Microfinance for women at high risk for HIV in Kazakhstan: study protocol for a cluster-randomized controlled trial Examining the use of process evaluations of randomised controlled trials of complex interventions addressing chronic disease in primary health care—a systematic review protocol 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? Falls prevention for the elderly Improving antiretroviral therapy adherence in resource‐limited settings at scale: a discussion of interventions and recommendations Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviors in young children (preschool 0 to 6 years): evidence mapping and syntheses Effectiveness of education in evidence-based healthcare: the current state of outcome assessments and a framework for future evaluations. Predictive ability of social cognitive theory in exercise research: an integrated literature review. Impact of Bridging Income Generation with Group Integrated Care (BIGPIC) on Hypertension and Diabetes in Rural Western Kenya Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review. Repayment Flexibility Can Reduce Financial Stress: A Randomized Control Trial with Microfinance Clients in India Integrating Children with Psychiatric Disorders in the Classroom: A Systematic Review A randomized controlled trial comparing Circle of Security Intervention and treatment as usual as interventions to increase attachment security in infants of mentally ill mothers: Study Protocol Promoting Employee Health by Integrating Health Protection, Health Promotion, and Continuous Improvement: A Longitudinal Quasi-Experimental Intervention Study Structural brain alterations following adult non-CNS cancers: a systematic review of the neuroimaging literature Maternal mental health and integrated programs for mothers with substance abuse issues. Integrating group counseling, cell phone messaging, and participant-generated songs and dramas into a microcredit program increases Nigerian women's adherence to international breastfeeding recommendations. Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity amongst children Understanding the implementation of complex interventions in health care: the normalization process model Digital Education in Health Professions: The Need for Overarching Evidence Synthesis Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: a randomized clinical trial. Improving Adherence to Smoking Cessation Treatment: Intervention Effects in a Web-Based Randomized Trial
Background Among women at high risk for HIV and other sexually transmitted diseases ( STIs ) , gender and economic issues limit the impact of behavioral prevention strategies . Women in Kazakhstan with dual risks of sex trading and drug use face elevated risk for HIV and STIs and may benefit from an economic empowerment intervention which combines HIV-risk reduction ( HIVRR ) education with financial skills-building and asset-building to promote reduced reliance on sex trading for income . Methods / design The study employs a two-arm , cluster-r and omized controlled trial ( c- RCT ) design . We will use cluster r and omization to assign 350 women in approximately 50 cohorts to a traditional four-session HIV-risk-reduction intervention combined with a six-session financial literacy intervention , enrollment in a 24-session vocational training program and receipt of matched savings ( HIVRR+MF ) ; or to the four-session HIV-risk-reduction intervention alone ( HIVRR ) . Repeated behavioral and biological assessment s will be conducted at baseline , then at 6 , 9 , and 15 months post r and omization/session 1 . Discussion This study responds to an identified need in the academic literature for rigorous testing of structural interventions , including combination microfinance and HIV-prevention interventions .Trial registration Clinical Trials.gov , ID : NCT02406482 . Registered on 30 March 2015 Background R and omised controlled trials ( RCTs ) of complex interventions in primary health care ( PHC ) are needed to provide evidence -based programmes to achieve the Declaration of Alma Ata goal of making PHC equitable , accessible and universal and to effectively address the rising burden from chronic disease . Process evaluations of these RCTs can provide insight into the causal mechanisms of complex interventions , the context ual factors , and inform as to whether an intervention is ineffective due to implementation failure or failure of the intervention itself . To build on this emerging body of work , we aim to consoli date the methodology and methods from process evaluations of complex interventions in PHC and their findings of facilitators and barriers to intervention implementation in this important area of health service delivery . Methods Systematic review of process evaluations of r and omised controlled trials of complex interventions  which address prevalent major chronic diseases in PHC setting s. Published process evaluations of RCTs will be identified through data base and clinical trial registry search es and contact with authors . Data from each study will be extracted by two review ers using st and ardised forms . Data extracted include descriptive items about ( 1 ) the RCT , ( 2 ) about the process evaluations ( such as methods , theories , risk of bias , analysis of process and outcome data , strengths and limitations ) and ( 3 ) any stated barriers and facilitators to conducting complex interventions . A narrative synthesis of the findings will be presented . Discussion Process evaluation findings are valuable in determining whether a complex intervention should be scaled up or modified for other context s. Publishing this protocol serves to encourage transparency in the reporting of our synthesis of current literature on how process evaluations have been conducted thus far and a deeper underst and ing of potential challenges and solutions to aid in the implementation of effective