Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. Sudden cardiac death in low- and middle-income countries. Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries A systematic review of online interventions for mental health in low and middle income countries: a neglected field Hypothermia for encephalopathy in low and middle-income countries (HELIX): study protocol for a randomised controlled trial Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country. What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts Utilization of evidence-based therapy for acute coronary syndrome in high-income and low/middle-income countries. A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries. Interventions for domestic violence among pregnant women in low- and middle-income countries: a systematic review protocol Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review protocol Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries. Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study. Gender (in) differences in prevalence and incidence of traumatic experiences among orphaned and separated children living in five low- and middle-income countries Screening for diabetes and hypertension in a rural low income setting in western Kenya utilizing home-based and community-based strategies Rationale and design of a randomized controlled trial evaluating community health worker-based interventions for the secondary prevention of acute coronary syndromes in India (SPREAD). Trauma History and Depression Predict Incomplete Adherence to Antiretroviral Therapies in a Low Income Country Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. Laboratory-based and office-based risk scores and charts to predict 10-year risk of cardiovascular disease in 182 countries: a pooled analysis of prospective cohorts and health surveys. mHealth Interventions in Low and Middle-Income Countries: A Systematic Review Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study Hypertension and Cardiovascular Risk Profile in a Middle-Income Setting: The HELISUR Study Effectiveness of a brief community outreach tobacco cessation intervention in India: a cluster-randomised controlled trial (the BABEX Trial) An intervention to stop smoking among patients suspected of TB - evaluation of an integrated approach Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. The effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial
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 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 Cardiovascular disease , and the incidence of sudden cardiac death ( SCD ) , will increase significantly in low- and middle-income countries ( LMIC ) . Thus , SCD threatens to become a global public health problem . We present a summary of the current research that has investigated the epidemiology of SCD in LMIC . Few studies of SCD in LMIC exist , and they are of variable method ological quality . Risk factors for SCD are described , taking into account recent global burden of disease and risk factor statistics . We describe 1 proposal for a community-based , prospect i ve , multiple- source methodology for SCD monitoring and surveillance that can be implemented in LMIC . Further research into the epidemiology of SCD in LMIC , using st and ardized methodology , would allow investigators and policy makers to determine the regions , communities , and individuals most at need for SCD prevention . Focusing on SCD and its prevention in LMIC should be a priority for the global health community People living with HIV ( PLWH ) experience greater psychological distress than the general population . Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms , quality of life , and HIV care engagement . However , little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries ( LMICs ) , where the large majority of PLWH reside . This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these setting s. A systematic search strategy was undertaken to identify peer- review ed published papers of intervention trials addressing negative psychological states or disorders ( e.g. depression , anxiety ) among PLWH in LMIC setting s. Search results were assessed against pre-established inclusion and exclusion criteria . Data from papers meeting criteria were extracted for synthesis . Twenty-six papers , published between 2000 and 2014 , describing 22 unique interventions were identified . Trials were implemented in sub-Saharan Africa ( n = 13 ) , Asia ( n = 7 ) , and the Middle East ( n = 2 ) , and addressed mental health using a variety of approaches , including cognitive-behavioral ( n = 18 ) , family-level ( n = 2 ) , and pharmacological ( n = 2 ) treatments . Four r and omized controlled trials reported significant intervention effects in mental health outcomes , and 11 preliminary studies demonstrated promising findings . Among the limited mental health intervention trials with PLWH in LMICs , few demonstrated efficacy .  