***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Objective Common mental disorders ( CMD ) are a leading global burden of disease . Up to 30 % of primary care attenders suffer from these disorders but most do not receive evidence -based drug or psychological treatments . There are no trials of interventions which attempt to integrate these treatments into routine primary care in developing countries . The aims of this trial ( the MANAS Project ) are to evaluate the clinical and cost-effectiveness of a collaborative stepped-care intervention for the treatment of CMD in India . Study Design A cluster r and omized controlled trial will be implemented in the state of Goa , on the west coast of India . Twenty-four primary care facilities , 12 from the government sector and 12 from the private sector , will be enrolled in two consecutive phases . For each sector , facilities will be r and omly allocated within strata defined by urban/rural location , population size and presence of a visiting psychiatrist . Facilities will be r and omly allocated to receive the collaborative stepped care intervention or the enhanced usual care control intervention . Both arms share two components of the intervention , viz . , routine screening , and in the government clinics provision of antidepressants . In addition , the collaborative stepped care arm also provides a range of psychosocial treatments delivered by a specially trained Health Counselor , and supervision by a visiting Psychiatrist .  A total of 3600 primary care attenders who are detected to suffer from a CMD based on a vali date d screening question naire will be recruited . The primary outcome is the proportion of subjects who recover from an ICD10 defined CMD at baseline by 6 months . Additional endpoints at 2 and 12 months will assess the speed and sustainability of achieving the primary outcomes . Other outcomes will include recovery from ICD10 defined depression and incidence of ICD-10 among individuals who were sub-threshold cases at baseline . Economic and disability outcomes will be assessed to estimate incremental cost-effectiveness ratios . Implication sThis will be the first trial of the effectiveness of a complex intervention aim ing to integrate efficacious treatments for CMD into routine primary care in a developing country . If effective , its findings will have relevance to policy makers who wish to scale up treatments for CMD in primary care across the world , but mostly in those countries where specialist mental health services are few . Study Registration The MANAS project is registered through the National Institutes of Health sponsored clinical trials registry and has been assigned the identifier : OBJECTIVES This study examines the impact of an intervention to promote dual- method contraceptive use among HIV concordant and discordant couples already using condoms for HIV prevention . METHODS A three-armed r and omized , controlled trial was conducted at a voluntary HIV testing and counseling clinic in Lusaka , Zambia ; 251 couples were r and omized . Control couples received family planning education and referral to an outside clinic for nonbarrier contraceptives , intervention 1 couples received education and offer of contraceptives at the research clinic , and intervention 2 couples received intervention 1 plus a presentation design ed to reduce outside pressures to conceive . RESULTS There was a 3-fold higher contraceptive initiation rate in both intervention arms compared with the control arm . The interventions had no impact on incident pregnancy , largely due to high levels of contraceptive discontinuation and user failure .  HIV-positive women who initially selected injectable contraception were less likely to ab and on the method and significantly less likely to conceive than other study participants . CONCLUSIONS Improving access to nonbarrier contraceptives among couples already using condoms for HIV prevention increased dual- method use . Selection of longer-acting injectable contraception was associated with lower pregnancy rates among HIV-positive women . Further research is needed to identify ways to help couples in this population continue to correctly use nonbarrier contraceptives Vitamin A deficiency is associated with increased morbidity and mortality from diarrheal disease , measles , and malaria . It has been proposed that vitamin A supplementation could be linked with childhood immunization programs to improve child health . We conducted a r and omized , double‐blind , placebo‐controlled clinical trial to evaluate the impact of linking vitamin A supplementation with the Exp and ed Programme on Immunization on morbidity and child growth .  In West Java , Indonesia , 467 six‐week‐old infants were r and omized to receive 7.5 mg retinol equivalent ( RE ) , 15 mg RE , or placebo with childhood immunization contacts at 6 , 10 , and 14 wks and 9 mo of age . Child growth was assessed through anthropometry , and morbidity histories were obtained . Vitamin A supplementation had no apparent impact upon linear or ponderal growth or infectious disease morbidity in the first 15 mo of age when integrated with the Exp and ed Programme on Immunization Background TB and HIV form a deadly synergy in much of the developing world , especially Africa . Interventions to reduce the impact of these diseases at community level are urgently needed . This paper presents the design of a community r and omised trial to evaluate the impact of two complex interventions on the  prevalence of tuberculosis ( TB ) in high HIV prevalence setting s in Zambia and South Africa . Methods The interaction between TB and HIV is review ed and possible interventions that could reduce the prevalence of TB in HIV-endemic population s are discussed . Two of these interventions are described in detail and the design of a 2 × 2 factorial community r and omised trial to test these interventions is presented . The limitations and challenges of the design are identified and discussed . Conclusion There is an urgent need to reduce the prevalence of TB in communities highly affected by HIV . Potential interventions are complex and require innovative trial design s to provide the rigorous evidence needed to inform health policy makers and to ensure that re sources are used optimally . Trial Registration Number : IS RCT BACKGROUND The Integrated Management of Childhood Illness ( IMCI ) strategy is design ed to address major causes of child mortality at the levels of community , health facility , and health system . We assessed the effectiveness of facility-based IMCI in rural Tanzania . METHODS We compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI , from 1997 to 2002 , in a non-r and omised study . We assessed quality of  case-management for children 's illness , drug and vaccine availability , and supervision involving case-management , through a health-facility survey in 2000 . Household surveys were used to assess child-health indicators in 1999 and 2002 . Survival of children was tracked through demographic surveillance over a predefined 2-year period from mid 2000 . Further information on context ual factors was gathered through interviews and record review . The economic cost of health care for children in IMCI and comparison districts was estimated through interviews and record review at national , district , facility , and household levels . FINDINGS During the IMCI phase-in period , mortality rates in children under 5 years old were almost identical in IMCI and comparison districts . Over the next 2 years , the mortality rate was 13 % lower in IMCI than in comparison districts ( 95 % CI -7 to 30 or 5 to 21 , depending on how adjustment is made for district-level clustering ) , with a rate difference of 3.8 fewer deaths per 1000 child-years . Context ual factors , such as use of mosquito nets , all favoured the comparison districts . Costs of children 's health care with IMCI were similar to or lower than those for case-management without IMCI . INTERPRETATION Our findings indicate that facility-based IMCI is good value for money , and support widespread implementation in the context of health-sector reform , basket funding , good facility access , and high utilisation of health facilities Objectives : To describe important details of the design and operational features of the Mwanza sexually transmitted diseases ( STD ) control programme . To assess the feasibility of the intervention , the distribution of STD syndromes observed , the clinical effectiveness of syndromic STD case management , the utilisation of STD services by the population , and the quality of syndromic STD services delivered at rural health units . Methods : The intervention was integrated into rural primary healthcare ( PHC ) units . It comprised improved STD case management using the syndromic approach , facilitated by a regional programme office which ensured the training of health workers , a reliable supply of effective drugs , and regular support supervision . Five studies were performed to evaluate operational performance : ( i ) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections ( RTIs ) to rural health units with improved STD services , ( ii ) a survey of register books from health units in communities without improved services , ( iii ) a survey of register books from referral clinics , ( iv ) a home based cross sectional study of STD patients who did not return to the intervention health units for follow up  , ( v ) a cross sectional survey of reported STD treatment seeking behaviour in a r and om cohort of 8845 adults served by rural health units . Results : During the 2 years of the Mwanza trial , 12 895 STD syndromes were treated at the 25 intervention health units . The most common syndromes were urethral discharge ( 67 % ) and genital ulcers ( 26 % ) in men and  vaginal discharge ( 50 % ) , lower abdominal tenderness ( 33 % ) , and genital ulcers ( 13 % ) in women . Clinical treatment effectiveness was high in patients from whom complete follow up data were available , reaching between 81 % and 98 % after first line treatment and 97%–99 % after first , second , and third line treatment . Only 26 % of patients referred to higher levels of health care had presented to their referral institutions . During the trial period , data from the cohort showed that 12.8 % of men and 8.6 % of women in the intervention communities experienced at least one STD syndrome . Based on various approaches , utilisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50 % and 75 % . During the first 6 months of intervention attendance at intervention units increased by 53 % . Thereafter , the average attendance rate was about 25 % higher than in comparison communities . Home visits to 367 non-returners revealed that 89 % had been free of symptoms after treatment , but 28 % became symptomatic again within 3 months of treatment . 100 % of these patients reported that they had received treatment , but only 74 % had been examined , only 57 % had been given health education , and only 30 % were offered condoms . Patients did not fully recall which treatment they had been given , but possibly only 63 % had been treated exactly according to guidelines . Conclusions : This study demonstrated that it is feasible to integrate effective STD services into the existing PHC structure of a developing country . Improved services attract more patients , but additional educational efforts are needed to further improve treatment seeking behaviour . Furthermore , clear treatment guidelines , a reliable drug supply system , and regular supervision are critical . All efforts should be made to treat patients on the spot , without delay , as referral to higher levels of care led to a high number of dropouts . The syndromic approach to STD control should be supported by at least one reference clinic and laboratory per country to ensure monitoring of prevalent aetiologies , of the development of bacterial resistance , and of the effectiveness of the syndromic algorithms in use Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration , which can be achieved through improved referral across categories of health programs . The use of an unobtrusive referral message that linked family planning and the Exp and ed Program of Immunizations ( EPI ) services was tested in an operations research study in Togo . The introduction of the referral message was accompanied by an 18-percent increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54 percent . These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time . In Togo , no evidence existed of a negative impact on EPI services , and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study Objective : To determine whether implementation of provider-initiated human immunodeficiency virus ( HIV ) counseling would increase the proportion of tuberculosis ( TB ) patients who received HIV counseling and testing . Design : Cluster-r and omized trial with clinic as the unit of r and omization . Setting : Twenty , medium-sized primary care TB clinics in the Nelson M and ela Metropolitan Municipality , Port Elizabeth , Eastern Cape Province , South Africa . Subjects : A total of 754 adults ( 18 years and older ) newly registered as TB patients in the 20 study clinics . Intervention : Implementation of provider-initiated HIV counseling and testing . Main Outcome Measures : Percentage of TB patients HIV counseled and tested . Secondary : Percentage of patients with HIV test positive , and percentage of those who received cotrimoxazole and who were referred for HIV care . Results : A total of 754 adults newly registered as TB patients were enrolled . In clinics r and omly assigned to implement provider-initiated HIV counseling and testing , 20.7 % ( 73/352 ) patients were counseled versus 7.7 % ( 31/402 ) in the control clinics ( P = 0.011 ) , and 20.2 % ( n = 71 ) versus 6.5 % ( n = 26 ) underwent HIV testing ( P = 0.009 ) . Of those patients counseled , 97 % in the intervention clinics accepted testing versus 79 % in control clinics ( P = 0.12 ) . The proportion of patients identified as HIV infected in intervention clinics was 8.5 % versus 2.5 % in control clinics ( P = 0.044 ) . Fewer than 40 % of patients with a positive HIV test were prescribed cotrimoxazole or referred for HIV care in either study arm . Conclusions : Provider-initiated HIV counseling significantly increased the proportion of adult TB patients 
    Output:
    
Based on the included studies , fully integrating sexually transmitted infection ( STI ) and family planning , and maternal and child health services into routine care as opposed to delivering them as special ' vertical ' services may decrease utilisation , client knowledge of and satisfaction with the services and may not result in any difference in health outcomes , such as child survival .
Integrating HIV prevention and control at facility and community level improved the effectiveness of certain services ( STI treatment in males ) but result ed in no difference in health seeking behaviour , STI incidence , or HIV incidence in the population .
There is some evidence that ' adding on ' services ( or linkages ) may improve the utilisation and outputs of healthcare delivery .
However , there is no evidence to date that a fuller form of integration improves healthcare delivery or health status .
Available evidence suggests that full integration probably decreases the knowledge and utilisation of specific services and may not result in any improvements in health status .