***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: The present study aim ed : ( 1 ) to assess and improve the level of women 's involvement in a strategy to control onchocerciasis by  community-directed treatment with ivermectin ( CDTI )  in three parishes of Rukungiri District , Ug and a ; ( 2 ) to measure the performance of female community-directed health workers ( CDHWs ) in comparison with males ; and ( 3 ) to identify culturally acceptable means of enhancing women 's involvement in community-directed healthcare . Health education sessions were used to instruct community members to select female CDHWs in Masya Parish and to stress their potential importance in Karangara Parish ; this subject was not raised in Mukono Parish . In all , 403 mature women who were r and omly selected from the three parishes were interviewed as to their : ( 1 ) knowledge of the classes of people not eligible to take ivermectin ; ( 2 ) knowledge and beliefs about the benefits of ivermectin ; ( 3 ) participation in decision-making ; and ( 4 ) attitudes on the performance of female CDHWs . For analysis , the respondees were divided into : ( 1 ) those who had or had not taken ivermectin treatment during the previous year ; and ( 2 ) those who had or had not attended health education sessions . During the period when face-to-face interviews with women in r and omly selected households were being carried out , participatory evaluation meetings ( PEMs ) were conducted in selected communities from the same parishes in order to reach a consensus on issues which could not easily be included in individual face-to-face interviews . Participant observations were also made regarding : how communities selected their CDHWs ; how the CDHWs organised the distribution exercise and treated community members ; and how the CDHWs kept records in order to underst and issues which were deliberately hidden from the research ers during face-to-face interviews and PEMs . Significantly , the women who had been treated or health educated in Masya Parish were : ( 1 ) more knowledgeable on the groups which were not supposed to be treated ; ( 2 ) aware of women 's involvement in mobilisation of other community members ; ( 3 ) involved in CDTI decision-making ; and ( 4 ) had a better attitude towards female CDHWs ' performance compared with males when compared with those from Karangara and Mukono parishes . There were no differences between the attitude of women in Karangara and Mukono parishes towards performance of female CDHWs . Face-to-face interviews and records from all parishes indicated that female CDHWs achieved as good a coverage as their male counterparts , and sometimes better , in about the same time . Health education increased the number of female CDHWs  from nine to 52 in Masya Parish , from 7 to 22 in Karangara Parish and from 6 to 20 in Mukono Parish . Health education improved the attitude of women towards female CDHWs , but the actual experience of having and observing female CDHWs in action in Masya Parish had a more significant positive impact on the womenfolk , as well as on the rest of the community members , and created an impetus for more of them to become actively involved in actual ivermectin distribution . The present authors conclude that recruiting more female CDHWs and supervisors would reduce the current male domination of the health delivery services , greatly strengthening the activities of CDTI programmes Background Few large and rigorous evaluations of participatory interventions systematic ally describe their context and implementation , or attempt to explain the mechanisms behind their impact . This study reports process evaluation data from the Ekjut cluster-r and omised controlled trial of a participatory learning and action cycle with women 's groups to improve maternal and newborn health outcomes in Jharkh and and Orissa , eastern India ( 2005 - 2008 ) . The study demonstrated a 45 % reduction in neonatal mortality in the last two years of the intervention , largely driven by improvements in safe practice s for home deliveries . Methods A participatory learning and action cycle with 244 women 's groups was implemented in 18 intervention clusters covering an estimated population of 114 141 . We describe the context , content , and implementation of this intervention , identify potential mechanisms behind its impact , and report challenges experienced in the field . Methods included a review of intervention documents , qualitative structured discussion s with group members and non-group members , meeting observations , as well as descriptive statistical analysis of data on meeting attendance , activities , and characteristics of group attendees . Results Six broad , interrelated factors influenced the intervention 's impact : ( 1 ) acceptability ; ( 2 ) a participatory approach to the development of knowledge , skills and ' critical consciousness ' ; ( 3 ) community involvement beyond the groups ; ( 4 ) a focus on marginalized communities ; ( 5 ) the active recruitment of newly pregnant women into groups ; ( 6 ) high population coverage . We hypothesize that these factors were responsible for the increase in safe delivery and care practice s that led to the reduction in neonatal mortality demonstrated in the Ekjut trial . Conclusions Participatory interventions with community groups can influence maternal and child health outcomes if key intervention characteristics are preserved and tailored to local context s. Scaling-up such interventions requires ( 1 ) a detailed underst and ing of the way in which context affects the acceptability and delivery of the intervention ; ( 2 ) planned but flexible replication of key content and implementation features ; ( 3 ) strong support for participatory methods from implementing agencies This article presents a detailed description of a community mobilization intervention involving women 's groups in Mchinji District , Malawi . The intervention was implemented between 2005 and 2010 . The intervention aims to build the capacities of communities to take control of the mother and child health issues that affect them . To achieve this it comprises trained local female facilitators establishing groups and using a manual , participatory rural appraisal tools and picture cards to guide them through a community action cycle to identify and implement solutions to mother and child health problems . Significant re source inputs include salaries for facilitators and supervisors , and training , equipment and material s to support their work with groups . It is hypothesized that the groups will catalyse community collective action to address mother and child health issues and improve the health and reduce the mortality of mothers and children . Their impact , implementation and cost-effectiveness have been rigorously evaluated through a r and omized controlled trial design . The results of these evaluations will be reported in 2011 OBJECTIVE To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions . METHODS A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon , Nigeria and Ug and a. Four trial districts and one comparison district were r and omly selected in each site . All districts had established ivermectin treatment programmes , and in the trial districts four other established interventions - vitamin A supplementation , use of insecticide-treated nets , home management of malaria and short-course , directly-observed treatment for tuberculosis patients - were progressively incorporated into a community-directed intervention ( CDI ) process . At the end of each of the three study years , we performed quantitative evaluations of intervention coverage and provider costs , as well as qualitative assessment s of the CDI process . FINDINGS With the CDI strategy , significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course , directly-observed treatment . The coverage of malaria interventions more than doubled . The district-level costs of delivering all five interventions were lower in the CDI districts , but no cost difference was found at the first-line health facility level . Process evaluation showed that : ( i ) participatory processes were important ; ( ii ) recurrent problems with the supply of intervention material s were a major constraint to implementation ; ( iii ) the communities and community implementers were deeply committed to the CDI process ; ( iv ) community implementers were more motivated by intangible incentives than by external financial incentives . CONCLUSION The CDI strategy , which builds upon the core principles of primary health care , is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa A study of knowledge , attitudes and practice was carried out in the Rukungiri district of Ug and a , in order to investigate the involvement of women in community-directed treatment with ivermectin ( CDTI ) , for the control of onchocerciasis . The data analysed came from interviews with 260 adult women ( one from each of 260 r and omly-selected households in 20 onchocerciasis-endemic communities ) , community informants , and participatory evaluation meetings ( PEM ) in eight communities . The women who had been treated with ivermectin  in 1999 generally had more knowledge of the benefits of taking ivermectin , were more likely to have attended the relevant health-education sessions and were more involved in community decisions on the method of ivermectin distribution than the women who had not received ivermectin in that year . There were fewer female community-directed health workers ( CDHW ) than male CDHW in the communities investigated . The reasons for not attending health-education sessions , not participating in community meetings concerning the CDTI , and the reluctance of some women to serve as CDHW were investigated . The most common reasons given were domestic chores , a reluctance to express their views in meetings outside their own kinship group , suspicions that other women might take advantage of them , and a lack of interest . Most of the women interviewed ( as well as other community members ) felt that there were relatively few women CDHW . The women attributed this to a lack of interaction and trust amongst themselves , which result ed in more men than women being selected as CDHW . The rest of the community members were not against women working as CDHW . It is recommended that communities be encouraged to select women to serve as CDHW in the CDTI , and that the performances of male and female CDHW be compared Background Neonatal mortality rates are high in rural Nepal where more than 90 % of deliveries are in the home . Evidence suggests that death rates can be reduced by interventions at community level . We describe an intervention which aim ed to harness the power of community planning and decision making to improve maternal and newborn care in rural Nepal . Methods The development of 111 women 's groups in a population of 86 704 in Makwanpur district , Nepal is described . The groups , facilitated by local women , were the intervention component of a r and omized controlled trial to reduce perinatal and neonatal mortality rates . Through participant observation and analysis of reports , we describe the implementation of this intervention : the community entry process , the facilitation of monthly meetings through a participatory action cycle of problem identification , community planning , and implementation and evaluation of strategies to tackle the identified problems . Results In response to the needs of the group , participatory health education was added to the intervention and the women 's groups developed varied strategies to tackle problems of maternal and newborn care : establishing mother and child health funds , producing clean home delivery kits and operating stretcher schemes . Close linkages with community leaders and community health workers improved strategy implementation . There were also indications of positive effects on group members and health services , and most groups remained active after 30 months . Conclusion A large scale and potentially sustainable participatory intervention with women 's groups , which focused on pregnancy , childbirth and the newborn period , result ed in innovative strategies identified by local communities to tackle perinatal care problems The challenges of community-directed treatment with ivermectin ( CDTI ) for onchocerciasis control in Africa have been : maintaining a desired treatment coverage , dem and for monetary incentives , high attrition of community distributors and low involvement of women . This study assessed how challenges could be minimised and performance improved using existing traditional kinship structures . In classic CDTI areas , community members decide upon selection criteria for community distributors , centers for health education and training , and methods of distributing ivermectin . In kinship enhanced CDTI , similar procedures were followed at the kinship level . We compared 14 r and omly selected kinship enhanced CDTI communities with 25 classic CDTI communities through interviews of 447 and 750 household members and 127 and 64 community distributors respectively . Household respondents from kinship enhanced CDTI reported better performance ( P<0.001 ) than classic CDTI on the following measures of program effectiveness : ( a ) treatment coverage ( b ) decision on treatment location and ( c ) mobilization for CDTI activities . There were more female distributors in kinship enhanced CDTI than in classic CDTI . Attrition was not a problem . Kinship enhanced CDTI had a higher number of community distributors per population working among relatives , and were more likely to be involved in additional health care activities . The results suggest that kinship enhanced CDTI was more effective than classic CDTI In Ug and a , human onchocerciasis is controlled by annual , mass , community-directed , ivermectin-treatment programmes ( CDITP ) in all endemic communities where the prevalence of the disease is > or = 30 % . This is a practical , long-term and cost-effective strategy . In some communities , this system succeeds in providing treatment at the desired level of coverage ( i.e. 90 % of the annual treatment objective , which is itself equivalent to all those individuals eligible to take ivermectin ) . Other communities , however , fail to reach this target . The aim of the present study was to determine the factors that were significantly associated with success or failure in achieving this target . The data analysed were answers to a question naire completed by 10 household heads r and omly selected from each of 64 r and omly selected endemic communities ( of which 36 succeeded and 28 failed to reach their coverage target ) in the four districts of Kabale , Moyo , Nebbi and Rukungiri . Among the programme-related factors investigated , success was associated , at a statistical level of significance ( P < or = 0.05 ) , with involvement of community members in : ( 1 ) decisions about the execution of the programme ; ( 2 ) attendance at health-education sessions ; ( 3 ) selection of the community-based distributors ( CDB ) ; and ( 4 ) rewarding CBD in kind . In general , the involvement of community members in the planning and execution of a CDITP ( and the result ant sense of pride in community ownership ) was more likely to produce successful results than when external health workers or even community leaders or local councils took responsibility OBJECTIVES To assess and compare the effectiveness of 
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Results When considering what communities have , articles reported external linkages as the most frequently gained re source , especially when partnerships result ed in more community power over the intervention .
In contrast , financial assets were the least mentioned , despite their importance for sustainability .
With how communities act , articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness .
Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives .
When review ing for whom communities act , the importance of strong local leadership was mentioned frequently , while conflict resolution strategies and skills were rarely discussed .
Synergies were found across these elements of community capability , with tangible success in one area leading to positive changes in another .
Access to information and opportunities to develop skills were crucial to community participation , critical thinking , problem solving and ownership .
Conclusions Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment .