Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China Promoting Employee Health by Integrating Health Protection, Health Promotion, and Continuous Improvement: A Longitudinal Quasi-Experimental Intervention Study Incorporating Patient Decision Aids into Standard Clinical Practice in an Integrated Delivery System 'The public is too subjective': public involvement at different levels of health-care decision making. Integrated care for patients with asthma: views of general practitioners. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Psychophysiological concomitants of organizational change in health care personnel: effects of a controlled intervention study. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care An integrated care facilitation model improves quality of life and reduces use of hospital resources by patients with chronic obstructive pulmonary disease and chronic heart failure. Integrating assessments of older people: examining evidence and impact from a randomised controlled trial. Developing and evaluating the implementation of a complex intervention: using mixed methods to inform the design of a randomised controlled trial of an oral healthcare intervention after stroke Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People—the ISCOPE study The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania. The effects of a pro-active integrated care intervention for frail community-dwelling older people: a quasi-experimental study with the GP-practice as single entry point Participating in a trial in a critical situation: a qualitative study in pregnancy
Background The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries . Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women , so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants . We present results of a study testing the viability of such integrated care , and its effects on follow-up of HIV-exposed infants , in Tete Province , Mozambique . Methods Between April 2009 and September 2010 , we conducted a mixed- method , intervention-control study in six rural public primary healthcare facilities , selected purposively for size and accessibility , with r and om allocation of three facilities each for intervention and control groups . The intervention consisted of a reorganization of services to provide one-stop , integrated care for mothers and their children under five years of age .  We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission ( PMTCT ) , follow-up of HIV-exposed infants , and other mother and child health ( MCH ) activities for the six months before ( January-June 2009 ) and 13 months after starting the intervention ( July 2009-July 2010 ) . Staff were interviewed at the start , after six months , and at the end of the study . Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention , between healthcare facilities in intervention and control groups , and for time trends . The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values . Thematic analysis of qualitative data was done manually . Results One-stop , integrated care for mother and child was feasible in all participating healthcare facilities , and staff evaluated this service organisation positively . We observed in both study groups an improvement in follow-up of HIV-exposed infants ( registration , follow-up visits , serological testing ) , but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups . Conclusions Despite improvement in various aspects of the follow-up of HIV-exposed infants , we observed no improvement attributable to one-stop , integrated MCH care . Structural healthcare system limitations , such as staff absences and irregular supply of essential commodities , appear to overshadow its potential effects . Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution Objective : To test the effects of integrating health protection and health promotion with a continuous improvement system ( Kaizen ) on proximal employee outcomes ( health promotion , integration , and Kaizen ) and distal outcomes ( workability , productivity , self-rated health and self-rated sickness absence ) . Methods : Twelve units in a county hospital in Sweden were r and omized to control or intervention groups using a quasiexperimental study design . All staff ( approximately 500 ) provided self-ratings in question naires at baseline , and a 12- and 24-month follow-up ( response rate , 79 % to 87.5 % ) . Result : There was a significant increase in the proximal outcomes over time in the intervention group compared with the control group , and a trend toward improvement in the distal outcomes workability and productivity . Conclusions : Integration seems to promote staff engagement in health protection and promotion , as well as to improve their underst and ing of the link between work and health Background . R and omized controlled trials show that patient decision aids ( DAs ) can promote shared decision making and improve decision quality . Despite this evidence , integration of DAs into routine clinical practice has proceeded slowly . Objective . To identify factors that promote or impede integrating DAs into clinical practice in a large health care delivery system . Design . Mixed- methods case study . Setting and Patients . Group Health , an integrated health plan and care delivery system in Washington state . Intervention . The project was carried out in 6 specialty service lines using 12 video-based DAs for preference-sensitive conditions related to elective surgical procedures . Measurements . Process data , site visits , meeting observations , and in-depth interviews conducted with clinical staff , project staff , and health plan leaders in 2009 and 2010 . Results . The project established systemwide and clinic-specific processes that facilitated the distribution of approximately 10,000 DAs over 2 years . Several factors were identified as important for success in this implementation , including strong support from senior leaders , establishing a system for previsit ordering and providing timely feedback to teams about distribution rates , engaging providers and staff in development of the implementation