Mental health interventions for PLWH in LMICs must be further developed and adapted for re source -limited setting s to improve effectiveness 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 Therapeutic hypothermia reduces death and disability after moderate or severe neonatal encephalopathy in high-income countries and is used as st and ard therapy in these setting s. However , the safety and efficacy of cooling therapy in low- and middle-income countries ( LMICs ) , where 99 % of the disease burden occurs , remains unclear . We will examine whether whole body cooling reduces death or neurodisability at 18–22 months after neonatal encephalopathy , in LMICs . Methods We will r and omly allocate 408 term or near-term babies ( aged ≤ 6 h ) with moderate or severe neonatal encephalopathy admitted to public sector neonatal units in LMIC countries ( India , Bangladesh or Sri Lanka ) , to either usual care alone or whole-body cooling with usual care . Babies allocated to the cooling arm will have core body temperature maintained at 33.5 ° C using a servo-controlled cooling device for 72 h , followed by re-warming at 0.5 ° C per hour . All babies will have detailed infection screening at the time of recruitment and 3 Telsa cerebral magnetic resonance imaging and spectroscopy at 1–2 weeks after birth . Our primary endpoint is death or moderate or severe disability at the age of 18 months . Discussion Upon completion , HELIX will be the largest cooling trial in neonatal encephalopathy and will provide a definitive answer regarding the safety and efficacy of cooling therapy for neonatal encephalopathy in LMICs . The trial will also provide important data about the influence of co-existent perinatal infection on the efficacy of hypothermic neuroprotection . Trial registration Clinical Trials.gov , NCT02387385 . Registered on 27 February 2015 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 A novel approach is explored for improving causal inference in observational studies by comparing cohorts from high-income with low- or middle-income countries ( LMIC ) , where confounding structures differ . This is applied to assessing causal effects of  breastfeeding  on child blood pressure ( BP ) , body mass index ( BMI ) and intelligence quotient ( IQ ) . Methods St and ardized approaches for assessing the confounding structure of breastfeeding by socio-economic position were applied to the British Avon Longitudinal Study of Parents and Children ( ALSPAC ) ( N ≃ 5000 ) and Brazilian Pelotas 1993 cohorts ( N ≃ 1000 ) . This was used to improve causal inference regarding associations of breastfeeding with child BP , BMI and IQ . Analyses were extended to include results from a meta- analysis of five LMICs ( N ≃ 10 000 ) and compared with a r and omized trial of breastfeeding promotion . Findings Although higher socio-economic position was strongly associated with breastfeeding in ALSPAC , there was little such patterning in Pelotas . In ALSPAC , breastfeeding was associated with lower BP , lower BMI and higher IQ , adjusted for confounders , but in the directions expected if due to socioeconomic patterning . In contrast , in Pelotas , breastfeeding was not strongly associated with BP or BMI but was associated with higher IQ . Differences in associations observed between ALSPAC and the LMIC meta- analysis were in line with those observed between ALSPAC and Pelotas , but with robust evidence of heterogeneity detected between ALSPAC and the LMIC meta- analysis associations . Trial data supported the conclusions inferred by the cross-cohort comparisons , which provided evidence for causal effects on IQ but not for BP or BMI . Conclusion While reported associations of breastfeeding with child BP and BMI are likely to reflect residual confounding , breastfeeding may have causal effects on IQ . Comparing associations between population s with differing confounding structures can be used to improve causal inference in observational studies 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 This paper describes the Common Elements Treatment Approach ( CETA ) for adults presenting with mood or anxiety problems developed specifically for use with lay counselors in low- and middle-income countries ( LMIC ) . Details of the intervention development , training , supervision , and decision-making process are presented . Case vignettes are used as examples throughout . Preliminary findings are presented on counselor/supervisor performance and client outcomes from practice cases completed prior to r and omized controlled trials ( RCT ) conducted at two sites for adult survivors of torture and /or systematic violence in ( a ) southern Iraq and ( b ) Thail and -Burma border . Data suggest that local supervisors and lay counselors with little prior mental health training or experience maintained fidelity to the model . The majority