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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 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 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 The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide . The mPower Heart Project aim ed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task‐sharing with the use of a mobile phone – based clinical decision support system at Community Health Centers in Himachal Pradesh , India . Methods and Results The development of the intervention and mobile phone – based clinical decision support system was carried out using mixed methods in five Community Health Centers . The intervention was subsequently evaluated using pre – post evaluation design . During intervention , a nurse care coordinator screened , examined , and entered patient parameters into mobile phone – based clinical decision support system to generate a prescription , which was vetted by a physician . The change in systolic blood pressure , diastolic blood pressure , and fasting plasma glucose ( FPG ) over 18 months of intervention was quantified using generalized estimating equations models . During intervention , 6797 participants were enrolled . Six thous and sixteen participants had hypertension ( mean systolic blood pressure : 146.1 mm Hg , 95 % CI : 145.7 , 146.5 ; diastolic blood pressure : 89.52 mm Hg , 95 % CI : 89.33 , 89.72 ) , of which 3152 ( 52 % ) subjects were newly detected . Similarly , 1516 participants had diabetes mellitus ( mean FPG : 177.9 mg/dL , 95 % CI : 175.8 , 180.0 ) , of which 450 ( 30 % ) subjects were newly detected . The changes in systolic blood pressure , diastolic blood pressure , and FPG observed at 18 months of follow‐up were −14.6 mm Hg ( 95 % CI : −15.3 , −13.8 ) , −7.6 mm Hg ( CI : −8.0 , −7.2 ) , and −50.0 mg/dL ( 95 % CI : −54.6 , −45.5 ) , respectively , and were statistically significant even after adjusting for age , sex , and Community Health Center . Conclusions A nurse‐facilitated , mobile phone – based clinical decision support system‐enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale‐up in re source poor setting s. Clinical Trial Registration URL : https://www . clinical trials.gov . Unique identifiers : NCT01794052 . Clinical Trial Registry — India : CTRI/2013/02/003412 Introduction Diabetes self-management education ( DSME ) is a fundamental element of type 2 diabetes care . Although 75 % of adults with diabetes worldwide live in low-income and middle-income countries ( LMICs ) , limited DSME research has been conducted in LMICs . The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala . Methods We conducted a prospect i ve study of a DSME intervention using a quasi-experimental , single-group pretest – posttest design . We enrolled 90 participants in the intervention , which consisted of 6 home visits ( May 2014–July 2016 ) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan population s. Primary outcomes were changes in mean hemoglobin A1c ( HbA1c ) and mean systolic and diastolic blood pressure at baseline and at 12 months . Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion . Results HbA1c decreased significantly from baseline to 12 months ( absolute mean change , −1.5 % ; 95 % confidence interval [ CI ] , −1.9 % to −1.0 % ; P < .001 ) . Systolic blood pressure also improved significantly at 12 months ( −6.2 mm Hg ; 95 % CI , −10.1 to −2.2 mm Hg ; P = .002 ) ; changes in diastolic blood pressure were not significant ( −1.6 mm Hg ; 95 % CI , −3.9 to −0.7 mm Hg ; P = .17 ) . We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion . Conclusion DSME interventions can be successfully delivered in a setting with an underre source d health system , high poverty rate , and unique cultural characteristics like Mayan Guatemala . Our findings point to the need for more DSME research in re source -limited setting s globally BACKGROUND Although most cardiovascular disease occurs in low-income and middle-income countries , little is known about the use of effective secondary prevention medications in these communities . We aim ed to assess use of proven effective secondary preventive drugs ( antiplatelet drugs , β blockers , angiotensin-converting-enzyme [ ACE ] inhibitors or angiotensin-receptor blockers [ ARBs ] , and statins ) in individuals with a history of coronary heart disease or stroke . METHODS In the Prospect i ve Urban Rural Epidemiological ( PURE ) study , we recruited individuals aged 35 - 70 years from rural and urban communities in countries at various stages of economic development . We assessed rates of previous cardiovascular disease ( coronary heart disease or stroke ) and use of proven effective  secondary preventive drugs  and blood-pressure-lowering drugs with st and ardised question naires , which were completed by telephone interviews , household visits , or on patient 's presentation to clinics . We report estimates of drug use at national , community , and individual levels . FINDINGS We enrolled 153,996 adults from 628 urban and rural communities in countries with incomes classified as high ( three countries ) , upper-middle ( seven ) , lower-middle ( three ) , or low ( four ) between January , 2003 , and December , 2009 . 5650 participants had a self-reported coronary heart disease event ( median 5·0 years previously [ IQR 2·0 - 10·0 ] ) and 2292 had stroke ( 4·0 years previously [ 2·0 - 8·0 ] ) . Overall , few individuals with cardiovascular disease took antiplatelet drugs  ( 25·3 % ) , β blockers ( 17·4 % ) , ACE inhibitors or ARBs ( 19·5 % ) , or statins ( 14·6 % ) . Use was highest in high-income countries ( antiplatelet drugs 62·0 % , β blockers 40·0 % , ACE inhibitors or ARBs 49·8 % , and statins 66·5 % ) , lowest in low-income countries ( 8·8 % , 9·7 % , 5·2 % , and 3·3 % , respectively ) , and decreased in line with reduction of country economic status ( p(trend)<0·0001 for every drug type ) . Fewest patients received no drugs in high-income countries ( 11·2 % ) , compared with 45·1 % in upper middle-income countries , 69·3 % in lower middle-income countries , and 80·2 % in low-income countries . Drug use was higher in urban than rural areas ( antiplatelet drugs 28·7 % urban vs 21·3 % rural , β blockers 23·5%vs 15·6 % , ACE inhibitors or ARBs 22·8%vs 15·5 % , and statins 19·9%vs 11·6 % ; all p<0·0001 ) , with greatest variation in poorest countries ( p(interaction)<0·0001 for urban vs rural differences by country economic status ) . Country-level factors ( eg , economic status ) affected rates of drug use more than did individual-level factors ( eg , age , sex , education , smoking status , body-mass index , and hypertension and diabetes statuses ) . INTERPRETATION Because use of secondary prevention medications is low worldwide-especially in low-income countries and rural areas - systematic approaches are needed to improve the long-term use of basic , inexpensive , and effective drugs . FUNDING Full funding sources listed at end of paper ( see Acknowledgments ) 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 AIM This paper reports a study evaluating the relationship between social and community level supports and  physical activity and dietary behaviours  among a low-income Latino population with multiple chronic conditions . BACKGROUND With consistently lower physical activity than whites and documented nutritional deficiencies , Latinos in the United States of America represent a disproportionate share of the population with chronic illness . This pattern of health disparities is seen across countries , where there is a struggle to raise the health status of low-income , immigrant and aboriginal communities . Social-ecological theories of health behaviour stress the importance of considering social and community support for health behaviour , and represent a useful framework for considering ways to improve physical activity and nutrition for immigrant and aboriginal groups . METHOD We report here on data from a baseline assessment of 200 patients from a health clinic in the United States of America serving a low-income , primarily Latino population . Participants were enrolled in Re sources for Health , a r and omized controlled trial to promote multi-level support for chronic illness self-management . Measures included  self-reported physical activity , dietary behaviour and multi-level support for chronic illness management  as well as demographic data . Baseline data reported on here were collected between February 2002 and September 2003 . FINDINGS Use of multi-level supports ( e.g. family , individual and healthcare provider ) was statistically significantly associated with meeting physical activity guidelines and better dietary behaviours . Being female and having multiple chronic conditions were also associated with better dietary behaviour . These variables explained 20 % of the variance in dietary behaviour . CONCLUSION Results support a social-ecological approach for promoting healthy behaviour in this low-income , primarily Latino sample with multiple chronic conditions . Addressing multiple levels of support for healthy behaviour is important in interventions to improve physical activity and diet , and nurses may be particularly well placed to address such issues for low-income , aboriginal and immigrant patients with chronic conditions Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in re source -poor setting s. Contribution Among 1341 patients living in 12 communities in Pakistan that were r and omly assigned to general practitioner education , home health visits by trained lay workers , both , or neither , patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure ( 10.8 mm Hg ) after 2 years . Improvements were similar in all other groups ( about 5 mm Hg ) . Caution Twenty-two percent of patients were lost to follow-up . Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in re source -poor setting s. The Editors Cardiovascular disease has , in just a few decades , become the leading cause of death in adults worldwide , accounting for 1 in 5 deaths . Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease ( 1 , 2 ) . Despite the demonstrated benefits of effective drug treatment ( 3 , 4 ) and the existence of many clinical practice guidelines ( 5 ) , hypertension prevention , treatment , and control rates remain suboptimal worldwide ( 6 ) . The situation is particularly acute in developing countries , such as Pakistan , India , and China , where hypertension has reached epidemic proportionsaffecting more than 20 % of the adult population (7)yet control rates are less than 6 % ( 8) . Poor health literacy and unhealthy lifestyles , compounded by lack of awareness of hypertension ( 7 ) , are part of the cause . In addition , the health systems in these countries are often dysfunctional : More than 80 % of the expenditure for chronic disease care is out-of-pocket ; private care general practitioners ( GPs ) , who primarily treat acute conditions , are the front-line service providers ; and national programs for preventing and controlling hypertension are inadequate . Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers . ( 9 ) However , evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking . We conducted the COBRA-1 ( Control of Blood Pressure and Risk Attenuation-1 ) trial in Karachi , Pakistan , to test the effectiveness of 2 community-based strategies : family-based home health education ( HHE ) , delivered by trained community health workers , to improve population -level health literacy and behaviors , and hypertension management training for GPs . We tested the effect of these interventions , alone and in combination , on blood pressure in adults with hypertension . We hypothesized that HHE would be more effective than no education , that the specially trained GPs would provide more effective care than that usually received in Karachi , and that the combined interventions would provide additional benefit . Methods Study Design and Setting We performed a cluster r and omized , controlled trial with a 22 factorial design to determine the effect of  family-based HHE and special training for GPs  on blood pressure in adults 40 years or older with hypertension . We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level , and an individual approach would be prone to contamination of interventions and biased outcomes ( 10 ) . The Aga Khan University Ethics Review Committee granted ethical approval . The sampling frame is described elsewhere ( 11 ) . In brief , we used a multistage r and om sampling technique to select 12 of 4200 low- to middle-income , geographic census-based clusters ( mean household monthly income , $ 70 ; about 250 households in each cluster ) in Karachi , the most populous city in Pakistan ( about 16 million inhabitants ) . We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention . Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits ( mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg ) were eligible for inclusion . We excluded pregnant women , persons who could not give informed consent , and bed-bound persons . R and omization and Intervention We used computer-generated codes to r and omly assign 3 clusters each to the following groups : HHE alone , GP alone , HHE and GP combined , and no intervention . Home Health Education We trained 6 community health workers ( 1 for each cluster ) over 6 weeks in methods for using behavior-changing communication strategies to convey st and ardized health education messages to all households in clusters assigned to receive HHE . The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan ( 8 or preferably 10 years of schooling ) ( 12 ) . Salary scales and assigned workload were similarly consistent . The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease , as well as advice on the importance of engaging in moderate physical activity ; maintaining normal body weight ; reducing salt intake ; consuming a diet rich in fruit , vegetables , and low-fat dairy products ; reducing intake of saturated and total fat ( including suggestions on sample recipes for culturally acceptable and economically feasible food products ) ; and smoking cessation ( Appendix 1 ) . The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized . The first HHE session , lasting 90 minutes , was held at a time when all members of the household could be present . Follow-up reinforcement visits of 30 minutes were made every 3 months . Appendix 1 . Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training , with the aim of training at least two thirds of the GPs in each area . We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training . Training was a 1-day session that focused on st and ard treatment algorithms for the stepped-care management of hypertension , which were based on the seventh report of the Joint National Committee ( 3 ) and the Fourth Working Party of the British Hypertension Society guidelines ( 4 ) and modified for the Indo-Asian population ( Appendix 2 ) . The course included components on nonpharmacologic ( diet , exercise , weight loss , and smoking cessation ) and pharmacologic interventions , prescription of low-cost and appropriate generic drugs , preferential use of single-dose drug regimens , scheduled follow-up visits guided by blood pressure , the stepped-care approach for titrating drugs to achieve target blood pressure , and satisfactory consultation sessions for patients , with explanations of treatment and use of appropriate communication strategies . For managing persons with known hypertension , GPs were advised to review medication and blood pressure ; simplify regimens ; and aim to return to a regimen that was in line , as reasonably as possible , with that recommended for those with newly diagnosed hypertension . The recommended target blood pressure was < 140/90 mm Hg for all patients . Although this diverges from recent guidelines for special subgroups ( such as diabetic persons or those with end-organ damage ) , we reasoned that we needed to keep the intervention , guidelines , and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3 % ( 7 ) . The training sessions for GPs used a case-based curriculum and were interactive . We provided a certificate of training at the end of the course . Appendix 2 . Training Manual for General Practitioner All study participants were advised to consult a local GP . If participants in the clusters r and omly assigned to a trained GP group did not already have a preferred GP , we gave them a list of trained GPs in their cluster from which to choose . However , it remained the participant 's choice whether they attended a physician on the list . We did not provide for medications or fee-for-health care services . Participants were blinded to intervention status ( training of GP ) . Neither the patients nor the GPs received reimbursement for participation . Screening and Recruitment All households in each cluster were visited , and we obtained informed consent for screening from all adults 40 years and older , whose blood pressure was then measured 3 times with a calibrated automated device ( Omron HEM-737 IntelliSense ; Omron Healthcare , Vernon Hills , Illinois ) in the sitting position after 5 minutes of rest . Those with known hypertension were invited to participate . Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit . If mean blood pressure remained elevated , these persons were also invited to participate . A routine physical examination was performed , and the following information was collected : smoking status , food frequency , and physical activity by question naire , the latter by using the international physical activity question naire ; blood pressure , measured as described above ; anthropometric characteristics ( height , weight , and waist and hip circumferences ) ; and fasting blood glucose level ( Synchron Cx-7/Delta , Beckman Coulter , Fullerton , California ) and lipid profile ( Hitachi-912 , Roche , Basel , Switzerl and ) ( 11 ) . Follow-up Procedures Trained outcomes assessors ( who were not part of and had no relationship with the community health worker team ) evaluated Does free medical care lead to better health than insurance plans that require the patient to shoulder part of the cost ? In an effort to answer this question , we studied 3958 people between the ages of 14 and 61 who were free of disability that precluded work and had been r and omly assigned to a set of insurance plans for three or five years . One plan provided free care ; the others required enrollees to pay a share of their medical bills . As previously reported , patients in the latter group made approximately one-third fewer visits to a physician and were hospitalized about one-third less often . For persons with poor vision and for low-income persons with high blood pressure , free care brought an improvement ( vision better by 0.2 Snellen lines , diastolic blood pressure lower by 3 mm Hg ) ; better control of blood pressure reduced the calculated risk of early death among those at high risk . For the average participant , as well as for subgroups differing in income and initial health status , no significant effects were detected on eight other measures of health status and health habits . Confidence intervals for these eight measures were sufficiently narrow to rule out all but a minimal influence , favorable or adverse , of free care for the average participant . For some measures of health in subgroups of the population , however , the broader confidence intervals make this conclusion less certain 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 - BACKGROUND Hypertension is the leading risk factor responsible for premature death worldwide , but its burden has shifted