A systematic review of online interventions for mental health in low and middle income countries: a neglected field Task-Shifting of Antiretroviral Delivery From Health Care Workers to Persons Living With HIV/AIDS: Clinical Outcomes of a Community-Based Program in Kenya A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Gender involvement in manual material handling (mmh) tasks in agriculture and technology intervention to mitigate the resulting musculoskeletal disorders. Increasing health worker capacity through distance learning: a comprehensive review of programmes in Tanzania Neonatal health program management in a resource-constrained setting in rural Uttar Pradesh, India. Biomechanical analysis of peak and cumulative spinal loads during simulated patient-handling activities: a substudy of a randomized controlled trial to prevent lift and transfer injury of health care workers. Comparison of Community Health WorkerLed Diabetes Medication Decision-Making Support for Low-Income Latino and African American Adults With Diabetes Using E-Health Tools Versus Print Materials The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project Evidence-based training of frontline health workers for door-to-door health promotion: a pilot randomized controlled cluster trial with Lady Health Workers in Sindh Province, Pakistan. ‘Opening up the mind’: problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe The Critical Role of Supervision in Retaining Staff in Obstetric Services: A Three Country Study Improving community case management of diarrhoea and pneumonia in district Badin, Pakistan through a cluster randomised study—the NIGRAAN trial protocol Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives Evaluating a streamlined clinical tool and educational outreach intervention for health care workers in Malawi: the PALM PLUS case study A Controlled Trial of a Short Course to Improve Residents' Communication With Patients at the End of Life Feasibility and evaluation of a pilot community health worker intervention to reduce hospital readmissions.
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 Objectives : To assess whether community-based care delivered by people living with HIV/AIDS ( PLWAs ) could replace clinic-based HIV care . Design : Prospect i ve cluster r and omized controlled clinical trial . Setting : Villages surrounding 1 rural clinic in western Kenya . Subjects : HIV-infected adults clinical ly stable on antiretroviral therapy ( ART ) . Intervention : The intervention group received monthly Personal Digital Assistant supported home assessment s by PLWAs with clinic appointments every 3 months . The control group received st and ard of care monthly clinic visits . Main Outcomes Measured : Viral load , CD4 count , Karnofsky score , stability of ART regimen , opportunistic infections , pregnancies , and number of clinic visits . Results : After 1 year , there were no significant intervention-control differences with regard to detectable viral load , mean CD4 count , decline in Karnofsky score , change in ART regimen , new opportunistic infection , or pregnancy rate . Intervention patients made half as many clinic visits as did controls ( P < 0.001 ) . Conclusions : Community-based care by PLWAs result ed in similar clinical outcomes as usual care but with half the number of clinic visits . This pilot study suggests that task-shifting and mobile technologies can deliver safe and effective community-based care to PLWAs , expediting ART rollout and increasing access to treatment while exp and ing the capacity of health care institutions in re source -constrained environments Although patient h and lers suffer from low-back injuries at an alarming rate worldwide , there has been limited research quantifying the risk for the specific tasks performed by the patient h and lers . The current study used both a comprehensive evaluation system ( low-back disorder risk model ) and theoretical model ( biomechanical spinal loading model ) to evaluate risk of LBD of 17 participants ( 12 experienced and five inexperienced ) performing several patient h and ling tasks . Eight of the participants were female and nine were male . Several patient transfers were evaluated as well as  repositioning of the patient in bed ; these were performed with one and two people . The patient transfers were between bed and wheelchair ( fixed and removable arms ) and between commode chair and hospital chair . A ' st and ard ' patient ( a 50 kg co-operative female ; non-weight bearing but had use of upper body ) was used in all patient h and ling tasks . Overall , patient h and ling was found to be an extremely hazardous job that had substantial risk of causing a low-back injury whether with one or two patient h and lers . The greatest risk was associated with the one-person transferring techniques with the actual task being performed having a limited effect . The repositioning techniques were found to have significant risk of LBD associated with them with the single hook method having the highest LBD risk and spinal loads that exceeded the tolerance limits ( worst patient h and ling job ) . The two-person draw sheet repositioning technique had the lowest LBD risk and spinal loads but still had relatively high spinal loads and LBD risk . Thus , even the safest of tasks ( of the tasks evaluated in this study ) had significant risk . Additionally , the current study represented a ' best ' case scenario since the patient was relatively light and co-operative . Thus , patient h and ling in real situations such as in a nursing home , would be expected to be worse . Therefore , to have an impact on LBD , it is necessary to provide mechanical lift assist devices The lifting and carrying of loads in agriculture on