of pilot clients were retained in treatment , suggesting acceptability . Using the Reliable Change Index ( RCI ) for each individual we examined the number of clients above a minimal threshold ( z > 1.96 ) for each outcome . In Iraq 100 % of clients had RCIs above the threshold for depression and posttraumatic stress , and 81.8 % for impaired function . In Thail and , 81.3 % of clients had RCIs above minimum threshold for depression , 68.8 % for posttraumatic stress , and 37.5 % for impaired function . Implementation of CETA is discussed in relation to cultural issues within LMIC . These findings , combined with US-based evidence , suggest that a common elements approach warrants further development and testing as a means for addressing the treatment gap for mental health problems in LMIC Background Violence during pregnancy is a global problem , associated with serious health risks for both the mother and baby . Evaluation of interventions targeted for reducing or controlling domestic violence ( DV ) is still in its infancy , and the majority of findings are primarily from high-income countries ( HICs ) . Therefore , there is an urgent need for generating evidence of DV interventions among pregnant women in low- and middle-income countries ( LMICs ) . Methods Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRISMA ) guidelines will be employed to structure the review . A comprehensive search will be carried out via electronic data bases including MEDLINE , CINAHL , Scopus , Embase , Web of Science , PsycINFO , and The Cochrane library . Gray literature will also be scrutinized for potential articles . An optimal search strategy has been developed following consultations with subject-matter experts and librarians . This search strategy will be adapted to the different data bases . Experimental studies evaluating DV interventions among pregnant women from LMICs will be included in the review . The review will only include literature written in English . Two review ers will independently screen and assess studies for inclusion in the review . A third author will resolve any discrepancies between the review ers . Risk of bias will be assessed based on the Cochrane risk of bias assessment tool , and overall quality of the evidence will be judged using Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) criteria . Findings will be presented with the narrative synthesis , and if applicable , they will be further quantified using r and om-effects meta- analysis . Effect size , risk ratio for dichotomous variables , and st and ardized mean differences for continuous variables will be calculated for each outcome using Review Manager 5.3 . Discussion Systematic review s to evaluate the efficacy of interventions to address DV within the perinatal context have been limited . Hence , no one intervention has emerged as substantially effective towards addressing perinatal DV and associated health consequences . The evidence generated from this systematic review will inform research ers and policy makers about the effectiveness of existing DV interventions among pregnant women in LMICs and provide recommendations for future research in this area . This in turn will contribute towards violence prevention in LMICs . Systematic review registration PROSPERO Background Cluster r and omised trials ( CRTs ) are a key instrument to evaluate public health interventions , particularly in low- and middle-income countries ( LMICs ) . Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned . Evaluation of implementation fidelity ( IF ) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions . Current CRT reporting guidelines offer no guidance on IF assessment . We will systematic ally review the scientific literature to study current practice s concerning the assessment of IF in CRTs of public health interventions in LMICs . Methods We will include  CRTs of public health interventions in LMICs that planned or assessed IF in either the trial protocol or the main trial report ( or an associated document ) . Search strategies use Medical Subject Headings ( MESH ) and text words related to CRTs , developing countries , and public health interventions . The electronic data base search was developed first for MEDLINE and adapted for the following data bases : EMBASE , CINAHL , PubMed , and EMB Review s , to identify CRT reports in English , Spanish , or French published on or after January 1 , 2012 . To ensure availability of a study protocol , we will include CRTs reporting a registration number in the abstract . For each included study , we will compare planned versus reported assessment of IF , and consider the dimensions of IF studied , and data collection methods used to evaluate each dimension . Data will be synthesis ed using quantitative and narrative techniques . Risk of bias for individual studies will be assessed using the Cochrane Collaboration Risk of Bias Tool criteria and additional criteria related to CRT methods . We will investigate possible sources of heterogeneity by performing subgroup analysis . This review was not eligible for inclusion in the PROSPERO registry . Discussion Fidelity assessment may be a key tool for making studies more reliable , internally valid , and externally generalizable . This review will provide a portrait of current practice s related to the assessment of intervention fidelity in CRTs and offer suggestions for improvement . Results will be relevant to research ers , those who finance health interventions , and for decision-makers who seek the best evidence on public health interventions IMPORTANCE Little is known about adoption of healthy lifestyle behaviors among individuals with a coronary heart disease ( CHD ) or stroke event in communities across a range of countries worldwide . OBJECTIVE To examine the prevalence of avoidance or cessation of smoking , eating a healthy diet  , and undertaking regular physical activities  by individuals with a CHD or stroke event . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve Urban Rural Epidemiology ( PURE ) was a large , prospect i ve cohort study that used an epidemiological survey of 153,996 adults , aged 35 to 70 years , from 628 urban and rural communities in 3 high-income countries ( HIC ) , 7 upper-middle-income countries ( UMIC ) , 3 lower-middle-income countries ( LMIC ) , and 4 low-income countries ( LIC ) , who were enrolled between January 2003 and December 2009 . MAIN OUTCOME MEASURES Smoking status ( current , former , never ) , level of exercise ( low , < 600 metabolic equivalent task [MET]-min/wk ; moderate , 600 - 3000 MET-min/wk ; high , > 3000 MET-min/wk ) , and diet ( classified by the Food Frequency Question naire and defined using the Alternative Healthy Eating Index ) . RESULTS Among 7519 individuals with self-reported CHD ( past event : median , 5.0 [ interquartile range { IQR } , 2.0 - 10.0 ] years ago ) or stroke ( past event : median , 4.0 [ IQR , 2.0 - 8.0 ] years ago ) , 18.5 % ( 95 % CI , 17.6%-19.4 % ) continued to smoke ; only 35.1 % ( 95 % CI , 29.6%-41.0 % ) undertook high levels of work- or leisure-related physical activity , and 39.0 % ( 95 % CI , 30.0%-48.7 % ) had healthy diets ; 14.3 % ( 95 % CI , 11.7%-17.3 % ) did not undertake any of the 3 healthy lifestyle behaviors and 4.3 % ( 95 % CI , 3.1%-5.8 % ) had all 3 . Overall , 52.5 % ( 95 % CI , 50.7%-54.3 % ) quit smoking ( by income country classification : 74.9 % [ 95 % CI , 71.1%-78.6 % ] in HIC ; 56.5 % [ 95 % CI , 53.4%-58.6 % ] in UMIC ; 42.6 % [ 95 % CI , 39.6%-45.6 % ] in LMIC ; and 38.1 % [ 95 % CI , 33.1%-43.2 % ] in LIC ) . Levels of physical activity increased with increasing country income but this trend was not statistically significant . The lowest prevalence of eating healthy diets was in LIC ( 25.8 % ; 95 % CI , 13.0%-44.8 % ) compared with LMIC ( 43.2 % ; 95 % CI , 30.0%-57.4 % ) , UMIC ( 45.1 % , 95 % CI , 30.9%-60.1 % ) , and HIC ( 43.4 % , 95 % CI , 21.0%-68.7 % ) . CONCLUSION AND RELEVANCE Among a sample of patients with a CHD or stroke event from countries with varying income levels , the prevalence  of healthy lifestyle behaviors  was low , with even lower levels in poorer countries OBJECTIVES To analyze data from recent Demographic and Health Surveys ( DHS ) conducted in 21 low- and middle-income countries ( LMICs ) to examine patterns of interpregnancy intervals , unmet need , pregnancy risk and family planning method use and method mix among women 0 - 23 months postpartum . STUDY DESIGN Secondary analysis of postpartum women aged 15 - 49 years in 22 DHS surveys from 21 LMICs conducted between 2005 and 2012 . We applied an adapted unmet need definition for postpartum women to look at prospect i ve fertility preferences . We also constructed a new composite pregnancy risk indicator for postpartum women who have been sexually active since their last birth . RESULTS In 9 of 22 surveys , 50 % or more of nonfirst births occur at interpregnancy intervals that are too short . Overall prospect i ve unmet need for family planning by postpartum women has not changed demonstrably since a 2001 analysis and is universally high : 61 % of all postpartum women across the 21 countries have an unmet need for family planning . In 10 of 22 surveys , pregnancy risk rises steadily throughout the 2 years after birth . In the remaining 12 surveys , the risk of pregnancy peaks at 6 - 11 months after birth . Even when postpartum women are using family planning , they rely overwhelmingly on short-acting methods ( 51 - 96 % in 21 of 22 surveys ) . CONCLUSION Our approach of estimating pregnancy risk by postpartum timing confirms a high probability for pregnancies to be less than optimally spaced within 2 years of a prior birth and suggests that special consideration is needed to effectively reach this population with the right messages and services . IMPLICATION S Using recent , multicountry data for women within 2 years postpartum in LMICs , this paper up date s existing estimates of high prospect i ve unmet need for family planning and presents a new composite pregnancy risk analysis based on postpartum women 's actual practice s to demonstrate the magnitude of missed opportunities for programmatic intervention for the postpartum population BACKGROUND Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day , but their intake is thought to be low worldwide . We aim ed to determine the extent to which such low intake is related to availability and affordability . METHODS We assessed  fruit and vegetable consumption  using data from country-specific , vali date d semi-quantitative food frequency question naires in the Prospect i ve Urban Rural Epidemiology ( PURE ) study , which enrolled participants from communities in 18 countries between Jan 1 , 2003 , and Dec 31 , 2013 . We documented household income data from participants in these communities ; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1 , 2009 , and Dec 31 , 2013 . We determined the cost of fruits and vegetables relative to income per household member . Linear r and om effects models , adjusting for the clustering of households within communities , were used to assess mean fruit and vegetable intake by their relative cost . FINDINGS Of 143 305 participants who reported plausible energy intake in the food frequency question naire  , mean fruit and vegetable intake was 3·76 servings ( 95 % CI 3·66 - 3·86 ) per day . Mean daily consumption was 2·14 servings ( 1·93 - 2·36 ) in low-income countries ( LICs ) , 3·17 servings ( 2·99 - 3·35 ) in lower-middle-income countries ( LMICs ) , 4·31 servings ( 4·09 - 4·53 ) in upper-middle-income countries ( UMICs ) , and 5·42 servings ( 5·13 - 5·71 ) in high-income countries ( HICs ) . In 130 402 participants who had household income data available , the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97 % ( 95 % CI 46·06 - 57·88 ) of household income in LICs , 18·10 % ( 14·53 - 21·68 ) in LMICs , 15·87 % ( 11·51 - 20·23 ) in UMICs , and 1·85 % ( -3·90 to 7·59 ) in HICs ( ptrend=0·0001 ) . In all regions , a higher percentage of income to meet the guidelines was required in rural areas than in urban areas ( p<0·0001 for each pairwise comparison ) . Fruit and vegetable consumption among individuals decreased as the relative cost increased ( ptrend=0·00040 ) . INTERPRETATION The consumption of fruit and vegetables is low worldwide , particularly in LICs , and this is associated with low affordability . Policies worldwide should enhance the availability and affordability of fruits and vegetables . FUNDING Population Health Research Institute , the Canadian Institutes of Health Research , Heart and Stroke Foundation of Ontario , AstraZeneca ( Canada ) , Sanofi-Aventis ( France and Canada ) , Boehringer Ingelheim ( Germany and Canada ) , Servier , GlaxoSmithKline , Novartis , King Pharma , and national or local organisations in participating countries Background . Approximately 153 million children worldwide are orphaned and vulnerable to potentially traumatic events ( PTEs ) . Gender differences in PTEs in low- and middle-income countries ( LMIC ) are not well-understood , although support services and prevention programs often primarily involve girls . Methods . The Positive Outcomes for Orphans study used a two-stage , cluster-r and omized sampling design to identify 2837 orphaned and separated children ( OSC ) in five LMIC in sub-Saharan Africa and Asia . We examined self-reported prevalence and incidence of several PTE types , including physical and sexual abuse , among 2235 children who were ≥10 years at baseline or follow-up , with a focus on gender comparisons . Results . Lifetime prevalence by age 13 of any PTE other than loss of a parent was similar in both boys [ 91.7 % ( 95 % confidence interval ( CI ) ( 85.0–95.5 ) ] and girls [ 90.3 % CI ( 84.2–94.1 ) ] in institutional-based care , and boys [ 92.0 % ( CI 89.0–94.2 ) ] and girls [ 92.9 % CI ( 89.8–95.1 ) ] in family-based care ; annual incidence was similarly comparable between institution dwelling boys [ 23.6 % CI ( 19.1,−29.3 ) ] and girls [ 23.6 % CI ( 18.6,−30.0 ) ] , as well as between family-dwelling boys [ 30.7 % CI ( 28.0,−33.6 ) ] and girls [ 29.3 % CI ( 26.8,−32.0 ) ] . Physical and sexual abuse had the highest overall annual incidence of any trauma type for institution-based OSC [ 12.9 % CI ( 9.6–17.4 ) ] and family-based OSC [ 19.4 % CI ( 14.5–26.1 ) ] , although estimates in each setting were no different between genders . Conclusion . Prevalence and annual incidence of PTEs were high among OSC in general , but gender-specific estimates were comparable . Although support services and prevention programs are essential for female OSC , programs for male OSC are equally important Background The burdens of hypertension and diabetes are increasing in low- and middle-income countries ( LMICs ) . It is important to identify patients with these conditions early in the disease process . The goal of this study , therefore , is to compare community- versus home-based screening for hypertension and diabetes in Kenya . Methods This was a feasibility study conducted by the Academic Model Providing Access to Healthcare ( AMPATH ) program in Webuye , a town in western Kenya .  