to low- and middle-income countries . Therefore , we studied hypertension and cardiovascular risk in the population of Suriname , a middle-income country with a predominantly urban population of African and Asian ancestry . METHODS A r and om sample of 1,800 noninstitutionalized men and women aged 18 - 70 years was selected to be interviewed at home and examined at the local hospital for cardiovascular risk factors , asymptomatic organ damage , and cardiovascular disease . RESULTS The 1,157 participants examined ( 37 % men ) were mainly of self-defined Asian ( 43 % ) or African ( 39 % ) ancestry , mean age 43 years ( SD 14 ) . The majority of the population ( 71 % ) had  hypertension or prehypertension  , respectively , 40 % and 31 % . Furthermore , 72 % was obese or overweight , while 63 % had diabetes or prediabetes . Only 1 % of the adult population had an optimal cardiovascular risk profile . Hypertension awareness , treatment , and control were respectively 68 % , 56 % , and 20 % . In line with this , 22 % of the adult population had asymptomatic organ damage , including increased arterial stiffness , left ventricular hypertrophy , microalbuminuria , or asymptomatic chronic kidney disease . CONCLUSIONS In this first extensive cardiovascular assessment in the general population of this middle-income Caribbean country , high prevalence of hypertension with inadequate levels of treatment and control was predominant . The findings emphasize the need for collaborative effort from national and international bodies to prioritize the implementation of affordable and sustainable public health programs that combat the escalating hypertension and cardiovascular risk factor burden 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 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 ABSTRACT BACKGROUND The U.S. Preventive Services Task Force has released new guidelines on obesity , urging primary care physicians to provide obese patients with intensive , multi-component behavioral interventions . However , there are few studies of weight loss in real world nonacademic primary care , and even fewer in largely racial/ethnic minority , low-income sample s. OBJECTIVE To evaluate the recruitment , intervention and replications costs of a 2-year , moderate intensity weight loss and blood pressure control intervention . DESIGN A comprehensive cost analysis was conducted , associated with a weight loss and hypertension management program delivered in three community health centers as part of a pragmatic r and omized trial . PARTICIPANTS Three hundred and sixty-five high risk , low-income , inner city , minority ( 71 % were Black/African American and 13 % were Hispanic ) patients who were both hypertensive and obese . MAIN MEASURES Measures included total recruitment costs and intervention costs , cost per participant , and incremental costs per unit reduction in weight and blood pressure . KEY RESULTS Recruitment and intervention costs were estimated $ 2,359 per participant for the 2-year program . Compared to the control intervention , the cost per additional kilogram lost was $ 2,204 /kg , and for blood pressure , $ 621 /mmHg . Sensitivity analyses suggest that if the program was offered to a larger sample and minor modifications were made , the cost per participant could be reduced to the levels of many commercially available products . CONCLUSIONS The costs associated with the Be Fit Be Well program were found to be significantly more expensive than many commercially available products , and much higher than the amount that the Centers for Medicare and Medicaid reimburse physicians for obesity counseling . However , given the serious and costly health consequences associated with obesity in high risk , multimorbid and socioeconomically disadvantaged patients , the re sources needed to provide interventions like those described here may still prove to be cost-effective with respect to producing long-term behavior change The study 's objective was to determine the effectiveness of a task-sharing psychological treatment for  perinatal depression  using non-specialist community health workers . A double-blind individual r and omised controlled trial was conducted in two antenatal clinics in the peri-urban settlement of Khayelitsha , Cape Town . Adult pregnant women who scored 13 or above on the Edinburgh Postnatal Depression rating Scale ( EPDS ) were r and omised into the intervention arm ( structured six-session psychological treatment ) or the control arm ( routine antenatal health care and three monthly phone calls ) . The primary outcome was response on the Hamilton Depression Rating Scale ( HDRS ) at three months postpartum ( minimum 40 % score reduction from baseline ) among participants who did not experience pregnancy or infant loss ( modified intention-to-treat population ) ( registered on Clinical Trials : NCT01977326 ) . Of 2187 eligible women approached , 425 ( 19.4 % ) screened positive on the EPDS and were r and omised ; 384 were included in the modified intention-to-treat analysis ( control : n = 200 ; intervention : n = 184 ) . There were no significant differences in response on the HDRS at three months postpartum between the intervention and control arm . A task-sharing psychological treatment was not effective in treating  depression among women living in Khayelitsha , South Africa . The findings give cause for reflection on the strategy of task-sharing in low-re source setting INTRODUCTION Elevated blood pressure greatly contributes to cardiovascular deaths in low-income and middle-income countries . We aim ed to investigate the effectiveness of a population -level intervention led by existing community health workers in reducing the burden of hypertension in a low-income population . METHODS We did a community-based , open-label , two-group , cluster-r and omised controlled trial in Nepal . Using computer-generated codes , we r and omly assigned ( 1:1 ) 14 clusters to a lifestyle intervention led by female community health volunteers ( FCHVs ) or usual care ( control group )  . In the intervention group , 43 FCHVs provided  home visits  every 4 months for lifestyle counselling and blood pressure monitoring .  Eligible participants had been involved in a previous population -based survey , were aged 25 - 65 years , did not have plans to migrate outside the study area , and were not severely ill or pregnant . The primary outcome was mean systolic blood pressure at 1 year . We included all participants who remained in the trial at 1 year in the primary analysis . This trial is registered with Clinical Trials.gov , number NCT02428075 . FINDINGS Between April 1 , 2015 , and Dec 31 , 2015 , we recruited 1638 participants ( 939 assigned to intervention ; 699 assigned to control ) . At 1 year , 855 participants remained in the intervention group ( 425 were normotensive , 175 were prehypertensive , and 255 had hypertension ) and 613 remained in the control group ( 305 were normotensive , 128 were prehypertensive , and 180 had hypertension ) . The mean systolic blood pressure at 1 year was significantly lower in the intervention group than in the control group for all cohorts : the difference was -2·28 mm Hg ( 95 % CI -3·77 to -0·79 , p=0·003 ) for participants who were normotensive , -3·08 mm Hg ( -5·58 to -0·59 , p=0·015 ) for participants who were prehypertensive , and -4·90 mm Hg ( -7·78 to -2·00 , p=0·001 ) for participants who were hypertensive . INTERPRETATION A simple , FCHV-led lifestyle intervention coupled with monitoring of blood pressure is effective for reduction of blood pressure in individuals with hypertension and ameliorates age-related increases in blood pressure in adults without hypertension in the general population of Nepal . FUNDING Aarhus University , Jayanti Memorial Trust 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 In low/middle-income countries with substantial HIV and tuberculosis epidemics , health services often neglect other highly prevalent chronic conditions , such as hypertension , which as a result are poorly managed . This paper reports on a study to assess the effect on hypertension management of lay health workers ( LHW ) working in South African rural primary healthcare clinics to support the provision of integrated chronic care . Methods A pragmatic cluster r and omised trial with a process evaluation in eight rural clinics assessed the effect of adding  two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months . Control clinics continued with usual care . The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure ( BP ) before and after the intervention , as measured by two cross-sectional population surveys . Results There was no improvement in BP control among users of intervention clinics as compared with control clinics . However , the LHWs improved clinic functioning , including overall attendance , and attendance on the correct day . All clinics faced numerous challenges , including rapidly increasing number of users of chronic care , unreliable BP machines and cuffs , intermittent drug shortages and insufficient space . Conclusion LHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients , the dominance of the vertically funded HIV programme and the poor st and ards of equipment in clinics . Trial registration number IS RCT N12128227 BACKGROUND WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80 % of communities and used by 50 % of eligible individuals by 2025 . We have previously reported that use of these medicines is very low , but now aim to assess how such low use relates to their lack of availability or poor affordability . METHODS We analysed information about availability and costs of cardiovascular disease medicines ( aspirin , β blockers , angiotensin-converting enzyme inhibitors , and statins ) in pharmacies gathered from 596 communities in 18 countries participating in the