A systematic review of online interventions for mental health in low and middle income countries: a neglected field Interventions for domestic violence among pregnant women in low- and middle-income countries: a systematic review protocol A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries. Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care. Sudden cardiac death in low- and middle-income countries. Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries Utilization of evidence-based therapy for acute coronary syndrome in high-income and low/middle-income countries. What is your research question? An introduction to the PICOT format for clinicians. Implementing a simplified neonatal resuscitation protocol-helping babies breathe at birth (HBB) - at a tertiary level hospital in Nepal for an increased perinatal survival Hypothermia for encephalopathy in low and middle-income countries (HELIX): study protocol for a randomised controlled trial Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Enhancing Routine Immunization Performance using Innovative Technology in an Urban Area of Nigeria. What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts Value of a mobile information system to improve quality of care by community health workers. Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review protocol Effectiveness of Evidence-Based Asthma Interventions mHealth Interventions in Low and Middle-Income Countries: A Systematic Review Intensive Patient Education Improves Glycaemic Control in Diabetes Compared to Conventional Education: A Randomised Controlled Trial in a Nigerian Tertiary Care Hospital Impact of an SMS advice programme on maternal and newborn health in rural China: study protocol for a quasi-randomised controlled trial A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala Setting Priorities for Comparative Effectiveness Research on Management of Primary Angle Closure: A Survey of Asia-Pacific Clinicians An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice 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 A global representation of vitamin D status in healthy populations A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial Protocol for process evaluation of a randomised controlled trial of family-led rehabilitation post stroke (ATTEND) in India Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study. The Systematic Development and Pilot Randomized Evaluation of Counselling for Alcohol Problems, a Lay Counselor‐Delivered Psychological Treatment for Harmful Drinking in Primary Care in India: The PREMIUM Study The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study Prioritization of Research Addressing Management Strategies for Ductal Carcinoma In Situ Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries. Improving antiretroviral therapy adherence in resource‐limited settings at scale: a discussion of interventions and recommendations Narrowing the income gaps in preventive care for young children: Families in healthy steps Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital. Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study. Effectiveness of education in evidence-based healthcare: the current state of outcome assessments and a framework for future evaluations. Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country. Preventing postpartum smoking relapse among diverse low-income women: a randomized clinical trial. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. Cost-Effectiveness of Community-Based Strategies for Blood Pressure Control in a Low-Income Developing Country: Findings From a Cluster-Randomized, Factorial-Controlled Trial Developing and evaluating communication strategies to support informed decisions and practice based on evidence (DECIDE): protocol and preliminary results Are support and parenting programmes of value for teenage parents? Who should provide them and what are the main goals? Implementing knowledge into practice for improved neonatal survival; a cluster-randomised, community-based trial in Quang Ninh province, Vietnam Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized trial The Feasibility and Effectiveness of PASS Plus, A Lay Health Worker Delivered Comprehensive Intervention for Autism Spectrum Disorders: Pilot RCT in a Rural Low and Middle Income Country Setting Infant-feeding patterns and cardiovascular risk factors in young adulthood: data from five cohorts in low- and middle-income countries
Background . Low and middle income countries ( LMICs ) are facing an increase of the impact of mental health problems while confronted with limited re sources and limited access to mental health care , known as the ‘ mental health gap ’ . One strategy to reduce the mental health gap would be to utilize the internet to provide more widely-distributed and low cost mental health care . We undertook this systematic review to investigate the effectiveness and efficacy of online interventions in LMICs . Methods . We systematic ally search ed the data -bases PubMed , PsycINFO , JMIR , and additional sources . MeSH terms , Thesaurus , and free text keywords were used . We included all r and omized controlled trials ( RCTs ) of online interventions in LMICs . Results . We found only three articles reported results of RCTs on  online interventions for mental health conditions in LMICs , but none of these interventions was compared with an active control condition . Also , the mental health conditions were diverse across the three studies . Conclusions . There is a dearth of studies examining the effect of online interventions  in LMICs , so we can not draw a firm conclusion on its effectiveness . However , given the effectiveness of  online interventions in high income countries and sharp increase of internet access in LMICs , online interventions may offer a potential to help reduce the ‘ mental health gap ’ . More studies are urgently needed in LMICs Background Violence during pregnancy is a global problem , associated with serious health risks for both the mother and baby . Evaluation of interventions targeted for reducing or controlling domestic violence ( DV ) is still in its infancy , and the majority of findings are primarily from high-income countries ( HICs ) . Therefore , there is an urgent need for generating evidence of DV interventions among pregnant women in low- and middle-income countries ( LMICs ) . Methods Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRISMA ) guidelines will be employed to structure the review . A comprehensive search will be carried out via electronic data bases including MEDLINE , CINAHL , Scopus , Embase , Web of Science , PsycINFO , and The Cochrane library . Gray literature will also be scrutinized for potential articles . An optimal search strategy has been developed following consultations with subject-matter experts and librarians . This search strategy will be adapted to the different data bases . Experimental studies evaluating DV interventions among pregnant women from LMICs will be included in the review . The review will only include literature written in English . Two review ers will independently screen and assess studies for inclusion in the review . A third author will resolve any discrepancies between the review ers . Risk of bias will be assessed based on the Cochrane risk of bias assessment tool , and overall quality of the evidence will be judged using Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) criteria . Findings will be presented with the narrative synthesis , and if applicable , they will be further quantified using r and om-effects meta- analysis . Effect size , risk ratio for dichotomous variables , and st and ardized mean differences for continuous variables will be calculated for each outcome using Review Manager 5.3 . Discussion Systematic review s to evaluate the efficacy of interventions to address DV within the perinatal context have been limited . Hence , no one intervention has emerged as substantially effective towards addressing perinatal DV and associated health consequences . The evidence generated from this systematic review will inform research ers and policy makers about the effectiveness of existing DV interventions among pregnant women in LMICs and provide recommendations for future research in this area . This in turn will contribute towards violence prevention in LMICs . Systematic review registration PROSPERO This paper describes the Common Elements Treatment Approach ( CETA ) for adults presenting with mood or anxiety problems developed specifically for use with lay counselors in low- and middle-income countries ( LMIC ) . Details of the intervention development , training , supervision , and decision-making process are presented . Case vignettes are used as examples throughout . Preliminary findings are presented on counselor/supervisor performance and client outcomes from practice cases completed prior to r and omized controlled trials ( RCT ) conducted at two sites for adult survivors of torture and /or systematic violence in ( a ) southern Iraq and ( b ) Thail and -Burma border . Data suggest that local supervisors and lay counselors with little prior mental health training or experience maintained fidelity to the model . The majority of pilot clients were retained in treatment , suggesting acceptability . Using the Reliable Change Index ( RCI ) for each individual we examined the number of clients above a minimal threshold ( z > 1.96 ) for each outcome . In Iraq 100 % of clients had RCIs above the threshold for depression and posttraumatic stress , and 81.8 % for impaired function . In Thail and , 81.3 % of clients had RCIs above minimum threshold for depression , 68.8 % for posttraumatic stress , and 37.5 % for impaired function . Implementation of CETA is discussed in relation to cultural issues within LMIC . These findings , combined with US-based evidence , suggest that a common elements approach warrants further development and testing as a means for addressing the treatment gap for mental health problems in LMIC The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development , borne out of powerful advocacy using public health , economic and human rights arguments . As funding comes on line for scale-up of evidence -based mental health care by task-sharing with primary care , it is time to take stock about care for people affected by severe mental illness ( SMI ) . The existing evidence base for task shared care for SMI provides an imperative to get started , but is skewed towards relatively more affluent and urban population s in middle-income countries where specialist mental health professionals provide most of the care . R and omised , controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving underst and ing of the quality , safety , effectiveness and acceptability of more widely generalisable care for people with SMI . A sub-group of people with SMI have more complex and long-term needs for care , with a high risk of homelessness , imprisonment and human rights violations as family and social supports become overwhelmed . Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation , recovery and empowerment of people with SMI , but rigorous comparative studies are needed to identify the most efficient , effective and scalable approaches to care . Health system constraints are emerging as the over-riding barriers to successful task-sharing , highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality , improving wellbeing and achieving better social outcomes . Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI CONTEXT Based on the clinical care pathway of delirium in palliative care ( PC ) , a published analytic framework ( AF ) formulated research questions in key domains and recommended a scoping review to identify evidence gaps . OBJECTIVES To produce a literature map for key domains of the published AF : screening , prognosis and diagnosis , management , and the health-related outcomes . METHODS A st and ard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium research ers , an information specialist , and review method ologists to conduct the review . Knowledge user engagement provided context in refining 19 AF questions . A peer- review ed search strategy identified citations in Medline , PsycINFO , Embase , and CINAHL data bases between 1980 and 2018 . Two review ers independently screened records for inclusion using explicit study eligibility criteria for the population , design , delirium diagnosis , and investigational intent . RESULTS Of 104 studies reporting empirical data and meeting eligibility criteria , most were conducted in patients with cancer ( 73.1 % ) and in inpatient PC units ( 52 % ) . The most frequent study design was a one or more group , nonr and omized trial or cohort ( 67.3 % ) . Evidence gaps were identified : delirium risk prediction ; comparative effectiveness and harms of prevention , variability in delirium management across PC setting s , advanced directive and substitute decision-maker input , and transition of care location ; and estimating delirium reversibility . Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature . CONCLUSION Substantial evidence gaps exist , providing opportunities for future research regarding the assessment , prognosis , and management of delirium in PC setting Cardiovascular disease , and the incidence of sudden cardiac death ( SCD ) , will increase significantly in low- and middle-income countries ( LMIC ) . Thus , SCD threatens to become a global public health problem . We present a summary of the current research that has investigated the epidemiology of SCD in LMIC . Few studies of SCD in LMIC exist , and they are of variable method ological quality . Risk factors for SCD are described , taking into account recent global burden of disease and risk factor statistics . We describe 1 proposal for a community-based , prospect i ve , multiple- source methodology for SCD monitoring and surveillance that can be implemented in LMIC . Further research into the epidemiology of SCD in LMIC , using st and ardized methodology , would allow investigators and policy makers to determine the regions , communities , and individuals most at need for SCD prevention . Focusing on SCD and its prevention in LMIC should be a priority for the global health community People living with HIV ( PLWH ) experience greater psychological distress than the general population . Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms , quality of life , and HIV care engagement . However , little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries ( LMICs ) , where the large majority of PLWH reside . This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these setting s. A systematic search strategy was undertaken to identify peer- review ed published papers of intervention trials addressing negative psychological states or disorders ( e.g. depression , anxiety ) among PLWH in LMIC setting s. Search results were assessed against pre-established inclusion and exclusion criteria . Data from papers meeting criteria were extracted for synthesis . Twenty-six papers , published between 2000 and 2014 , describing 22 unique interventions were identified . Trials were implemented in sub-Saharan Africa ( n = 13 ) , Asia ( n = 7 ) , and the Middle East ( n = 2 ) , and addressed mental health using a variety of approaches , including cognitive-behavioral ( n = 18 ) , family-level ( n = 2 ) , and pharmacological ( n = 2 ) treatments . Four r and omized controlled trials reported significant intervention effects in mental health outcomes , and 11 preliminary studies demonstrated promising findings . Among the limited mental health intervention trials with PLWH in LMICs , few demonstrated efficacy .  Mental health interventions for PLWH in LMICs must be further developed and adapted for re source -limited setting s to improve effectiveness Limited data exist regarding the management of patients with acute coronary syndrome ( ACS ) in high-income countries compared with low/middle-income countries . We aim ed to compare in-hospital trends of revascularization and prescription of medications  at discharge in patients with ACS from high-income ( Canada and United States ) and low/middle-income ( India , Iran , Pakistan , and Tunisia ) countries . Data from a double-blind , placebo-controlled , r and omized trial investigating the effect of bupropion on smoking cessation in patients after an enzyme-positive ACS was used for our study . A total of 392 patients , 265 and 127 from high-income and from low/middle-income countries , respectively , were enrolled . Patients from high-income countries were older , and were more likely to have diagnosed hypertension and dyslipidemia . During the index hospitalization , patients from high-income countries were more likely to be treated by  percutaneous coronary intervention  ( odds ratio [ OR ] 19.7 , 95 % confidence interval [ CI ] 10.5 to 37.0 ) . Patients with ST elevation myocardial infa rct ion from high-income countries were more often treated by  primary percutaneous coronary intervention  ( OR 16.3 , 95 % CI 6.3 to 42.3 ) in contrast with thrombolytic therapy ( OR 0.24 , 95 % CI 0.14 to 0.41 ) . Patients from high-income countries were also more likely to receive evidence -based medications at discharge ( OR 2.32 , 95 % CI 1.19 to 4.52 , a composite of aspirin , clopidogrel , and statin ) . In conclusion , patients with ACS in low/middle-income countries were less likely to be revascularized and to receive evidence -based medications at discharge . Further studies are needed to underst and the underutilization of procedures and evidence -based medications in low/middle-income countries Clinicians often witness impressive treatment results in practice and may wish to pursue research to formally explore their anecdotal experiences . The potential to further new knowledge both within the profession and to the greater healthcare system is compelling . An obvious next step for a practitioner considering research is to connect with experienced research ers to convey their idea for a study , who may in turn ask , “ What is your research question ? ” With limited underst and ing of how to respond , this interaction may result in the first and last experience these clinicians will have with the research community . It has been estimated that between 1 % and 7 % of the chiropractic profession in Canada is engaged in research . 1,2 Arguably , this low engagement could be the result of practitioners ’ perceived importance of research and levels of research literacy and capacity . However , increasing dem and s for evidence -based approaches across the health system puts pressure on all clinicians to base their decisions on the best available scientific evidence . Lack of clinician representation in research has the probable effect of limiting growth and new developments for the profession . Furthermore , lack of clinician involvement in research complicates the transfer of study findings into practical setting s. The Canadian Institutes of Health Research describes integrated knowledge translation as a process that involves collaboration between research ers and knowledge users at all stages of a research project.3 This necessitates involvement of clinicians to help in forming a research question , interpreting the results , and moving research findings into practice . This shared effort between clinicians and research ers increases the likelihood that research initiatives will be relevant to practice .3 Conversely , it has been reported that there is a growing communication gap between clinicians and academics in chiropractic . 4 Clinicians have important practice -related questions to ask , but many may lack the ability to map out their research strategy , specifically in communicating their question in a manner required to develop a research protocol . David L. Sackett , Officer of the Order of Canada and the founding Chair of Canada ’s first Department of Clinical Epidemiology & Biostatistics at McMaster University , highlights the importance of mapping one ’s research strategy in exploration of the research question : “ one-third of a trial ’s time between the germ of your idea and its publication in the New Engl and Journal of Medicine should be spent fighting about the research question . ” ( personal communication , November 30 , 2011 ) We describe a r and omized controlled trial ( RCT ) example to highlight how clinicians may use existing literature and the PICOT format to formulate a research question on treatment efficacy Background Reducing neonatal death has been an emerging challenge in low and middle income countries in the past decade . The development of the low cost interventions and their effective delivery are needed to reduce deaths from birth asphyxia . This study will assess the impact of a simplified neonatal resuscitation protocol provided by Helping Babies Breathe ( HBB ) at a tertiary hospital in Nepal .  Perinatal outcomes and performance of skilled birth attendants on management of intrapartum-related neonatal hypoxia will be the main measurements . Methods / Design The study will be carried out at a tertiary level maternity hospital in Nepal . A prospect i ve cohort- study will include a six-month baseline a six month intervention period and a three-month post intervention period . A quality improvement process cycle will introduce the neonatal resuscitation protocol . A surveillance system , including CCD cameras and pulse oximeters , will be set up to evaluate the intervention . Discussion Along with a technique to improve health workers performance on the protocol , the study will generate evidence on the research gap on the effectiveness of the simplified neonatal resuscitation protocol on intrapartum outcome and early neonatal survival . This will generate a global interest and inform policymaking in relation to delivery care in all income setting s . Trial registration IS RCT Background Therapeutic hypothermia reduces death and disability after moderate or severe neonatal encephalopathy in high-income countries and is used as st and ard therapy in these setting s. However , the safety and efficacy of cooling therapy in low- and middle-income countries ( LMICs ) , where 99 % of the disease burden occurs , remains unclear . We will examine whether whole body cooling reduces death or neurodisability at 18–22 months after neonatal encephalopathy , in LMICs . Methods We will r and omly allocate 408 term or near-term babies ( aged ≤ 6 h ) with moderate or severe neonatal encephalopathy admitted to public sector neonatal units in LMIC countries ( India , Bangladesh or Sri Lanka ) , to either usual care alone or whole-body cooling with usual care . Babies allocated to the cooling arm will have core body temperature maintained at 33.5 ° C using a servo-controlled cooling device for 72 h , followed by re-warming at 0.5 ° C per hour . All babies will have detailed infection screening at the time of recruitment and 3 Telsa cerebral magnetic resonance imaging and spectroscopy at 1–2 weeks after birth . Our primary endpoint is death or moderate or severe disability at the age of 18 months . Discussion Upon completion , HELIX will be the largest cooling trial in neonatal encephalopathy and will provide a definitive answer regarding the safety and efficacy of cooling therapy for neonatal encephalopathy in LMICs . The trial will also provide important data about the influence of co-existent perinatal infection on the efficacy of hypothermic neuroprotection . Trial registration Clinical Trials.gov , NCT02387385 . Registered on 27 February 2015 OBJECTIVE Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries ( LMICs ) . Mobile health technologies may improve noncommunicable disease outcomes , but LMICs lack re sources to provide these services . We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure ( BP ) monitoring as a strategy for improving systolic BPs ( SBPs ) and other outcomes of hypertensive patients in two LMICs . SUBJECTS AND METHODS This was a r and omized trial with a 6-week follow-up . Participants with high SBPs ( ≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic ) were enrolled from clinics in Honduras and Mexico . Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States , plus a home BP monitor . At baseline , control patients received BP results , hypertension information , and usual healthcare . The primary outcome , SBP , was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs . Secondary outcomes included perceived health status and medication-related problems . RESULTS Of the 200 patients recruited , 181 ( 90 % ) completed follow-up , and 117 of 181 had low literacy or high hypertension information needs . The median annual income was $ 2,900 USD , and average educational attainment was 6.5 years . At follow-up intervention patients ' SBPs decreased 4.2 mm Hg relative to controls ( 95 % confidence interval -9.1 , 0.7 ; p=0.09 ) . In the subgroup with high information needs , intervention patients ' average SBPs decreased 8.8 mm Hg ( -14.2 , -3.4 , p=0.002 ) . Compared with controls , intervention patients at follow-up reported fewer depressive symptoms ( p=0.004 ) , fewer medication problems ( p<0.0001 ) , better general health ( p<0.0001 ) , and greater satisfaction with care ( p≤0.004 ) . CONCLUSIONS Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs . A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support BACKGROUND Routine Immunization (RI)is known to beone of the most cost-effective public health strategies ever , and a cornerstone among all primary healthcare efforts but has been bedevilledin Low and Middle Income Countries ( LMICs ) in the last two decadesby poor coverage and lack of timeliness -both due , among other factors , to clients forgetting appointments . These setback RI effectiveness from ensuring herd immunity and preventing disease . Across the world , different cost-effective mobile telephone-based reminder systems are currently in use as strategies for improving coverage and compliance in various health interventions .Their application to RI is thereforehighly recommended . OBJECTIVE This study sought to provide evidence validating the need for development and deployment of automated client Reminder-Recall systems for the Nigerian National Routine Immunisation Program and to compare its projected cost withthe cost of a health personnel-based defaulter tracking system . METHODOLOGY A multi-centre , parallel-group , R and omized Controlled Trial was carried outusing multi-stage sampling . Nine hundred and five child-caregivers were followed-upat 8 health facilities in an urban/sub-urban area in South-South Nigeria . Text messagereminders were sent to the Intervention group only , with concurrent weekly data collection , including that for controls , at each of the enrolled health facilities . Recall messages were sent to defaulters and their responses ( presence at immunization session ) assessed the next RI session . Receipt of DPT3 vaccine on or before the 18th week was categorized early , while receiptafter was categorized delayed . RESULTS Clients in the Interventiongroup were1.5times earlier than Controls intheir receipt of DPT3 . Immunization coverage was also 8.7%better in the Interventiongroup . A first year estimate of cost of deploying this strategy was less than a quarter ofthe estimated cost of using home-visits which is the defaulter tracking method currently recommended by regulatory authorities . CONCLUSION Routine immunization performance was significantly better in the Interventiongroup who received SMS reminders compared to the controls who did not . Since this occurred at a cheaper rate than projected costs of home visits , in a habitual stock-out situation , this is ample evidence for health policy-makers in LMICs to leverage the ever exp and ing mobile telecom platforms for future sustainable improvements in routine immunisation performance and even other disease control efforts in Nigeria Background A novel approach is explored for improving causal inference in observational studies by comparing cohorts from high-income with low- or middle-income countries ( LMIC ) , where confounding structures differ . This is applied to assessing causal effects of  breastfeeding  on child blood pressure ( BP ) , body mass index ( BMI ) and intelligence quotient ( IQ ) . Methods St and ardized approaches for assessing the confounding structure of breastfeeding by socio-economic position were applied to the British Avon Longitudinal Study of Parents and Children ( ALSPAC ) ( N ≃ 5000 ) and Brazilian Pelotas 1993 cohorts ( N ≃ 1000 ) . This was used to improve causal inference regarding associations of breastfeeding with child BP , BMI and IQ . Analyses were extended to include results from a meta- analysis of five LMICs ( N ≃ 10 000 ) and compared with a r and omized trial of breastfeeding promotion . Findings Although higher socio-economic position was strongly associated with breastfeeding in ALSPAC , there was little such patterning in Pelotas . In ALSPAC , breastfeeding was associated with lower BP , lower BMI and higher IQ , adjusted for confounders , but in the directions expected if due to socioeconomic patterning . In contrast , in Pelotas , breastfeeding was not strongly associated with BP or BMI but was associated with higher IQ . Differences in associations observed between ALSPAC and the LMIC meta- analysis were in line with those observed between ALSPAC and Pelotas , but with robust evidence of heterogeneity detected between ALSPAC and the LMIC meta- analysis associations . Trial data supported the conclusions inferred by the cross-cohort comparisons , which provided evidence for causal effects on IQ but not for BP or BMI . Conclusion While reported associations of breastfeeding with child BP and BMI are likely to reflect residual confounding , breastfeeding may have causal effects on IQ . Comparing associations between population s with differing confounding structures can be used to improve causal inference in observational studies INTRODUCTION We will be unable to achieve sustained impact on health outcomes with community health worker (CHW)-based interventions unless we bridge the gap between small scale efficacy studies and large scale interventions . Effective strategies to support the management of CHWs are central to bridging the gap . Mobile phones are broadly available , particularly in low and middle income countries ( LAMIC 's ) , where the penetration rate approaches 100 % . In this article we describe how mobile phones may be combined with mobile web-based technology to assist in the management of CHWs in two projects in South Africa . METHODS This paper is a descriptive one , drawing lessons from two R and omised Controlled Trials ( RCT ' s ) , outlining how a mobile phone information system can be utilized to enhance the quality of health interventions . We organized our comprehensive management and supervision system around a previously published management framework . The system is composed of mobile phones utilized by CHWs and a web-based interface utilized by CHW supervisors  . Computerized algorithms were design ed with intervention and assessment protocol s to aid in the real-time supervision and management of CHWs . RESULTS CHWs used mobile phones to initiate intervention visits and trigger content to be delivered during the course of intervention visits . Supervisors used the web-based interface for real-time monitoring of the location , timing , and content of intervention visits . Additional real-time support was provided through direct support calls in the event of crises in the field . CONCLUSION Mobile phone-based information system platforms offer significant opportunities to improve CHW-delivered interventions . The extent to which these efficiency gains can be translated into realized health gains for communities is yet to be tested Background Cluster r and omised trials ( CRTs ) are a key instrument to evaluate public health interventions , particularly in low- and middle-income countries ( LMICs ) . Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned . Evaluation of implementation fidelity ( IF ) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions . Current CRT reporting guidelines offer no guidance on IF assessment . We will systematic ally review the scientific literature to study current practice s concerning the assessment of IF in CRTs of public health interventions in LMICs . Methods We will include  CRTs of public health interventions in LMICs that planned or assessed IF in either the trial protocol or the main trial report ( or an associated document ) . Search strategies use Medical Subject Headings ( MESH ) and text words related to CRTs , developing countries , and public health interventions . The electronic data base search was developed first for MEDLINE and adapted for the following data bases : EMBASE , CINAHL , PubMed , and EMB Review s , to identify CRT reports in English , Spanish , or French published on or after January 1 , 2012 . To ensure availability of a study protocol , we will include CRTs reporting a registration number in the abstract . For each included study , we will compare planned versus reported assessment of IF , and consider the dimensions of IF studied , and data collection methods used to evaluate each dimension . Data will be synthesis ed using quantitative and narrative techniques . Risk of bias for individual studies will be assessed using the Cochrane Collaboration Risk of Bias Tool criteria and additional criteria related to CRT methods . We will investigate possible sources of heterogeneity by performing subgroup analysis . This review was not eligible for inclusion in the PROSPERO registry . Discussion Fidelity assessment may be a key tool for making studies more reliable , internally valid , and externally generalizable . This review will provide a portrait of current practice s related to the assessment of intervention fidelity in CRTs and offer suggestions for improvement . Results will be relevant to research ers , those who finance health interventions , and for decision-makers who seek the best evidence on public health interventions This study assessed the effectiveness of translating evidence -based asthma interventions into community health centers . BACKGROUND AND OBJECTIVES : Research ers often struggle with the gap between efficacy and effectiveness in clinical research . To bridge this gap , the Community Healthcare for Asthma Management and Prevention of Symptoms ( CHAMPS ) study adapted an efficacious , r and omized controlled trial that result ed in evidence -based asthma interventions in community health centers . METHODS : Children ( aged 5–12 years ; N = 590 ) with moderate to severe asthma were enrolled from 3 intervention and 3 geographically/capacity-matched control sites in high-risk , low-income communities located in Arizona , Michigan , and Puerto Rico . The asthma intervention was tailored to the participant ’s allergen sensitivity and exposure , and it comprised 4 visits over the course of 1 year . Study visits were documented and monitored prospect ively via electronic data capture . Asthma symptoms and health care utilization were evaluated at baseline , and at 6 and 12 months . RESULTS : A total of 314 intervention children and 276 control children were enrolled in the study .  Allergen sensitivity testing ( 96 % ) and home environmental assessment s ( 89 % ) were performed on the majority of intervention children . Overall study activity completion ( eg , intervention visits , clinical assessment s ) was 70 % . Overall and individual site participant symptom days in the previous 4 weeks were significantly reduced compared with control findings ( control , change of −2.28 ; intervention , change of −3.27 ; difference , −0.99 ; P < .001 ) , and this result was consistent with changes found in the rigorous evidence -based interventions . CONCLUSIONS : Evidence -based interventions can be successfully adapted into primary care setting s that serve impoverished , high-risk population s , reducing the morbidity of asthma in these high-need population The purpose of this review was to determine whether mHealth interventions were effective in low- and middle-income countries in order to create a baseline for the evidence to support mHealth in developing countries . Studies were identified by search ing Medline on 02 October 2014 for articles published in the English language between January 2000 and September 2014 . Inclusion criteria were : 1 ) written in English , 2 ) completion of an mHealth intervention in a low or middle-income country , 3 ) measurement of patient outcomes , and 4 ) participants 18 years of age or older . 7,920 titles were review ed and 7 were determined eligible based on inclusion criteria . Interventions included a cluster r and omized trial , mixed methods study , retrospective comparison of an opt-in text message program , a two-arm proof of concept , single arm trial , a r and omized trial , and a single subject design . Five out of seven of the studies showed significant difference between the control and intervention . Currently there is little evidence on mHealth interventions in developing countries , and existing studies are very diverse ; however initial studies show changes in clinical outcomes , adherence , and health communication , including improved communication with providers , decrease in travel time , ability to receive expert advice , changes in clinical outcomes , and new forms of cost-effective education . While this initial review is promising , more evidence is needed to support and direct system-level re source investment Background Diabetes is now a global epidemic , but most cases are now in low- and middle-income countries . Diabetes self-management education ( DSME ) is key to enabling patients to manage their chronic condition and can reduce the occurrence of costly and devastating complications . However , there is limited evidence on the effectiveness of different DSME programmes in re source limited setting s. Methods We conducted an unblinded , parallel-group , individually-r and omised controlled trial at the University of Calabar Teaching Hospital ( Nigeria ) to evaluate whether an intensive and systematic DSME programme , using structured guidelines , improved glycaemic control compared to the existing ad hoc patient education ( clinical practice was unchanged ) . Eligible patients ( ≥18 years , HbA1c > 8.5 % and physically able to participate ) were r and omly allocated by permuted block r and omisation to participate for six months in either an intensive or conventional education group . The primary outcome was HbA1c ( % ) at six-months . Results We r and omised 59 participants to each group and obtained six-month HbA1c outcomes from 53 and 51 participants in the intensive and conventional education groups , respectively . Intensive group participants had a mean six-month HbA1c ( % ) of 8.4 ( 95 % CI : 8 to 8.9 ) , while participants in the conventional education group had a mean six-month HbA1c ( % ) of 10.2 ( 95 % CI : 9.8 to 10.7 ) . The difference was statistically ( P < 0.0001 ) and clinical ly significant , with intensive group participants having HbA1c outcomes on average -1.8 ( 95 % CI : -2.4 to -1.2 ) percentage points lower than conventional group participants . Results were robust to adjustment for a range of covariates and multiple imputation of missing outcome data . Conclusions This study demonstrates the effectiveness of a structured , guideline -based DSME intervention in a LMIC setting versus a pragmatic comparator . The intervention is potentially replicable at other levels of the Nigerian healthcare system and in other LMICs , where nurses/diabetes educators can run the programme . Trial Registration Pan African Clinical Trial Registry Introduction Expectant mothers in low-income and middle-income countries often lack access to vital information about pregnancy , preparation for birth and best practice s when caring for their newborn . Innovative solutions are needed to bridge this knowledge gap and dramatically improve maternal and neonatal health in these setting s. This study aims to evaluate the impact of an innovative text messaging intervention on maternal and neonatal health outcomes . Methods and analysis This study offers expectant mothers in rural China a package of free short messages via cell phone regarding pregnancy and childbirth . These messages are tailored to each mother 's gestational week . It is hypothesised that delivering these short advice messages to pregnant women can improve maternal and newborn health . The study uses factorial quasi-r and omisation to compare psychological , behavioural and health outcomes between 4 groups : 2 groups receiving different sets of short message interventions ( ie , good household prenatal practice s and healthcare seeking ) , a group receiving both interventions and a control group . Treatment assignment occurs at the individual level . The primary outcome is newborn health , measured by appropriateness of weight for gestational age . Secondary outcomes include severe neonatal and maternal morbidity as well as psychological and behavioural measures . This study has enrolled pregnant women who attend county maternal and child health centres for their prenatal visits . Discussion This pilot is the first large-scale effort to build a comprehensive evidence base on the impact of prenatal text messages via cell phone on maternal and newborn health outcomes in China . The study has broad implication s for public health policy in China and the implementation of mobile health interventions in low-re source setting s around the world . Ethics This study was approved by the Ethics Committee of the School of Medicine at Xi'an Jiaotong University on 18 January 2013 . Trial registration number NCT02037087 ; Pre- results Introduction Diabetes self-management education ( DSME ) is a fundamental element of type 2 diabetes care . Although 75 % of adults with diabetes worldwide live in low-income and middle-income countries ( LMICs ) , limited DSME research has been conducted in LMICs . The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala . Methods We conducted a prospect i ve study of a DSME intervention using a quasi-experimental , single-group pretest – posttest design . We enrolled 90 participants in the intervention , which consisted of 6 home visits ( May 2014–July 2016 ) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan population s. Primary outcomes were changes in mean hemoglobin A1c ( HbA1c ) and mean systolic and diastolic blood pressure at baseline and at 12 months . Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion . Results HbA1c decreased significantly from baseline to 12 months ( absolute mean change , −1.5 % ; 95 % confidence interval [ CI ] , −1.9 % to −1.0 % ; P < .001 ) . Systolic blood pressure also improved significantly at 12 months ( −6.2 mm Hg ; 95 % CI , −10.1 to −2.2 mm Hg ; P = .002 ) ; changes in diastolic blood pressure were not significant ( −1.6 mm Hg ; 95 % CI , −3.9 to −0.7 mm Hg ; P = .17 ) . We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion . Conclusion DSME interventions can be successfully delivered in a setting with an underre source d health system , high poverty rate , and unique cultural characteristics like Mayan Guatemala . Our findings point to the need for more DSME research in re source -limited setting s globally Purpose : To set priorities for new systematic review s ( SRs ) and r and omized clinical trials on the management of primary angle closure ( PAC ) using clinical practice guidelines and a survey of Asia-Pacific clinicians . Methods : We restated the American Academy of Ophthalmology ’s Preferred Practice Patterns recommendations for management of PAC into answerable clinical questions . We asked participants at the Asia-Pacific Joint Glaucoma Congress 2010 in Taipei to rate the importance of having an answer to each question for providing effective patient care , using a Likert-type scale and scoring from 0 ( not important at all ) to 10 ( highly important ) . We identified relevant SRs and mapped the evidence to clinical questions to identify evidence gaps . Results : We generated 42 clinical questions . One hundred seventy-five individuals agreed to participate in the survey , 132 responded ( 75.4 % response rate ) and 96 completed the question naire ( 54.9 % usable response rate ) . Questions rated important include laser iridotomy for the prevention of angle closure in primary angle-closure suspects , further therapies in eyes with plateau iris syndrome after laser iridotomy , and evaluation of the fellow eye in acute angle-closure patients for improving prognosis . Up-to- date and conclusive SR evidence was not available for any of the 42 clinical questions . Conclusions : We identified high priority clinical questions on the management of PAC , none of which had reliable SR evidence available . New SRs and r and omized clinical trials can be initiated to address these evidence gaps Maternal health services continue to favour the wealthiest in lower and middle income countries . Debate about the potential of performance-based financing ( PBF ) to address these disparities continues . As PBF is adopted by countries , it is critical to underst and the equity effects for maternal services . The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population . In Rw and a , PBF was design ed to increase health service use , which was universally low . Paired districts were r and omly assigned to intervention and control for PBF implementation . Using Rw and a 's Demographic Health Survey data from 2005 ( pre-intervention ) and 2007 - 8 ( post-intervention ) , a cluster-level panel data set of 7899 women 15 - 49 years of age from intervention ( 4477 ) and control districts ( 3422 ) was created . The impact of PBF on reported use of facility deliveries , antenatal care ( ANC ) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects . Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women . The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts ( P = 0.014 ) , while no significant effects were noted for ANC visits or modern contraceptive use . Service use increased for intervention and control population s and across all wealth quintiles from 2005 to 2007 , with no evidence that PBF was a pro-poor or a pro-rich strategy . Insurance remained a positive predictor of service use . This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services , such as facility deliveries , may improve service use overall . However , if the equity gap is extreme , then a PBF programme without equity targets will do little to alleviate disparities Background Primary health professionals are well positioned to support the delivery of patient self-management in an evidence -based , structured capacity . A need exists to better underst and the active components required for effective self-management support , how these might be delivered within primary care , and the training and system changes that would subsequently be needed . Objectives ( 1 ) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual st and ard of care ; and ( 2 ) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting . Method A systematic review of r and omized controlled trials evaluating self-management support interventions was conducted following the Cochrane h and book & PRISMA guidelines . Published literature was systematic ally search ed from inception to June 2019 in PubMed , Scopus and Web of Science . Eligible studies assessed the effectiveness of individualized interventions with follow-up , delivered face-to-face to adult patients with any condition in primary care , compared with usual st and ard of care . Matrices were developed that mapped the evidence and components for each intervention . The method ological quality of included studies were appraised . Results 6,510 records were retrieved . 58 studies were included in the final qualitative synthesis . Findings reveal a structured patient-provider exchange is required in primary care ( including a one-on-one patient-provider consultation , ongoing follow up and provision of self-help material s ) . Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient ’s disease or treatment knowledge ; independent monitoring of symptoms , encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations , psychological coping and stress management strategies , and enhancing responsibility in medication adherence and lifestyle choices . Follow-up may include tailored feedback , monitoring of progress with respect to patient set healthcare goals , or honing problem-solving and decision-making skills . Theoretical models provided a strong base for effective SMS interventions . Positive outcomes for effective SMS included improvements in clinical indicators , health-related quality of life , self-efficacy ( confidence to self-manage ) , disease knowledge or control . An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice . Conclusions These findings provide primary care professionals with evidence -based strategies and structure to deliver SMS in practice . For this collaborative partnership approach to be more widely applied , future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process 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 : Purpose This paper visualizes the available data on vitamin D status on a global map , examines the existing heterogeneities in vitamin D status and identifies research gaps . Methods A graphical illustration of global vitamin D status was developed based on a systematic review of the worldwide literature published between 1990 and 2011 . Studies were eligible if they included sample s of r and omly selected males and females from the general population and assessed  circulating 25-hydroxyvitamin D [ 25(OH)D ] levels .  Two different age categories were selected : children and adolescents ( 1–18 years ) and adults ( > 18 years ) . Studies were chosen to represent a country based on a hierarchical set of criteria . Results In total , 200 studies from 46 countries met the inclusion criteria , most coming from Europe . Forty-two of these studies ( 21 % ) were classified as representative . In children , gaps in data were identified in large parts of Africa , Central and South America , Europe , and most of the Asia/Pacific region . In adults , there was lack of information in Central America , much of South America and Africa . Large regions were identified for which the mean 25(OH)D levels were below 50 nmol/L. Conclusions This study provides an overview of 25(OH)D levels around the globe . It reveals large gaps in information in children and adolescents and smaller but important gaps in adults . In view of the importance of vitamin D to musculoskeletal growth , development , and preservation , and of its potential importance in other tissues , we strongly encourage new research to clearly define 25(OH)D status around the world Background Blood Pressure related disease affected 118 million people in India in the year 2000 ; this figure will double by 2025 . Around one in four adults in rural India have hypertension , and of those , only a minority are accessing appropriate care . Health systems in India face substantial challenges to meet these gaps in care , and innovative solutions are needed . Methods We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare . This intervention will be implemented as a stepped wedge , cluster r and omised controlled trial in 18 primary health centres and 54 villages in rural And hra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk ( approximately 15,000 people ) . Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension ’s region-specific risk charts . Cluster r and omisation will occur at the level of the primary health centres . Outcome analyses will be conducted blinded to intervention allocation . Expected outcomes The primary study outcome is the difference in the proportion of people meeting guideline -recommended blood pressure targets in the intervention period vs. the control period . Secondary outcomes include mean reduction in blood pressure levels ; change in other cardiovascular disease risk factors , including body mass index , current smoking , reported healthy eating habits , and reported physical activity levels ; self-reported use of blood pressure and other cardiovascular medicines ; quality of life ( using the EQ-5D ) ; and cardiovascular disease events ( using hospitalisation data ) . Trial outcomes will be accompanied by detailed process and economic evaluations . Significance The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served population s in low and middle income country setting s . Trial registration Clinical Trial Registry India CTRI/2013/06/003753 Introduction We are undertaking a r and omised controlled trial ( fAmily led rehabiliTaTion aftEr stroke in INDia , ATTEND ) evaluating training a family carer to enable maximal rehabilitation  of patients with stroke-related disability ; as a potentially affordable , culturally acceptable and effective intervention for use in India . A process evaluation is needed to underst and how and why this complex intervention may be effective , and to capture important barriers and facilitators to its implementation . We describe the protocol for our process evaluation to encourage the development of in-process evaluation methodology and transparency in reporting . Methods and analysis The realist and RE- AIM ( Reach , Effectiveness , Adoption , Implementation and Maintenance ) frameworks informed the design . Mixed methods include semistructured interviews with health providers , patients and their carers , analysis of quantitative  process data describing fidelity and dose of intervention , observations of trial set up and implementation , and the analysis of the cost data from the patients and their families perspective and programme budgets . These qualitative and quantitative data will be analysed iteratively prior to knowing the quantitative outcomes of the trial , and then triangulated with the results from the primary outcome evaluation . Ethics and dissemination The process evaluation has received ethical approval for all sites in India . In low-income and middle-income countries , the available human capital can form an approach to reducing the evidence practice gap , compared with the high cost alternatives available in established market economies . This process evaluation will provide insights into how such a programme can be implemented in practice and brought to scale . Through local stakeholder engagement and dissemination of findings globally we hope to build on patient-centred , cost-effective and sustainable models of stroke rehabilitation . Trial registration number CTRI/2013/04/003557 BACKGROUND Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day , but their intake is thought to be low worldwide . We aim ed to determine the extent to which such low intake is related to availability and affordability . METHODS We assessed  fruit and vegetable consumption  using data from country-specific , vali date d semi-quantitative food frequency question naires in the Prospect i ve Urban Rural Epidemiology ( PURE ) study , which enrolled participants from communities in 18 countries between Jan 1 , 2003 , and Dec 31 , 2013 . We documented household income data from participants in these communities ; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1 , 2009 , and Dec 31 , 2013 . We determined the cost of fruits and vegetables relative to income per household member . Linear r and om effects models , adjusting for the clustering of households within communities , were used to assess mean fruit and vegetable intake by their relative cost . FINDINGS Of 143 305 participants who reported plausible energy intake in the food frequency question naire  , mean fruit and vegetable intake was 3·76 servings ( 95 % CI 3·66 - 3·86 ) per day . Mean daily consumption was 2·14 servings ( 1·93 - 2·36 ) in low-income countries ( LICs ) , 3·17 servings ( 2·99 - 3·35 ) in lower-middle-income countries ( LMICs ) , 4·31 servings ( 4·09 - 4·53 ) in upper-middle-income countries ( UMICs ) , and 5·42 servings ( 5·13 - 5·71 ) in high-income countries ( HICs ) . In 130 402 participants who had household income data available , the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97 % ( 95 % CI 46·06 - 57·88 ) of household income in LICs , 18·10 % ( 14·53 - 21·68 ) in LMICs , 15·87 % ( 11·51 - 20·23 ) in UMICs , and 1·85 % ( -3·90 to 7·59 ) in HICs ( ptrend=0·0001 ) . In all regions , a higher percentage of income to meet the guidelines was required in rural areas than in urban areas ( p<0·0001 for each pairwise comparison ) . Fruit and vegetable consumption among individuals decreased as the relative cost increased ( ptrend=0·00040 ) . INTERPRETATION The consumption of fruit and vegetables is low worldwide , particularly in LICs , and this is associated with low affordability . Policies worldwide should enhance the availability and affordability of fruits and vegetables . FUNDING Population Health Research Institute , the Canadian Institutes of Health Research , Heart and Stroke Foundation of Ontario , AstraZeneca ( Canada ) , Sanofi-Aventis ( France and Canada ) , Boehringer Ingelheim ( Germany and Canada ) , Servier , GlaxoSmithKline , Novartis , King Pharma , and national or local organisations in participating countries Background Despite harmful drinking causing a significant burden on global health , there is a large treatment gap , especially in low‐ and middle‐income countries . A major barrier to care is the lack of adequately skilled human re sources to deliver context ually appropriate treatments . This paper describes the systematic process used to develop Counselling for Alcohol Problems ( CAP ) , a brief psychological treatment ( PT ) for delivery by lay counselors in routine primary care setting s to men with harmful drinking in India . Methods CAP was developed using a methodology involving 3 sequential steps : ( i ) identifying potential treatment strategies ; ( ii ) developing a theoretical framework for the treatment ; and ( iii ) evaluating the acceptability and feasibility of the treatment . Results CAP is a 3‐phase treatment delivered over 1 to 4 sessions based on a motivational interviewing ( MI ) stance and involves the following strategies : assessment and personalized feedback , family engagement , drink refusal skills , skills to address drinking urges , problem‐solving skills and h and ling difficult emotions , and relapse prevention and management . Data from a case series were used to inform several adaptations to enhance the acceptability of CAP to the recipients and feasibility of delivery by lay counselors of the treatment , for example expansion of the target group to include alcohol‐dependent patients and the extension of the delivery setting s to include home‐based delivery . There was preliminary evidence of the effectiveness of CAP . Conclusions CAP is an acceptable brief PT for harmful drinking delivered by lay counselors in primary care whose effectiveness is currently being tested in a r and omized controlled trial based in primary care in Goa , India BACKGROUND Physical activity has a protective effect against  cardiovascular disease ( CVD )  in high-income countries , where physical activity is mainly recreational , but it is not known if this is also observed in lower-income countries , where physical activity is mainly non-recreational . We examined whether different amounts and types of physical activity are associated with lower mortality and CVD  in countries at different economic levels . METHODS In this prospect i ve cohort study , we recruited participants from 17 countries ( Canada , Sweden , United Arab Emirates , Argentina , Brazil , Chile , Pol and , Turkey , Malaysia , South Africa , China , Colombia , Iran , Bangladesh , India , Pakistan , and Zimbabwe ) . Within each country , urban and rural areas in and around selected cities and towns were identified to reflect the geographical diversity . Within these communities , we invited individuals aged between 35 and 70 years who intended to live at their current address for at least another 4 years .  Total physical activity  was assessed using the  International Physical Activity Question naire ( IPQA ) . Participants with pre-existing CVD were excluded from the analyses . Mortality and CVD were recorded during a mean of 6·9 years of follow-up . Primary clinical outcomes during follow-up were mortality plus major CVD ( CVD mortality , incident myocardial infa rct ion , stroke , or heart failure ) , either as a composite or separately . The effects of physical activity on mortality and CVD were adjusted for sociodemographic factors and other risk factors taking into account household , community , and country clustering . FINDINGS Between Jan 1 , 2003 , and Dec 31 , 2010 , 168 916 participants were enrolled , of whom 141 945 completed the IPAQ . Analyses were limited to the 130 843 participants without pre-existing CVD . Compared with low physical activity ( < 600 metabolic equivalents [ MET ] × minutes per week or < 150 minutes per week of moderate intensity physical activity ) , moderate ( 600 - 3000 MET × minutes or 150 - 750 minutes per week ) and high physical activity ( > 3000 MET × minutes or > 750 minutes per week ) were associated with grade d reduction in mortality ( hazard ratio 0·80 , 95 % CI 0·74 - 0·87 and 0·65 , 0·60 - 0·71 ; p<0·0001 for trend ) , and major CVD ( 0·86 , 0·78 - 0·93 ; p<0·001 for trend  ) . Higher physical activity was associated with lower risk of CVD and mortality  in high-income , middle-income , and low-income countries . The adjusted population attributable fraction for not meeting the physical activity guidelines was 8·0 % for mortality and 4·6 % for major CVD , and for not meeting high physical activity was 13·0 % for mortality and 9·5 % for major CVD . Both recreational and non-recreational physical activity were associated with benefits . INTERPRETATION Higher recreational and non-recreational physical activity was associated with a lower risk of mortality and CVD events in individuals from low-income , middle-income , and high-income countries . Increasing physical activity is a simple , widely applicable , low cost global strategy that could reduce deaths and CVD in middle age . FUNDING Population Health Research Institute , the Canadian Institutes of Health Research , Heart and Stroke Foundation of Ontario , Ontario SPOR Support Unit , Ontario Ministry of Health and Long-Term Care , AstraZeneca , Sanofi-Aventis , Boehringer Ingelheim , Servier , GSK , Novartis , King Pharma , and national and local organisations in participating countries that are listed at the end of the Article Ductal carcinoma in situ ( DCIS ) is a condition in which abnormal cells line the milk ducts of the breast but have not invaded the underlying breast tissue . Approximately 55000 new cases of DCIS were expected to occur among U.S. women in 2013 , which accounted for approximately 24 % of all new breast cancer diagnoses ( 1 ) . Although the annual incidence of DCIS is less than that of invasive breast cancer , exp and ed use of screening mammography has led to a dramatic increase in the diagnosis of DCIS ( 32.5 cases per 100000 women ) ( 2 ) . There is considerable uncertainty about the optimal clinical management of DCIS because of the lack of reliable methods for distinguishing DCIS that would never become symptomatic from DCIS that is likely to progress to life-threatening invasive cancer ( 3 ) . Current treatment options for DCIS include mastectomy , breast-conserving surgery ( BCS ) , and BCS plus radiation therapy ( 2 , 46 ) . There are limited r and omized , controlled trials ( RCTs ) on which to base decisions about the tradeoffs among DCIS treatment options , and the existing trials may not capture all relevant patient-centered outcomes . For example , 4 large RCTs comparing BCS alone with BCS plus radiation therapy all show similar , very high overall survival regardless of treatment ( 710 ) . The addition of radiation therapy significantly reduces the risk for local recurrence ; approximately one half of all recurrences are DCIS rather than invasive cancer ( 5 , 11 ) . The long-term benefit of preventing the recurrence of an asymptomatic condition that may or may not progress to cancer is difficult to quantify . In other conditions where screening may detect early cancer or cancer precursors that may not progress to a life-threatening stage , such as early-stage prostate cancer , active surveillance or watchful waiting ( an observation strategy ) is an acceptable option for some patients . A similar strategy may be acceptable for some women diagnosed with DCIS , although no studies have compared management strategies that involve no immediate treatment ( that is , observation or active surveillance ) versus immediate treatments . The most important potential benefit of treatment of DCIS is the reduction in the number of deaths due to invasive breast cancer . For many women with a DCIS