Home-based ( door-to-door ) screening occurred in March 2010 and community-based screening in November 2011 . HIV counselors were trained to screen for diabetes and hypertension in the home-based screening with local district hospital based staff conducting the community-based screening . Participants > 18 years old qualified for screening in both groups . Counselors referred all participants with a systolic blood pressure (  SBP  )  ≥160 mmHg and /or a r and om blood glucose ≥7 mmol/L ( 126 mg/dL ) to a local clinic for follow-up . Differences in likelihood of screening positive between the two strategies were compared using Fischer ’s Exact Test . Logistic regression models were used to identify factors associated with the likelihood of following-up after a positive screening . Results There were 236 participants in home-based screening : 13 ( 6 % ) had a SBP ≥160 mmHg , and 54 ( 23 % ) had a r and om glucose ≥ 7 mmol/L. There were 346 participants in community-based screening : 35 ( 10 % ) had a SBP ≥160 mmHg , and 27 ( 8 % ) had a r and om glucose ≥ 7 mmol/L. Participants in community-based screening were twice as likely to screen positive for hypertension compared to home-based screening ( OR=1.93 , P=0.06 ) . In contrast , participants were 3.5 times more likely to screen positive for a r and om blood glucose ≥7 mmol/L with home-based screening ( OR=3.51 , P<0.01 ) . Rates for following-up at the clinic after a positive screen were low for both groups with 31 % of patients with an elevated SBP returning for confirmation in both the community-based and home-based group ( P=1.0 ) . Follow-up after a r and om glucose was also low with 23 % returning in the home-based group and 22 % in the community-based group ( P=1.0 ) . Conclusion Community- or home-based screening for diabetes and hypertension in LMICs is feasible . Due to low rates of follow-up , screening efforts in rural setting s should focus on linking cases to care BACKGROUND There is a need to evaluate and implement cost-effective strategies to improve adherence to treatments in coronary heart disease . There are no studies from low- to middle income countries ( LMICs ) evaluating trained community health worker (CHW)-based interventions for the secondary prevention of coronary heart disease . METHODS We design ed a hospital-based , open r and omized trial of CHW-based interventions versus st and ard care .  Patients after an acute coronary syndrome ( ACS ) were r and omized to an intervention group ( a CHW-based intervention package , comprising education tools to enhance self-care and adherence , and regular follow-up by the CHW ) or to st and ard care for 12 months during which study outcomes were recorded . The CHWs were trained over a period of 6 months . The primary outcome measure was medication adherence . The secondary outcomes were differences in adherence to lifestyle modification , physiological parameters ( blood pressure [ BP ] , body weight , body mass index [ BMI ] , heart rate , lipids ) , and major adverse cardiovascular events . RESULTS We recruited 806 patients stabilized after an ACS from 14 hospitals in 13 Indian cities . The mean age was 56.4 ( ± 11.32 ) years , and 17.2 % were females . A high prevalence of risk factors such as hypertension ( 43.4 % ) , diabetes ( 31.9 % ) , tobacco consumption ( 35.4 % ) , and inadequate physical activity ( 70.5 % ) was documented . A little over half had ST-elevation myocardial infa rct ion ( 53.7 % ) , and 46.3 % had non-ST-elevation myocardial infa rct ion or unstable angina . CONCLUSION The CHW interventions and training for SPREAD have been developed and adapted for local use . The results and experience of this study will be important to counter the burden of cardiovascular diseases in low- to middle income countries Background As antiretroviral therapy ( ART ) for HIV becomes increasingly available in low and middle income countries ( LMICs ) , underst and ing reasons for lack of adherence is critical to stemming the tide of infections and improving health . Underst and ing the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of exp and ed ART programs by indicating types of services , which could be offered in combination with HIV care . Methodology The Coping with HIV/AIDS in Tanzania ( CHAT ) study is a longitudinal cohort study in the Kilimanjaro Region that included r and omly selected HIV-infected ( HIV+ ) participants from two local hospital-based HIV clinics and four free-st and ing voluntary HIV counselling and testing sites . Baseline data were collected in 2008 and 2009 ; this paper used data from 36 month follow-up interviews ( N = 468 ) . Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART . Results Incomplete ART adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events : sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely . Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder ( PTSD ) . In multivariable analyses , childhood trauma , depression , and financial sacrifice remained associated with incomplete adherence . Discussion This is the first study to examine the effect of childhood trauma , depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV . Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of exp and ed antiretroviral access to improve health and reduce new infections The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development , borne out of powerful advocacy using public health , economic and human rights arguments . As funding comes on line for scale-up of evidence -based mental health care by task-sharing with primary care , it is time to take stock about care for people affected by severe mental illness ( SMI ) . The existing evidence base for task shared care for SMI provides an imperative to get started , but is skewed towards relatively more affluent and urban population s in middle-income countries where specialist mental health professionals provide most of the care . R and omised , controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving underst and ing of the quality , safety , effectiveness and acceptability of more widely generalisable care for people with SMI . A sub-group of people with SMI have more complex and long-term needs for care , with a high risk of homelessness , imprisonment and human rights violations as family and social supports become overwhelmed . Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation , recovery and empowerment of people with SMI , but rigorous comparative studies are needed to identify the most efficient , effective and scalable approaches to care . Health system constraints are emerging as the over-riding barriers to successful task-sharing , highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality , improving wellbeing and achieving better social outcomes . Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI BACKGROUND 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 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 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 ) Asthma is a common cause of emergency care attendance in low- and middle-income countries ( LMICs ) . While few prospect i ve studies of predictors for emergency care attendance have been undertaken in high-income countries , none have been performed in a LMIC . We followed a cohort of 5–15-year-old children treated for asthma attacks in emergency rooms of public health facilities in Esmeraldas City , Ecuador . We collected blood and nasal wash sample s , and performed spirometry and exhaled nitric oxide fraction measurements . We explored potential predictors for recurrence of severe asthma attacks requiring emergency care over 6 months ’ follow-up . We recruited 283 children of whom 264 ( 93 % ) were followed-up for ≥6 months or until their next asthma attack . Almost half ( 46 % ) had a subsequent severe asthma attack requiring emergency care . Predictors of recurrence in adjusted analyses were ( adjusted OR , 95 % CI ) younger age ( 0.87 , 0.79–0.96 per year ) , previous asthma diagnosis ( 2.2 , 1.2–3.9 ) , number of parenteral corticosteroid courses in previous year ( 1.3 , 1.1–1.5 ) , food triggers ( 2.0 , 1.1–3.6 ) and eczema diagnosis ( 4.2 , 1.02–17.6 ) . A parsimonious Cox regression model included the first three predictors plus urban residence as a protective factor ( adjusted hazard ratio 0.69 , 95 % CI 0.50–0.95 ) . Laboratory and lung function tests did not predict recurrence . Factors independently associated with recurrent emergency attendance for asthma attacks were identified in a low-re source LMIC setting . This study suggests that a simple risk- assessment tool could potentially be created for emergency rooms in similar setting s to identify higher-risk children on whom limited re sources might be better focused . Among children in a low-re source setting in Latin America , younger age , an established asthma diagnosis and history of severe asthma attacks in the previous year were associated with recurrence of severe asthma attacks , irrespective of biomarkers 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 Tobacco use kills half a million people every month , most in low – middle income countries ( LMICs ) . There is an urgent need to identify potentially low-cost , scalable tobacco cessation interventions for these countries . Objective To evaluate a brief community outreach intervention delivered