Prospect i ve Urban Rural Epidemiology ( PURE ) study . Medicines were considered available if present at the pharmacy when surveyed , and affordable if their combined cost was less than 20 % of household capacity-to-pay . We compared results from high-income , upper middle-income , lower middle-income , and low-income countries . Data from India were presented separately given its large , generic pharmaceutical industry . FINDINGS Communities were recruited between Jan 1 , 2003 , and Dec 31 , 2013 . All four cardiovascular disease medicines were available in 61 ( 95 % ) of 64 urban and 27 ( 90 % ) of 30 rural communities in high-income countries , 53 ( 80 % ) of 66 urban and 43 ( 73 % ) of 59 rural communities in upper middle-income countries , 69 ( 62 % ) of 111 urban and 42 ( 37 % ) of 114 rural communities in lower middle-income countries , eight ( 25 % ) of 32 urban and one ( 3 % ) of 30 rural communities in low-income countries ( excluding India ) , and 34 ( 89 % ) of 38 urban and 42 ( 81 % ) of 52 rural communities in India . The four cardiovascular disease medicines were potentially unaffordable for 0·14 % of households in high-income countries ( 14 of 9934 households ) , 25 % of upper middle-income countries ( 6299 of 24,776 ) , 33 % of lower middle-income countries ( 13,253 of 40,023 ) , 60 % of low-income countries ( excluding India ; 1976 of 3312 ) , and 59 % households in India ( 9939 of 16,874 ) . In low-income and middle-income countries , patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available ( odds ratio [ OR ] 0·16 , 95 % CI 0·04 - 0·57 ) . In communities in which all four medicines were available , patients were less likely to use medicines if the household potentially could not afford them ( 0·16 , 0·04 - 0·55 ) . INTERPRETATION Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income , lower middle-income , and low-income countries , which have very low use of these medicines . Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO 's targets of 50 % use of key medicines by 2025 . 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 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 Cervix cancer is a worldwide scourge . It is the second leading cause of cancer deaths in women worldwide with a rate of 728 deaths per day . 87 % of cervix cancer deaths occur in low- and middle-income countries , with mortality rates varying 18-fold.1 Even in high-income nations , there has been little improvement in survival rates.2 The last major improvement in cervix cancer was published 15 years ago with the superiority of cisplatin-based chemoradiotherapy to radiotherapy alone.3,4 The Cervix Cancer Research Network ( CCRN ) developed within the Gynecologic Cancer Intergroup ( GCIG ) out of a realisation that cervical cancer trials were becoming scarce . While cervical cancer rates are declining in GCIG countries , low- and middle-income countries are coping with large disease burdens . This led to extending trial development beyond GCIG borders to involve a network of accredited , capable centres in other areas of the world . It was envisaged that this could harness local enthusiasm to raise st and ards of care . The CCRN would provide the infrastructure and support for high quality trials . The CCRN recognized that many low- and middle-income countries would not be eligible to participate in trials since the degree of infrastructure required to participate would be lacking . The literature was evaluated for best practice s for clinical trials within gynecologic cancers.5 The CCRN developed st and ard operating procedures to ensure adequate infrastructure . A pre-qualifying question naire was developed to evaluate potential sites addressing clinical activity , site re sources , trials operation , radiation records , quality assurance , and clinical management information . Participation in a beam measurement program is required every two years to determine the stability of linear accelerators . The Imaging and Radiation Oncology Imaging Core ( IROC ) in Houston , Texas has partnered with CCRN to provide regular quality assurance . Site visits are performed by an audit team , including a physician and clinical trial manager , to evaluate the appropriateness to participate in CCRN trials . The GCIG has grown to include 28 member groups , and worldwide interest in the CCRN is shown in Figure 1 . To date , 17 different CCRN site visits have been performed . There are ten approved CCRN sites including Tata Memorial Hospital ; Bangalore , India ; Ramathibodi , Thail and ; Triv and rum , India ; Siriaj , Thail and ; Pramongkutklao , Thail and ; Ho Chi Minh , Vietnam ; Blokhin Russian Cancer Research Center , the Hertzen Moscow Cancer Research Institute , and the Russian Scientific Center of Roentgenoradiology . Several additional sites have been approved with contingencies , including Cluj , Romania and Minsk , Belarus . Figure 1 Worldwide GCIG and CCRN participation . CCRN currently has four multinational publicly funded clinical trials that are open for enrollment in low- , middle- , and high-income countries . The TACO Trial , which was developed by investigators from the Korean Gynecologic Oncology Group ( KGOG ) and the Thai Cooperative Group , is comparing weekly cisplatin cancer to every-three-week chemotherapy for locally advanced cervical cancer .  Cisplatin delivered every three weeks may be more effective by achieving a higher peak concentration.6 The OUTBACK Trial , sponsored by the Australia New Zeal and Gynaecology Oncology Group ( ANZGOG ) with participation from NRG Oncology and other cooperative groups , is evaluating the efficacy of extended adjuvant chemotherapy compared to the st and ard weekly cisplatin chemoradiotherapy . The extended adjuvant chemotherapy consists of four cycles of carboplatin and paclitaxel . The INTERLACE Trial is headed by the National Cancer Research Institute ( NCRI ) from the United Kingdom . This trial is evaluating neoadjuvant chemotherapy prior to definitive chemoradiotherapy . Compliance with chemotherapy may be higher in a neoadjuvant approach than in an extended adjuvant approach . In the meta- analysis for neoadjuvant chemotherapy in locally advanced cervix cancer , a benefit was observed when the dose intensity of cisplatin was greater than 25 mg/m2 per week.8 The SHAPE Trial , led by the NCIC Clinical Trials Group in Canada , is a r and omized trial evaluating radical hysterectomy  versus  simple hysterectomy  in low risk , early-stage cervix cancer ( lesions < 2 cm ) . The primary endpoint is pelvic relapse-free survival with secondary endpoints of quality of life , sexual health , and cost-effectiveness.9 The greatest burden of cervix cancer resides in low- and middle-income countries , most notably in Central and South America , sub-Saharan Africa , Eastern Europe , India , and parts of Asia . Simultaneously , the incidence of cervix cancer is declining in the high-income countries . Clinical research is an ongoing challenge , and requires collaboration amongst physicians , hospitals , and patients . In many countries , there are governmental barriers to trial participation and data sharing . The legislation and bureaucracy involved in clinical trials means there is significant cost associated with participation . Physicians and hospitals frequently donate their time to these important efforts , but even in developed nations governmental funding is not sufficient to cover all costs . As technology improves , the information sharing and data collection are easier , but rigorous quality assurance is necessary to maintain the validity of the research question and the credibility of the results . Radiotherapy quality assurance in these trials is done via an internet-based approach . Many areas of the world have experienced relatively rapid economic growth and investment in health systems , which will provide more opportunity for conducting trials . The mission of the CCRN is to promote high quality research performed in locations where there is significant need . In three years we have met with success in this endeavor : there are four fully funded cervix cancer trials ; st and ard operating procedures ; a large cadre of expert volunteer site visitors ; 8 sites have been opened in 6 countries ; and 50 patients have been accrued . The cost of clinical research is small compared with the cost of clinical care . Through these efforts , CCRN hopes to improve the care of women with cervical cancer worldwide . As CCRN exp and s , an additional goal is to provide formalized training to physicians , study staff , and patient navigators to ensure high quality care delivery and follow-up . This can be a motivational aspect for international collaboration and development of country-specific , comprehensive healthcare programs . The goal , to save more lives from cervical cancer , is one that must be achieved BACKGROUND 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 Importance Despite extensive knowledge of hypertension treatment , the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries . Objective To test whether a community health worker – led multicomponent intervention would improve blood pressure ( BP ) control among low-income patients with hypertension . Design , Setting , and Participants A cluster r and omized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina . A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016 . Interventions Nine centers ( 743 patients ) were r and omized to the multicomponent intervention , which included a community health worker – led home intervention ( health coaching , home BP monitoring , and BP audit and feedback ) , a physician intervention , and a text-messaging intervention over 18 months .  Nine centers ( 689 patients ) were r and omized to usual care . Main Outcomes and Measures The co primary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension . Secondary outcomes included the proportion of patients with controlled hypertension ( BP < 140/90 mm Hg ) . Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a st and ard protocol , the means of which were used for analyses . Results Of 1432 participants ( mean age , 55.8 years [ SD , 13.3 ] ; 772 women [ 53.0 % ] ) , 1357 ( 94.8 % ) completed the trial . Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group ; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care  group . Systolic BP reduction from baseline to month 18 was 19.3 mm Hg ( 95 % CI , 17.9 - 20.8 mm Hg ) for the intervention group and 12.7 mm Hg ( 95 % CI , 11.3 - 14.2 mm Hg ) for the usual care group ; the difference in the reduction was 6.6 mm Hg ( 95 % CI , 4.6 - 8.6 ; P < .001 ) . Diastolic BP decreased by 12.2 mm Hg ( 95 % CI , 11.2 - 13.2 mm Hg ) in the intervention group and 6.9 mm Hg ( 95 % CI , 5.9 - 7.8 mm Hg ) in the control group ; the difference in the reduction was 5.4 mm Hg ( 95 % CI , 4.0 - 6.8 mm Hg ; P < .001 ) . The proportion of patients with controlled hypertension increased from 17.0 % at baseline to 72.9 % at 18 months in the intervention group and from 17.6 % to 52.2 % in the usual care group ; the difference in the increase was 20.6 % ( 95 % CI , 15.4%-25.9 % ; P < .001 ) . No adverse events were reported . Conclusions and Relevance Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker – led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months . Further research is needed to assess generalizability and cost-effectiveness of this intervention and to underst and which components may have contributed most to the outcome . Trial Registration clinical trials.gov Identifier : 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 Chronic kidney disease is an important cause of global mortality and morbidity . Data for epidemiological features of chronic kidney disease and its risk factors are limited for low-income and middle-income countries . The International Society of Nephrology 's Kidney Disease Data Center ( ISN-KDDC ) aim ed to assess the prevalence and awareness of chronic kidney disease and its risk factors , and to investigate the risk of cardiovascular disease , in countries of low and middle income . METHODS We did a cross-sectional study in 12 countries from six world regions : Bangladesh , Bolivia , Bosnia and Herzegovina , China , Egypt , Georgia , India , Iran , Moldova , Mongolia , Nepal , and Nigeria . We analysed data from screening programmes in these countries , matching eight general and four high-risk population cohorts collected in the ISN-KDDC data base . High-risk cohorts were individuals at risk of or with a diagnosis of either chronic kidney disease , hypertension , diabetes , or cardiovascular disease . Participants completed a self-report question naire , had their blood pressure measured , and blood and urine sample s taken . We defined chronic kidney disease according to modified KDIGO ( Kidney Disease : Improving Global Outcomes ) criteria ; risk of cardiovascular disease development was estimated with the Framingham risk score . FINDINGS 75,058 individuals were included in the study . The prevalence of chronic kidney disease was 14·3 % ( 95 % CI 14·0 - 14·5 ) in general population s and 36·1 % ( 34·7 - 37·6 ) in high-risk population s. Overall awareness of chronic kidney disease was low , with 409 ( 6 % ) of 6631 individuals in general population s and 150 ( 10 % ) of 1524 participants from high-risk population s aware they had chronic kidney disease . Moreover , in the general population , 5600 ( 44 % ) of 12,751 individuals with hypertension did not know they had the disorder , and 973 ( 31 % ) of 3130 people with diabetes were unaware they had that disease . The number of participants at high risk of cardiovascular disease , according to the Framingham risk score , was underestimated compared with KDIGO guidelines . For example , all individuals with chronic kidney disease should be considered at high risk of cardiovascular disease , but the Framingham risk score detects only 23 % in the general population , and only 38 % in high-risk cohorts . INTERPRETATION Prevalence of chronic kidney disease was high in general and high-risk population s from countries of low and middle income . Moreover , awareness of chronic kidney disease and other non-communicable diseases was low , and a substantial number of individuals who knew they were ill did not receive treatment . Prospect i ve programmes with repeat testing are needed to confirm the diagnosis of chronic kidney disease and its risk factors . Furthermore , in general , health-care workforces in countries of low and middle income need strengthening . FUNDING International Society of Nephrology 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 Mobile phone technology is utilized for better delivery of health services worldwide . In low- and -middle income countries mobile phones are now ubiquitous . Thus leveraging mHealth applications in health sector is becoming popular rapidly in these countries . To assess the effectiveness of the Continuum of Care Services ( CCS ) mHealth platform in terms of strengthening the delivery of maternal and child health ( MCH ) services in a district in Bihar , a re source -poor state in India . Methods The CommCare mHealth platform was customized to CCS as one of the innovations under a project funded by the Bill and Melinda Gates Foundation to improve the maternal and newborn health services in Bihar . The intervention was rolled out in one project district in Bihar , during July 2012 . More than 550 frontline workers out of a total of 3000 including Accredited Social Health Activists , Anganwadi Workers , Auxilliary Nurse Midwives and Lady Health Supervisors were trained to use the mHealth platform . The service delivery components namely early registration of pregnant women , three antenatal visits , tetanus toxoid immunization of the mother , iron and folic acid tablet supply , institutional delivery , postnatal home visits and early initiation of breastfeeding were used as indicators for good quality services . The result ant coverage of these services in the implementation area was compared with rest of Bihar and previous year statistics of the same area . The time lag between delivery of a service and its record capture in the maternal and child tracking system ( MCTS ) data base was computed in a r and om sample of 16,000 beneficiaries . The coverage of services among marginalized and non-marginalized castes was compared to indicate equity of service delivery . Health system strengthening was viewed from the angle of coverage , quality , equity and efficiency of services . Results The implementation blocks had higher coverage of all the eight indicator services compared to rest of Bihar and the previous year . There was equity of services across castes for all the indicators . Timely capture of data was also ensured compared to paper-based reporting . Conclusion By virtue of its impact on quality , efficiency and equity of service delivery , health care manpower efficiency and governance , the mHealth inclusion at service provision level can be one of the potential strategy to strengthen the health system Background Despite the many antihypertensive medications available , two-thirds of patients with hypertension do not achieve blood pressure control . This is thought to be due to a combination of poor patient education , poor medication adherence , and " clinical inertia . " The present trial evaluates an intervention consisting of health coaching , home blood pressure monitoring , and home medication titration as a method to address these three causes of poor hypertension control . Methods / Design The r and omized controlled trial will include 300 patients with poorly controlled hypertension . Participants will be recruited from a primary care clinic in a teaching hospital that primarily serves low-income population s . An intervention group of 150 participants will receive health coaching , home blood pressure monitoring , and home-titration of antihypertensive medications during 6 months . The control group ( n = 150 ) will receive health coaching plus home blood pressure monitoring for the same duration . A passive control group will receive usual care .  Blood pressure measurements will take place at baseline , and after 6 and 12 months . The primary outcome will be change in systolic blood pressure after 6 and 12 months . Secondary outcomes measured will be change in diastolic blood pressure , adverse events , and patient and provider satisfaction . Discussion The present study is design ed to assess whether the 3-pronged approach of health coaching , home blood pressure monitoring , and home medication titration can successfully improve blood pressure , and if so , whether this effect persists beyond the period of the intervention . Trial Registration Clinical Trials.gov identifier : Background Effective strategies for implementing best practice s in low and middle income countries are needed . RHL is an annually up date d electronic publication containing Cochrane systematic review s , commentaries and practical recommendations on how to implement evidence -based practice s. We are conducting a trial to evaluate the improvement in obstetric practice s using an active dissemination strategy to promote uptake of recommendations in The WHO Reproductive Health Library ( RHL ) . Methods A cluster r and omized trial to improve obstetric practice s in 40 hospitals in Mexico and Thail and is conducted . The trial uses a stratified r and om allocation based on country , size and type of hospitals . The core intervention consists of three interactive workshops delivered over a period of six months . The main outcome measures are changes in clinical practice s that are recommended in RHL measured approximately a year after