interventions in PHC beyond the research setting . Systematic review registration PROSPERO 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 Background An ageing population , a growing prevalence of chronic diseases and limited financial re sources for health care underpin the importance of prevention of disabling health disorders and care dependency in the elderly . A wide variety of measures is generally available for the prevention of falls and fall-related injuries . The spectrum ranges from diagnostic procedures for identifying individuals at risk of falling to complex interventions for the removal or reduction of identified risk factors . However , the clinical and economic effectiveness of the majority of recommended strategies for fall prevention is unclear . Against this background , the literature analyses in this HTA report aim to support decision-making for effective and efficient fall prevention . Research questions The pivotal research question addresses the effectiveness of single interventions and complex programmes for the prevention of falls and fall-related injuries . The target population are the elderly ( > 60 years ) , living in their own housing or in long term care facilities . Further research questions refer to the cost-effectiveness of fall prevention measures , and their ethical , social and legal implication s. Methods Systematic literature search es were performed in 31 data bases covering the publication period from January 2003 to January 2010 . While the effectiveness of interventions is solely assessed on the basis of r and omised controlled trials ( RCT ) , the assessment of the effectiveness of diagnostic procedures also considers prospect i ve accuracy studies . In order to clarify social , ethical and legal aspects all studies deemed relevant with regard to content were taken into consideration , irrespective of their study design . Study selection and critical appraisal were conducted by two independent assessors . Due to clinical heterogeneity of the studies no meta-analyses were performed . Results Out of 12,000 references retrieved by literature search es , 184 meet the inclusion criteria . However , to a variable degree the validity of their results must be rated as compromised due to different biasing factors . In summary , it appears that the performance of tests or the application of parameters to identify individuals at risk of falling yields little or no clinical ly relevant information . Positive effects of exercise interventions  may be expected in relatively young and healthy seniors , while studies indicate opposite effects in the fragile elderly . For this specific vulnerable population the modification of the housing environment shows protective effects . A low number of studies , low quality of studies or inconsistent results lead to the conclusion that the effectiveness of the following interventions has to be rated unclear yet : correction of vision disorders , modification of psychotropic medication , vitamin D supplementation , nutritional supplements , psychological interventions , education of nursing personnel , multiple and multifactorial programs as well as the application of hip protectors . For the context of the German health care system the  economic evaluations of fall prevention  retrieved by the literature search es yield very few useful results . Cost-effectiveness calculations of fall prevention are mostly based on weak effectiveness data as well as on epidemiological and cost data from foreign health care systems . Ethical analysis demonstrates ambivalent views of the target population concerning fall risk and the necessity of fall prevention . The willingness to take up preventive measures depends on a variety of personal factors , the quality of information , guidance and decision-making , the prevention program itself and social support . The analysis of papers regarding legal issues shows three main challenges : the uncertainty of which st and ard of care has to be expected with regard to fall prevention , the necessity to consider the specific conditions of every single case when measures for fall prevention are applied , and the difficulty to balance the rights to autonomous decision making and physical integrity . Discussion and conclusions The assessment of clinical effectiveness of interventions for fall prevention is complicated by inherent method ological problems ( esp . absence of blinding ) and meaningful clinical heterogeneity of available studies . Therefore meta-analyses are not appropriate , and single study results are difficult to interpret . Both problems also impair the informative value of economic analyses . With this background it has to be stated that current recommendations regarding fall prevention in the elderly are not fully supported by scientific evidence . In particular , for the generation of new recommendations the dependency of probable effects on specific characteristics of the target population s or care setting s should be taken into consideration . This also applies to the variable factors influencing the willingness of the target population to take up and pursue preventive measures . In the planning of future studies equal weight should be placed on method ological rigour ( freedom from biases ) and transferability of results into routine care . Economic analyses require input of German data , either in form of a “ piggy back study “ or in form of a modelling study that reflects the structures of the German health care system and is based on German epidemiological and cost data Abstract Introduction : Successful population ‐level antiretroviral therapy ( ART ) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale‐up and , ultimately , the end of AIDS . Although many people living with HIV are adhering well , others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy . Despite the importance of ART adherence , supportive interventions have generally not been implemented at scale . The objective of this review is to summarize the recommendations of clinical , research , and public health experts for scalable ART adherence interventions in re source ‐limited setting s. Methods : In July 2015 , the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in re source ‐limited setting s. This article summarizes that discussion with recent up date s. It is not a systematic review , but rather provides practical considerations for programme implementation based on evidence from individual studies , systematic review s , meta‐analyses , and the World Health Organization Consoli date d Guidelines for HIV , which include evidence from r and omized controlled trials in low‐ and middle‐income countries . Interventions are categorized broadly as education and counselling ; information and communication technology‐enhanced solutions ; healthcare delivery restructuring ; and economic incentives and social protection interventions . Each category is discussed , including descriptions of interventions , current evidence for effectiveness , and what appears promising for the near future . Approaches to intervention implementation and impact assessment are then described . Results and discussion : The evidence base is promising for currently available , effective , and scalable ART adherence interventions for re source ‐limited setting s. Numerous interventions build on existing health care infrastructure and leverage available re sources . Those most widely studied and implemented to date involve peer counselling , adherence clubs , and short message service ( SMS ) . Many additional interventions could have an important impact on ART adherence with further development , including st and ardized counselling through multi‐media technology , electronic dose monitoring , de central ized and differentiated models of care , and livelihood interventions . Optimal targeting and tailoring of interventions will require improved adherence measurement . Conclusions : The opportunity exists today to address and resolve many of the challenges to effective ART adherence , so that they do not limit the potential of ART to help bring about the end of AIDS Background The aim of these review s is to inform the design and content of interventions to reduce obesity in young children . The behaviors that are associated with obesity/overweight have been studied extensively ; however , the factors associated with these behaviors in young children ( 0 to 6 years ) have not been systematic ally review ed . Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life could track into adulthood . In order to develop effective interventions and change behavior , it is important to underst and the factors that are associated with those behaviors . For example , we need to underst and whether it would be more important to target the family , childcare setting s or the wider environment and identify the most effective way of changing these energy balance related behaviors . Methods / Design Quantitative ( intervention and observational ) and qualitative literature on determinants/correlates of fruit and vegetable intake , sugar sweetened beverage and other unhealthy diet intake , and physical activity and sedentary behaviors in young children will be systematic ally identified , mapped and review ed . A common search strategy ( no language or period restrictions ) will be used to identify papers from eight electronic data bases and this will be supplemented by h and - search ing . Next , studies in developed countries that examine the factors associated with these behaviors in children aged 0 to 6 years ( at baseline ) will be screened and mapped descriptively followed by in-depth data extraction , quality assessment and synthesis . Data from quantitative studies will be summarized using either forest plots or harvest plots and narrative synthesis , and qualitative studies using thematic analysis . Qualitative evidence will be integrated with the quantitative evidence , using a parallel synthesis approach , to provide a deeper underst and ing of effective strategies to influence these energy balance related behaviors . Discussion In addition to updating and mapping current research , these review s will be the first to comprehensively synthesize and integrate both the quantitative and qualitative evidence pertaining to determinants/correlates/barriers/facilitators of obesity related behaviors in this young age group ( 0 to 6 years ) with the aim of informing future interventions . Systematic review registration International Prospect i ve Register for Systematic Review s ( PROSPERO ) Registration number : Background A discipline which critically looks at the evidence for practice should itself be critically examined . Credible evidence for the effectiveness of training in evidence -based healthcare ( EBHC ) is essential . We attempted to summarise the current knowledge on evaluating the effectiveness of training in EBHC while identifying the gaps . Methods A working group of EBHC teachers developed a conceptual framework of key areas of EBHC teaching and practice in need of evidence mapped to appropriate methods and outcomes . A literature search was conducted to review the current state of research in these key areas . Studies of training interventions that evaluated effectiveness by considering learner , patient or health system outcomes in terms of knowledge , skills , attitude , judgement , competence , decision-making , patient satisfaction , quality of life , clinical indicators or cost were included . There was no language restriction . Results Of 55 articles review ed , 15 met the inclusion criteria : six systematic review s , three r and omised controlled trials and six before-after studies . We found weak indications that undergraduate training in EBHC improves knowledge but not skills , and that clinical ly integrated postgraduate teaching improves both knowledge and skills . Two r and omised controlled trials reported no impact on attitudes or behaviour . One before-after study found a positive impact on decision-making , while another suggested change in learners ' behaviour and improved patient outcome . We found no studies assessing the impact of EBHC training on patient satisfaction , health-related quality of life , cost or population -level indicators of health . Conclusions Literature evaluating the effectiveness of training in EBHC has focused on short-term acquisition of knowledge and skills . Evaluation design s were method ologically weak , controlled trials appeared inadequately powered and systematic review s could not provide conclusive evidence owing to weakness of study design The mechanisms that underlie successful initiation and adherence to physical activity regimens are not well understood . Few theoretical models have used consistent explanatory variables that are theory-driven and many findings that use extant models are equivocal . Social Cognitive Theory ( SCT ) as presented by B and ura ( 1986 , 1997 ) appears to have strong promise as a guide to underst and ing physical activity behaviors and developing clinical ly relevant interventions to promote the initiation and maintenance of physical activity . This critical systematic review of research using SCT was completed to determine the predictive ability of model constructs in explaining physical activity behavior and in identifying key intervention components found to enhance physical activity initiation and maintenance . Following review for quality and adequacy , published research during the years 1990 - 1998 contained 27 studies that examined the relationship between the construct of SCT , self-efficacy  , and physical activity .  All of the descriptive studies found a statistically significant relationship between self-efficacy and exercise behavior . Intervention studies demonstrated that participation in an exercise program promoted self-efficacy , and that programs design ed to increase outcome expectations and self-efficacy significantly increased exercise behavior . Due to the central ity of self-efficacy in many of the social psychological theories that help explain the attitude-intention-behavior triad , a strong need remains to design interventions to maximize its usefulness . Clear , generalizable , systematic and theoretically comprehensive , r and omized , controlled studies are needed to underst and the usefulness of the construct Background Rural setting s in Sub-Saharan Africa ( SSA ) consistently report low participation in non-communicable disease ( NCD ) treatment programs and poor outcomes . Objective The objective of this study is to assess the impact of the implementation of a patient-centered rural NCD care delivery model called Bridging Income Generation through grouP Integrated Care ( BIGPIC ) . Design The study prospect ively tracked participation and health outcomes for participants in a screening event and compared linkage frequencies to a historical comparison group . Participants Rural Kenyan participants attending a voluntary NCD screening event were included within the BIGPIC model of care . Interventions The BIGPIC model utilizes a context ualized care delivery model design ed to address the unique barriers faced in rural setting s. This model emphasizes the following steps : ( 1 ) find patients in the community , ( 2 ) link to peer/microfinance groups , ( 3 ) integrate education , ( 4 ) treat in the community , ( 5 ) enhance economic sustainability and ( 6 ) generate dem and for care through incentives . Main Measures The primary outcome is the linkage frequency , which measures the percentage of patients who return for care after screening positive for either hypertension and /or diabetes . Secondary measures include retention frequencies defined as the percentage of patients remaining engaged in care throughout the 9-month follow-up period and changes in systolic ( SBP ) and diastolic blood pressure ( DBP ) and blood sugar over 12 months . Key Results Of the 879 individuals who were screened , 14.2 % were confirmed to have hypertension , while only 1.4 % were confirmed to have diabetes . The implementation of a comprehensive microfinance-linked , community-based , group care model result ed in 72.4 % of screen-positive participants returning for subsequent care , of which 70.3 % remained in care through the 12 months of the evaluation period . Patients remaining in care demonstrated a statistically significant mean decline of 21 mmHg in SBP [ 95 % CI ( 13.9 to 28.4 ) , P < 0.01 ] and 5 mmHg drop in DBP [ 95 % CI ( 1.4 to 7.6 ) , P < 0.01 ] . Conclusions The implementation of a context ualized care delivery model built around the unique needs of rural SSA participants led to statistically significant improvements in linkage to care and blood pressure reduction BACKGROUND Community-based health workers ( CBHWs ) are frontline public health workers who are trusted members of the community they serve . Recently , considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable population s who often face health inequities . OBJECTIVES We performed a systematic review to synthesize evidence concerning the types of CBHW interventions , the qualification and characteristics of CBHWs , and patient outcomes and cost-effectiveness of such interventions in vulnerable population s with chronic , noncommunicable conditions . SEARCH METHODS We undertook 4 electronic data base search es- PubMed , EMBASE , Cumulative Index to Nursing and Allied Health Literature , and Cochrane- and h and search ed reference collection s to identify r and omized controlled trials published in English before August 2014 . SELECTION We screened a total of 934 unique citations initially for titles and abstract