by health workers to promote tobacco cessation in India . Design Cluster-r and omised controlled trial . Setting 32 low-income administrative blocks in Delhi , half government authorised ( ‘ resettlement colony ’ ) and half unauthorised ( ‘ J.J. cluster ’ ) communities . Participants 1213 adult tobacco users . Interventions Administrative blocks were computer r and omised in a 1:1 ratio , to the intervention ( 16 clusters ; n=611 ) or control treatment ( 16 clusters ; n=602 ) , delivered and assessed at individual level between 07/2012 and 11/2013 . The intervention was single session quit advice ( 15 min ) plus a single training session in yogic breathing exercises ; the control condition comprised very brief quit advice ( 1 min ) alone . Both were delivered via outreach , with contact made though household visits . Measurements The primary outcome was 6-month sustained abstinence from all tobacco , assessed 7 months post intervention delivery , biochemically verified with salivary cotinine . Results The smoking cessation rate was higher in the intervention group ( 2.6 % ( 16/611 ) ) than in the control group ( 0.5 % ( 3/602 ) ) ( relative risk=5.32 , 95 % CI 1.43 to 19.74 , p=0.013 ) . There was no interaction with type of tobacco use ( smoked vs smokeless ) . Results did not change material ly in adjusted analyses , controlling for participant characteristics . Conclusions A single session community outreach intervention can increase tobacco cessation in LMIC . The effect size , while small , could impact public health if scaled up with high coverage . Trial registration number IS RCT CN23362894 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 Vitamin A deficiency is a risk factor for blindness and for mortality from measles and diarrhoea in children aged 6 - 59 months . We aim ed to estimate trends in the prevalence of vitamin A deficiency between 1991 and 2013 and its mortality burden in low-income and middle-income countries . METHODS We collated 134 population -representative data sources from 83 countries with measured serum retinol concentration data . We used a Bayesian hierarchical model to estimate the prevalence of vitamin A deficiency , defined as a serum retinol concentration lower than 0·70 μmol/L. We estimated the relative risks ( RRs ) for the effects of vitamin A deficiency on mortality from measles and diarrhoea by pooling effect sizes from r and omised trials of vitamin A supplementation . We used information about prevalences of deficiency , RRs , and number of cause-specific child deaths to estimate deaths attributable to vitamin A deficiency . All analyses included a systematic quantification of uncertainty . FINDINGS In 1991 , 39 % ( 95 % credible interval 27 - 52 ) of children aged 6 - 59 months in low-income and middle-income countries were vitamin A deficient . In 2013 , the prevalence of deficiency was 29 % ( 17 - 42 ; posterior probability [ PP ] of being a true decline=0·81 ) . Vitamin A deficiency significantly declined in east and southeast Asia and Oceania from 42 % ( 19 - 70 ) to 6 % ( 1 - 16 ; PP>0·99 ) ; a decline in Latin America and the Caribbean from 21 % ( 11 - 33 ) to 11 % ( 4 - 23 ; PP=0·89 ) also occurred . In 2013 , the prevalence of deficiency was highest in sub-Saharan Africa ( 48 % ; 25 - 75 ) and south Asia ( 44 % ; 13 - 79 ) . 94 500 ( 54 200 - 146 800 ) deaths from diarrhoea and 11 200 ( 4300 - 20 500 ) deaths from measles were attributable to vitamin A deficiency in 2013 , which accounted for 1·7 % ( 1·0 - 2·6 ) of all deaths in children younger than 5 years in low-income and middle-income countries . More than 95 % of these deaths occurred in sub-Saharan Africa and south Asia . INTERPRETATION Vitamin A deficiency remains prevalent in south Asia and sub-Saharan Africa . Deaths attributable to this deficiency have decreased over time worldwide , and have been almost eliminated in regions other than south Asia and sub-Saharan Africa . This new evidence for both prevalence and absolute burden of vitamin A deficiency should be used to reconsider , and possibly revise , the list of priority countries for high-dose vitamin A supplementation such that a country 's priority status takes into account both the prevalence of deficiency and the expected mortality benefits of supplementation . FUNDIN Bill & Melinda Gates Foundation , Gr and Challenges Canada , UK Medical Research Council 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 :
Subgroup analyses showed smaller sample s reporting larger effect sizes ; intervention lasting less than 6 months showed larger effect sizes and intention-to-treat analysis showed smaller effect sizes Lifestyle interventions may be of value in preventing and reducing blood pressure in LMICs .
Despite the overwhelming evidence supporting the effectiveness of antihypertensive medication , hypertension remains poorly controlled in low and middle-income countries ( LMICs ) .