the first workshop . Results The design and implementation of a complex intervention using a cluster r and omized trial design are presented . Conclusion Design ing the intervention , choosing outcome variables and implementing the protocol in two diverse setting s has been a time-consuming and challenging process . We hope that sharing this experience will help others planning similar projects and improve our ability to implement change BACKGROUND A recent cluster r and omized trial evaluating a multicomponent intervention showed significant reductions in blood pressure in low-income hypertensive subjects in Argentina . OBJECTIVES To assess the cost-effectiveness of this intervention . METHODS A total of 1432 hypertensive participants were recruited from 18 primary health care centers . The intervention included home visits led by community health workers , physician education , and text messaging . Re source use and quality of life data using the three-level EuroQol five-dimensional question naire were prospect ively collected . The study perspective was that of the public health care system , and the time horizon was 18 months . Intention-to-treat analysis was used to analyze cost and health outcomes ( systolic blood pressure [ SBP ] change and quality -adjusted life-years [ QALYs ] ) . A 1 time gross domestic product per capita per QALY was used as the cost-effectiveness threshold ( US $ 14,062 ) . RESULTS Baseline characteristics were similar in the two arms . QALYs significantly increased by 0.06 ( 95 % confidence interval [ CI ] 0.04 - 0.09 ) in the intervention group , and SBP net difference favored the intervention group : 5.3 mm Hg ( 95 % CI 0.27 - 10.34 ) . Mean total costs per participant were higher in the intervention arm : US $ 304 in the intervention group and US $ 154 in the control group ( adjusted difference of US $ 140.18 ; 95 % CI US $ 75.41-US $ 204.94 ) . The incremental cost-effectiveness ratio was $ 3299 per QALY ( 95 % credible interval 1635 - 6099 ) and US $ 26 per mm Hg of SBP ( 95 % credible interval 13 - 46 ) . Subgroup analysis showed that the intervention was cost-effective in all prespecified subgroups ( age , sex , cardiovascular risk , and body mass index ) . CONCLUSIONS The multicomponent intervention was cost-effective for blood pressure control among low-income hypertensive patients 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 Background Hypertension is the leading global risk factor for mortality . Hypertension treatment and control rates are low worldwide , and delays in seeking care are associated with increased mortality . Thus , a critical component of hypertension management is to optimize linkage and retention to care . Methods / Design This study investigates whether community health workers , equipped with a tailored behavioral communication strategy and smartphone technology , can increase linkage and retention of hypertensive individuals to a hypertension care program and significantly reduce blood pressure among them . The study will be conducted in the Kosirai and Turbo Divisions of western Kenya . An initial phase of qualitative inquiry will assess facilitators and barriers of linkage and retention to care using a modified Health Belief Model as a conceptual framework . Subsequently , we will conduct a cluster r and omized controlled trial with three arms : 1 ) usual care ( community health workers with the st and ard level of hypertension care training ) ; 2 ) community health workers with an additional tailored behavioral communication strategy ; and 3 ) community health workers with a tailored behavioral communication strategy who are also equipped with smartphone technology . The co- primary outcome measures are : 1 ) linkage to hypertension care , and 2 ) one-year change in systolic blood pressure among hypertensive individuals . Cost-effectiveness analysis will be conducted in terms of costs per unit decrease in blood pressure and costs per disability-adjusted life year gained . Discussion This study will provide evidence regarding the effectiveness and cost-effectiveness of strategies to optimize linkage and retention to hypertension care that can be applicable to non-communicable disease management in low- and middle-income countries . Trial registration This trial is registered with ( NCT01844596 ) on 30 April 2013 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 Rationale Stroke is the second-leading cause of death in low- and middle-income countries , but use of evidence -based therapies for stroke prevention in such countries , especially those in Africa , is extremely poor . This study is design ed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge . Aim /Hypothesis The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke ( THRIVES ) significantly improves blood pressure control after stroke . Design This prospect i ve triple-blind r and omized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria . The culturally sensitive , system-appropriate intervention comprises patient report cards , phone text messaging , an educational video , and coordination of posthospitalization care . Study Outcomes The primary outcome is improvement of blood pressure control . Secondary endpoints include control of other stroke risk factors , medication adherence , functional status , and quality of life . We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers . Discussion We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region Background In many low- and middle-income countries , where tobacco use is common , tuberculosis is also a major problem . Tobacco use increases the risk of developing tuberculosis , secondary mortality , poor treatment compliance and relapses . In countries with TB epidemic , even a modest relative risk leads to a significant attributable risk . Treating tobacco dependence , therefore , is likely to have benefits for controlling tuberculosis in addition to reducing the non-communicable disease burden associated with smoking . In poorly re source d health systems which face a dual burden of disease secondary to tuberculosis and tobacco , an integrated approach to tackle tobacco dependence in TB control could be economically desirable . During TB screening , health professionals come across large numbers of patients with respiratory symptoms , a significant proportion of which are likely to be tobacco users . These clinical encounters , considered to be " teachable moments " , provide a window of opportunity to offer treatment for tobacco dependence . Methods / Design We aim to develop and trial a complex intervention to reduce  tobacco dependence among TB suspects based on the WHO ' five steps to quit ' model . This model relies on assessing personal motivation to quit tobacco use and uses it as the basis for assessing suitability for the different therapeutic options for tobacco dependence . We will use the Medical Research Council framework approach for evaluating complex interventions to : ( a ) design an evidence -based treatment package ( likely to consist of training material s for health professionals and education tools for patients ) ; ( b ) pilot the package to determine the delivery modalities in TB programme ( c ) assess the incremental cost-effectiveness of the package compared to usual care using a cluster RCT design ; ( d ) to determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes ; and ( e ) support long term implementation . The main outcomes to assess the effectiveness would be point abstinence at 4 weeks and continuous abstinence up to 6 months . Discussion This work will be carried out in Pakistan and is expected to have relevance for other low and middle income countries with high tobacco use and TB incidence . This will enhance our knowledge of the cost-effectiveness of treating tobacco dependence in patients suspected of TB.Trial Registration Trial Registration Number : IS RCT Background Controlling hypertension rates and maintaining normal blood pressure , particularly in re source -constrained setting s , represent ongoing challenges of effective and affordable implementation in health care . One of the strategies being largely advocated to improve high blood pressure calls for salt reduction strategies . This study aims to estimate the impact of a population -level intervention based on sodium reduction and potassium increase – in practice , introducing a low-sodium , high-potassium salt substitute – on adult blood pressure levels . Methods / Design The proposed implementation research study includes two components : Phase 1 , an exploratory component , and Phase 2 , an intervention component . The exploratory component involves a triangle taste test and a formative research study design ed to gain an underst and ing of the best implementation methods . Phase 2 involves a pragmatic stepped wedge trial design where the intervention will be progressively implemented in several clusters starting the intervention r and omly at different times . In addition , we will evaluate the implementation strategy using a cost-effectiveness analysis . Discussion This is the first project in a Latin-American setting to implement a salt substitution intervention at the population level to tackle high blood pressure . Data generated and lessons learnt from this study will provide a strong platform to address potential interventions applicable to other similar low- and middle-income setting s . Trial registration This study is registered in Clinical Trials.gov NCT01960972 Summary Background Fast weight gain and linear growth in children in low-income and middle-income countries are associated with enhanced survival and improved cognitive development , but might increase risk of obesity and related adult cardiometabolic diseases . We investigated how linear growth and relative weight gain during infancy and childhood are related to health and human