small l and holdings are unavoidable . Rural communities often lack access to appropriate technologies which may result in various health hazards . The objective was to study gender participation in agricultural activities involving manual material h and ling tasks , to assess MSDs experienced in various MMH tasks and to evaluate traditional method and design ed technology . The study was conducted on 100 agricultural workers . Data on gender participation in MMH tasks in household , animal husb and ry and agriculture and result ing MSDs was gathered . Pre and post assessment of technology intervention was done for NIOSH Lifting Index , QEC , and RPE . The results revealed greater susceptibility of females to musculoskeletal problems in most of the household and animal husb and ry tasks . The h and trucks design ed were pushing type with power grasp h and le . The respondents were advised to carry 5 kg of weight per lift instead of lifting more weight in one lift/minute while filling the h and truck . By decreasing the weight and increasing the number of lifts per minute the respondents were seen falling in green zone indicating significant reduction in NIOSH lifting index . QEC scores concluded that for filling the h and truck 5 kg of weight should be carried to keep the exposure level low Background Tanzania , like many developing countries , faces a crisis in human re sources for health . The government has looked for ways to increase the number and skills of health workers , including using distance learning in their training . In 2008 , the authors review ed and assessed the country 's current distance learning programmes for health care workers , as well as those in countries with similar human re source challenges , to determine the feasibility of distance learning to meet the need of an increased and more skilled health workforce . Methods Data were collected from 25 distance learning programmes at health training institutions , universities , and non-governmental organizations throughout the country from May to August 2008 . Methods included internet research ; desk review ; telephone , email and mail-in surveys ; on-site observations ; interviews with programme managers , instructors , students , information technology specialists , preceptors , health care workers and Ministry of Health and Social Welfare representatives ; and a focus group with national HIV/AIDS care and treatment organizations . Results Challenges include lack of guidelines for administrators , instructors and preceptors of distance learning programmes regarding roles and responsibilities ; absence of competencies for clinical components of curricula ; and technological constraints such as lack of access to computers and to the internet . Insufficient funding result ed in personnel shortages , lack of appropriate training for personnel , and lack of material s for students . Nonetheless , current and prospect i ve students expressed overwhelming enthusiasm for scale-up of distance learning because of the unique financial and social benefits offered by these programs . Participants were retained as employees in their health care facilities , and remained in their communities and supported their families while advancing their careers . Space in health training institutions was freed up for new students entering in-residence pre-service training . Conclusions A blended print-based distance learning model is most feasible at the national level due to current re source and infrastructure constraints . With an increase in staffing ; improvement of infrastructure , coordination and curricula ; and de central ization to the zonal or district level , distance learning can be an effective method to increase both the skills and the numbers of qualified health care workers capable of meeting the health care needs of the Tanzanian population 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 Back injuries are a serious problem for nursing personnel who perform frequent patient-h and ling activities . Common prevention strategies include body mechanics education , technique training , and ergonomic interventions such as the introduction of assistive equipment . This investigation assessed and compared the effectiveness of two patient-h and ling approaches to reducing injury risk . One strategy involved using improved patient-h and ling technique with existing equipment , and the other approach aim ed at eliminating manual patient h and ling through the use of additional mechanical and other assistive equipment . Both intervention arms received training in back care , patient assessment , and use of the equipment available on their particular wards . An analysis of compliance with interventions and the effects of patient-h and ling methods on both peak and cumulative spinal compression and shear during various tasks was conducted . Results showed greater compliance with interventions that incorporated new assistive patient-h and ling equipment , as opposed to those consisting of education and technique training alone . In several tasks , subjects who were untrained or non-compliant with interventions experienced significantly higher peak spinal loading . However , patient-h and ling tasks conducted with the aid of assistive equipment took substantially longer than those performed manually . This , along with variations in techniques , led to increases in cumulative spinal loading with the use of patient-h and ling equipment on some tasks . Thus , the use of mechanical assistive devices may not always be the best approach to reducing back injuries in all situations . No single intervention can be recommended ; instead all patient-h and ling tasks should be examined separately to determine which methods maximize reductions in both peak and cumulative lumbar forces during a manoeuver Adults with type 2 diabetes mellitus often struggle with their antihyperglycemic medication regimens . To improve medication management , providers must ensure that their patients underst and potential benefits , harms , and burdens of available options and elicit patients ' preferences and barriers to taking medications . Patients who are actively involved in treatment decision making tend to be more satisfied with their health care , be more adherent to treatment , and have improved clinical outcomes ( 13 ) . Such discussion s , however , can be too time-consuming for clinic visits . For inner-city low-income African American and Latino adults , low health literacy and limited English proficiency are often additional barriers ( 4 ) that reduce the exchange of information and decrease patient participation during primary care visits ( 58 ) . This contributes to less optimal treatment decisions and lower patient satisfaction , leading to poor medication adherence and outcomes ( 3 , 911 ) . There is therefore an urgent need for cost-effective approaches to enable low-re source health systems to help these high-risk population s gain information and decision support so that they can more actively participate in and improve satisfaction with their treatment decision making . Since 2000 , the REACH ( Racial and Ethnic Approaches to Community Health 2010 ) Detroit Partnership , a coalition of community , health system , and academic partners , has used community-based participatory research principles to guide development , implementation , and evaluation of interventions to meet this need among African American and Latino adults with diabetes in Detroit , Michigan . These interventions have built on evidence that community health workers ( CHWs ) are effective in improving diabetes outcomes , particularly among racial and ethnic minority communities ( 12 ) . CHW interventions train community members to work as bridges between their ethnic , cultural , or geographic communities and health care providers ( 13 ) . Two cohorts of participants in our previous CHW-led diabetes self-management support interventions  improved hemoglobin A1c ( HbA1c ) levels and diabetes distress compared with usual care ( 14 , 15 ) . An important next step in increasing the potential effect of CHWs and other lay health care workers is to develop and test effective tools they can use to better present evidence -based information to patients and to help patients make better self-management decisions ( 16 ) . Little is known about the effectiveness of different approaches for nontraditional care providers , such as CHWs , to deliver health information to ethnic minority and low-literacy population s ( 17 ) . By definition , CHWs and other lay workers do not have medical expertise and thus rely on effectively sharing printed educational and support material s with patients as part of their coaching and counseling efforts . Decision aids can increase satisfaction with treatment decisions and result in treatments that better reflect patients ' preferences ( 18 , 19 ) . There is also evidence that tailored health messages are more effective than generic group messages ( 20 , 21 ) , including for patients with diabetes ( 22 , 23 ) . Tailoring individualizes information and behavior change strategies to reach each person based on characteristics unique to that person derived from an individual assessment and related to the outcome of interest ( 24 ) . Software programs that are being developed to automatically embed tailored content into portable e-health Web applications show promise in improving health behaviors and outcomes ( 25 , 26 ) . To date , however , most e-health applications have been design ed for use by patients with relatively high literacy and the skills to navigate them ( 27 ) . Do more sophisticated , tailored , interactive e-health tools increase the effectiveness of CHW outreach with underserved patients compared with reliance on printed educational material s alone ? We addressed this question by developing and evaluating a personally tailored , interactive diabetes medication decision aid ( iDecide [ in English ] or iDecido [ in Spanish ] ) design ed for CHWs to deliver on tablet computers with 3 G wireless access to African American and Latino adults with diabetes and low health literacy . We then evaluated the effectiveness of iDecide in improving key diabetes outcomes compared with CHW delivery of the same evidence -based information , without tailoring , through print consumer booklets developed by the Agency for Healthcare Research and Quality ( AHRQ ) . Methods Setting This study was developed and implemented by using community-based participatory research principles ( 28 ) in partnership with the REACH Detroit Partnership and the Community Health and Social Services Center ( CHASS ) , a federally qualified health center in Southwest Detroit serving more than 13000 patients with 47099 visits in 2012 ( 29 ) . The University of Michigan and CHASS institutional review boards approved the study . Content of AHRQ Consumer Guides The AHRQ guides ( Pills for Type 2 Diabetes and Premixed Insulin for Type 2 Diabetes ) ( 30 , 31 ) provide information on diabetes and summarize the effectiveness of currently available medication classes  ( oral and insulin ) on HbA1c . They also provide information on administration methods , costs , medication adverse effects , risks for diabetes complications , suggested questions to discuss with health care providers , and prompts to make notes of any questions for the doctor . The booklets include pictures of patients and tables and graphs summarizing information . Content of iDecide The development process and content of the iDecide program have been described in detail elsewhere ( 32 ) . Briefly , we used community-based participatory research and user-centered design ( 33 , 34 ) principles to iteratively develop and refine the iDecide tool . iDecide is available in English and Spanish , can be delivered via tablet computers , and enables navigation by the CHW and participant to selectively explore issues most important to the participant . The iDecide program is organized into 4 main sections and includes the same content as the AHRQ consumer guides . However , its information is presented in a more graphical style suited to patients with low literacy . Table 1 summarizes key differences between the presentation of information in iDecide and the printed material s. The first section illustrates , through animations , how diabetes affects the way glucose is processed in the body and how different medication classes , foods , and physical activity affect blood glucose . The second section includes pictographs showing participants ' own risk for diabetes complications ( tailored according to their baseline HbA1c ) and enabling participants to explore how their risk for different complications changes with their HbA1c levels . In the third section , participants review their current diabetes medications and barriers to taking the medications they had reported on the baseline survey . This section includes an interactive issue card approach to help elicit patient preferences and priorities about different medication characteristics ( for example , cost , adverse effects , effects on weight , and dosing schedules ) ( 22 , 35 ) . The fourth section prompts participants to set goals and develop specific action plans to address identified barriers or other concerns and identify specific questions and concerns to discuss with their doctor about their medications or making lifestyle changes . Personal information from the baseline assessment is interwoven throughout the program ( high-depth tailoring within sentences ) . Motivational interviewingbased , tailored discussion prompts encourage autonomy-supportive CHWpatient interactions at key points with open-ended questions and values exploration to help participants discover their motivation , overcome barriers to change , and develop an action plan ( 36 ) . Table 1 . Comparison of Content and Mode of Delivery Between the iDecide Study Group and the Printed Material s Group Recruitment and R and omization From September 2011 to August 2012 , potentially eligible participants were identified from a computer-generated list of CHASS patients with physician-diagnosed type 2 diabetes . Inclusion criteria required a HbA1c value greater than 7.5 % in the previous 6 months or expressed concerns about current diabetes medications during the screening assessment . Exclusion criteria were age younger than 21 years , terminal health conditions , self-reported alcohol or drug abuse , and conditions ( such as blindness and dementia ) that would impede meaningful participation . Pregnant women and individuals who reported that they could not be contacted by telephone were also excluded . Introductory letters were sent in timed batches . Research staff then telephoned patients and screened them for eligibility . Interested eligible patients met with research staff , who facilitated completion of written informed consent , administered baseline surveys in English or Spanish , and measured HbA1c and blood pressure . Participants received a stipend of $ 20 after each assessment . Within 1 to 14 days , participants were scheduled for a visit with a CHW ( at home , the clinic , or another agreed-upon place ) . At the beginning of the CHW visits , participants were registered into the iDecide program and r and omly assigned by the computer program , through use of a r and om-sequence algorithm , into 1 of 2 study groups . There were no differences between the steps to participate in either study group . Patients , research staff , and CHWs were blinded to r and omization results through completion of all baseline measures up to the start of the intervention . Data assessors remained blinded to group assignment throughout the study . CHW Intervention for Both Study Groups All participants received an initial one-on-one , face-to-face session with a CHW and a copy of the printed material s to take home . The iDecide sessions lasted approximately 2 hours , and the sessions using printed material s lasted Background Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe . Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths ; many of these in sub-Saharan countries . Many of these deaths are preventable . Countries , like Malawi , do not have the re sources nor highly trained medical specialists using complex technologies within their healthcare system . Much of the burden falls on healthcare staff other than doctors including non-physician clinicians ( NPCs ) such as clinical officers , midwives and community health-workers . The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care . Training that will hopefully be cascaded to their colleagues ( other NPCs , midwives , nurses ) . Methods / design This is a cluster r and omised controlled trial with the unit of r and omisation being the 14 districts of central and northern Malawi ( one large district was divided into two giving an overall total of 15 ) . Eight districts will be r and omly allocated the intervention . Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme ( the intervention ) . Primary outcome will be maternal and perinatal ( defined as until discharge from health facility ) mortality . Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project ( 3–4 years ) and comparisons made . In addition a process evaluation using both quantitative and qualitative ( e.g. interviews ) will be undertaken to evaluate the intervention implementation . Discussion Education and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi . Some of the challenges faced are discussed as are the potential limitations . It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training . Trial registration IS RCT OBJECTIVE Demonstrate the effective use of community-based evidence for health promotion by Lady Health Workers ( LHWs ) in Sindh , Pakistan . METHODS A baseline study on mothers and children provided local evidence for risk communication tools design ed and tested by LHWs . The communities were r and omized to intervention and control . LHWs visited  women before and after childbirth  to discuss safe practice s in pregnancy , in the intervention group LHW using the new tools and in the control group using their st and ard procedures . A household survey and focus groups permitted assessment of the impact of the intervention . RESULTS Women in the intervention communities were more likely to attend prenatal checkups , to stop routine heavy work during pregnancy , to give colostrum to newborn babies , and to maintain exclusive breastfeeding for four months . Community focus groups confirmed a positive reaction to the tools . CONCLUSION Discussion by lay health workers of local evidence underlying safe motherhood messages improved uptake of protective health practice s. PRACTICE IMPLICATION S Door-to-door health promotion based on culturally appropriate interaction around relevant evidence can have a positive impact on health practice s. Engaging health workers from the onset builds capacities , improves dialogue within the health system and performance of frontline health workers Background There are few accounts of evidence -based interventions for depression and other common mental disorders ( CMDs ) in primary care in low-income countries . The Friendship Bench Project is a collaborative care mental health intervention in primary care in Harare for CMDs which began as a pilot in 2006.Case presentationWe employed a mixture of quantitative and qualitative approaches to investigate the project ’s acceptability and implementation , 4–8 years after the initial pilot study . We carried out basic descriptive analyses of routine data on attendance collected between 2010 and 2014 . We also conducted five focus group discussion s ( FGDs ) with LHWs in 2013 and 12 in-depth interviews , six with staff and six with patients , to explore experiences of the intervention , which we analysed using grounded theory . Results show that the intervention appears highly acceptable as evidence d by a consistent number of visits between 2010 and 2014 ( mean 505 per year , SD 132 ) ; by the finding that the same team of female community LHWs employed as government health promoters continue to deliver assessment and problem-solving therapy , and the perceived positive benefits expressed by those interviewed . Clients described feeling ‘ relieved and relaxed ’ after therapy , and having their ‘ mind opened ’ , and LHWs describing satisfaction from being agents of change . Characteristics of the LHWs ( status in the community , maturity , trustworthiness ) , and of the intervention ( use of locally vali date d symptom screen , perceived relevance of problem-solving therapy ) and continuity of the LHW team appeared crucial . Challenges to implementation included the LHWs ongoing need for weekly supervision despite years of experience ; the supervisors need for supervision for herself ; training needs in managing suicidal and hostile clients ; poor documentation ; lack of follow-up of depressed clients ; and poor access to antidepressants . Conclusions This case study shows that a collaborative care intervention for CMDs is positively received by patients , rewarding for LHWs to deliver , and can be sustained over time at low cost . Next steps include evaluation of the impact of the intervention through a r and omised trial , and testing of a technological platform for supporting supervision and monitoring clients ’ attendance Millennium Development Goal ( MDG ) 5 commits us to reducing maternal mortality rates by three quarters and MDG 4 commits us to reducing child mortality by two-thirds between 1990 and 2015 . In order to reach these goals , greater access to basic emergency obstetric care ( EmOC ) as well as comprehensive EmOC which includes safe Caesarean section , is needed .. The limited capacity of health systems to meet dem and for obstetric services has led several countries to utilize mid-level cadres as a substitute to more extensively trained and more internationally mobile healthcare workers . Although this does provide greater capacity for service delivery , concern about the performance and motivation of these workers is emerging . We propose that poor leadership characterized by inadequate and unstructured supervision underlies much of the dissatisfaction and turnover that has been shown to exist amongst these mid-level healthcare workers and indeed health workers more generally . To investigate this , we conducted a large-scale survey of 1,561 mid-level cadre healthcare workers ( health workers trained for shorter periods to perform specific tasks e.g. clinical officers ) delivering obstetric care in Malawi , Tanzania , and Mozambique . Participants indicated the primary supervision method used in their facility and we assessed their job satisfaction and intentions to leave their current workplace . In all three countries we found robust evidence indicating that a formal supervision process predicted high levels of job satisfaction and low intentions to leave . We find no evidence that facility level factors modify the link between supervisory methods and key outcomes . We interpret this evidence as strongly supporting the need to strengthen leadership and implement a framework and mechanism for systematic supportive supervision . This will promote better job satisfaction and improve the retention and performance of obstetric care workers , something which has the potential to improve maternal and neonatal outcomes in the countdown to 2015 Background Diarrhoea and pneumonia contribute 30 % of deaths in children under 5 in Pakistan . Pakistan ’s Lady Health Workers Programme ( LHW-P ) covers about 60 % of the population but has had little impact in reducing morbidity and mortality related to these major childhood killers . An external evaluation of the LHW-P suggests that lack of supportive supervision of LHWs by lady health supervisors ( LHSs ) is a key determinant of this problem . Project NIGRAAN aims to improve knowledge and skills of LHWs and community caregivers through supervisory strategies employed by LHSs . Ultimately , community case management ( CCM ) of childhood pneumonia and diarrhoea will improve . Methods / Design NIGRAAN is a cluster-r and omised trial in District Badin , Pakistan . There are approximately 1100 LHWs supervised by 36 LHSs in Badin . For this study , each LHS serves as a cluster . All LHSs working permanently in Badin who regularly conduct and report field visits are eligible . Thirty-four LHSs have been allocated to either intervention or control arms in a ratio of 1:1 through computer-generated simple r and omisation technique . Five LHWs from each LHSs are also r and omly picked . All 34 LHSs and 170 LHWs will be actively monitored . The intervention consists of training to build LHS knowledge and skills , clinical mentorship and written feedback to LHWs . Pre- and post-intervention assessment s of LHSs , LHWs and community caregivers will be conducted via focus group discussion s , in-depth interviews , knowledge assessment question naires , skill assessment scorecards and household surveys . Primary outcome is improvement in CCM practice s of childhood diarrhoea and pneumonia and will be assessed at the cluster level . Discussion NIGRAAN takes a novel approach to implementation research and explores whether training of LHSs in supervisory skills results in improving the CCM practice s of childhood diarrhoea and pneumonia . No significant harm to participants is anticipated . The enablers and barriers towards improved CCM would provide recommendations to policymakers for scale up of this intervention nationally and regionally . Trial registration NIGRAAN is registered with the ‘ Australian New Zeal and Clinical Trials Registry ’ . Registration Number : Background Community health workers ( CHWs ) can play important roles in primary health care delivery , particularly in setting s of health workforce shortages . However , little is known about CHWs ’ perceptions of barriers and motivations , as well as those of the beneficiaries of CHWs . In Rw and a , which faces a significant gap in human re sources for health , the Ministry of Health exp and ed its community health programme beginning in 2007 , eventually placing 4 trained CHWs in every village in the country by 2009 . The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme , as perceived by the CHWs and their beneficiaries . Methods As part of a larger report assessing CHWs in Rw and a , a cross-sectional descriptive study was conducted using focus group discussion s ( FGDs ) to collect qualitative information regarding educational background , knowledge and practice s of CHWs , and the benefits of community-based care as perceived by CHWs and household beneficiaries . A r and om sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level ( low , middle and high ) . Qualitative and demographic data were analyzed . Results CHWs were found to be closely involved in the community , and widely respected by the beneficiaries . Rw and a ’s community performance-based financing ( cPBF ) was an important incentive , but CHWs were also strongly motivated by community respect . The key challenges identified were an overwhelming workload , irregular trainings , and lack of sufficient supervision . Conclusions This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries , in regards to a nationwide scale-up of CHW interventions in a re source -challenged country . Identifying and underst and ing these barriers , and addressing them accordingly , particularly within the context of performance-based financing , will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rw and Background Nearly 3 million people in re source -poor countries receive antiretrovirals for the treatment of HIV/AIDS , yet millions more require treatment . Key barriers to treatment scale up are shortages of trained health care workers , and challenges integrating HIV/AIDS care with primary care . The research PALM PLUS ( Practical Approach to Lung Health and HIV/AIDS in Malawi ) is an intervention design ed to simplify and integrate existing Malawian national guidelines into a single , simple , user-friendly guideline for mid-level health care workers . Training utilizes a peer-to-peer educational outreach approach . Research is being undertaken to evaluate this intervention to generate evidence that will guide future decision-making for consideration of roll out in Malawi . The research consists of a cluster r and omized trial in 30 public health centres in Zomba District that measures the effect of the intervention on staff satisfaction and retention , quality of patient care , and costs through quantitative , qualitative and health economics methods . Results and outcomes In the first phase of qualitative inquiry respondents from intervention sites