s. Two review ers then independently evaluated 166 full-text articles that were passed onto review processes . Sixty-one studies and 6 companion articles ( e.g. , cost-effectiveness analysis ) met eligibility criteria for inclusion . DATA COLLECTION AND ANALYSIS Four trained research assistants extracted data by using a st and ardized data extraction form developed by the authors . Subsequently , an independent research assistant review ed extracted data to check accuracy . Discrepancies were resolved through discussion s among the study team members . Each study was evaluated for its quality by 2 research assistants who extracted relevant study information . Interrater agreement rates ranged from 61 % to 91 % ( average 86 % ) . Any discrepancies in terms of quality rating were resolved through team discussion s. MAIN RESULTS All but 4 studies were conducted in the United States . The 2 most common areas for CBHW interventions were cancer prevention ( n = 30 ) and cardiovascular disease risk reduction ( n = 26 ) . The roles assumed by CBHWs included health education ( n = 48 ) , counseling ( n = 36 ) , navigation assistance ( n = 21 ) , case management ( n = 4 ) , social services ( n = 7 ) , and social support ( n = 18 ) . Fifty-three studies provided information regarding CBHW training , yet CBHW competency evaluation ( n = 9 ) and supervision procedures ( n = 24 ) were largely underreported . The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours ( median : 16.5 hours ) in 24 studies that reported length of training . Eight studies reported the frequency of supervision , which ranged from weekly to monthly . There was a trend toward improvements in cancer prevention ( n = 21 ) and cardiovascular risk reduction ( n = 16 ) . Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care . CONCLUSIONS Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions , particularly when partnering with low-income , underserved , and racial and ethnic minority communities . Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable population Financial stress is widely believed to cause health problems . However , policies seeking to relieve financial stress by limiting debt levels of poor households may directly worsen their economic well-being . We evaluate an alternative policy – increasing the repayment flexibility of debt contracts . A field experiment r and omly assigned  microfinance clients to a monthly or a traditional weekly installment schedule ( N = 200 ) . We used cell phones to gather survey data on income , expenditure , and financial stress every 48 hours over seven weeks . Clients repaying monthly were 51 percent less likely to report feeling “ worried , tense , or anxious ” about repaying , were 54 percent more likely to report feeling confident about repaying , and reported spending less time thinking about their loan compared to weekly clients . Monthly clients also reported higher business investment and income , suggesting that the flexibility encouraged them to invest their loans more profitably , which ultimately reduced financial stress Background : The school setting may be the optimal context for early screening of and intervention on child mental health problems , because of its large reach and intertwinement with various participants ( child , teacher , parent , other community services ) . But this setting also exposes children to the risk of stigma , peer rejection and social exclusion . This systematic literature review investigates the efficacy of mental health interventions addressed to children and adolescents in school setting s , and it evaluates which programs explicitly take into account social inclusion indicators . Method : Only r and omized controlled trials conducted on clinical population s of students and carried out in school setting s were selected : 27 studies overall . Most studies applied group Cognitive Behavioural Therapy or Interpersonal Psychotherapy . Results : Findings were suggestive of the effectiveness of  school-based intervention programs  in reducing symptoms of most mental disorders . Some evidence was found about the idea that effective studies on clinical population s may promote the social inclusion of children with an ongoing mental disorder and avoid the risk of being highly stigmatized . Conclusion : School programs are still needed that implement st and ardized models with verifiable and evidence -based practice s involving the whole school community Background Psychopathology in women after childbirth represents a significant risk factor for parenting and infant mental health . Regarding child development , these infants are at increased risk for developing unfavorable attachment strategies to their mothers and for subsequent behavioral , emotional and cognitive impairments throughout childhood . To date , the specific efficacy of an early attachment-based parenting group intervention under st and ard clinical outpatient conditions , and the moderators and mediators that promote attachment security in infants of mentally ill mothers , have been poorly evaluated . Methods / Design This r and omized controlled clinical trial tests whether promoting attachment security in infancy with the Circle of Security ( COS ) Intervention will result in a higher rate of securely attached children compared to treatment as usual ( TAU ) . Furthermore , we will determine whether the distributions of securely attached children are moderated or mediated by variations in maternal sensitivity , mentalizing , attachment representations , and psychopathology obtained at baseline and at follow-up . We plan to recruit 80 mother-infant dyads when infants are aged 4 - 9 months with 40 dyads being r and omized to each treatment arm . Infants and mothers will be reassessed when the children are 16 - 18 months of age . Method ological aspects of the study are systematic recruitment and r and omization , explicit inclusion and exclusion criteria , research assessors and coders blinded to treatment allocation , advanced statistical analysis , manualized treatment protocol s and assessment s of treatment adherence and integrity . Discussion The aim of this clinical trial is to determine whether there are specific effects of an attachment-based intervention that promotes attachment security in infants . Additionally , we anticipate being able to utilize data on maternal and child outcome measures to obtain preliminary indications about potential moderators of the intervention and inform hypotheses about which intervention may be most suitable when offered in a clinical psychiatric outpatient context .Trial registration Current Controlled Trials IS RCT Objective : To test the effects of integrating health protection and health promotion with a continuous improvement system ( Kaizen ) on proximal employee outcomes ( health promotion , integration , and Kaizen ) and distal outcomes ( workability , productivity , self-rated health and self-rated sickness absence ) . Methods : Twelve units in a county hospital in Sweden were r and omized to control or intervention groups using a quasiexperimental study design . All staff ( approximately 500 ) provided self-ratings in question naires at baseline , and a 12- and 24-month follow-up ( response rate , 79 % to 87.5 % ) . Result : There was a significant increase in the proximal outcomes over time in the intervention group compared with the control group , and a trend toward improvement in the distal outcomes workability and productivity . Conclusions : Integration seems to promote staff engagement in health protection and promotion , as well as to improve their underst and ing of the link between work and health Abstract Background : Cancer and cancer treatments may impact the brain through several pathways leading to cognitive impairment . Neuroimaging evidence has begun to eluci date the neurobiological underpinnings of cancer-related cognitive impairment . The aim of this paper was to systematic ally review available literature on structural brain alterations following adult non- central nervous system ( CNS ) cancers and associated treatments . Methods : This review followed PRISMA guidelines and was registered in PROSPERO ( ID#107387 ) . Comprehensive search es were conducted in June 2018 using PubMed and Web of Science . Inclusion criteria were English peer- review ed journal articles of formal , controlled studies that examined structural neuroimaging outcomes in adult non-CNS cancer patients and survivors . Selected articles were assessed for quality and risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies . Results : Thirty-six publications of prospect i ve and cross-sectional studies met inclusion criteria and were included . Structural brain alterations following cancer and its treatment were reported in a majority of the publications as evidence d by reduced global and local gray matter volumes , impaired white matter microstructural integrity , and brain network alterations . Structural alterations were most often evident when cancer-treated groups were compared with healthy controls , and more subtle when compared with cancer controls . Regarding the existence of pretreatment impairments , the evidence was equivocal . There was significant between- study heterogeneity in imaging analytical approaches and use of statistical adjustments . Over half reported associations with cognitive outcomes , though regions and associated cognitive domains were heterogeneous . Conclusions : Structural brain alterations following cancer and cancer treatments were reported in a majority of the review ed studies . However , the extent of observed alterations depended on the choice of comparison groups . Method ological issues exist that will need to be addressed systematic ally to ensure the validity of findings . Large-scale prospect i ve studies with extended assessment points are warranted to replicate and build upon initial findings To examine the impact of integrated treatment programs ( those with substance use treatment and pregnancy- , parenting- , or child-related services ) on  maternal mental health  , we compiled a data base of studies of  integrated programs published between 1990 and 2007 with outcome data on maternal mental health . There were 18 cohort studies , 3 r and omized trials , and 2 quasi-experimental studies . Of the five studies comparing integrated to nonintegrated programs , three studies provided enough information to allow for them to be combined in a meta- analysis . The average effect size was 0.23 ( 95 % CI = 0.15 to 0.31 , SE = 0.04 ) , p < .001 . There was no statistically significant heterogeneity among the studies , Q = 5.66 , p = .059 . This meta- analysis is the first systematic quantitative review of studies evaluating the impact of integrated programs on maternal mental health . Findings suggest that integrated programs may be associated with a small advantage over nonintegrated programs in improving maternal mental health . This review highlights the need for further research with improved methodology , study quality , and reporting to improve our underst and ing of how best to meet the mental health needs of mothers with substance abuse issues In northern Nigeria , interventions are urgently needed to narrow the large gap between international breastfeeding recommendations and actual breastfeeding practice s. Studies of integrated microcredit and community health interventions documented success in modifying health behaviors but typically had uncontrolled design s. We conducted a cluster-r and omized controlled trial in Bauchi State , Nigeria , with the aim of increasing early breastfeeding initiation and exclusive breastfeeding among female microcredit clients . The intervention had 3 components . Trained credit officers led monthly breastfeeding learning sessions during regularly scheduled microcredit meetings for 10 mo . Text and voice messages were sent out weekly to a cell phone provided to small groups of microcredit clients ( 5 - 7 women ) . The small groups prepared songs or dramas about the messages and presented them at the monthly microcredit meetings . The control arm continued with the regular microcredit program . R and omization occurred at the level of the monthly meeting groups . Pregnant clients were recruited at baseline and interviewed again when their infants were aged ≥6 mo . Logistic regression models accounting for clustering were used to estimate the odds of performing recommended behaviors . Among the clients who completed the final survey ( n = 390 ) , the odds of exclusive breastfeeding to 6 mo ( OR : 2.4 ; 95 % CI : 1.4 , 4.0 ) and timely breastfeeding initiation ( OR : 2.6 ; 95 % CI : 1.6 , 4.1 ) were increased in the intervention vs. control arm . Delayed introduction of water explained most of the increase in exclusive breastfeeding among clients receiving the intervention . In conclusion , a breastfeeding promotion intervention integrated into microcredit increased the likelihood that women adopted recommended breastfeeding practice s. This intervention could be scaled up in Nigeria , where local organizations provide microcredit to > 500,000 clients . Furthermore , the intervention could be adopted more widely given that > 150 million women , many of childbearing age , are involved in microfinance globally Background There is growing evidence of the impact of overweight and obesity on short- and long-term functioning , health and well-being . Internationally , childhood obesity rates continue to rise in some countries ( for example , Mexico , India , China and Canada ) , although there is emerging evidence of a slowing of this increase or a plateauing in some age groups . In most European countries , the United States and Australia , however , socioeconomic inequalities in relation to obesity and risk factors for obesity are widening . Addressing inequalities in obesity , therefore , has a very high profile on the public health and health services agendas . However , there is a lack of accessible policy-ready evidence on what works in terms of interventions to reduce inequalities in obesity . Methods and design This article describes the protocol for a National Health Service Trust ( NHS ) National Institute for Health Research -funded systematic review of public health interventions at the individual , community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years . The studies will be selected only if ( 1 ) they included a primary outcome that is a proxy for body fatness and ( 2 ) examined differential effects with regard to socioeconomic status ( education , income , occupation , social class , deprivation and poverty ) or the intervention was targeted specifically at disadvantaged groups ( for example , children of the unemployed , lone parents , low income and so on ) or at people who live in deprived areas . A rigorous and inclusive international literature search will be conducted for r and omised and nonr and omised controlled trials , prospect i ve and retrospective cohort studies ( with and /or without control groups ) and prospect i ve repeat cross-sectional studies ( with and /or without control groups ) . The following electronic data bases will be search ed : MEDLINE , Embase , CINAHL , PsycINFO , Social Science Citation Index , ASSIA , IBSS , Sociological Abstract s and the NHS Economic Evaluation Data base . Data base search es will be supplemented with website and grey literature search es . No studies will be excluded on the basis of language , country of origin or publication date . Study inclusion , data extraction and quality appraisal will be conducted by two review ers . Meta- analysis and narrative synthesis will be conducted . The main analysis will examine the effects of ( 1 ) individual , ( 2 ) community and ( 3 ) societal level public health interventions on socioeconomic inequalities in childhood obesity . Interventions will be characterised by their level of action and their approach to tackling inequalities . Context ual information on how such public health interventions are organised , implemented and delivered will also be examined . Discussion In this review , we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity , highlight any gaps in the evidence base and seek to establish how such public health interventions are organised , implemented and delivered . PROSPERO registration number : 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 Synthesizing evidence from r and omized controlled trials of  digital health education  poses some challenges . These include a lack of clear categorization of digital health education in the literature ; constantly evolving concepts , pedagogies , or theories ; and a multitude of methods , features , technologies , or delivery setting s. The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions ; inform policymakers , educators , and students ; and ultimately , change the way in which these professionals learn and are taught . The aim of this paper is to present the overarching methodology that we use to synthesize evidence across our digital health education review s and to discuss challenges related to the process . For our research , we followed Cochrane recommendations for the conduct of systematic review s ; all review s are reported according to the PRISMA ( Preferred Reporting Items for Systematic Review s and Meta-Analyses ) guidance . This included assembling experts in various digital health education fields ; identifying gaps in the evidence base ; formulating focused research questions , aims , and outcome measures ; choosing appropriate search terms and data bases ; defining inclusion and exclusion criteria ; running the search es jointly