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INTRODUCTION: Community engagement is key to improving the quality of primary health care (PHC), with asset-based interventions shown to have a positive impact on equity and health outcomes. However, there tends to be a disconnect between community-based interventions and PHC, with a lack of evidence on how to develop sustainable community-primary care partnerships. This paper reports on the formative phases of 2 studies exploring the feasibility of embedding community assets, namely places of worship and barbershops, into the PHC pathway for the prevention and control of NCDs in deprived settings. It describes the participatory approach used to map and gather contextual readiness information, including the enablers and constrainers for collaborative partnerships with PHC. METHODS: Grounded in community-based participatory research, we used elements of ground-truthing and participatory mapping to locate and gather contextual information on places of worship and barbershops in urban and rural communities. Local knowledge, gathered from community dialogs, led to the creation of sampling frames of these community assets. Selected places of worship were administered a 66-item readiness questionnaire, which included domains on governance and financing, congregation profile, and existing health programs and collaborations. Participating barbershops were administered a 40-item readiness questionnaire, which covered barbers' demographic information, previous training in health promotion, and barbers' willingness to deliver health promotion activities. RESULTS: Fourteen barbershops were identified, of which 10 participated in the readiness survey, while 240 places of worship were identified, of which 14 were selected and assessed for readiness. Contextual differences were found within and between these assets regarding governance, accessibility, and reach. Key enablers for both include training in health promotion, an overwhelming enthusiasm for participation and recognition of the potential benefits of a community-primary care partnership. Lack of previous collaborations with the formal health system was common to both. CONCLUSION: The participatory approach extended reach within underserved communities, while the readiness data informed intervention design and identified opportunities for partnership development. Contextual differences between community assets require comprehensive readiness investigations to develop suitably tailored interventions that promote reach, acceptance, and sustainability.

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BACKGROUND: Depression is a common condition in older adults, being often detected and treated initially in primary care. Collaborative care models including, for example, task-shifting and stepped-care approaches have been investigated to overcome the current scarcity of strategies and trained mental health professionals to treat depression. The PROACTIVE study developed a psychosocial intervention, which makes extensive use of technology in an intervention delivered mainly by non-specialists to treat older adults with depression. The aim of this qualitative study is to assess: 1. Health workers' fidelity to the intervention protocol; 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants; and 3. Perceptions of the psychosocial intervention by the health workers. METHODS: Qualitative methods were used to achieve our aims. The sample included participants (N = 31) receiving the intervention in the pilot trial and health workers (N = 11) working in a Basic Health Unit in the northern area of São Paulo, Brazil. Focus group, non-participant observation and structured interviews were used. Data were analysed using a thematic analysis approach. RESULTS: 1. Health workers' fidelity to the intervention protocol: training, supervision and the structured intervention were crucial and guaranteed health workers' fidelity to the protocol. 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants: Collaborative care, task-shifting, and stepped-care approaches were well accepted. The structured protocol of the intervention including different activities and videos was important to adherence of older adult participants 3. Perceptions of the psychosocial intervention by the health workers: It was feasible to have the home psychosocial sessions conducted by health workers, who are non-mental health specialists and received 3-day training. Training and supervision were perceived as crucial to support health workers before and during the intervention. Technology served as a tool to structure the sessions, obtain and store patient data, present multi-media content, guarantee fidelity to the protocol and facilitate communication among members of the team. However, extra burden was mentioned by the health workers indicating the need of adjustments in their daily duties. CONCLUSIONS: The PROACTIVE intervention was demonstrated to be feasible and accepted by both health workers and older adult participants. The qualitative assessments suggested improvements in training and supervision to ensure fidelity to protocol. To assess effectiveness a randomised controlled trial of the intervention will be conducted with the addition of improvements suggested by this qualitative study. TRIAL REGISTRATION: The pilot study of which the present study gives support to was registered at the Brazilian Clinical Trials, UTN code: U1111-1218-6717 on 26/09/2018.

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BACKGROUND: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. OBJECTIVE: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. METHODS: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top-down and bottom-up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. RESULTS: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. CONCLUSIONS: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26164.

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BACKGROUND: Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations - incorporating a task-shifting approach and modifying the mode of community-based service delivery - are examined from users' perspectives. METHODS: A secondary analysis of in-depth interviews with CTI-TS users (n = 9 in Brazil; n = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS. RESULTS: Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil. CONCLUSION: CTI-TS' major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers.

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BACKGROUND: Task-shifting and technology in psychological interventions are two solutions to increasing access to mental health intervention and overcoming the treatment gap in low and middle-income countries. The CONEMO intervention combines a smartphone app with support from non-specialized professionals, aiming to treat depression in patients with diabetes and/or hypertension. The aim of this paper is to describe the process of recruitment, training and supervision of the non-specialized professionals who participated in the CONEMO task-shifting intervention in Brazil and Peru. METHODS: We described and analyzed data related to the recruitment, training and supervision of 62 nurse assistants from the health system in Sao Paulo, Brazil, and three hired nurses in Lima, Peru. The data were collected from information provided by nurses and nurse assistants, supervisor records from supervision meetings and the CONEMO platform database. RESULTS: We found that task-shifting was feasible using existing resources in Sao Paulo and additional human resources in Lima. Training and supervision were found to be crucial and well received by the staff; however, time was a limitation when using existing human resources. Ensuring technological competence prior to the start of the intervention was essential. Group supervision meetings allowed non-specialized professionals to learn from each other's experiences. CONCLUSION: Carefully considering recruitment, training and supervision of non-specialized professionals is important for effective task-shifting when delivering an mHealth intervention for depression. Opportunities and challenges of working in different health systems are described, which should be considered in future implementation, either for research or real settings. Trial registration NCT028406662 (Sao Paulo), NCT03026426 (Peru).

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Mental healthcare is largely unavailable throughout Haiti, particularly in rural areas. The aim of the current study is to explore perceived feasibility, acceptability, and effectiveness of potential culturally adapted interventions to improve mental health among Haitian women. The study used focus group discussions (n = 12) to explore five potential interventions to promote mental health: individual counseling, income-generating skills training, peer support groups, reproductive health education, and couples' communication training. Findings indicate that individual counseling, support group, and skills training components were generally anticipated to be effective, acceptable, and feasible by both male and female participants. That being said, participants expressed doubts regarding the acceptability of the couples' communication training and reproductive health education due to: a perceived lack of male interest, traditional male and female gender roles, lack of female autonomy, and misconceptions about family planning. Additionally, the feasibility, effectiveness, and acceptability of the components were described as dependent on cost, proximity to participants, and inclusion of a female health promoter that is known in the community. Given the lack of research on intervention approaches in Haiti, particularly those targeting mental health, this study provides a foundation for developing prevention and treatment approaches for mental distress among Haitian women.

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BACKGROUND: Latin America, and Chile in particular, has a rich tradition of community mental health services and programs. However, in vivo community-based psychosocial interventions, especially those with a recovery-oriented approach, remain scarce in the region. Between 2014 and 2015, a Critical Time Intervention-Task Shifting project (CTI-TS) was implemented in Santiago, Chile, as part of a larger pilot randomized control trial. CTI is a time-limited intervention delivered at a critical-time to users, is organized by phases, focuses on specific objectives and decreases in intensity over time. CTI-TS, which combines both the task-shifting strategy and the use of peers, introduces a novel approach to community mental health care that has not yet been tried in Chile. AIMS: We aim to evaluate the feasibility, acceptability and applicability of such a community-based psychosocial intervention in urban settings in Latin America - specifically, in Santiago (Chile) from a user perspective. METHOD: We analyzed 15 in-depth interviews ( n = 15) with service users who participated in the intervention about their perceptions and experiences with CTI-TS through thematic analysis. RESULTS: Three themes were revealed. The first was related to the structural characteristics of CTI-TS, especially regarding the timing, duration and phasic nature of the intervention. The second pertained to the acceptability of the in vivo community-based approach. The third theme dealt with the task-shifting aspect, that is, users' perceptions of the peer support workers and the community mental health workers. CONCLUSIONS: CTI-TS was generally acceptable in this Latin American context. Users' perspectives pointed to the need to make adjustments to some of the structural characteristics of the CTI model and to combine this type of intervention with others that can address stigma. Thus, future adaptations of CTI-TS or similar psychosocial interventions in Latin American contexts are feasible and can enhance community mental health in the region.

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Globally, community-based care and task shifting strategies are used to address maternal healthcare shortages in low-income countries. Limited research exists on models that combine these strategies. Using a qualitative approach, we explored Haitian women's perceptions of the Midwives for Haiti model, which unites task shifting and community-based care by training nurses as skilled birth attendants and offering healthcare via rotating, mobile clinics. Eight focus groups (N = 52) were conducted in rural Haiti in March 2017. Thematic analysis of data indicated that perceptions of care were universally positive. Participants cited accessible patient-centred care, affordable services, and health education as primary motivators to attend. Results illustrated the importance of women's perceptions on the future use of mobile clinic sites or other formal care. Future efforts to address maternal healthcare shortages should consider the Midwives for Haiti model, combining task shifting and community-based care to address common social, topographical, or financial barriers to maternal healthcare.

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BACKGROUND: Echocardiographic screening represents an opportunity for reduction in the global burden of rheumatic heart disease. A focussed single-view screening protocol could allow for the rapid training of healthcare providers and screening of patients. OBJECTIVE: The aim of this study was to determine the sensitivity and specificity of a focussed single-view hand-held echocardiographic protocol for the diagnosis of rheumatic heart disease in children. METHODS: A total of nine readers were divided into three reading groups; each interpreted 200 hand-held echocardiography studies retrospectively as screen-positive, if mitral regurgitation ⩾1.5 cm and/or any aortic insufficiency were observed, or screen-negative from a pooled study library. The performance of experts receiving focussed hand-held protocols, non-experts receiving focussed hand-held protocols, and experts receiving complete hand-held protocols were determined in comparison with consensus interpretations on fully functional echocardiography machines. RESULTS: In all, 587 studies including 76 on definite rheumatic heart disease, 122 on borderline rheumatic heart disease, and 389 on normal cases were available for analysis. The focussed single-view protocol had a sensitivity of 81.1%, specificity of 75.5%, negative predictive value of 88.5%, and a positive predictive value of 63.2%; expert readers had higher specificity (86.1 versus 64.8%, p<0.01) but equal sensitivity. Sensitivity - experts, 96% and non-experts, 95% - and negative predictive value - experts, 99% and non-experts, 98% - were better for definite rheumatic heart disease. False-positive screening studies resulting from erroneous identification of mitral regurgitation and aortic insufficiency colour jets increased with shortened protocols and less experience (p<0.01). CONCLUSION: Our data support a focussed screening protocol limited to parasternal long-axis images. This holds promise in making echocardiographic screening more practical in regions where rheumatic heart disease remains endemic.

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BACKGROUND: Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care. METHODS: We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options. RESULTS: Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers' knowledge about abortion legislation and services; and health workers' willingness to provide abortion care. Health workers' willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers' and co-workers' attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies. CONCLUSIONS: To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.

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Stroke is a major cause of death and disability, with most of its burden now affecting low- and middle-income countries (LMIC). People in rural areas of LMIC who have a stroke receive very little acute stroke care and local healthcare workers and family caregivers in these regions lack the necessary knowledge to assist them. Intriguingly, a recent rapid growth in cell-phone use and digital technology in rural areas has not yet been appropriately exploited for health care training and delivery purposes. What should be done in rural areas, at the community setting-level, where access to healthcare is limited remains a challenge. We review the evidence on improving post-stroke outcomes including lowering the risks of functional disability, stroke recurrence, and mortality, and propose some approaches, to target post-stroke care and rehabilitation, noting key challenges in designing suitable interventions and emphasizing the advantages mHealth and communication technologies can offer. In the article, we present the prevailing stroke care situation and technological opportunities in rural Peru as a case study. As such, by addressing major limitations in rural healthcare systems, we investigate the potential of task-shifting complemented with technology to utilize and strengthen both community-based informal caregivers and community healthcare workers.

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The shortage of health workers worldwide has been identified as a barrier to achieving targeted health goals. Task shifting has been recommended by the World Health Organization to increase access to trained and skilled birth attendants. One example of task shifting is the use of cadres of health care workers, such as nurses and auxiliary nurse-midwives, who can successfully deliver skilled care to women and infants in low-resource areas where women would otherwise lack access to critical health interventions during the childbearing years. Midwives for Haiti is an organization demonstrating the use of task shifting in its education program for auxiliary midwives. Graduates of the Midwives for Haiti education program are employed and working with women in hospitals, birth centers, and clinics across Haiti. This article reviews the Midwives for Haiti education program and presents successes and challenges in task shifting as a strategy to increase access to skilled maternal and newborn care and to meet international health goals to reduce maternal and infant mortality in a low-resource country.

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Despite growing support for supervision after task sharing trainings in humanitarian settings, there is limited research on the experience of trainees in apprenticeship and other supervision approaches. Studying apprenticeships from trainees' perspectives is crucial to refine supervision and enhance motivation for service implementation. The authors implemented a multi-stage, transcultural adaptation for a pilot task sharing training in Haiti entailing three phases: 1) literature review and qualitative research to adapt a mental health and psychosocial support training; 2) implementation and qualitative process evaluation of a brief, structured group training; and 3) implementation and qualitative evaluation of an apprenticeship training, including a two year follow-up of trainees. Structured group training revealed limited knowledge acquisition, low motivation, time and resource constraints on mastery, and limited incorporation of skills into practice. Adding an apprenticeship component was associated with subjective clinical competency, increased confidence regarding utilising skills, and career advancement. Qualitative findings support the added value of apprenticeship according to trainees.