process , and finding ways to address concerns about conditions that were perceived as life-threatening and /or time sensitive . Limitations . Limitations included lack of data on patient perspectives , an implementation setting with salaried providers , and frontline provider interviews conducted in only selected service lines . Conclusions . With strong leadership , financial support , and a well-defined implementation strategy , 12 video-based DAs in 6 specialty service lines were integrated into routine practice over 2 years . Findings from this demonstration may advance the ability of other organizations to use DAs effectively and promote widespread adoption of shared decision making in routine patient care There are a number of impulses towards public participation in health care decision making including instrumentalist , communitarian , educative and expressive impulses and the desire for increased accountability . There has , however , been little research looking systematic ally at the public 's preferences for being involved in particular types of rationing decisions , nor indeed , has there been a critical examination of the degree of involvement desired by the public . The research reported here uses findings from focus groups and in-depth interviews to explore these questions . Eight focus groups were conducted with a total of 57 informants , four amongst r and omly selected members of the public and four with informants from health and non-health related organisations . Nineteen interviews were conducted to allow the elaboration of focus group comments , to probe views more deeply and to pursue emerging themes . The findings show variations in the willingness of members of the public to be involved in health care decisions and consistency across the different forms of the public as represented by the focus groups with r and omly selected citizens and pre-existing organisations . There was a strong desire in all the groups for the public to be involved both at the system and programme levels , with much less willingness to be involved at the individual level . At the system and programme levels informants generally favoured consultation , without responsibility for decisions , but with the guarantee that their contribution would be heard and that decisions taken following consultation would be explained . At the patient level informants felt that the public should participate only by setting criteria for deciding between potential beneficiaries of treatment . The public has much to contribute , particularly at the system and programme levels , to supplement the inputs of health care professionals BACKGROUND In 1989 , a shared or integrated care scheme was developed for hospital out patients with asthma , using the computerized patient record system of Grampian Health Board , Scotl and . Patients with asthma attending hospital clinics were entered into this scheme and were invited to attend their general practitioner instead of an outpatient clinic for review of their asthma . Three-monthly question naires covering clinical aspects of asthma were sent to these patients and their general practitioners ; the latter then returned them to the specialist . Patients could be recalled to the hospital clinic if either the general practitioner or consultant felt this was necessary and all patients were review ed after one year by the specialist . The success of integrated care for patients with asthma relies on the cooperation of general practitioners . AIM The aim of this study was to investigate how this scheme worked in general practice , and general practitioners ' perceptions of it , in order to identify factors that enhance or inhibit integrated care for patients with asthma in general practice . METHOD A qualitative survey was carried out with a r and om , stratified sample of 38 of the 317 general practitioners in the region . Semi-structured interviews were design ed to elicit general practitioners ' accounts of their operation of integrated care and their attitudes towards the scheme . RESULTS General practitioners perceived the scheme to have several advantages : the continuity and quality of care provided was improved ; and the transmission of information between general practitioner and specialist was enhanced . Regular general practitioner review s , instigated by st and ard letters generated by computer , were favoured as being clearly structured . Concerns were raised about the processing of paperwork , and the possibility that unnecessary review s might be generated . CONCLUSION Integrated care for asthma patients is an acceptable management option among general practitioners OBJECTIVE To determine the impact of a hospital-coordinated discharge care plan , involving a multidisciplinary team of primary health care providers , on hospital length of stay , quality of life , and both patient and general practitioner inclusion in , and satisfaction with , discharge procedures . DESIGN This investigation comprised a prospect i ve , r and omized , controlled , clinical trial . SETTING This multicentre and cross-jurisdictional study focused on areas of tertiary and primary health care as well as community allied health in Western Australia . PARTICIPANTS Patients ( n = 189 ) with chronic cardiorespiratory diagnoses were recruited from respiratory , cardiovascular , and general medical wards at two tertiary hospitals . INTERVENTION Subjects were r and omly assigned to one of two groups . Intervention group patients received a discharge care plan in accordance with that outlined in the Australian Enhanced Primary Care Package , completed before discharge and sent to the patient 's general practitioner and other community service providers for review . Control patients were discharged under existing hospital processes . Outcome measures . Patients and general practitioners were surveyed pre-discharge and 7 days post-discharge for quality of life and opinion of discharge procedures . Hospital length of stay was also determined . RESULTS Significant improvements in discharge planning involvement , health service access , confidence with discharge procedures , and opinion of discharge based on previous experience were seen for patients who received the discharge care plan . Further , improved perceptions of mental quality of life were observed within the first week post-discharge for intervention patients . Length of stay showed no difference between groups . Extent and speed of hospital-general practitioner communication were significantly improved via the intervention . CONCLUSIONS Our results indicate that a multidisciplinary discharge care plan , initiated before separation , improves quality of life , involvement , and satisfaction with discharge care , and hospital-general practitioner integration . As such , it possesses benefits over current Western Australian hospital discharge procedures for the care of chronically ill population BACKGROUND To assess possible psychophysiological changes in personnel being exposed to organizational change and to assess the effects of a structured empowerment programme . METHODS A r and omized , prospect i ve , controlled , and non-blinded intervention was carried out in two wards within a geriatric hospital . The I-ward ( intervention ) was offered a structured intervention programme with a trained , registered psychologist during 20 weekly 1-hour sessions before and after the organizational change . The C-ward ( control ) was passively attended by the same psychologist during equal time conditions .  Blood pressure as well as pulse rate were taken and blood sample s were drawn from all participants before ( 0 weeks ) , immediately after the intervention ( 20 weeks ) and after another 10 weeks ' follow-up ( 30 weeks ) . RESULTS There was a significant time x group interaction with increasing prolactin levels on the C-ward as compared to decreasing levels on the I-ward during the intervention . CONCLUSIONS Our study results suggest a picture of differentiated changes in stress hormone levels . The I-ward exhibited less psychoendocrine stress compared to the C-ward , probably due to the intervention and the possibility for personnel to influence the programme . We suggest that psychosocial empowerment programmes are beneficial when organizational changes are enacted in health care setting Background Many promising technological innovations in health and social care are characterized by nonadoption or ab and onment by individuals or by failed attempts to scale up locally , spread distantly , or sustain the innovation long term at the organization or system level . Objective Our objective was to produce an evidence -based , theory-informed , and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program . Methods The study had 2 parallel components : ( 1 ) secondary research ( hermeneutic systematic review ) to identify key domains , and ( 2 ) empirical case studies of technology implementation to explore , test , and refine these domains . We studied 6 technology-supported programs — video outpatient consultations , global positioning system tracking for cognitive impairment , pendant alarm services , remote biomarker monitoring for heart failure , care organizing software , and integrated case management via data sharing — using longitudinal ethnography and action research for up to 3 years across more than 20 organizations . Data were collected at micro level ( individual technology users ) , meso level ( organizational processes and systems ) , and macro level ( national policy and wider context ) . Analysis and synthesis was aided by sociotechnically informed theories of individual , organizational , and system change . The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback . Results The literature review identified 28 previous technology implementation frameworks , of which 14 had taken a dynamic systems approach ( including 2 integrative review s of previous work ) . Our empirical data set consisted of over 400 hours of ethnographic observation , 165 semistructured interviews , and 200 documents . The final nonadoption , ab and onment , scale-up , spread , and sustainability ( NASSS ) framework included questions in 7 domains : the condition or illness , the technology , the value proposition , the adopter system ( comprising professional staff , patient , and lay caregivers ) , the organization(s ) , the wider ( institutional and societal ) context , and the interaction and mutual adaptation between all these domains over time . Our empirical case studies raised a variety of challenges across all 7 domains , each classified as simple ( straightforward , predictable , few components ) , complicated ( multiple interacting components or issues ) , or complex ( dynamic , unpredictable , not easily disaggregated into constituent components ) . Programs characterized by complicatedness proved difficult but not impossible to implement . Those characterized by complexity in multiple NASSS domains rarely , if ever , became mainstreamed . The framework showed promise when applied ( both prospect ively and retrospectively ) to other programs . Conclusions Subject to further empirical testing , NASSS could be applied across a range of technological innovations in health and social care . It has several potential uses : ( 1 ) to inform the design of a new technology ; ( 2 ) to identify technological solutions that ( perhaps despite policy or industry enthusiasm ) have a limited chance of achieving large-scale , sustained adoption ; ( 3 ) to plan the implementation , scale-up , or rollout of a technology program ; and ( 4 ) to explain and learn from program failures Background There is a need to find innovative approaches for translating best practice s for chronic disease care into daily primary care practice routines . Primary care plays a crucial role in the prevention and management of cardiovascular disease . There is , however , a substantive care gap , and many challenges exist in implementing evidence -based care . The Improved Delivery of Cardiovascular Care ( IDOCC ) project is a pragmatic trial design ed to improve the delivery of evidence -based care for the prevention and management of cardiovascular disease in primary care practice s using practice outreach facilitation . Methods The IDOCC