demonstrated in-depth knowledge of PALM PLUS compared to those from control sites . Participants in intervention sites felt that the PALM PLUS tool empowered them to provide better health services to patients . Interim staff retention data shows that there were , on average , 3 to 4 staff departing from the control and intervention sites per month . Additional qualitative , quantitative and economic analyses are planned . The partnershipDignitas International and the Knowledge Translation Unit at the University of Cape Town Lung Institute have led the adaptation and development of the PALM PLUS intervention , using experience gained through the implementation of the South African precursor , PALSA PLUS . The Malawian partners , REACH Trust and the Research Unit at the Ministry of Health , have led the qualitative and economic evaluations . Dignitas and Ministry of Health have facilitated interaction with implementers and policy-makers . Challenges and successesThis initiative is an example of South-South knowledge translation between South Africa and Malawi , mediated by a Canadian academic-NGO hybrid . Our success in developing and rolling out PALM PLUS in Malawi suggests that it is possible to adapt and implement this intervention for use in other re source -limited setting Purpose High- quality palliative care requires physicians who communicate effectively , yet many do not receive adequate training . Leading efforts to demonstrate the effectiveness of such training have involved time-intensive programs that included primarily attending physicians , which have been conducted outside of the United States . The goal was to evaluate the effect of a short course to improve residents ' communication skills delivering bad news and eliciting patients ' preferences for end-of-life care . Method This prospect i ve trial enrolled internal medicine residents at Duke University Medical Center from 1999 to 2001 . The course consisted of small-group teaching with lecture , discussion , and role-play . The outcome measure was observed communication skills delivering bad news and eliciting patients ' preferences for end-of-life treatment , assessed via audio-recorded st and ardized patient encounters before and after receiving the intervention . Results Thirty-seven residents received the intervention and 19 were in the control group . Residents attending the course demonstrated statistically significant increases in their overall skill ratings in the delivery of bad news , with improvement in the specific areas of information giving and responding to emotional cues . Although cumulative scores for discussion s about patient preferences for treatment did not increase , residents demonstrated enhanced specific skills including discussing probability , presenting clinical scenarios , and asking about prior experience with end-of-life decision making . Conclusion A relatively short , intensive course can improve the end-of-life communication skills of U.S. medical residents OBJECTIVE To pilot-test the feasibility and preliminary effect of a community health worker ( CHW ) intervention to reduce hospital readmissions . DESIGN Patient-level r and omized quality improvement intervention . SETTING An academic medical center serving a predominantly low-income population in the Boston , Massachusetts area and 10 affiliated primary care practice s. PARTICIPANTS Medical service patients with an in-network primary care physician who were discharged to home ( n = 423 ) and had one of five risk factors for readmission within 30 days . INTERVENTION Inpatient introductory visit and weekly post-discharge telephonic support for 4 weeks to assist patient in coordinating medical visits , obtaining and using medications , and in self-management . MAIN OUTCOME MEASURES Number of completed CHW contacts ; CHW-reported barriers and facilitators to assisting patients ; primary care , emergency department and inpatient care use . RESULTS Roughly 70 % of patients received at least one post-discharge CHW call ; only 38 % of patients received at least four calls as intended . Hospital readmission rates were lower among CHW patients ( 15.4 % ) compared with usual care ( 17.9 % ) ; the difference was not statistically significant . CONCLUSION Under performance-based payment systems , identifying cost-effective solutions for reducing hospital readmissions will be crucial to the economic survival of all hospitals , especially safety-net systems . This pilot study suggests that with appropriate supportive infrastructure , hospital-based CHWs may represent a feasible strategy for improving transitional care among vulnerable population s. An ongoing , r and omized , controlled trial of a CHW intervention , developed according to the lessons of this pilot , will provide further insight into the utility of this approach to reducing readmissions
The majority of studies showed improved health outcomes when compared with usual healthcare , including reductions in blood pressure , increased uptake of medications and lower depression scores .
Factors such as training of NPHWs , provision of algorithms and protocol s for screening , treatment and drug titration were the main enablers of the task-shifting intervention .
The main barriers identified were restrictions on prescribing medications and availability of medicines .
CONCLUSIONS Task-shifting from physicians to NPHWs , if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs .
BACKGROUND One potential solution to limited healthcare access in low and middle income countries ( LMIC ) is task-shifting- the training of  non-physician healthcare workers ( NPHWs ) to perform tasks traditionally undertaken by physicians .
The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease ( NCD ) in LMIC .