with librarians and information specialists ; managing abstract s ; retrieving full-text versions of papers ; extracting and storing large data sets , critically appraising the quality of studies ; analyzing data ; discussing findings ; drawing meaningful conclusions ; and drafting research papers . The approach used for synthesizing evidence from digital health education trials is commonly regarded as the most rigorous benchmark for conducting systematic review s. Although we acknowledge the presence of certain biases ingrained in the process , we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor , method ological integrity , and st and ard operating procedures . This paper will be a valuable asset for research ers and method ologists undertaking systematic review s in digital health education OBJECTIVES We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced reductions in sexual risk among women engaging in street-based sex work in Ulaanbaatar , Mongolia , compared with an HIV prevention intervention alone . METHODS Between November 2011 and August 2012 , we r and omized 107 eligible women who completed baseline assessment s to either a 4-session HIV sexual risk reduction intervention ( HIVSRR ) alone ( n=50 ) or a 34-session HIVSRR plus a savings-led microfinance intervention ( n=57 ) . At 3- and 6-month follow-up assessment s , participants reported unprotected acts of vaginal intercourse with paying partners and number of paying partners with whom they engaged in sexual intercourse in the previous 90 days . Using Poisson and zero-inflated Poisson model regressions , we examined the effects of assignment to treatment versus control condition on outcomes . RESULTS At 6-month follow-up , the HIVSRR plus microfinance participants reported significantly fewer paying sexual partners and were more likely to report zero unprotected vaginal sex acts with paying sexual partners . CONCLUSIONS Findings advance the HIV prevention repertoire for women , demonstrating that risk reduction may be achieved through a structural intervention that relies on asset building , including savings , and alternatives to income from sex work Background Web-based smoking cessation interventions can deliver evidence -based treatments to a wide swath of the population , but effectiveness is often limited by insufficient adherence to proven treatment components . This study evaluated the impact of a social network ( SN ) intervention and free nicotine replacement therapy ( NRT ) on adherence to evidence -based components of smoking cessation treatment in the context of a Web-based intervention . Methods A sample of adult U.S. smokers ( N = 5290 ) was recruited via BecomeAnEX.org , a free smoking cessation Web site . Smokers were r and omized to one of four arms : ( 1 ) an interactive , evidence -based smoking cessation Web site ( WEB ) alone ; ( 2 ) WEB in conjunction with an SN intervention design ed to integrate participants into the online community ( WEB+SN ) ; ( 3 ) WEB plus free NRT ( WEB+NRT ) ; and ( 4 ) the combination of all treatments ( WEB+SN+NRT ) . Adherence outcomes assessed at 3-month follow-up were as follows : Web site utilization metrics , use of skills training components , intratreatment social support , and pharmacotherapy use . Results WEB+SN+NRT outperformed all others on Web site utilization metrics , use of practical counseling tools , intratreatment social support , and NRT use . It was the only intervention to promote the sending of private messages and the viewing of community pages over WEB alone . Both social network arms outperformed WEB on most metrics of online community engagement . Both NRT arms showed higher medication use compared to WEB alone . Conclusions This study demonstrated the effectiveness of two approaches for improving adherence to evidence -based components of smoking cessation treatment . Integrated approaches to medication provision and social network engagement can enhance adherence to components known to improve cessation . Implication s This study demonstrated that an integrated approach to medication provision and social network integration , when delivered through an online program , can enhance adherence across all three recommended components of an evidence -based smoking cessation program ( skills training , social support , and pharmacotherapy use ) . Nicotine replacement therapy-when provided as part of an integrated program-increases adherence to other program elements , which in turn augment its own therapeutic effects . An explicit focus on approaches to improve treatment adherence is an important first step to identifying leverage points for optimizing intervention effectiveness
Results Most interventions combined microfinance with health education , which demonstrated positive effects on health knowledge and behaviours , though not health status .
Interventions combining multiple health components in a given study demonstrated positive effects , though it was unclear which component was driving the effect .
Discussion Integrated microfinance and health education programs were effective , though longer intervention periods are necessary to measure more complex pathways to health status .
The effect of microfinance combined with other health components was less clear .
Background Solutions delivered within firm sectoral boundaries are inadequate in achieving income security and better health for poor population s.  Integrated microfinance and health interventions leverage networks of women to promote financial inclusion , build livelihoods , and safeguard against high cost illnesses .
Our underst and ing of the effect of integrated interventions has been limited by variability in intervention , outcome , design , and method ological rigour .
This systematic review synthesis es the literature through 2015 to underst and the effect of  integrated microfinance and health programs .