Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol A systematic review of online interventions for mental health in low and middle income countries: a neglected field Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries Uterine Tonus Assessment by Midwives versus Patient self-assessment in the active management of the third stage of labor (UTAMP): study protocol for a randomized controlled trial Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol Costs of Promoting Exclusive Breastfeeding at Community Level in Three Sites in South Africa Sudden cardiac death in low- and middle-income countries. Economic evaluation of a task-shifting intervention for common mental disorders in India. Value of a mobile information system to improve quality of care by community health workers. Rationale and design of a randomized controlled trial evaluating community health worker-based interventions for the secondary prevention of acute coronary syndromes in India (SPREAD). 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 Specialist outreach clinics in primary care and rural hospital settings (Cochrane Review). Effectiveness of the parent-mediated intervention for children with autism spectrum disorder in south Asia in India and Pakistan (PASS): a randomised controlled trial. Assisted partner notification services are cost-effective for decreasing HIV burden in western Kenya Using IT to improve access, communication, and asthma in African American and Hispanic/Latino Adults: Rationale, design, and methods of a randomized controlled trial.
Introduction Task shifting interventions are intended to both deliver clinical ly effective treatments to reduce disease burden and address health inequities or population vulnerability . Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting . This systematic review will address the following questions : Among  task shifting interventions in high-income setting s that have been studied using r and omised controlled trials or variants , how are health inequity or population vulnerability identified and defined ? What methods and indicators are used to describe , characterise and measure the population ’s baseline status and the intervention ’s impacts on inequity and vulnerability ? Methods and analysis Studies were identified through data base search es ( MEDLINE , Embase , CINAHL , PsycINFO and Web of Science ) . Eligible studies will be r and omised controlled trials published since 2004 , conducted in high-income countries , concerning task shifting interventions to treat any disease , in any population that may face health disadvantage as defined by the PROGRESS-Plus framework ( place of residence , race/ethnicity/culture/ language , occupation , gender/sex , religion , social capital , socioeconomic position , age , disability , sexual orientation , other vulnerable groups ) . We will conduct independent and duplicate title and abstract screening , then identify related papers from the same programme of research through further data base and manual search ing . From each programme of research , we will extract study details , and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework . Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study . A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implication s. Ethics and dissemination This review does not involve primary data collection , does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures . Dissemination will include open-access peer- review ed publication and academic conference presentations . PROSPERO Registration Number CRD42017049959 Background . Low and middle income countries ( LMICs ) are facing an increase of the impact of mental health problems while confronted with limited re sources and limited access to mental health care , known as the ‘ mental health gap ’ . One strategy to reduce the mental health gap would be to utilize the internet to provide more widely-distributed and low cost mental health care . We undertook this systematic review to investigate the effectiveness and efficacy of online interventions in LMICs . Methods . We systematic ally search ed the data -bases PubMed , PsycINFO , JMIR , and additional sources . MeSH terms , Thesaurus , and free text keywords were used . We included all r and omized controlled trials ( RCTs ) of online interventions in LMICs . Results . We found only three articles reported results of RCTs on  online interventions for mental health conditions in LMICs , but none of these interventions was compared with an active control condition . Also , the mental health conditions were diverse across the three studies . Conclusions . There is a dearth of studies examining the effect of online interventions  in LMICs , so we can not draw a firm conclusion on its effectiveness . However , given the effectiveness of  online interventions in high income countries and sharp increase of internet access in LMICs , online interventions may offer a potential to help reduce the ‘ mental health gap ’ . More studies are urgently needed in LMICs People living with HIV ( PLWH ) experience greater psychological distress than the general population . Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms , quality of life , and HIV care engagement . However , little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries ( LMICs ) , where the large majority of PLWH reside . This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these setting s. A systematic search strategy was undertaken to identify peer- review ed published papers of intervention trials addressing negative psychological states or disorders ( e.g. depression , anxiety ) among PLWH in LMIC setting s. Search results were assessed against pre-established inclusion and exclusion criteria . Data from papers meeting criteria were extracted for synthesis . Twenty-six papers , published between 2000 and 2014 , describing 22 unique interventions were identified . Trials were implemented in sub-Saharan Africa ( n = 13 ) , Asia ( n = 7 ) , and the Middle East ( n = 2 ) , and addressed mental health using a variety of approaches , including cognitive-behavioral ( n = 18 ) , family-level ( n = 2 ) , and pharmacological ( n = 2 ) treatments . Four r and omized controlled trials reported significant intervention effects in mental health outcomes , and 11 preliminary studies demonstrated promising findings . Among the limited mental health intervention trials with PLWH in LMICs , few demonstrated efficacy .  