A systematic review of online interventions for mental health in low and middle income countries: a neglected field Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India Involvement of patients or their representatives in quality management functions in EU hospitals: implementation and impact on patient-centred care strategies Neonatal health program management in a resource-constrained setting in rural Uttar Pradesh, India. Overcoming methodological challenges in evaluating health communication campaigns: evidence from rural Bangladesh. Promoting evidence-based childhood fever management through a peer education programme based on the theory of planned behaviour. Leadership facilitation strategies to establish evidence-based practice in an acute care hospital. mHealth Interventions in Low and Middle-Income Countries: A Systematic Review Continuum of Care Services for Maternal and Child Health using mobile technology – a health system strengthening strategy in low and middle income countries Use of an 'evidence-based implementation' strategy to implement evidence-based care of asthma into rural district hospital emergency departments. Effective behavioral intervention strategies using mobile health applications for chronic disease management: a systematic review Process evaluation of a mobile health intervention for people with diabetes in low income countries – the implementation of the TEXT4DSM study Providing reviews of evidence to COPD patients: controlled prospective 12-month trial A controlled before-after trial of structured diabetes care in primary health centres in a newly developed country. Examining the use of process evaluations of randomised controlled trials of complex interventions addressing chronic disease in primary health care—a systematic review protocol Impact of performance-based financing on primary health care services in Haiti. Effectiveness of prize-based contingency management in a methadone maintenance program in China.
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 After the launch of Janani Suraksha Yojana , a conditional cash transfer scheme in India , the proportion of women giving birth in institutions has rapidly increased . However , there are important gaps in quality of childbirth services during institutional deliveries . The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan . This intervention titled “ Parijaat ” was design ed by Action Research & Training for Health , in partnership with the state government and United Nations Population Fund . Methods The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan , India . These included district hospitals ( 9 ) , community health centres ( 32 ) and primary health centres ( 3 ) . The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment , feedback , training and action . The adherence to evidence based practice s before , during and after this intervention were measured using structured checklists and scoring sheets . Main outcome measures included changes in practice s during labour , delivery or immediate postpartum period . Results Use of several unnecessary or harmful practice s reduced significantly . Most importantly , proportion of facilities using routine augmentation of labour reduced ( p = 0 ) , episiotomy for primigravidas ( p = 0.0003 ) , fundal pressure ( p = 0.0003 ) , and routine suction of newborns ( 0 = 0.0005 ) . Among the beneficial practice s , use of oxytocin after delivery increased ( p = 0.0001 ) and the practice of listening foetal heart sounds during labour ( p = 0.0001 ) . Some practice s did not show any improvements , such as dorsal position for delivery , use of partograph , and h and -washing . Conclusions An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practice s at health facilities Objective The objective of this study was to describe the involvement of patients or their representatives in quality management ( QM ) functions  and to assess associations between levels of involvement and the implementation of patient-centred care strategies . Design A cross-sectional , multilevel study design that surveyed quality managers and department heads and data from an organizational audit . Setting R and omly selected hospitals ( n = 74 ) from seven European countries ( The Czech Republic , France , Germany , Pol and , Portugal , Spain and Turkey ) . Participants Hospital quality managers ( n = 74 ) and heads of clinical departments ( n = 262 ) in charge of four patient pathways ( acute myocardial infa rct ion , stroke , hip fracture and deliveries ) participated in the data collection between May 2011 and February 2012 . Main Outcome Measures Four items reflecting essential patient-centred care strategies based on an on-site hospital visit : ( 1 )  formal survey seeking views of patients and carers , ( 2 ) written policies on patients ' rights , ( 3 ) patient information literature including guidelines and ( 4  ) fact sheets for post-discharge care .  