***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: OBJECTIVE To conduct the first rigorous evaluation of the long-term effect of the Comprehensive Rural Health Project on  childhood mortality in rural Maharashtra . METHODS Background information and full birth histories were collected by conducting household surveys and interviewing  women . Control villages resembling project villages in terms of population size were r and omly selected from an area enclosed by two ellipses centred around , but not including , the project area . An equal number of villages and approximately equal numbers of households and women were r and omly sample d from both areas . Cox models with robust st and ard errors were used to compare the hazard of death among children under 5 years of age in project and control villages . FINDINGS The hazard of death was reduced by 30 % ( 95 % confidence interval , CI : 6 % to 48 % ) after the neonatal period in the project villages compared with control villages after adjustment for caste and religion of subjects and for availability of irrigation in the villages . During the neonatal period there was an increase of 3 % in the hazard of death , but it was not statistically significant ( 95 % CI : -18 % to 29 % ) . CONCLUSION Our methods provide useful tools for evaluating long-running community-based primary health care programmes . Our findings add to the growing debate on the long-term sustainability of community-based interventions design ed to reduce child mortality Although evidence suggests that lifestyle interventions can reduce blood pressure ( BP ) and glucose levels , there is little information about the feasibility of such interventions when implemented in community setting s. This study evaluated the effectiveness of a community-based lifestyle intervention on BP and glucose in the middle-aged and older Chinese population . By using a cluster r and omisation approach , 474 participants from two communities were assigned to the intervention group which received intensive health education and behavioural intervention , or the control group which received conventional education . Linear mixed models were used to compare between-group differences on change in BP and fasting glucose after 6 , 12 and 24 months . At the 12-month follow-up , the intervention group experienced significantly reductions in systolic BP ( −4.9 vs. 2.4 mmHg ; mean difference [ MD ] −7.3 mmHg ; p < 0.001 ) , diastolic BP ( −1.9 vs. 1.9 mmHg ; MD −3.8 mmHg ; p < 0.001 ) and fasting glucose ( −0.59 vs. 0.08 mmol/L ; MD −0.67 mmol/L ; p < 0.001 ) . These differences were sustained at the 24-month follow-up . With only two communities , it was not possible to adjust for potential clustering by site . This approach of lifestyle interventions conducted through primary care services may be a potential solution for combating hypertension and diabetes in a re source -limited country context in China Background After the launch of Janani Suraksha Yojana , a conditional cash transfer scheme in India , the proportion of women giving birth in institutions has rapidly increased . However , there are important gaps in quality of childbirth services during institutional deliveries . The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan . This intervention titled “ Parijaat ” was design ed by Action Research & Training for Health , in partnership with the state government and United Nations Population Fund . Methods The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan , India . These included district hospitals ( 9 ) , community health centres ( 32 ) and primary health centres ( 3 ) . The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment , feedback , training and action . The adherence to evidence based practice s before , during and after this intervention were measured using structured checklists and scoring sheets . Main outcome measures included changes in practice s during labour , delivery or immediate postpartum period . Results Use of several unnecessary or harmful practice s reduced significantly . Most importantly , proportion of facilities using routine augmentation of labour reduced ( p = 0 ) , episiotomy for primigravidas ( p = 0.0003 ) , fundal pressure ( p = 0.0003 ) , and routine suction of newborns ( 0 = 0.0005 ) . Among the beneficial practice s , use of oxytocin after delivery increased ( p = 0.0001 ) and the practice of listening foetal heart sounds during labour ( p = 0.0001 ) . Some practice s did not show any improvements , such as dorsal position for delivery , use of partograph , and h and -washing . Conclusions An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practice s at health facilities Background The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide . The mPower Heart Project aim ed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task‐sharing with the use of a mobile phone – based clinical decision support system at Community Health Centers in Himachal Pradesh , India . Methods and Results The development of the intervention and mobile phone – based clinical decision support system was carried out using mixed methods in five Community Health Centers . The intervention was subsequently evaluated using pre – post evaluation design . During intervention , a nurse care coordinator screened , examined , and entered patient parameters into mobile phone – based clinical decision support system to generate a prescription , which was vetted by a physician . The change in systolic blood pressure , diastolic blood pressure , and fasting plasma glucose ( FPG ) over 18 months of intervention was quantified using generalized estimating equations models . During intervention , 6797 participants were enrolled . Six thous and sixteen participants had hypertension ( mean systolic blood pressure : 146.1 mm Hg , 95 % CI : 145.7 , 146.5 ; diastolic blood pressure : 89.52 mm Hg , 95 % CI : 89.33 , 89.72 ) , of which 3152 ( 52 % ) subjects were newly detected . Similarly , 1516 participants had diabetes mellitus ( mean FPG : 177.9 mg/dL , 95 % CI : 175.8 , 180.0 ) , of which 450 ( 30 % ) subjects were newly detected . The changes in systolic blood pressure , diastolic blood pressure , and FPG observed at 18 months of follow‐up were −14.6 mm Hg ( 95 % CI : −15.3 , −13.8 ) , −7.6 mm Hg ( CI : −8.0 , −7.2 ) , and −50.0 mg/dL ( 95 % CI : −54.6 , −45.5 ) , respectively , and were statistically significant even after adjusting for age , sex , and Community Health Center . Conclusions A nurse‐facilitated , mobile phone – based clinical decision support system‐enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale‐up in re source poor setting s. Clinical Trial Registration URL : https://www . clinical trials.gov . Unique identifiers : NCT01794052 . Clinical Trial Registry — India : CTRI/2013/02/003412 Background Very few studies having decision support systems as an intervention report on patient outcomes for cardiovascular disease in the Western world . The potential role of decision support system for the management of blood pressure among Indian hypertensives remains unclear . We propose a cluster r and omised trial that aims to test the effectiveness and cost effectiveness of DSS among Indian hypertensive patients . Methods The trial design is a cluster r and omised community intervention trial , in which the participants would be adult male and female hypertensive patients , in the age group of 35 to 64 years , reporting to the Primary Health Care centres of Mahabubnagar district , And hra Pradesh , India . The objective of the study is to test the effectiveness and compare the cost effectiveness and cost utility among hypertensive subjects r and omized to receive either decision support system or a chart based algorithmic support system in urban and rural areas of a district in the state of And hra Pradesh , India ( baseline versus 12 months follow up ) . The primary outcome would be a comparison of the systolic blood pressure at 0 and 12 months among hypertensive patients r and omized to receive the decision support system or the chart based algorithmic support system . Computer generated r and omisation and an investigator and analyser blinded method would be followed . 1600 participants ; 800 to each arm ; each arm having eight clusters of hundred participants each have been recruited between 01 August 2011 - 01 March 2012 . A twelve month follow up will be completed by March 2013 and results are expected by April 2013 . Discussion This cluster r and omized community intervention trial on DSS will enable policy makers to find out the effectiveness , cost effectiveness and cost utility of decision support system for management of blood pressure among hypertensive patients in India . Most of the previous studies on decision support system have focused on physician performance , adherence and on preventive care reminders . The uniqueness of the proposed study lies in finding out the effectiveness of a decision support system on patient related outcomes .Trial registration CTRI/2012/03/002476 , Clinical Trial Registry - India Delivering health care to mystery patients Many families in developing countries do not have access to medical doctors and instead receive health care from informal providers . Das et al. used “ mystery ” patients ( trained actors ) to test whether a 9-month training program  improved the quality of care delivered by informal providers in West Bengal ( see the Perspective by Powell-Jackson ) . The patients did not identify themselves to the providers and were not told which providers had participated in the training program . The results of this blinded assessment showed that medical doctors delivered better care than informal providers but that the training program closed much of the gap . Science , this issue p. 80 ; see also p. 34 Training helped informal providers deliver better care for angina , diarrhea , and asthma . [ Also see Perspective by Powell-Jackson ] INTRODUCTION In rural India , health care providers without formal medical training and self-declared “ doctors ” are sought for up to 75 % of primary care visits . The frequent use of such informal providers , despite legal prohibitions on their practice s , in part reflects the absence of trained medical professionals in rural locations . For example , in the majority of villages in the Indian states of Rajasthan , Madhya Pradesh , and West Bengal , informal providers are the only proximate source of health care . RATIONALE The status of informal providers in the complex Indian health system is the subject of a highly charged debate among policy-makers and the medical establishment . The official view of the establishment is that fully trained providers are the only legitimate source of health care , and training informal providers legitimizes an illegal activity and worsens population health outcomes . In contrast , given the lack of availability of trained providers and the fact that informal providers are tightly linked with the communities that they serve , others believe that training can serve as a stopgap measure to improve health care in t and em with better regulation and reform of the public health care system . However , despite the policy interest and important ramifications for the country , there is little evidence regarding the benefits ( or lack thereof ) of training informal providers . We report on the impact of a multitopic training program for informal providers in the Indian state of West Bengal that provided 72 sessions of training over 9 months . We used a r and omized controlled trial design , together with visits by unannounced st and ardized patients ( “ mystery clients ” ) , to measure the extent to which training could improve the clinical practice of informal providers over the range of conditions that they face . The conditions presented by st and ardized patients were blinded from program implementers . Therefore , we view the evaluation of this multitopic training program as a measure of impact on primary care in general . St and ardized patient data are accompanied by data from day-long clinical observations , providing a comprehensive picture of provider practice . Our study also benchmarks the impact of training against the performance of doctors in public primary health centers serving the same region . Lastly , it explores whether the training affected patient dem and for informal providers .  RESULTS Mean attendance at each training session was 56 % [ 95 % confidence interval ( CI ) : 51 , 62 % ] , with no contamination from the control group . Using st and ardized patient data , we find that providers allocated to the training group were 4.1 ( 1.7 , 6.5 ) percentage points , or 15.2 % , more likely to adhere to condition-specific checklists than those in the control group . The training increased rates of correct case management by 7.9 ( 0.4 , 15.5 ) percentage points , or 14.2 % , and patient caseload by 0.8 to 1.8 ( 0.13 , 3.57 ) patients per day , or 7.6 to 17.0 % . Data from clinical observations show similar patterns . Although correct case management among doctors in public clinics was 14.7 ( –0.1 , 30.4 ) percentage points , or 28.3 % , higher than among untrained informal providers , the training program reduced this gap by half for providers with mean attendance and reduced the gap almost entirely for providers who completed the full course . However , the training had no effect on the use of unnecessary medicines and antibiotics , although both training- and control-group informal providers prescribed 18.8 ( 7.7 , 28.9 ) percentage points , or 28.2 % , fewer unnecessary antibiotics than public-sector providers . CONCLUSION Training informal providers increased correct case management rates but did not reduce the use of unnecessary medicines or antibiotics . At the same time , training did not lead informal providers to violate rules with greater frequency or worsen their clinical practice , both of which are concerns that have been raised by representatives of the Indian Medical Association . Our findings thus suggest that mult 
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We found evidence on the impact of non-physician health workers ( NPHWs ) on coverage and quality of care , though better integration with other PHC services is needed .
Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements , and have a reliable supply of medicines .
Many studies point to the importance of community engagement in improving service dem and .