diagnosis , this may be an unrealized benefit . Some proportion of DCIS may never progress to life-threatening invasive cancer , so these women only have the adverse outcomes of diagnosis and treatments . Both active management strategies and surveillance approaches present tradeoffs relevant to patient-centered outcomes , such as symptoms , function , and well-being . Given the clinical importance of DCIS , the diversity of available treatment strategies , variety of patient-centered outcomes of interest , and areas of uncertainty , we sought to create a prioritized research agenda for the Patient-Centered Outcomes Research Institute ( PCORI ) that would incorporate different stakeholders ' perspectives . A central goal of PCORI is to engage stakeholders in its work in a meaningful way . Between September 2012 and January 2013 , PCORI undertook a broad effort tosolicit research topics to consider for targeted funding from patients , caregivers , research ers , and results of previous prioritization processes by groups , such as the Institute of Medicine . In April 2013 , PCORI 's Assessment of Prevention , Diagnosis , and Treatment Options program , together with the program 's external advisory panel , have identified DCIS management as an important topic with unmet research needs . Then , PCORI tasked the Duke University Evidence Synthesis Group ( ESG ) to work with various stakeholders to identify and prioritize the future research that is most needed by patients and other decision makers on this topic . Methods Overview of Prioritization Approach Our approach to prioritizing future research and developing recommendations for targeted future funding by PCORI included several steps ( Figure 1 ) . These included appraisal s of recent systematic review s to preliminarily identify important evidence gaps , transformation of evidence gaps into research questions and organization of the questions within a comprehensive analytic framework , engagement of stakeholders to identify additional gaps and prioritize research needs or questions , scans of recently published and ongoing studies relevant to the stakeholders ' list of prioritized research needs , and identification of potential study design s to address prioritized research questions . Figure 1 . Overview of prioritization process Adapted from reference 12 . ESG = Evidence Synthesis Group ; PCORI = Patient-Centered Outcomes Research Institute . Identification of Evidence Gaps We used an iterative process to identify evidence gaps for DCIS management . First , we identified and appraised recent published systematic review s , clinical practice guidelines , and future research needs documents to develop an initial list of evidence gaps . This list was neither exhaustive nor prioritized . Next , we organized these gaps according to the population s , interventions , comparators , outcomes , timing , and setting of interest and transformed them into research questions informed by the criteria . Selection and Engagement of Stakeholders We convened a group of 9 stakeholders , including clinical experts and research ers in DCIS management strategies , representatives from federal and nongovernmental funding agencies , representatives from relevant professional societies , health care decision makers and policymakers , and representatives from related consumer and patient advocacy groups ( Table 1 of the Supplement ) . Within each of these categories , we sought to identify a person who was either familiar with the clinical area and its current uncertainties or brought a specific method ological expertise to the stakeholder panel . The University of Minnesota Evidence -based Practice Center , which did a comparative effectiveness review on DCIS management in 2009 ( 13 ) , and PCORI 's patient engagement group provided input on potential stakeholders . Each potential stakeholder completed a disclosure statement and was screened for conflicts of interest . We solicited and received stakeholder input at various points in the process through group discussion s via teleconferences detailing the process and outlining existing evidence gaps , Web-based surveys to obtain priority ranking of topics , and e-mail communications to solicit or provide further clarification of research gaps from teleconferences . Supplement . Supplementary Data for Prioritization of Research Addressing the Management of DCIS Development of an Analytic Framework On the basis of the exp and ed list of 30 evidence gaps and informed by an analytic framework in a recent evidence synthesis on DCIS ( 13 ) , we constructed an analytic framework that depicted the identified knowledge gaps within the context of the population s , interventions , comparators , outcomes , timing , and setting criteria ( Figure 2 ) . This framework shows that women diagnosed with DCIS may have pretreatment evaluations . After these evaluations , women may undergo several management strategies . These management strategies affect patient-centered outcomes ( such as development of comorbid conditions , DCIS recurrence , invasive cancer , and sexual functioning ) . Throughout the analytic framework , population factors ( such as socioeconomic , family history , and genetic factors ) and effects of decisional uncertainty about management strategies were highlighted as potential modifiers . Figure 2 . Analytic framework . DCIS = ductal carcinoma in situ ; FRN = future research need ; MRI = magnetic resonance imaging . Prioritization of Future Research After expansion of the identified research priorities , stakeholders were invited to rank the revised future research needs online . The survey used a forced-ranking prioritization method described by the Agency for Healthcare Research and Quality Evidence -based Practice Center 's Future Research Needs projects ( 14 ) , whereby participants were given 10 votes that could be allocated to any identified research priorities , with a maximum of 3 votes per item . The stakeholders were not given specific prioritization criteria to use but rather were told to decide , on the basis of their perspectives , which were the most important unanswered research questions in DCIS management . Only the priorities in the top tier ( n= 10 ) moved on to the final stage of horizon scan and study design determination . Stakeholders were informed of the final ranking of future research priorities . Horizon Scan of Studies Potentially Relevant to Top-Tier Research Questions We performed 2 data base search es to identify recently published and ongoing studies relevant to the top-tier future research questions result ing from the stakeholder forced-ranking prioritization exercise . We search ed PubMed to identify relevant literature published since 2008 and Clinical Trials.gov for ongoing studies . Members of the ESG team review ed the titles and abstract s identified by search ing PubMed for applicability to the top-tier research questions ; full texts were then obtained and screened for all citations passing the title- and - abstract screening . At both the title- and - abstract and full-text screening stages , articles were included if they met all of the following criteria : presented original data or secondary analysis of data from an RCT , prospect i ve or retrospective observational study , or relevant modeling study ; included data for a pretreatment evaluation or management strategy of interest ; included women with DCIS ; and had a stated objective that could be categorized according to our identified list of research priorities . We search ed Clinical Trials.gov using the keywords ductal carcinoma in situ and DCIS . A member of the ESG team review ed all study abstract s result ing from the search and coded them as potentially relevant to 1 or more of the identified research priorities . We then abstract ed study type ( such as OBJECTIVES To analyze data from recent Demographic and Health Surveys ( DHS ) conducted in 21 low- and middle-income countries ( LMICs ) to examine patterns of interpregnancy intervals , unmet need , pregnancy risk and family planning method use and method mix among women 0 - 23 months postpartum . STUDY DESIGN Secondary analysis of postpartum women aged 15 - 49 years in 22 DHS surveys from 21 LMICs conducted between 2005 and 2012 . We applied an adapted unmet need definition for postpartum women to look at prospect i ve fertility preferences . We also constructed a new composite pregnancy risk indicator for postpartum women who have been sexually active since their last birth . RESULTS In 9 of 22 surveys , 50 % or more of nonfirst births occur at interpregnancy intervals that are too short . Overall prospect i ve unmet need for family planning by postpartum women has not changed demonstrably since a 2001 analysis and is universally high : 61 % of all postpartum women across the 21 countries have an unmet need for family planning . In 10 of 22 surveys , pregnancy risk rises steadily throughout the 2 years after birth . In the remaining 12 surveys , the risk of pregnancy peaks at 6 - 11 months after birth . Even when postpartum women are using family planning , they rely overwhelmingly on short-acting methods ( 51 - 96 % in 21 of 22 surveys ) . CONCLUSION Our approach of estimating pregnancy risk by postpartum timing confirms a high probability for pregnancies to be less than optimally spaced within 2 years of a prior birth and suggests that special consideration is needed to effectively reach this population with the right messages and services . IMPLICATION S Using recent , multicountry data for women within 2 years postpartum in LMICs , this paper up date s existing estimates of high prospect i ve unmet need for family planning and presents a new composite pregnancy risk analysis based on postpartum women 's actual practice s to demonstrate the magnitude of missed opportunities for programmatic intervention for the postpartum population 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 Persistent unmet preventive and developmental health care needs of children in low-income families are a national concern . Recently , there have been efforts to promote developmental services as part of primary care for all young children . However , there is limited research to determine whether the neediest families are well in universal interventions . In our study , we assessed if disparities persist in utilization of developmental services , well child care , and satisfaction with care among low- , middle- , and high-income families participating in Healthy Steps for Young Children . Healthy Steps is a national experiment that incorporated developmental services into primary care for children from birth to 3 years of age . In the United States , 15 pediatric practice s participated in this prospect i ve study . At birth , 2,963 children were enrolled between September 1996 and November 1998 and followed through 33 months of age . The utilization of developmental services , satisfaction with care , and receipt of age-appropriate well child visits were measured at 30–33 months and adjusted for demographic and economic covariates . We found that the adjusted odds of low-income families did not differ from high-income families in receipt of four or more  Healthy Steps services  , a home visit , or discussing five or more child rearing topics . Low- and middle-income families had reduced adjusted odds of receiving a developmental assessment and books to read . The adjusted odds of low- and middle-income families did not differ from high-income families in being very satisfied with care provided or receiving age-appropriate well child visits . A universal practice -based intervention such as Healthy Steps has the potential to reduce income disparities in the utilization of preventive services , timely well child care , and satisfaction with care INTRODUCTION Despite the frequency of acute asthma in the emergency department ( ED ) and the availability of guidelines , significant practice variation exists . Asthma care maps ( ACMs ) may st and ardize treatment . This study examined the use of an ACM to determine its effects on patient management in a regional hospital . METHODS Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospect i ve study that took place 5 months before ( pre ) and 5 months after ( post ) ACM implementation . Research assistants using a st and ardized question naire abstract ed data through direct patient interviews and then followed up at 2 weeks with a st and ardized telephone interview . RESULTS Overall , 71 pre patients and 70 post patients were enrolled . Characteristics in both groups were similar . The care map was used in 100 % of the cases during the post period . The mean length of stay in the ED for the pre , compared with the post period , was similar ( 2 h 14 min v. 2 h 25 min ; p = 0.60 ) , as were admission rates ( 11 % v. 9 % ; p = 0.59 ) . Systemic corticosteroid use was similar ( 62 % v. 57 % ; p = 0.56 ) ; however , the total number of beta-agonists ( 2 v. 4 treatments ; p = 0.002 ) and  anticholinergics  ( 1 v. 2 treatments ; p < 0.001 ) administered in the ED was higher during the post period . Prescriptions for oral ( 73 % v. 60 % ; p = 0.15 ) and inhaled ( 78 % v. 78 % ; p = 0.98 ) corticosteroids at discharge remained the same . Relapse rates at follow-up were unchanged ( 29 % v. 34 % ; p = 0.52 ) . CONCLUSION This study provides evidence that implementation of an ACM increased acute bronchodilator use ; however , prescribing preventive medications did not increase . Further research is required to evaluate other strategies to improve asthma care by emergency physicians IMPORTANCE Little is known about adoption of healthy lifestyle behaviors among individuals with a coronary heart disease ( CHD ) or stroke event in communities across a range of countries worldwide . OBJECTIVE To examine the prevalence of avoidance or cessation of smoking , eating a healthy diet  , and undertaking regular physical activities  by individuals with a CHD or stroke event . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve Urban Rural Epidemiology ( PURE ) was a large , prospect i ve cohort study that used an epidemiological survey of 153,996 adults , aged 35 to 70 years , from 628 urban and rural communities in 3 high-income countries ( HIC ) , 7 upper-middle-income countries ( UMIC ) , 3 lower-middle-income countries ( LMIC ) , and 4 low-income countries ( LIC ) , who were enrolled between January 2003 and December 2009 . MAIN OUTCOME MEASURES Smoking status ( current , former , never ) , level of exercise ( low , < 600 metabolic equivalent task [MET]-min/wk ; moderate , 600 - 3000 MET-min/wk ; high , > 3000 MET-min/wk ) , and diet ( classified by the Food Frequency Question naire and defined using the Alternative Healthy Eating Index ) . RESULTS Among 7519 individuals with self-reported CHD ( past event : median , 5.0 [ interquartile range { IQR } , 2.0 - 10.0 ] years ago ) or stroke ( past event : median , 4.0 [ IQR , 2.0 - 8.0 ] years ago ) , 18.5 % ( 95 % CI , 17.6%-19.4 % ) continued to smoke ; only 35.1 % ( 95 % CI , 29.6%-41.0 % ) undertook high levels of work- or leisure-related physical activity , and 39.0 % ( 95 % CI , 30.0%-48.7 % ) had healthy diets ; 14.3 % ( 95 % CI , 11.7%-17.3 % ) did not undertake any of the 3 healthy lifestyle behaviors and 4.3 % ( 95 % CI , 3.1%-5.8 % ) had all 3 . Overall , 52.5 % ( 95 % CI , 50.7%-54.3 % ) quit smoking ( by income country classification : 74.9 % [ 95 % CI , 71.1%-78.6 % ] in HIC ; 56.5 % [ 95 % CI , 53.4%-58.6 % ] in UMIC ; 42.6 % [ 95 % CI , 39.6%-45.6 % ] in LMIC ; and 38.1 % [ 95 % CI , 33.1%-43.2 % ] in LIC ) . Levels of physical activity increased with increasing country income but this trend was not statistically significant . The lowest prevalence of eating healthy diets was in LIC ( 25.8 % ; 95 % CI , 13.0%-44.8 % ) compared with LMIC ( 43.2 % ; 95 % CI , 30.0%-57.4 % ) , UMIC ( 45.1 % , 95 % CI , 30.9%-60.1 % ) , and HIC ( 43.4 % , 95 % CI , 21.0%-68.7 % ) . CONCLUSION AND RELEVANCE Among a sample of patients with a CHD or stroke event from countries with varying income levels , the prevalence  of healthy lifestyle behaviors  was low , with even lower levels in poorer countries OBJECTIVE Disparities exist in the diabetes health status of ethnic minority and /or low-income population s relative to other groups . A primary objective of diabetes management is to improve glycemic control . The feasibility of implementing intensive diabetes case management in disparate population s remains largely untested . RESEARCH DESIGN AND METHODS Clinical sites in three southern California counties serving low-income , ethnic minority population s participated in our study . We r and omized 362 Medicaid ( called Medi-Cal in California ) recipients with type 2 diabetes for at least 1 year to intervention ( diabetes case management ) or control ( traditional primary care treatment ) groups . Fifty-five percent of participants were minorities . Participants with HbA(1c ) levels less than 7.5 % , serious diabetes-related complications , or other serious medical conditions were excluded . We assessed the effect of the intervention ( ongoing diabetes case management added to primary care ) on glycemic control using serial HbA(1c ) measurements over several years . RESULTS The mean duration of follow-up was 25.3 months . HbA(1c ) decreased substantially in both groups from an average of 9.54 - 7.66 % ( a reduction of 1.88 % ) in the intervention group and from an average of 9.66 - 8.53 % ( a reduction of 1.13 % ) in the control group . This improvement was sustained throughout the study . The reduction in HbA(1c ) was consistently greater in the intervention group at each time point ( P < 0.001 ) , ranging between 0.65 at 6 months and 0.87 at study end . CONCLUSIONS Diabetes case management , added to primary care , substantially improved glycemic control compared with the control group . Diabetes case management can help reduce disparities in diabetes health status among low-income ethnic population 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 BACKGROUND Patients ' engagement in mobile health ( m-health ) interventions using interactive voice response ( IVR ) calls is less in low- and middle-income countries ( LMICs ) than in industrialized ones . We conducted a study to determine whether automated telephone feedback to informal caregivers ( " CarePartners " ) increased engagement in m-health support among diabetes and hypertension patients in Bolivia . MATERIAL S AND METHODS Patients with diabetes and /or hypertension were identified through ambulatory clinics affiliated with four hospitals . All patients enrolled with a CarePartner . Patients were r and omized to weekly IVR calls including self-management questions and self-care education either alone ( " st and ard m-health " ) or with automated feedback about health and self-care needs sent to their CarePartner after each IVR call ( " m-health+CP " ) . RESULTS The 72 participants included 39 with diabetes and 53 with hypertension , of whom 19 had ≤6 years of education . After 1,225 patient-weeks of attempted IVR assessment s , the call completion rate was higher among patients r and omized to m-health+CP compared with st and ard m-health ( 62.0 % versus 44.9 % ; p < 0.047 ) . CarePartner feedback more than tripled call completion rates among indigenous patients and patients with low literacy ( p < 0.001 for both ) . M-health+CP patients were more likely to report excellent health via IVR ( adjusted odds ratio [ AOR ] = 2.60 ; 95 % confidence interval [ CI ] , 1.07 , 6.32 ) and less likely to report days in bed due to illness ( AOR = 0.42 ; 95 % CI , 0.19 , 0.91 ) . CONCLUSIONS In this study we found that caregiver feedback increased engagement in m-health and may improve patients ' health status relative to st and ard approaches . M-health+CP represents a scalable strategy for increasing the reach of self-management support in LMICs INTRODUCTION Postpartum relapse rates are high among women who spontaneously quit smoking during pregnancy . This r and omized clinical trial tested a Motivation and Problem-Solving ( MAPS ) treatment for reducing postpartum relapse among diverse low-income women who quit smoking during pregnancy ( N = 251 ; 32 % Black , 30 % Latino , and 36 % White ; 55 % < $ 30,000/year household income ) . METHODS Pregnant women were r and omly assigned to MAPS/MAPS+ or Usual Care ( UC ) . Continuation ratio logit models were used to examine differences in biochemically confirmed continuous abstinence at Weeks 8 and 26 postpartum by treatment group and moderators of the treatment effect . Analyses controlled for age , race/ethnicity , partner status , education , smoking rate , and the number of smokers in the participant 's environment . RESULTS MAPS/MAPS+ was more efficacious than UC in the prevention of postpartum relapse ( p = .05 ) . An interaction between treatment and the number of cigarettes smoked per day before quitting approached significance ( p = .09 ) , suggesting that the MAPS/MAPS+ treatment effect was stronger among women who smoked more cigarettes per day . DISCUSSION MAPS , a holistic and dynamic approach to changing behavior using a combined motivational enhancement and social cognitive approach , is a promising intervention for postpartum smoking relapse prevention among low-income women , which may have particular relevance for women with higher prequit smoking rates IMPORTANCE Hypertension is the most important preventable cause of morbidity and mortality globally , yet there are relatively few data collected using st and ardized methods . OBJECTIVE To examine hypertension prevalence , awareness , treatment , and control in participants at baseline in the Prospect i ve Urban Rural Epidemiology ( PURE ) study . DESIGN , SETTING , AND PARTICIPANTS A cross-sectional study of 153,996 adults ( complete data for this analysis on 142,042 ) aged 35 to 70 years , recruited between January 2003 and December 2009 . Participants were from 628 communities in 3 high-income countries ( HIC ) , 10 upper-middle-income and low-middle-income countries ( UMIC and LMIC ) , and 4 low-income countries ( LIC ) . MAIN OUTCOMES AND MEASURES Hypertension was defined as individuals with self-reported treated hypertension  or with an average of 2 blood pressure measurements of at least 140/90 mm Hg using an automated digital device . Awareness was based on self-reports , treatment was based on the regular use of blood pressure-lowering medications , and control was defined as individuals with blood pressure lower than 140/90 mm Hg . RESULTS Among the 142,042 participants , 57,840 ( 40.8 % ; 95 % CI , 40.5%-41.0 % ) had hypertension and 26,877 ( 46.5 % ; 95 % CI , 46.1%-46.9 % ) were aware of the diagnosis . Of those who were aware of the diagnosis , the majority ( 23,510 [ 87.5 % ; 95 % CI , 87.1%-87.9 % ] of those who were aware ) were receiving pharmacological treatments , but only a minority of those receiving treatment were controlled ( 7634 [ 32.5 % ; 95 % CI , 31.9%-33.1 % ] ) . Overall , 30.8 % , 95 % CI , 30.2%-31.4 % of treated patients were taking 2 or more types of blood pressure-lowering medications . The percentages aware ( 49.0 % [ 95 % CI , 47.8%-50.3 % ] in HICs , 52.5 % [ 95 % CI , 51.8%-53.2 % ] in UMICs , 43.6 % [ 95 % CI , 42.9%-44.2 % ] in LMICs , and 40.8 % [ 95 % CI , 39.9%-41.8 % ] in LICs ) and treated ( 46.7 % [ 95 % CI , 45.5%-47.9 % ] in HICs , 48.3 % , [ 95 % CI , 47.6%-49.1 % ] in UMICs , 36.9 % , [ 95 % CI , 36.3%-37.6 % ] in LMICs , and 31.7 % [ 95 % CI , 30.8%-32.6 % ] in LICs ) were lower in LICs compared with all other countries for awareness ( P < .001 ) and treatment ( P < .001 ) . Awareness , treatment , and control of hypertension were higher in urban communities compared with rural ones in LICs ( urban vs rural , P < .001 ) and LMICs ( urban vs rural , P < .001 ) , but similar for other countries . Low education was associated with lower rates of awareness , treatment , and control in LICs , but not in other countries . CONCLUSIONS AND RELEVANCE Among a multinational study population , 46.5 % of participants with hypertension were aware of the diagnosis , with blood pressure control among 32.5 % of those being treated . These findings suggest substantial room for improvement in hypertension diagnosis and treatment Background — Evidence on economically efficient strategies to lower  blood pressure ( BP )  from low- and middle-income countries remains scarce . The Control of Blood Pressure and Risk Attenuation ( COBRA ) trial r and omized 1341 hypertensive subjects in 12 r and omly selected communities in Karachi , Pakistan , to 3 intervention programs : ( 1 ) combined home health education ( HHE ) plus trained general practitioner ( GP ) ; ( 2 ) HHE only ; and ( 3 ) trained GP only . The comparator was no intervention ( or usual care ) . The reduction in BP was most pronounced in the combined group . The present study examined the cost-effectiveness of these strategies . Methods and Results — Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on ( 1 ) intervention cost ; ( 2 ) cost of physician consultation , medications , diagnostics , changes in lifestyle , and productivity loss ; and ( 3 ) change in systolic BP . Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications . Bayesian probabilistic sensitivity analysis was also performed . The annual costs per participant associated with the combined HHE plus trained GP , HHE alone , and trained GP alone were $ 3.99 , $ 3.34 , and $ 0.65 , respectively . HHE plus trained GP was the most cost-effective intervention , with an incremental cost-effectiveness ratio of $ 23 ( 95 confidence interval , 6–99 ) per mm Hg reduction in systolic BP compared with usual care , and remained so in 97.7 of 1000 bootstrapped replications . Conclusions — The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan , and possibly other countries in Indochina with similar healthcare infrastructure . Clinical Trial Registration — http://www . clinical trials.gov . Unique identifier : NCT00327574 Background Healthcare decision makers face challenges when using guidelines , including underst and ing the quality of the evidence or the values and preferences upon which recommendations are made , which are often not clear . Methods GRADE is a systematic approach towards assessing the quality of evidence and the strength of recommendations in healthcare . GRADE also gives advice on how to go from evidence to decisions . It has been developed to address the weaknesses of other grading systems and is now widely used internationally . The Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence ( DECIDE ) consortium ( http://www.decide-collaboration.eu/ ) , which includes members of the GRADE Working Group and other partners , will explore methods to ensure effective communication of evidence -based recommendations targeted at key stakeholders : healthcare professionals , policymakers , and managers , as well as patients and the general public . Surveys and interviews with guideline producers and other stakeholders will explore how presentation of the evidence could be improved to better meet their information needs . We will collect further stakeholder input from advisory groups , via consultations and user testing ; this will be done across a wide range of healthcare systems in Europe , North America , and other countries . Targeted communication strategies will be developed , evaluated in r and omized trials , refined , and assessed during the development of real guidelines . Discussion Results of the DECIDE project will improve the communication of evidence -based healthcare recommendations . Building on the work of the GRADE Working Group , DECIDE will develop and evaluate methods that address communication needs of guideline users . The project will produce strategies for communicating recommendations that have been rigorously evaluated in diverse setting s , and it will support the transfer of research into practice in healthcare systems globally OBJECTIVE To review the evidence on what works in  teenage parent support programmes ; to determine the key elements of successful  teenage parent support and parenting programmes ; and to determine the gaps in the evidence . METHODS Data bases were search ed , using a specific search strategy , for systematic review s and r and omised controlled trials , to ascertain whether social support , parenting programmes , or both , are effective in improving maternal or infant outcomes . The findings were summarized . RESULTS Only one systematic review specifically addressed interventions among teenage parents and their children , although several r and omised trials have since been published . CONCLUSIONS Key questions remain for future support and parenting programmes . Social support and parenting interventions improve maternal-child interactions and child cognitive development , but do not reduce low-birth weight , stillbirth or neonatal death .  Social support and parenting programmes need to be combined with measures to increase the minimum income , reduce smoking in pregnancy and increase breast-feeding rates . Robust evaluations of packages of care in the UK are needed to inform national and local teenage pregnancy strategies Background Globally , almost 4 million newborns die during the first 4 weeks of life every year . By increased use of evidence -based knowledge in the healthcare system a large proportion of these neonatal deaths could be prevented . But there is a severe lack of knowledge on effective methods for successful implementation of evidence into practice , particularly in low- and middle-income countries . Recent studies have demonstrated promising results with increased survival among both mothers and newborns using community-based approaches . In Vietnam  evidence -based guidelines on reproductive health were launched in 2003 and revised in 2009 . The overall objective of the current project is to evaluate if a facilitation intervention on the community level , with a problem-solving approach involving local representatives if the healthcare system and the community , results in improvements of neonatal health and survival . Methods / Design The study , which has been given the acronym NeoKIP ( Neonatal Health - Knowledge Into Practice ) , took place in 8 districts composed by 90 communes in a province in northern Vietnam , where neonatal mortality rate was 24/1000 in 2005 . A cluster r and omised design was used , allocating clusters , as defined as a commune and its correponding Commune Health Center ( CHC ) to either intervention or control arm . The facilitation intervention targeted staff at healthcare centres and key persons in the communes . The facilitator role was performed by lay women ( Women 's Union representatives ) using quality improvement techniques to initiate and sustain improvement processes targeting identified problem areas . The intervention has been running over 3 years and data were collected on the facilitation process , healthcare staff knowledge in neonatal care and their behaviour in clinical practice , and reproductive and perinatal health indicators . Primary outcome is neonatal mortality . Discussion The intervention is participatory and dynamic , focused on developing a learning process and a problem-solving cycle . The study recognises the vital role of the local community as actors in improving their own and their newborns ' health , and applies a bottom-up approach where change will be accomplished by an increasing awareness at and dem and from grass root level . By utilising the existing healthcare structure this intervention may , if proven successful , be well suited for scaling up . Trial registration Current Controlled Trials IS RCT Background Despite significant increases in global health investment and the availability of low-cost , efficacious interventions to prevent mother-to-child HIV transmission ( pMTCT ) in low- and middle-income countries with high HIV burden , the translation of scientific advances into effective delivery strategies has been slow , uneven and incomplete . As a result , pediatric HIV infection remains largely uncontrolled . A five-step , facility-level systems analysis and improvement intervention ( SAIA ) was design ed to maximize effectiveness of pMTCT service provision by improving underst and ing of inefficiencies ( step one : cascade analysis ) , guiding identification and prioritization of low-cost workflow modifications ( step two : value stream mapping ) , and iteratively testing and re design ing these modifications ( steps three through five ) . This protocol describes the SAIA intervention and methods to evaluate the intervention ’s impact on reducing drop-offs along the pMTCT cascade . Methods This study employs a two-arm , longitudinal cluster r and omized trial design . The unit of r and omization is the health facility . A total of 90 facilities were identified in Côte d’Ivoire , Kenya and Mozambique ( 30 per country ) . A subset was r and omly selected and assigned to intervention and comparison arms , stratified by country and service volume , result ing in 18 intervention and 18 comparison facilities across all three countries , with six intervention and six comparison facilities per country . The SAIA intervention will be implemented for six months in the 18 intervention facilities . Primary trial outcomes are design ed to assess improvements in the pMTCT service cascade , and include the percentage of pregnant women being tested for HIV at the first antenatal care visit , the percentage of HIV-infected pregnant women receiving adequate prophylaxis or combination antiretroviral therapy in pregnancy , and the percentage of newborns exposed to HIV in pregnancy receiving an HIV diagnosis eight weeks postpartum . The Consoli date d Framework for Implementation Research ( CFIR ) will guide collection and analysis of qualitative data on implementation process . Discussion This study is a pragmatic trial that has the potential benefit of improving maternal and infant outcomes by reducing drop-offs along the pMTCT cascade . The SAIA intervention is design ed to provide simple tools to guide decision-making for pMTCT program staff at the facility level , and to identify low cost , context ually appropriate pMTCT improvement strategies . Trial registration Clinical Trials.gov The treatment gap for autism globally is high . Our previous PASS intervention , delivered by community based lay health workers , showed effectiveness . This article reports the development and evaluation of a new “ PASS ‘ Plus ’ ” intervention in a rural population in India . Using formative research methods , we supplemented the PASS intervention with additional ( Plus ) modules to address autism comorbidities . This is the first time that a rigorous methodology has been used to evaluate autism symptom outcomes in a low and middle‐income country setting . 40 parent – child dyads were recruited in a pilot r and omized controlled trial against usual care ( mean age 65 months ( 34 boys ) ; n = 19 PASS Plus , n = 21 UC ) . 89 % of intervention families partially or entirely completed the 12‐session intervention . Intention to treat analysis showed a reduction in mean scores of autism symptom severity , though the confidence interval contains zero , ( adjusted mean difference AMD −2.42 95 % CI −7.75 , 2.92 ; ES 0.22 ) ; large treatment effects on proximal outcomes of proportion of parent synchronous responses ( AMD 0.35 ; 95 % CI 0.18 , 0.52 ; effect size ES 3.97 ) and proportion of child communication initiations with parent ( AMD 0·17 ; 95 % CI 0.03 , 0.32 ; ES 1.02 ) . Confidence intervals for effects on mutual shared attention ( AMD 0.10 ; 95 % CI −0.07 , 0.27 ; ES 0.5 ) and co‐morbid symptoms ( AMD −9.0 ; 95 % CI −24.26 , 6.26 ; ES 0.32 ) contained zero . There were significant effects to improve parental mental health . PASS Plus shows good feasibility and adds to the evidence of the effectiveness of task sharing complex autism interventions to lay health workers in India . Autism Res 2019 , 12 : 328–339 © 2018 International Society for Autism Research , Wiley Periodicals , Background Infant-feeding patterns may influence lifelong health . This study tested the hypothesis that longer duration of breastfeeding and later introduction of complementary foods in infancy are associated with reduced adult cardiovascular risk . Methods Data were pooled from 10 912 subjects in the age range of 15–41 years from five prospect i ve birth-cohort studies in low-/middle-income countries ( Brazil , Guatemala , India , Philippines and South Africa ) . Associations were examined between infant feeding ( duration of breastfeeding and age at introduction of complementary foods ) and adult blood pressure ( BP ) , plasma glucose concentration and adiposity ( skinfolds , waist circumference , percentage body fat and overweight/obesity ) . Analyses were adjusted for maternal socio-economic status , education , age , smoking , race and urban/rural residence and infant birth weight . Results There were no differences in outcomes between adults who were ever breastfed compared with those who were never breastfed . Duration of breastfeeding was not associated with adult diabetes prevalence or adiposity . There were U-shaped associations between duration of breastfeeding and systolic BP and hypertension ; however , these were weak and inconsistent among the cohorts . Later introduction of complementary foods was associated with lower adult adiposity . Body mass index changed by −0.19 kg/m2 [ 95 % confidence interval ( CI ) −0.37 to −0.01 ] and waist circumference by −0.45 cm ( 95 % CI −0.88 to −0.02 ) per 3-month increase in age at introduction of complementary foods . Conclusions There was no evidence that longer duration of breastfeeding is protective against adult hypertension , diabetes or overweight/adiposity in these low-/middle-income population s. Further research is required to determine whether ‘ exclusive ’ breastfeeding may be protective . Delaying complementary foods until 6 months , as recommended by the World Health Organization , may reduce the risk of adult overweight/adiposity , but the effect is likely to be small
The evidence is concentrated in two types of PMM strategies : implementation strategies ( in-service training , continuing education , supervision ) and performance-based financing .
Major gaps exist in accountability arrangements particularly the use of audit and feedback .
The least studied types of outcomes were unintended effects , harm and social equity .
Conclusions The evidence is clustered around interventions that are unlikely to achieve transformational change in health outcomes .
The gaps identified suggest that routinely used PMM strategies are implemented without sufficient knowledge of their effects .
Introduction We mapped available evidence on  performance measurement and management ( PMM ) strategies in primary healthcare ( PHC ) systems of low-income and middle-income countries ( LMICs ) .
Widely used , their effectiveness remains inconclusive .
This evidence gap map characterises existing research and evidence gaps .