The main predictors were patient involvement in QM  at the ( i ) hospital level and ( ii ) pathway level . Results Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level ( mean score 1.6 on a scale of 0 to 5 , SD 0.7 ) , but even lower at departmental level ( mean 0.6 , SD 0.7 ) . We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies ; however , the smallest hospitals were more likely to have implemented patient-centred care strategies . Conclusions There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care ; however , lack of evidence should not be interpreted as evidence of no effect This analysis identifies salient features of team management that were critical to the efficiency of program implementation and the effectiveness of behavior change management to promote essential newborn care practice s in Uttar Pradesh , India . In May 2003 , the Johns Hopkins Bloomberg School of Public Health and King George Medical University initiated a cluster-r and omized , controlled neonatal health research program . In less than 2 years , the trial demonstrated rapid adoption of several evidence -based newborn care practice s and a substantial reduction in neonatal mortality in intervention clusters . Existing literature involving research program management in re source -constrained areas of developing countries is limited and fails to provide models for team organization and empowerment . The neonatal research project examined in this paper developed a unique management strategy that provides an effective blueprint for future projects . Transferable learning points from the project include emphasizing a common vision , utilizing a live-in field site office , prioritizing character and potential in the hiring process , implementing a learning-by-doing training program , creating tiers of staff recognition , encouraging staff autonomy , ensuring a broad staff knowledge base to seamlessly h and le absences , and maintaining the flexibility to change partnerships or strategies In this study , we examine the effectiveness of the Smiling Sun multimedia health communication campaign in encouraging women to use family health services in rural Bangladesh . We control for endogenous program placement and address the potential endogeneity of self-reported campaign exposure in health-behavior equations by estimating a set of exposure , contraceptive-use , and antenatal-care equations by full information maximum likelihood ( FIML ) . We find that evaluation methods that do not take into account these nonr and om characteristics of communication and program exposure may produce underestimates of program benefits . Relative to the exposure effect of 3.7 percentage points in the simple model of contraceptive use , the exposure effect in the FIML model is a larger 5.5 percentage points , corresponding to as many as 40,000 additional contraceptive users . We conclude that evaluations of health communication campaigns would benefit from methods such as estimation by FIML that address nonr and om exposure and program targeting AIMS AND OBJECTIVES This study examined effectiveness of a theoretically based education programme in reducing inappropriate antipyretic use in fever management . BACKGROUND Paediatric nurses ' inconsistent , ritualistic antipyretic use in fever management is influenced by many factors including inconsistent beliefs and parental requests . Determinants of antipyretic administration , identified by the theory of planned behaviour , were belief-based attitudes and subjective norms . DESIGN A quasi-experiment explored group effects of a peer education programme , based on the theory of planned behaviour , on factors influencing paediatric nurses ' antipyretic administration . Surveys and chart audits collected data from medical wards at experimental and control hospitals one month pre and one and four months postpeer education programme .  METHODS All nurses employed in targeted wards were eligible to participate in surveys and all eligible charts were audited . The peer education programme consisted of four one-hour sessions targeting evidence -based knowledge , myths and misconceptions , normative , attitudinal and control influences over and rehearsal of evidence -based fever management .  All nurses in experimental hospital targeted wards were eligible to attend .  Peer education and support facilitated session information reaching those unable to attend sessions . RESULTS Two-way univariate anovas explored between subject , experimental and control group and within subject factors , pre , post and latency data . Significant interactions in normative influence ( p = 0.01 ) and intentions ( p = 0.01 ) , a significant main group effect in control influence ( p = 0.01 ) and a significant main effect between audit data across time points ( p = 0.03 ) highlight peer education programme effectiveness in behaviour change . Normative , control and intention changes postpeer education programme were maintained in latency data ; mean temperature was not . CONCLUSION The peer education programme , based on a behaviour change theory , initiated and maintained evidence -based intentions for antipyretics use in fever management . RELEVANCE TO CLINICAL PRACTICE The promotion of evidence -based change in organizational unit intentions and behaviour highlights the crucial role peer support and education can play in continuing educational programmes AIM To assess the impact of leadership facilitation strategies on nurses ' beliefs of the importance and frequency of using evidence in daily nursing practice and the perception of organizational readiness in an acute care hospital . BACKGROUND Integrating evidence in practice is a prominent issue for hospital nursing as knowledge and skills , beliefs , organizational infrastructure and nursing leadership must all be addressed . DESIGN Prospect i ve , descriptive comparative . METHOD Three surveys were used in this prospect i ve descriptive comparative study . Evidence -Based Practice Beliefs Scale , the Implementation Scale and Organizational Culture & Readiness for System-Wide Integration Survey measured change before and after facilitating strategies for evidence -based practice enculturation . Data were collected in December 2008 ( N = 427 ) and in December 2010 ( N = 469 ) . RESULTS Leadership facilitated infrastructure development in three major areas : incorporating evidence -based practice outcomes in the strategic plan ; supporting mentors ; and advocating for re sources for education and outcome dissemination . With the interventions in place , the total group scores for beliefs and organizational readiness improved significantly . Analyses by job role showed that direct care nurses scores improved more than other role types . No differences were found in the implementation scores . CONCLUSION Successful key strategies were evidence -based practice education and establishing internal opportunities to disseminate findings . Transformational nursing leadership drives organizational change and provides vision , human and financial re sources and time that empowers nurses to include evidence in practice 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 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 INTRODUCTION To determine if an evidence -based implementation ( EBI ) could lead to the successful implementation of evidence based care for adult asthma in small rural district hospitals . METHODS A controlled trial involving eight small rural hospitals ( four each in the study and control groups ) was conducted . Retrospective pre-intervention audits were conducted at all eight hospitals for 7 months ( 1 January 2004 to 31 July 2004 ) and evidence - practice gaps identified . An EBI was then used to implement established guidelines for the management of asthma in the study hospitals . Post-intervention audits were then performed over a period of 7 months ( 1 October 2004 to 31 April 2005 ) . RESULTS There were 52 presentations of asthma in the study hospitals in the pre-implementation phase and 47 post-implementation . The corresponding numbers for the control hospitals were 46 and 42 respectively . There were no statistically significant differences in the severity between the groups . Following the EBI there were significant improvements at the study hospitals for the documentation of severity ( 8 % to 62 % , p < 0.001 ) , use of spirometry ( 12 % to 62 % , p < 0.001 ) and the use of written short-term asthma plans ( 9 % to 26 % , p = 0.05 ) . There was a decrease in use of ipratropium in mild asthma ( 44 % to 30 % , p = 0.228 ) , an increase in the use of systemic steroids ( 61 % to 72 % , p = 0.255 ) and no change in prescribing antibiotics for afebrile patients with asthma ( 21 % to 21 % p = 0.956 ) . There was no significant change in practice at the control hospitals except for a decrease in the use of systemic steroids ( 48 % to 21 % , p = 0.011 ) . For the six clinical indicators aggregate there was a significant increase in compliance with guidelines at the study hospitals ( 36 % to 62 % , p < 0.001 ) but no change at the control hospitals ( 31 % to 31 % , p = 0.970 ) . CONCLUSION The pre-intervention audits demonstrated low levels of compliance with asthma guidelines across six clinical indicators . An EBI significantly improved compliance across these six indicators , and no improvement was noted in the control hospitals . This study demonstrates that an EBI can alter clinical practice in small rural district hospitals Background Mobile health ( mHealth ) has continuously been used as a method in behavioral research to improve self-management in patients with chronic diseases . However , the evidence of its effectiveness in chronic disease management in the adult population is still lacking . We conducted a systematic review to examine the effectiveness of mHealth interventions on process measures as well as health outcomes in r and omized controlled trials ( RCTs ) to improve chronic disease management . Methods Relevant r and omized controlled studies that were published between January 2005 and March 2016 were search ed in six data bases : PubMed , CINAHL , EMBASE , the Cochrane Library , PsycINFO , and Web of Science . The inclusion criteria were RCTs that conducted an intervention using mobile devices such as smartphones or tablets for adult patients with chronic diseases to examine disease management or health promotion . Results Of the 12 RCTs review ed , 10 of the mHealth interventions demonstrated statistically significant improvement in some health outcomes . The most common features of mHealth systems used in the review ed RCTs were real-time or regular basis symptom assessment s , pre-programed reminders , or feedbacks tailored specifically to the data provided by participants via mHealth devices . Most studies developed their own mHealth systems including mobile apps . Training of mHealth systems was provided to participants in person or through paper-based instructions . None of the studies reported the relationship between health outcomes and patient engagement levels on the mHealth system . Conclusions Findings from mHealth intervention studies for chronic disease management have shown promising aspects , particularly in improving self-management and some health outcomes Introduction Evidence about mobile health ( mHealth ) approaches to manage diabetes shows modest effects on outcomes , but little is known about implementation variability . This is a process evaluation of an mHealth intervention to improve diabetes self-management through Short Message Service ( SMS ) provision in three diabetes care programmes in the Democratic Republic of Congo ( DRC ) , Cambodia and the Philippines . Methods The intervention involved Diabetes Self-Management Support via text messages . The content and process of the intervention is based upon the core principles of diabetes self-management and behaviour theory . In each country , messages were sent by project managers to 240 participants in each country , who were r and omly assigned to the intervention group . Contracts were negotiated with national phone providers and open access software was used to send the messages . Participants received a mobile phone and SIM card . We analysed data about the implementation process over a one year period . Results The mean monthly number of messages delivered to recipients ’ phones was 67.7 % of the planned number in DRC , 92.3 % in Cambodia and 83.9 % in the Philippines . A telephone check revealed problems with one-third of the phones , including breakage , loss and cancelled subscriptions . The number of people reached at least once  was 177 ( 70.0 % ) in DRC ; 147 ( 60.7 % ) in Cambodia ; five in the Philippines ( 2.0 % ) . Those reached each time was 144 in DRC ( 56.9 % ) , 28 ( 9.9 % ) in Cambodia , none in the Philippines . People used their phone more frequently than before the intervention . Discussion Implementation of the intervention meets constraints at every step in the process . Barriers relate to the technology , the context and the participants The aim of this study was to evaluate a novel patient-held manual design ed to reduce the evidence – practice gap in chronic obstructive pulmonary disease ( COPD ) . The intervention manual contained summaries of research evidence . It was developed using current best practice for patient information material s and design ed to cause discussion of evidence between patient and doctor . A controlled before- and -after study was employed in two similar but geographically separate regions of metropolitan Adelaide , South Australia . Participants had moderate to severe COPD , with 249 included at baseline and 201 completing the study .  Evidence -based COPD management was measured using an indicator with three components : rates of influenza vaccination , bone density testing , and pulmonary rehabilitation . A survey of behavioral steps leading to practice change was conducted with the trial . Analysis , by median split of socioeconomic disadvantage , showed significant difference between study arms for only one component of the indicator of evidence -based practice , enrolment in pulmonary rehabilitation and only for the most socioeconomically disadvantaged stratum . For both socioeconomic strata , more intervention participants than control participants reported remembering being given the information material , reading part or all , and finding it very or quite helpful . Other significant differences were restricted to the stratum of greatest socioeconomic disadvantage : reading all of the material , learning from it , referring back , and talking to a doctor about a topic from the material . Above 90 % of all participants who received the manual reported reading from it , 42 % reported discussing topics with a doctor , but only 10 % reported treatment change attributable to the manual . We have found that people with COPD will read an evidence manual developed using current best practice . However , the study demonstrated improvement for only one of the three components of an indicator of evidence -based disease management for only the most socioeconomically disadvantaged stratum of participants . Future interventions should be design ed to better translate reading uptake into evidence -based disease management OBJECTIVE To evaluate the long-term impact of a structured approach to improving the quality of diabetes care in general practice in the United Arab Emirates . DESIGN Controlled before-after trial within a health district with three primary health centres ( PHCs ) in the intervention group and the six remaining serving as controls .  Outcomes and adherence to guidelines were measured over the year before the intervention began and for a second 1-year period at the end of the intervention period . Data were collected by chart abstract ion . SETTING The study was performed in PHCs in the United Arab Emirates , a newly developed country on the Arabian peninsula . STUDY PARTICIPANTS Subjects continuously followed in nine PHCs for diabetes care for the period of the study ( N = 738 ) were included in the study . INTERVENTION Structured diabetes care , including the development of general practice diabetes clinics , a patient education program , a health care professional education program , and improved recording of clinical information , was provided for the 33-month time period . RESULTS There was a statistically significant improvement in three of the process of care variables ( ordering HbA1c , cholesterol , and documenting foot examinations ) whereas the four remaining variables did not improve . There was limited impact on outcome variables . CONCLUSIONS The intervention described in this study demonstrated an improvement in some process of care measures suggesting an impact of this type of delivery model in this environment Background R and omised controlled trials ( RCTs ) of complex interventions in primary health care ( PHC ) are needed to provide evidence -based programmes to achieve the Declaration of Alma Ata goal of making PHC equitable , accessible and universal and to effectively address the rising burden from chronic disease . Process evaluations of these RCTs can provide insight into the causal mechanisms of complex interventions , the context ual factors , and inform as to whether an intervention is ineffective due to implementation failure or failure of the intervention itself . To build on this emerging body of work , we aim to consoli date the methodology and methods from process evaluations of complex interventions in PHC and their findings of facilitators and barriers to intervention implementation in this important area of health service delivery . Methods Systematic review of process evaluations of r and omised controlled trials of complex interventions  which address prevalent major chronic diseases in PHC setting s. Published process evaluations of RCTs will be identified through data base and clinical trial registry search es and contact with authors . Data from each study will be extracted by two review ers using st and ardised forms . Data extracted include descriptive items about ( 1 ) the RCT , ( 2 ) about the process evaluations ( such as methods , theories , risk of bias , analysis of process and outcome data , strengths and limitations ) and ( 3 ) any stated barriers and facilitators to conducting complex interventions . A narrative synthesis of the findings will be presented . Discussion Process evaluation findings are valuable in determining whether a complex intervention should be scaled up or modified for other context s. Publishing this protocol serves to encourage transparency in the reporting of our synthesis of current literature on how process evaluations have been conducted thus far and a deeper underst and ing of potential challenges and solutions to aid in the implementation of effective interventions in PHC beyond the research setting . Systematic review registration PROSPERO To strengthen Haiti 's primary health care ( PHC ) system , the country first piloted performance-based financing ( PBF ) in 1999 and subsequently exp and ed the approach to most internationally funded non-government organizations . PBF complements support ( training and technical assistance ) . This study evaluates ( a ) the separate impact of PBF and international support on PHC 's service delivery ; ( b ) the combined impact of PBF and technical assistance on PHC 's service delivery ; and ( c ) the costs of  PBF  implementation in Haiti . To minimize the risk of facilities neglecting potential non-incentivized services , the incentivized indicators were r and omly chosen at the end of each year . We obtained quantities of key services from four departments for 217 health centres ( 15 with PBF and 202 without ) from 2008 through 2010 , computed quarterly growth rates and analysed the results using a difference-in-differences approach by comparing the growth of incentivized and non-incentivized services between PBF and non-PBF facilities . To interpret the statistical analyses , we also interviewed staff in four facilities . Whereas international support added 39 % to base costs of PHC , incentive payments added only 6 % . Support alone increased the quantities of PHC services over 3 years by 35 % ( 2.7%/quarter ) . However , support plus incentives increased these amounts by 87 % over 3 years ( 5.7%/quarter ) compared with facilities with neither input . Incentives alone was associated with a net 39 % increase over this period , and more than doubled the growth of services ( P < 0.05 ) . Interview findings found no adverse impacts and , in fact , indicated beneficial impacts on quality . Incentives proved to be a relatively inexpensive , well accepted and very effective complement to support , suggesting that a small amount of money , strategically used , can substantially improve PHC .  Haiti 's experience , after more than a decade of use , indicates that incentives are an effective tool to strengthen PHC BACKGROUND Methadone maintenance treatment ( MMT ) has been successfully scaled up nationally in China . However , the program faces problems of poor attendance and high rates of continued drug use . We assessed whether a contingency management ( CM ) intervention implemented by MMT clinic staff could improve treatment attendance and drug abstinence . METHODS Eight MMT clinics in Guangdong province were r and omly selected and divided into two groups . A total of 126 participants ( 55 in urban clinics and 71 in rural clinics ) received CM  during a 12-week trial , 120 participants ( 83 in urban clinics and 37 in rural clinics ) received usual treatment ( UT )  . Participants in the CM group had the opportunity to draw for prizes contingent on attending treatment daily and testing negative for morphine . Clinic- and individual-level outcomes were compared between the intervention and control groups . RESULTS The retention rate and negative urine testing rate were 14.2 % ( P=0.010 ) and 10.7 % ( P<0.001 ) higher in the CM group compared to the UT group , respectively . Compared with participants who received UT , CM participants missed on average 7.3 fewer ( P=0.008 ) visits and were 1.91 ( 95 % CI : 1.53 - 2.39 ) times more likely to su bmi t a negative urine sample . All clinic- and individual- level effects of the intervention were observed at rural clinics , but the difference in retention rate between urban CM and UT clinics was not significant . CONCLUSION Although the frequency of monitoring and value of the incentives in this study was lower than in previous studies , the CM intervention significantly improved attendance and reduced drug use in China
The evidence is concentrated in two types of PMM strategies : implementation strategies ( in-service training , continuing education , supervision ) and performance-based financing .
Major gaps exist in accountability arrangements particularly the use of audit and feedback .
The least studied types of outcomes were unintended effects , harm and social equity .
Conclusions The evidence is clustered around interventions that are unlikely to achieve transformational change in health outcomes .
The gaps identified suggest that routinely used PMM strategies are implemented without sufficient knowledge of their effects .
Introduction We mapped available evidence on  performance measurement and management ( PMM ) strategies in primary healthcare ( PHC ) systems of low-income and middle-income countries ( LMICs ) .
Widely used , their effectiveness remains inconclusive .
This evidence gap map characterises existing research and evidence gaps .