Mental health interventions for PLWH in LMICs must be further developed and adapted for re source -limited setting s to improve effectiveness Background Postpartum hemorrhage ( PPH ) is the leading cause of maternal mortality worldwide and accounts for one third of maternal deaths in low-income and middle-income countries . PPH can be prevented by active management of the third stage of labor ( AMTSL ) , a series of steps recommended by the World Health Organization to be performed by skilled birth attendants ( SBAs ) . Task shifting in the AMTSL step of uterotonic drugs administration to community health workers , traditional birth attendants and self-administration has been investigated as a strategy to increase access to quality obstetric care considering persistent SBA and facility-based delivery shortages . The aim of this study is to assess task shifting in the final step of AMTSL and compare uterine tonus assessment by a SBA to self- assessment . Methods and Design The study is an individual-level two-arm non-inferiority r and omized controlled trial ( RCT ) . A total of 800 women will be recruited in Korle Bu Teaching Hospital in Accra , Ghana . Adult women in labor at term with an expected vaginal delivery who received antenatal instructions for self- assessment of uterine tonus will be eligible for inclusion . Women with an increased risk for PPH will be excluded . Women will be r and omized to uterine tone assessment by a skilled birth attendant ( midwife ) or uterine tone self- assessment ( with the safety back-up of a midwife present in case of PPH or uterine atony ) . Postpartum blood loss will be measured through weighing of disposable mats . The main study endpoints are PPH ( ≥500 ml blood loss ) , severe PPH ( ≥1000 ml blood loss ) , mean blood loss , and routine maternal and neonatal outcomes . Participants and caregivers will not be blinded given the nature of the intervention . Discussion A reduction of PPH-related maternal mortality requires full implementation of AMTSL . Task shifting of uterine tone assessment may contribute to increased AMTSL implementation in ( clinical ) setting s where SBAs capacity is constrained . Trial registration Clinical trials.gov : NCT02223806 , registration August 2014 . PACTR : PACTR201402000736158 , registration July 2014 . University of Ghana , Medical School Ethical and Protocol Review Committee : MS-Et/M.8–P4.1/2014 - 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 Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Background Community-based peer support has been shown to be effective in improving exclusive breastfeeding rates in a variety of setting s. Methods We conducted a cost analysis of a community cluster r and omised-controlled trial ( Promise-EBF ) , aim ed at promoting exclusive infant feeding in three sites in South Africa . The costs were considered from the perspective of health service providers . Peer supporters in this trial visited women to support exclusive infant feeding , once antenatally and four times postpartum . Results The total economic cost of the Promise-EBF intervention was US$ 393 656 , with average costs per woman and per visit of US$ 228 and US$ 52 , respectively . The average costs per woman and visit in an operational ‘ non research ’ scenario were US$ 137 and US$ 32 per woman and visit , respectively . Investing in the promotion of exclusive infant feeding requires substantial financial commitment from policy makers . Extending the tasks of multi-skilled community health workers ( CHWs ) to include promoting exclusive infant feeding is a potential option for reducing these costs . In order to avoid efficiency losses , we recommend that the time requirements for delivering the promotion of exclusive infant feeding are considered when integrating it within the existing activities of CHWs . Discussion This paper focuses on interventions for exclusive infant feeding , but its findings more generally illustrate the importance of documenting and quantifying factors that affect the feasibility and sustainability of community-based interventions , which are receiving increased focus in low income 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 OBJECTIVE To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary -care setting s in Goa , India . METHODS Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary -care facilities . Subjects were r and omly assigned to an intervention or a control arm . Eligible subjects in the intervention arm were given psycho-education , case management , interpersonal psychotherapy and /or antidepressants by lay health workers . Subjects in the control arm were treated by physicians . The use of health-care re sources , the disability of each subject and degree of psychiatric morbidity , as measured by the Revised Clinical Interview Schedule , were determined at 2 , 6 and 12 months . FINDINGS Complete data , from all three follow-ups , were collected from 1243 ( 75.4 % ) and 938 ( 81.7 % ) of the subjects enrolled in the study facilities from the public and private sectors , respectively . Within the public facilities , subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm . Time costs were also significantly lower in the intervention arm than in the control arm , whereas health system costs in the two arms were similar . Within the private facilities , however , the effectiveness and costs recorded in the two arms were similar . CONCLUSION Within public primary -care facilities in Goa , the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving 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 There is a need to evaluate and implement cost-effective strategies to improve adherence to treatments in coronary heart disease . There are no studies from low- to middle income countries ( LMICs ) evaluating trained community health worker (CHW)-based interventions for the secondary prevention of coronary heart disease . METHODS We design ed a hospital-based , open r and omized trial of CHW-based interventions versus st and ard care .  Patients after an acute coronary syndrome ( ACS ) were r and omized to an intervention group ( a CHW-based intervention package , comprising education tools to enhance self-care and adherence , and regular follow-up by the CHW ) or to st and ard care for 12 months during which study outcomes were recorded . The CHWs were trained over a period of 6 months . The primary outcome measure was medication adherence . The secondary outcomes were differences in adherence to lifestyle modification , physiological parameters ( blood pressure [ BP ] , body weight , body mass index [ BMI ] , heart rate , lipids ) , and major adverse cardiovascular events . RESULTS We recruited 806 patients stabilized after an ACS from 14 hospitals in 13 Indian cities . The mean age was 56.4 ( ± 11.32 ) years , and 17.2 % were females . A high prevalence of risk factors such as hypertension ( 43.4 % ) , diabetes ( 31.9 % ) , tobacco consumption ( 35.4 % ) , and inadequate physical activity ( 70.5 % ) was documented . A little over half had ST-elevation myocardial infa rct ion ( 53.7 % ) , and 46.3 % had non-ST-elevation myocardial infa rct ion or unstable angina . CONCLUSION The CHW interventions and training for SPREAD have been developed and adapted for local use . The results and experience of this study will be important to counter the burden of cardiovascular diseases in low- to middle income countries 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 Background : Specialist medical practitioners have conducted clinics in primary care and rural hospital setting s for a variety of reasons in many different countries . Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services . Objectives : To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access , quality , health outcomes , patient satisfaction , use of services , and costs . Search strategy : We search ed the Cochrane Effective Practice and Organisation of Care ( EPOC ) specialised register ( March 2002 ) , the Cochrane Controlled Trials Register ( CCTR ) ( Cochrane Library Issue 1 , 2002 ) , MEDLINE ( including HealthStar ) ( 1966 to May 2002 ) , EMBASE ( 1988 to March 2002 ) , CINAHL ( 1982 to March 2002 ) , the Primary - Secondary Care Data base previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester , a collection of studies from the UK collated in Specialist Outreach Clinics  in General Practice ( Rol and 1998 ) , and the reference lists of all retrieved articles . Selection criteria : R and omised trials , controlled before and after studies and interrupted time series analyses of  visiting specialist outreach clinics in primary care or rural hospital setting s , either providing simple consultations or as part of complex multifaceted interventions . The participants were patients , specialists , and primary care providers . The outcomes included objective measures of access , quality , health outcomes , satisfaction , service use , and cost . Data collection and analysis : Four review ers working in pairs independently extracted data and assessed study quality . Main results : 73 outreach interventions were identified covering many specialties , countries and setting s. Nine studies met the inclusion criteria . Most comparative studies came from urban non-disadvantaged population s in developed countries . Simple ‘ shifted out patients ’ styles of specialist outreach were shown to improve access , but there was no evidence of impact on health outcomes .  Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care , education or other services was associated with improved health outcomes , more efficient and guideline -consistent care , and less use of inpatient services . The additional costs of outreach may be balanced by improved health outcomes . Authors ' conclusions : This review supports the hypothesis that specialist outreach can improve access , outcomes and service use , especially when delivered as part of a multifaceted intervention . The benefits of simple outreach models in urban non-disadvantaged setting s seem small . There is a need for good comparative studies of outreach in rural and disadvantaged setting s where outreach may confer most benefit to access and health outcomes BACKGROUND Autism spectrum disorder affects more than 5 million children in south Asia . Although early interventions have been used for the treatment of children in high-income countries , no substantive trials have been done of the interventions adapted for use in low-income and middle-income countries ( LMICs ) . We therefore assessed the feasibility and acceptability of the parent-mediated intervention for autism spectrum disorder in south Asia ( PASS ) in India and Pakistan . METHODS A single-blind r and omised trial of the comparison of 12 sessions of PASS ( plus treatment as usual ) with treatment as usual alone delivered by non-specialist health workers was done at two centres in Goa , India , and Rawalpindi , Pakistan . Children aged 2 - 9 years with autism spectrum disorder were r and omly assigned ( 1:1 ) by use of probabilistic minimisation , controlling for treatment centre ( Goa or Rawalpindi ) , age ( < 6 years or ≥6 years ) , and functional impairment ( Vinel and Adaptive Behaviour Scale Composite score < 65 or ≥65 ) . The primary outcome was quality of parent-child interaction on the Dyadic Communication Measure for Autism at 8 months . Analysis was by intention to treat . The study is registered with IS RCT N , number IS RCT N79675498 . FINDINGS From Jan 1 to July 30 , 2013 , 65 children were r and omly allocated , 32 to the PASS group ( 15 in Goa and 17 in Rawalpindi ) and 33 to the treatment-as-usual group ( 15 in Goa and 18 in Rawalpindi ) . 26 ( 81 % ) of 32 participants completed the intervention . After adjustment for minimisation factors and baseline outcome , the primary outcome showed a treatment effect in favour of PASS in parental synchrony ( adjusted mean difference 0·25 [ 95 % CI 0·14 to 0·36 ] ; effect size 1·61 [ 95 % CI 0·90 to 2·32 ] ) and initiation of communication by the child with the parent ( 0·15 [ 0·04 to 0·26 ] ; effect size 0·99 [ 0·29 to 1·68 ] ) , but time in mutual shared attention was reduced ( -0·16 [ -0·26 to -0·05 ] ; effect size -0·70 [ -1·16 to -0·23 ] ) . INTERPRETATION Our results show the feasibility of adapting and task-shifting an intervention used in a high-income context to LMICs . The findings also replicate the positive primary outcome treatment effects of a parent-mediated communication-focused intervention in the original UK Preschool Autism Communication Trial , with one negative effect not reported previously . FUNDING Autism Speaks , USA Background : Assisted partner services ( aPS ) or provider notification for sexual partners of persons diagnosed HIV positive can increase HIV testing and linkage in Sub-Saharan Africa and is a high yield strategy to identify HIV-positive persons . However , its cost-effectiveness is not well evaluated . Methods : Using effectiveness and cost data from an aPS trial in Kenya , we parameterized an individual-based , dynamic HIV transmission model . We estimated costs for both a program scenario and a task-shifting scenario using community health workers to conduct the intervention . We simulated 200 cohorts of 500 000 individuals and projected the health and economic effects of scaling up aPS in a region of western Kenya ( formerly Nyanza Province ) . Findings : Over a 10-year time horizon with universal antiretroviral therapy ( ART ) initiation , implementing aPS in western Kenya was projected to reach 12.5 % of the population and reduce incident HIV infections by 3.7 % . In sexual partners receiving aPS , HIV-related deaths were reduced by 13.7 % . The incremental cost-effectiveness ratio of aPS was $ 1094 ( US dollars ) ( 90 % model variability $ 823–1619 ) and $ 833 ( 90 % model variability $ 628–1224 ) per disability-adjusted life year averted under the program and task-shifting scenario , respectively . The incremental cost-effectiveness ratios for both scenarios fall below Kenya 's gross domestic product per capita ( $ 1358 ) and are therefore considered very cost-effective . Results were robust to varying healthcare costs , linkage to care rates , partner concurrency rates , and ART eligibility thresholds ( ⩽350 cells/&mgr;l , ⩽500 cells/&mgr;l , and universal ART ) . Interpretation : APS  is cost-effective for reducing HIV-related morbidity and mortality in western Kenya and similar setting s. Task shifting can increase program affordability Asthma morbidity is high among inner-city minority adults . Improving access to care and patient-provider communication are believed to be essential for improving outcomes . Access and communication in turn increasingly rely on information technology including features of the Electronic Health Record . Its patient portal offers web-based communication with providers and practice s. How patients with limited re sources and educational opportunities can benefit from this portal is unclear . In contrast , home visits by community health workers ( CHWs ) have improved access to care for asthmatic children and promoted caretaker-clinician communication . We describe the planning , design , and methodology of an ongoing r and omized controlled trial for 300 adults , predominantly African American and Hispanic/Latino , with uncontrolled asthma recruited from low income urban neighborhoods who are directed to the most convenient internet access and taught to use the portal , with and without home visits from a CHW . The study 1 ) compares the effects of the 1-year interventions on asthma outcomes ( improved asthma control , quality of life ; fewer ED visits and hospitalizations for asthma or any cause ) , 2 ) evaluates whether communication ( portal use ) and access ( appointments made/kept ) mediate the interventions ' effects on asthma outcomes , and 3 ) investigates effect modification by literacy level , primary language , and convenience of internet access . In home visits , CHWs 1 ) train patients to competency in portal use , 2 ) enhance care coordination , 3 ) communicate the complex social circumstances of patients ' lives to providers , and 4 ) compensate for differences in patients ' health literacy skills . The practical challenges to design and implementation in the targeted population are presented
We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS , and additional evidence exists for the potential to achieve cost savings from activities related to malaria , NCDs , NTDs , childhood illness , and other disease areas , especially at the primary health care and community levels .
Conclusions Task shifting presents a viable option for health system cost savings in LMICs .
Background Task shifting has become an increasingly popular way to increase access to health services , especially in low-re source setting s. Research has demonstrated that task shifting , including the use of community health workers ( CHWs ) to deliver care , can improve population health .
This systematic review investigates whether task shifting in low-income and middle-income countries ( LMICs ) results in efficiency improvements by achieving cost savings .