capital outcomes in young adults . Methods We used data from five prospect i ve birth cohort studies from Brazil , Guatemala , India , the Philippines , and South Africa . We investigated  body-mass index , systolic and diastolic blood pressure , plasma glucose concentration , height , years of attained schooling , and related categorical indicators of adverse outcomes in young adults . With linear and logistic regression models , we assessed how these outcomes relate to birthweight and to statistically independent measures representing linear growth and weight gain independent of linear growth ( relative weight gain ) in three age periods : 0–2 years , 2 years to mid-childhood , and mid-childhood to adulthood . Findings We obtained data for 8362 participants who had at least one adult outcome of interest . A higher birthweight was consistently associated with an adult body-mass index of greater than 25 kg/m2 ( odds ratio 1·28 , 95 % CI 1·21–1·35 ) and a reduced likelihood of short adult stature ( 0·49 , 0·44–0·54 ) and of not completing secondary school ( 0·82 , 0·78–0·87 ) . Faster linear growth was strongly associated with a reduced risk of short adult stature ( age 2 years : 0·23 , 0·20–0·52 ; mid-childhood : 0·39 , 0·36–0·43 ) and of not completing secondary school ( age 2 years : 0·74 , 0·67–0·78 ; mid-childhood : 0·87 , 0·83–0·92 ) , but did raise the likelihood of overweight ( age 2 years : 1·24 , 1·17–1·31 ; mid-childhood : 1·12 , 1·06–1·18 ) and elevated blood pressure ( age 2 years : 1·12 , 1·06–1·19 ; mid-childhood : 1·07 , 1·01–1·13 ) . Faster relative weight gain was associated with an increased risk of adult overweight ( age 2 years : 1·51 , 1·43–1·60 ; mid-childhood : 1·76 , 1·69–1·91 ) and elevated blood pressure ( age 2 years : 1·07 , 1·01–1·13 ; mid-childhood : 1·22 , 1·15–1·30 ) . Linear growth and relative weight gain were not associated with dysglycaemia , but a higher birthweight was associated with decreased risk of the disorder ( 0·89 , 0·81–0·98 ) . Interpretation Interventions in countries of low and middle income to increase birthweight and linear growth during the first 2 years of life are likely to result in substantial gains in height and schooling and give some protection from adult chronic disease risk factors , with few adverse trade-offs . Funding Wellcome Trust and Bill & Melinda Gates Foundation The present study was design ed to examine the finger-pinch force control , digit force sharing and digit coupling relations of 13 young and 14 older adults . Subjects performed four isometric tri-digit finger-pinch force production conditions reflecting all combinations of mean force level ( 20 and 40 % MVC ) and target shape ( constant and sinusoidal ) . Older adults had significantly reduced force control , as indicated by their greater levels of absolute and relative force variability and targeting error than young adults . The age-related loss of relative force control was more pronounced at low ( 20 % MVC ) than high ( 40 % MVC ) forces , and to a lesser extent , in sinusoidal than constant force conditions . Older adults had significantly greater peak and proportional power below 1.5 Hz than young adults , with this especially pronounced in constant force conditions . Digit force sharing results indicated that the index finger ’s contribution to total force was increased and the middle finger ’s contribution reduced in older than young adults . The results of the cross-correlation analyses revealed that older subjects had a significantly reduced level of coupling between the middle finger and the target force , thumb force and EMG signals , with longer time lags in comparison to young adults . These differences in force sharing and middle finger force coupling were more pronounced in sinusoidal than constant force conditions . Overall , these results suggest that the older adults ’ reduced force control reflected age-related differences in the sharing and coupling of the finger forces . The results also highlighted that tasks of this nature display a degree of task-dependency , with these overall differences in digit force output and coupling not consistently observed across all force conditions OBJECTIVE We examined whether low-income patients with diabetes were able and willing to use automated telephone disease management ( ATDM ) calls to provide health status information that could improve the quality of their care . RESEARCH DESIGN AND METHODS A total of 252 adults with diabetes , 30 of whom spoke Spanish as their primary language , were enrolled at the time of clinic visits in a Department of Veterans Affairs health care system ( n = 132 ) or a county health care system ( n = 120 ) . Patients received ATDM calls for 12 months and responded to queries using their touch-tone telephones . We examined 1 ) whether patients completed ATDM assessment s consistently over the year and used the calls to report their  self-monitored blood glucose ( SMBG ) levels , 2 ) the characteristics of patients most likely to use the system frequently , 3 ) whether patients responded consistently within ATDM assessment s , and 4 ) whether ATDM assessment s differentiated among groups of patients with different clinical profiles at baseline . RESULTS Half of all patients completed at least 77 % of their attempted assessment s , and one-fourth completed at least 91 % . Half of all patients reported SMBG levels during at least 86 % of their assessment s. Patients completed assessment s and reported glucose levels consistently over the year . Health status indicators were the most important determinants of assessment completion rates , while socioeconomic factors were more strongly associated with patients ' likelihood of reporting SMBG data during assessment s. Patients ' responses within assessment s were consistent , and the information they provided during their initial assessment s identified groups with poor glycemic control and other health problems . CONCLUSIONS Most low-income patients with diabetes can and will use ATDM calls as part of their care . The information they provide is reliable and has clinical significance . ATDM calls could improve the information base for diabetes management while relieving some of the pressures of delivering diabetes care under cost constraints BACKGROUND Chronic kidney disease ( CKD ) is highly prevalent in patients with diabetes or hypertension in primary care . A shared care model could improve quality of care in these patients AIM To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension . Design and setting A cluster r and omised controlled trial in nine general practice s in The Netherl and s. METHOD Five practice s were allocated to the shared care model and four practice s to usual care for 1 year . Primary outcome was the achievement of blood pressure targets ( 130/80 mmHg ) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60 ml/min/1.73 m(2 ) . RESULTS Data of 90 intervention and 74 control patients could be analysed . Blood pressure in the intervention group decreased with 8.1 ( 95 % CI = 4.8 to 11.3)/1.1 ( 95 % CI = -1.0 to 3.2 ) compared to -0.2 ( 95 % CI = -3.8 to 3.3)/-0.5 ( 95 % CI = -2.9 to 1.8 ) in the control group . Use of lipid-lowering drugs , angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group ( 73 % versus 51 % , 81 % versus 64 % , and 15 % versus 1 % , respectively , [ P = 0.004 , P = 0.01 , and P = 0.002 ] ) . CONCLUSION A shared care model between GP , nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care Background Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension . Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening , monitoring , treatment and control of high blood pressure . Methods Better Health Outcomes through Mentoring and Assessment ( BHOMA ) is a 5-year , r and omized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics . Clinical data were collected as part of routine patient care from an electronic medical record system , and review ed for site performance over time according to hypertension related indicators : screening ( blood pressure measurement ) , management ( recorded diagnosis , physical exam or urinalysis ) , treatment ( on medication ) , and control . Quantitative data was used to develop guides for qualitative in-depth interviews , conducted with health care providers at a proportional sample of half ( 20 ) of clinics . Qualitative data was iteratively analyzed for thematic content . Results From January 2011 to December 2014 , 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included  . Blood pressure measurement at vital sign screening was initially high at 89.1 % overall ( range : 70.1–100 % ) , but decreased to 62.1 % ( range : 0–100 % ) by 48 months after intervention start . The majority of hypertensive patients made only one visit to the clinics ( 57.8 % ) . Out of 9022 patients with at least two visits with an elevated blood pressure , only 49.3 % had a chart recorded hypertension diagnosis . Process indicators for monitoring hypertension were < 10 % and did not improve with time . In in-depth interviews , antihypertensive medication shortages were common , with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts . Principal challenges in hypertension management included 1 ) equipment and personnel shortages , 2 ) provider belief that multiple visits were needed before official management , 3 ) medication stock-outs , leading to improper prescriptions and 4 ) poor patient visit attendance . Conclusions Our findings suggest that numerous barriers st and in the way of hypertension diagnosis and management in Zambian primary health facilities . Future work should focus on performance indicator development and validation in low re source context s , to facilitate regular and systematic data review to improve patient outcomes .Trial registration Clinical Trials.gov , Identifier NCT01942278 . Date of