81 % and 98 % after first line treatment and 97%–99 % after first , second , and third line treatment . Only 26 % of patients referred to higher levels of health care had presented to their referral institutions . During the trial period , data from the cohort showed that 12.8 % of men and 8.6 % of women in the intervention communities experienced at least one STD syndrome . Based on various approaches , utilisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50 % and 75 % . During the first 6 months of intervention attendance at intervention units increased by 53 % . Thereafter , the average attendance rate was about 25 % higher than in comparison communities . Home visits to 367 non-returners revealed that 89 % had been free of symptoms after treatment , but 28 % became symptomatic again within 3 months of treatment . 100 % of these patients reported that they had received treatment , but only 74 % had been examined , only 57 % had been given health education , and only 30 % were offered condoms . Patients did not fully recall which treatment they had been given , but possibly only 63 % had been treated exactly according to guidelines . Conclusions : This study demonstrated that it is feasible to integrate effective STD services into the existing PHC structure of a developing country . Improved services attract more patients , but additional educational efforts are needed to further improve treatment seeking behaviour . Furthermore , clear treatment guidelines , a reliable drug supply system , and regular supervision are critical . All efforts should be made to treat patients on the spot , without delay , as referral to higher levels of care led to a high number of dropouts . The syndromic approach to STD control should be supported by at least one reference clinic and laboratory per country to ensure monitoring of prevalent aetiologies , of the development of bacterial resistance , and of the effectiveness of the syndromic algorithms in use Background and objectives Evidence -based health care requires clinicians to engage with use of evidence in decision-making at the workplace . A learner-centred , problem-based course that integrates e-learning in the clinical setting has been developed for application in obstetrics and gynaecology units . The course content uses the WHO reproductive health library ( RHL ) as the re source for systematic review s. This project aims to evaluate a clinical ly integrated teaching programme for incorporation of evidence provided through the WHO RHL . The hypothesis is that the RHL-EBM ( clinical ly integrated e-learning ) course will improve participants ' knowledge , skills and attitudes , as well as institutional practice and educational environment , as compared to the use of st and ard postgraduate educational re sources for EBM teaching that are not clinical ly integrated . Methods The study will be a multicentre , cluster r and omized controlled trial , carried out in seven countries ( Argentina , Brazil , Democratic Republic of Congo , India , Philippines , South Africa , Thail and ) , involving 50 - 60 obstetrics and gynaecology teaching units . The trial will be carried out on postgraduate trainees in the first two years of their training . In the intervention group , trainees will receive the RHL-EBM course .  The course consists of five modules , each comprising self-directed e-learning components and clinical ly related activities , assignments and assessment s , coordinated between the facilitator and the postgraduate trainee . The course will take about 12 weeks , with assessment s taking place pre-course and 4 weeks post-course . In the control group , trainees will receive electronic , self-directed EBM-teaching material s. All data collection will be online . The primary outcome measures are gain in EBM knowledge , change in attitudes towards EBM and competencies in EBM measured by multiple choice questions ( MCQs ) and a skills-assessing question niare administered eletronically . These questions have been developed by using questions from vali date d question naires and adapting them to the current course . Secondary outcome measure will be educational environment towards EBM which will be assessed by a specifically developed question naire . Expected outcomes The trial will determine whether the RHL EBM ( clinical ly integrated e-leraning ) course will increase knowledge , skills and attitudes towards EBM and improve the educational environment as compared to st and ard teaching that is not clinical ly integrated . If effective , the RHL-EBM course can be implemented in teaching institutions worldwide in both , low- and middle income countries as well as industrialized setting s. The results will have a broader impact than just EBM training because if the approach is successful then the same educational strategy can be used to target other priority clinical and method ological areas .Trial Registration
Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated .
Instead , there exists a highly heterogeneous picture both for the nature and also for the extent of integration .
Health systems combine both non-integrated and integrated interventions , but the balance of these interventions varies considerably
A longst and ing debate on health systems organization relates to benefits of integrating  health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes .
This debate has long been characterized by polarization of views and ideologies , with protagonists for and against integration arguing the relative merits of each approach .
However , all too frequently these arguments have not been based on hard evidence .
The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach , but the relative merits of integration in various context s and for different interventions have not been systematic ally analysed and documented .
In this paper we present findings of a systematic review that explores a broad range of evidence on : ( i ) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions , ( ii ) how the integration or non-integration of health programmes into critical health systems functions in different context s has influenced programme success , ( iii ) how context ual factors have affected the extent to which these programmes were integrated into critical health systems functions .