project is a stepped-wedge cluster r and omized control trial in which Practice Outreach Facilitators work with primary care practice s to improve cardiovascular disease prevention and management for patients at highest risk . Primary care practice s in a large health region in Eastern Ontario , Canada , were eligible to participate . The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period . Starting with audit and feedback , consensus building , and goal setting , the practice s are supported in changing practice behavior by incorporating chronic care model elements . These elements include ( a ) evidence -based decision support for providers , ( b ) delivery system re design for practice s , ( c ) enhanced self-management support tools provided to practice s to help them engage patients , and ( d ) increased community re source linkages for practice s to enhance referral of patients . The primary outcome is a composite score measured at the level of the patient to represent each practice 's adherence to evidence -based guidelines for cardiovascular care . Qualitative analysis of the Practice Outreach Facilitators ' written narratives of their ongoing practice interactions will be done . These textual analyses will add further insight into underst and ing critical factors impacting project implementation . Discussion This pragmatic , stepped-wedge r and omized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence -based approaches to care delivery . This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality -improvement program in primary care . It is anticipated that through the evaluation of IDOCC , we will demonstrate an effective , practical , and sustainable means of improving the cardiovascular health of patients across Canada . Trial Registration Clinical Trials.gov : As part of the Department of Human Services Hospital Admissions Risk Program ( HARP ) , a group of acute and community based health care providers located in the western suburbs of Melbourne formed a consortium to reduce the dem and on hospital emergency services and improve health outcomes for patients with chronic obstructive pulmonary disease ( COPD ) and chronic heart failure ( CHF ) . The model of care was design ed by a team of multidisciplinary specialists and medical consultants . In addition to receiving normal care , patients recruited to the project were assessed by ' Care Facilitators ' , who identified unmet health care needs and provided information , advice and education for the patient concerning their condition and self-management . Patients declining recruitment received all normal care services . The patients ' rates of emergency department ( ED ) presentations , inpatient admissions and hospital inpatient bed-days before and after their recruitment were calculated from the Western Health patient activity records , and pre- versus post-recruitment rates were compared using ANOVA . Changes relative to the ongoing use by those who declined recruitment were compared using the group-by-time interaction . Patient health outcomes were assessed using established disease-specific tools , and pre- versus post-recruitment values were compared using paired t-tests . Patients recruited to the COPD project reduced ( P<0.05 ) their emergency presentations , admissions and hospital inpatient bed-days by 10 , 25 and 18 % , respectively , whereas those declining recruitment increased their usage by 45 , 41 and 51 % respectively . Recruited CHF patients also displayed reductions in emergency presentations ( 39 % ) , admissions ( 36 % ) and hospital inpatient bed-days ( 33 % ) , whereas those who declined recruitment displayed lesser reductions for ED presentations ( 26 % ) and admissions ( 20 % ) , and increased their use of hospital inpatient bed-days ( 15 % ) . The recruited COPD patients reported a significant reduction in their symptoms ( P<0.005 ) and the CHF patients reported an improvement in their overall health and quality of life scores ( P<0.001 ) . The outcome measures used in this evaluation suggest that an integrated care facilitation model that is patient focussed , provides an education component to promote greater self-management compliance and delivers a continuum of care through the acute and community health sectors , may reduce the utilisation of acute health care facilities and benefit the patient SIR — The needs of older people are often multiple , complex and are at times experienced in combination , which require closely targeted services [ 1 ] and necessitate the collaboration of several professional groups . However , care has often been disjointed and compartmentalised [ 2 ] . One response to this has been a call for integration , between health and social care . Integrated care can operate at the organisational level , in terms of structures [ 3 , 4 ] or the professional level , in terms of shared working arrangements , multidisciplinary teams and case management [ 5 , 6 ] ; an issue being that integrated structures , although conducive to interprofessional working , do not necessarily guarantee it [ 7 ] . Integration is assumed to produce benefits in terms of better co-ordination of services , better outcomes and greater efficiency [ 8 ] . Integration remains an aim pursued by successive governments [ 9 ] . Policies in several countries call for integration at the assessment stage ; a key phase in terms of ensuring care closely matches older people ’s needs [ 10 , 11 ] . In Engl and , examples are the single assessment process ( SAP ) , offering a common structure through shared tools and processes [ 12 ] , and the common assessment framework ( CAF ) for adults , advocating technical solutions for information sharing [ 13 ] . However , while evidence identifies potential benefits of integrating assessment information from different professionals [ 5 , 14 ] and of more comprehensive geriatric assessment [ 15 ] , there remains a need to examine the cost-effectiveness of such approaches to guide future policy . We reanalysed data from a r and omised controlled trial of integrated assessment between specialist clinicians and social services care managers in Engl and [ 14 ] to offer evidence of the costs and benefits of integration . We evaluated the experiment ’s impact on changes in functioning , admissions to care homes and use and costs of health and social services for frail older people at risk of entering care homes Background Many interventions delivered within the stroke rehabilitation setting could be considered complex , though some are more complex than others . The degree of complexity might be based on the number of and interactions between levels , components and actions targeted within the intervention . The number of ( and variation within ) participant groups and the context s in which it is delivered might also reflect the extent of complexity . Similarly , design ing the evaluation of a complex intervention can be challenging . Considerations include the necessity for intervention st and ardisation , the multiplicity of outcome measures employed to capture the impact of a multifaceted intervention and the delivery of the intervention across different clinical setting s operating within varying healthcare context s. Our aim was to develop and evaluate the implementation of a complex , multidimensional oral health care ( OHC ) intervention for people in stroke rehabilitation setting s which would inform the development of a r and omised controlled trial . Methods After review ing the evidence for the provision of OHC following stroke , multi-disciplinary experts informed the development of our intervention . Using both quantitative and qualitative methods we evaluated the implementation of the complex OHC intervention across patients , staff and service levels of care . We also adopted a pragmatic approach to patient recruitment , the completion of assessment tools and delivery of OHC , alongside an attention to the context in which it was delivered . Results We demonstrated the feasibility of implementing a  complex OHC intervention  across three levels of care . The complementary nature of the mixed methods approach to data gathering provided a complete picture of the implementation of the intervention and a detailed underst and ing of the variations within and interactions between the components of the intervention . Information on the feasibility of the outcome measures used to capture impact across a range of components was also collected , though some process orientated uncertainties including eligibility and recruitment rates remain to be further explored within a Phase II exploratory trial . Conclusions Complex interventions can be captured and described in a manner which facilitates evaluation in the form of exploratory and subsequently definitive clinical trials . If effective , the evidence captured relating to the intervention context will facilitate translation into clinical practice Background : older people often experience complex problems . Because of multiple problems , care for older people in general practice needs to shift from a ‘ problem-based , disease-oriented ’ care aim ing at improvement of outcomes per disease to a ‘ goal -oriented care ’ , aim ing at improvement of functioning and personal quality of life , integrating all healthcare providers . Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established . Design : cluster r and omised trial . Participants : all persons aged ≥75 in 59 general practice s ( 30 intervention , 29 control ) , with a combination of problems , as identified with a structured postal question naire with 21 questions on four health domains . Intervention : for participants with problems on ≥3 domains , general practitioners ( GPs ) made an integrated care plan using a functional geriatric approach . Control practice s : care as usual . Outcome measures : ( i ) quality of life ( QoL ) , ( ii ) activities of daily living , ( iii ) satisfaction with delivered health care and ( iv ) cost-effectiveness of the intervention at 1-year follow-up . Trial registration : Netherl and s trial register , NTR1946 . Results : of the 11,476 registered eligible older persons , 7,285 ( 63 % ) participated in the screening . One thous and nine hundred and twenty-one ( 26 % ) had problems on ≥3 health domains . For 225 r and omly chosen persons , a care plan was made . No beneficial effects were found on QoL , patients ' functioning or healthcare use/costs . GPs experienced better overview of the care and stability , e.g. less unexpected dem and s , in the care . Conclusions : GPs prefer proactive integrated care . ‘ Horizontal ’ care using care plans for older people with complex problems can be a valuable tool in general practice . However , no direct beneficial effect was found for older persons Integrated Management of Childhood Illness ( IMCI ) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development . It includes complementary interventions design ed to address the major causes of child mortality at community , health facility , and health system levels . The Multi-Country Evaluation of IMCI  Effectiveness , Cost and Impact ( IMCI-MCE ) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness . The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization . MCE studies are under way in Bangladesh , Brazil , Peru , Tanzania and Ug and a. In Tanzania , the IMCI-MCE study uses a non-r and omized observational design comparing four neighbouring districts , two of which have been implementing IMCI in conjunction with evidence -based planning and expenditure mapping at district level since 1997 , and two of which began IMCI implementation in 2002 . In these four districts , child health and child survival are documented at household level through cross-sectional , before- and -after surveys and through longitudinal demographic surveillance respectively . Here we present results of a survey conducted in August 2000 in stratified r and om sample s of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts . The results indicate that children in IMCI districts received better care than children in comparison districts : their health problems were more thoroughly assessed , they were more likely to be diagnosed and treated correctly as determined through a gold-st and ard re-examination , and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children . There were few differences between  IMCI  and comparison districts in the level of health system support for child health services at facility level . This study suggests that IMCI , in the presence of a de central ized health system with practical health system planning tools , is feasible for implementation in re source -poor countries and can lead to rapid gains in the quality of case-management .  IMCI is therefore likely to lead to rapid gains in child survival , health and development if adequate coverage levels can be achieved and maintained Background This study explored the effectiveness of a pro-active , integrated care model for community-dwelling frail older people compared to care as usual by evaluating the effects on a comprehensive set of outcomes : health outcomes ( experienced health , mental health and social functioning ) ; functional abilities ; and quality of life ( general , health-related and well-being ) . Methods The design of this study was quasi-experimental . In this study , 184 frail older patients of three GP practice s that implemented the Walcheren Integrated Care Model were compared with 193 frail older patients of five GP practice s that provided care as usual .  In the Walcheren Integrated Care Model , community-dwelling elderly were pro-actively screened for frailty from the GP practice using the Groningen Frailty Indicator , and care needs were assessed with the EASYcare instrument . The GP practice functioned as single entry point from which case management was provided , and the GP was the coordinator of care . The entire process was supported by multidisciplinary meetings , multidisciplinary protocol s and web-based patient files . The outcomes of this study were obtained at baseline , after 3 months and after 12 months and analyzed with linear mixed models of repeated measures . Results The Walcheren Integrated Care Model had a positive effect on love and friendship and a moderately positive effect on general quality of life . The ability to receive love and friendship and general quality of life decreased in the control group but was preserved in the experimental group . No significant differences were found on health outcomes such as experienced health , mental health , social functioning and functional abilities . Conclusions The results indicated that pro-active , integrated care can be beneficial for frail older people in terms of quality of life and love and friendship but not in terms of health outcomes and functional abilities . Recommendations for future research are to gain greater insight into what specific outcomes can be achieved with proactive and integrated care , considering the specific content of this care , and to allow for the heterogeneity of frail older people in evaluation research .Trial registration Current Controlled Trials IS RCT N05748494 . Registration date : 14/03/2013 Background : R and omised controlled trials of interventions in critical situations are necessary to establish safety and evaluate outcomes .  Pregnant women have been identified as a potentially vulnerable population . Objective : To explore women ’s experiences of being recruited to ORACLE , a r and omised controlled trial of antibiotics in pre-term labour . Methods : Twenty qualitative interviews were conducted with women who had participated in ORACLE . Analysis was based on the constant comparative method . Results : Women gave prominence to the socioemotional aspects of their interactions with healthcare professionals in making decisions on trial participation . Comments on the quality of written and spoken information were generally favourable , but women ’s accounts suggest that the stressful nature of the situation affected their ability to absorb the information . Women generally had poor underst and ing of trial design and practice s. The main motivation for trial participation was the possibility of an improved outcome for the baby . The second and less prominent motivation was the opportunity to help others , but this was conditional on there being no risks associated with trial participation . In judging the risks of participation , women seemed to draw on “ common sense ” underst and ings including a perception that antibiotics were risk free . Discussion : Recruitment to trials in critical situations raises important questions . Future studies should explore how rigorous governance arrangements for trials , particularly in critical situations , can protect participants rather than relying on ideals of informed consent that may be impossible to achieve . Future research should include a focus on interactions between research c and i date s and professionals involved in recruitment
Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated .
Instead , there exists a highly heterogeneous picture both for the nature and also for the extent of integration .
Health systems combine both non-integrated and integrated interventions , but the balance of these interventions varies considerably
A longst and ing debate on health systems organization relates to benefits of integrating  health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes .
This debate has long been characterized by polarization of views and ideologies , with protagonists for and against integration arguing the relative merits of each approach .
However , all too frequently these arguments have not been based on hard evidence .
The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach , but the relative merits of integration in various context s and for different interventions have not been systematic ally analysed and documented .
In this paper we present findings of a systematic review that explores a broad range of evidence on : ( i ) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions , ( ii ) how the integration or non-integration of health programmes into critical health systems functions in different context s has influenced programme success , ( iii ) how context ual factors have affected the extent to which these programmes were integrated into critical health systems functions .