Registration : September 2013 Background Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries . These differences have been related to poor access to and poor quality of obstetric and neonatal care . Methods This trial tested the hypothesis that teams of health care providers , administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations . In seven geographic areas in five low-income and one middle-income country , most with high perinatal mortality rates and substantial numbers of home deliveries , we performed a cluster r and omized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport , community birth attendant training in problem recognition , and facility staff training in the management of obstetric and neonatal emergencies . The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g. Results Despite extensive effort in all sites in each of the three intervention areas , no differences emerged in the primary or any secondary outcome between the intervention and control clusters . In both groups , the mean perinatal mortality was 40.1/1,000 births ( P = 0.9996 ) . Neither were there differences between the two groups in outcomes in the last six months of the project , in the year following intervention cessation , nor in the clusters that best implemented the intervention . Conclusions This cluster r and omized comprehensive , large-scale , multi-sector intervention did not result in detectable impact on the proposed outcomes . While this does not negate the importance of these interventions , we expect that achieving improvement in pregnancy outcomes in these setting s will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial , and without them provider training and community mobilization will not be sufficient . Our results highlight the critical importance of evaluating outcomes in r and omized trials , as interventions that should be effective may not be . Trial registration Clinical Trials.gov Background Globally , most strokes occur in low- and middle-income countries , such as India , with many affected people having no or limited access to rehabilitation services . Western models of stroke rehabilitation are often unaffordable in many population s but evidence from systematic review s of stroke unit care and early supported discharge rehabilitation trials suggest that some components might form the basis of affordable interventions in low-re source setting s. We describe the background , history and design of the ATTEND trial , a complex intervention centred on family-led stroke rehabilitation in India . Methods / design The ATTEND trial aims to test the hypothesis that a family-led caregiver-delivered home-based rehabilitation intervention , design ed for the Indian context , will reduce the composite poor outcome of death or dependency at 6 months after stroke , in a multicentre , individually r and omized controlled trial with blinded outcome assessment , involving 1200 patients across 14 hospital sites in India . Discussion The ATTEND trial is testing the effectiveness of a low-cost rehabilitation intervention that could be widely generalizable to other low- and middle-income countries . Trial registration Clinical Trials Registry-India CTRI/2013/04/003557 . Australian New Zeal and Clinical Trials Registry ACTRN12613000078752 . Universal Trial Number U1111 - 1138 - 6707 BACKGROUND Worldwide implementation of risk-based cardiovascular disease ( CVD ) prevention requires risk prediction tools that are contemporarily recalibrated for the target country and can be used where laboratory measurements are unavailable . We present two cardiovascular risk scores , with and without laboratory-based measurements , and the corresponding risk charts for 182 countries to predict 10-year risk of fatal and non-fatal CVD in adults aged 40 - 74 years . METHODS Based on our previous laboratory-based prediction model ( Globorisk ) , we used data from eight prospect i ve studies to estimate coefficients of the risk equations using proportional hazard regressions . The laboratory-based risk score included age , sex , smoking , blood pressure , diabetes , and total cholesterol ; in the non-laboratory ( office-based ) risk score , we replaced diabetes and total cholesterol with BMI . We recalibrated risk scores for each sex and age group in each country using country-specific mean risk factor levels and CVD rates . We used recalibrated risk scores and data from national surveys ( using data from adults aged 40 - 64 years ) to estimate the proportion of the population at different levels of CVD risk  for ten countries from different world regions as examples of the information the risk scores provide ; we applied a risk threshold for high risk of at least 10 % for high-income countries ( HICs ) and at least 20 % for low-income and middle-income countries ( LMICs ) on the basis of national and international guidelines for CVD prevention . We estimated the proportion of men and women who were similarly categorised as high risk or low risk by the two risk scores . FINDINGS Predicted risks for the same risk factor profile were generally lower in HICs than in LMICs , with the highest risks in countries in central and southeast Asia and eastern Europe , including China and Russia . In HICs , the proportion of people aged 40 - 64 years at high risk of CVD ranged from 1 % for South Korean women to 42 % for Czech men ( using a ≥10 % risk threshold ) , and in low-income countries ranged from 2 % in Ug and a ( men and women ) to 13 % in Iranian men ( using a ≥20 % risk threshold ) . More than 80 % of adults were similarly classified as low or high risk by the laboratory-based and office-based risk scores . However , the office-based model substantially underestimated the risk among patients with diabetes . INTERPRETATION Our risk charts provide risk assessment tools that are recalibrated for each country and make the estimation of CVD risk possible without using laboratory-based measurements . FUNDING National Institutes of Health Introduction Community health workers ( CHWs ) can improve diabetes outcomes ; however , questions remain about translating research findings into practical low-intensity models for safety-net providers . We tested the effectiveness of a home-based low-intensity CHW intervention for improving health outcomes among low-income adults with diabetes . Methods Low-income patients with glycated hemoglobin A1c ( HbA1c ) of 8.0 % or higher in the 12 months before enrollment from 3 safety-net providers were r and omized to a 12-month CHW-delivered diabetes self-management intervention or usual care . CHWs were based at a local health department . The primary outcome was change in HbA1c from baseline enrollment to 12 months ; secondary outcomes included blood pressure and lipid levels , quality of life , and health care use . Results The change in HbA1c in the intervention group ( n = 145 ) ( unadjusted mean of 9.09 % to 8.58 % , change of −0.51 ) compared with the control group ( n = 142 ) ( 9.04 % to 8.71 % , change of −0.33 ) was not significant ( P = .54 ) . In an analysis of participants with poor glycemic control ( HbA1c > 10 % ) , the intervention group had a 1.23-point greater decrease in HbA1c compared with controls ( P = .046 ) . For the entire study population , we found a decrease in reported physician visits ( P < .001 ) and no improvement in health-related quality of life ( P = .07 ) in the intervention group compared with the control group . Conclusion A low-intensity CHW-delivered intervention to support diabetes self-management did not significantly improve HbA1c relative to usual care . Among the subgroup of participants with poor glycemic control ( HbA1c > 10 % at baseline ) , the intervention was effective Interventions aim ed at improving glucose regulatory mechanisms have been suggested as a possible source of cognitive enhancement in the elderly . In particular , previous research has identified episodic memory as a target for facilitation after either moderate increases in glycaemia ( after a glucose drink ) or after improvements in glucose regulation . The present study aim ed to extend this research by examining the joint effects of glucose ingestion and glucose regulation on cognition . In addition , risk factors associated with the development of poor glucose regulation in middle-aged adults were considered . In a repeated measures design , thirty-three middle-aged adults ( aged 35 - 55 years ) performed a battery of memory and non-memory tasks after either 25 g or 50 g glucose or a sweetness matched placebo drink . To assess the impact of individual differences in glucose regulation  , blood glucose measurements were taken on four occasions during testing . A lifestyle and diet question naire was also administered . Consistent with previous research , episodic memory ability benefited from glucose ingestion when task dem and s were high . Blood glucose concentration was also found to predict performance across a number of cognitive domains . Interestingly , the risk factors associated with poor glucose regulation were linked to dietary impacts traditionally associated with poor health , e.g. the consumption of high-sugar sweets and drinks . The research replicates earlier work suggesting that task dem and s are critical to the glucose facilitation effect . Importantly , the data demonstrate clear associations between elevated glycaemia and relatively poor cognitive performance , which may be partly due to the effect of dietary and lifestyle factors
The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure , but low for diastolic blood pressure .
INTERPRETATION Task-sharing interventions are effective in reducing blood pressure .
BACKGROUND Task sharing for the management of hypertension could be useful for understaffed and re source -poor health systems .
We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries .