A public health framework for chronic disease prevention and control

Strengthening complex systems for chronic disease prevention: a systematic review

BACKGROUND

While frameworks exist for strengthening health care systems and public health systems, there are no practical frameworks to describe, assess and strengthen systems for chronic disease prevention (CDP) using complex systems approaches.

METHODS

A systematic and integrative review of peer reviewed literature was conducted to answer the following questions: How can systems for CDP be defined? What are key attributes of effective systems? How are complex systems approaches discussed? Search terms were identified and the Medline, SCOPUS, and Global Health databases were searched December 2017 and January 2018. Reference lists and selected journals were hand searched. A working definition for a system for CDP was developed to provide a guideline for inclusion. Key exclusion criteria were literature did not address the research questions or working definition; was published in a language other than English and before 2000; focused on specific chronic diseases and/or risk factors and not CDP broadly; concentrated on the health care sector and clinical services and/or health status and surveillance data; and described evaluations of setting specific actions such as policies, programs, interventions, approaches, projects, laws, or regulations. Selected literature (n = 141) was coded in terms of the extent to which the research questions and the working definition of systems for CDP were addressed. Data was then analysed and synthesized to determine key themes.

RESULTS

A revised definition of systems for CDP and seven attributes of effective systems for CDP are reported (collaborative capacity, health equity paradigm, leadership and governance, resources, implementation of desired actions, information and complex systems paradigm). A framework was developed to provide a foundation for describing, assessing and strengthening systems for CDP.

CONCLUSIONS

The results of this literature review provide a strong foundation for a framework to help strengthen systems for CDP. The framework consolidates not only well-established attributes of effective CDP but also highlights theoretical and practical insights from complex systems perspectives.

Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India

BACKGROUND

India accounts for more than two-third of mortality due to non-communicable diseases (NCDs) in south-east Asia. The burden is high in Karnataka, one of the largest states in southern India. There is a need for integration of disease prevention, health promotion, treatment and care within the national program at primary level. A public-private partnership initiative explored evidence gaps to inform a health system based, integrated NCD programme across care continuum with a focus on hypertension and diabetes.

METHODS

The study was conducted during 2017-18 in urban parts of Mysore city, covering a population of 58,000. Mixed methods were used in the study; a population-based screening to estimate denominators for those with disease and at risk; cross-sectional surveys to understand distribution of risk factors, treatment adherence and out of pocket expenses; facility audits to assess readiness of public and private facilities; in-depth interviews and focus group discussions to understand practices, myths and perceptions in the community. Chi-square tests were used to test differences between the groups. Framework analysis approach was used for qualitative analysis.

RESULTS

Twelve and 19% of the adult population had raised blood sugar and blood pressure, respectively, which increased with age, to 32 and 44% for over 50 years. 11% reported tobacco consumption; 5.5%, high alcohol consumption; 40%, inadequate physical activity and 81%, inappropriate diet consumption. These correlated strongly with elderly age and poor education. The public facilities lacked diagnostics and specialist services; care in the private sector was expensive. Qualitative data revealed fears and cultural myths that affected treatment adherence. The results informed intervention design across the NCD care continuum.

CONCLUSIONS

The study provides tools and methodology to gather evidence in designing comprehensive NCD programmes in low and middle income settings. The study also provides important insights into public-private partnership driving effective NCD care at primary care level.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework

Background

Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare.

Methods

This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group.

Results

A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires.

Conclusion

Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient–provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0426-1) contains supplementary material, which is available to authorized users.

Hypertension and diabetes management: a policy perspective from Ghana

PURPOSE

The purpose of this paper is to assess policy and management of hypertension and diabetes in Ghana.

DESIGN/METHODOLOGY/APPROACH

The authors conducted 26 key informant interviews with policy makers, payers, providers and participants from advocacy groups associated with the management of hypertension and diabetes both at national and district levels in Ghana; conducted focus group discussions with a total of 18 hypertensive and diabetic patients; and analyzed documentation detailing activities that have been undertaken in response to the management of hypertension and diabetes in Ghana. The authors then conducted a content analysis after combining the three sources of information.

FINDINGS

Using a stepwise policy process, the Ghanaian health sector has developed overarching policies and strategies on management of diabetes, hypertension, other non-communicable diseases, tobacco, alcohol and nutrition-related issues. Availability of funds and over-concentration on communicable diseases are the main barriers to the implementation of policies. Besides, response of the health sector to address the problems of hypertension and diabetes is focused more on clinical management than prevention; while the structures and processes to manage diabetes and hypertension is available at all levels of service delivery, more needs to be done on preventive aspects.

ORIGINALITY/VALUE

This is the first study in Ghana to combine individual interviews, focus groups and document analysis to review policy development, implementation and response activities on the management of hypertension and diabetes. The authors believe that the evidence from this research will inform future policy initiatives on hypertension and diabetes management in Ghana.

Status and determinants of intra-household food allocation in rural Nepal

Background/objectives

Understanding of the patterns and predictors of intra-household food allocation could enable nutrition programmes to better target nutritionally vulnerable individuals. This study aims to characterise the status and determinants of intra-household food and nutrient allocation in Nepal.

Subjects/methods

Pregnant women, their mothers-in-law and male household heads from Dhanusha and Mahottari districts in Nepal responded to 24-h dietary recalls, thrice repeated on non-consecutive days (n = 150 households; 1278 individual recalls). Intra-household inequity was measured using ratios between household members in food intakes (food shares); food-energy intake proportions (‘food shares-to-energy shares’, FS:ES); calorie-requirement proportions (‘relative dietary energy adequacy ratios’, RDEARs) and mean probability of adequacy for 11 micronutrients (MPA ratios). Hypothesised determinants were collected during the recalls, and their associations with the outcomes were tested using multivariable mixed-effects linear regression models.

Results

Women’s diets (pregnant women and mothers-in-law) consisted of larger FS:ES of starchy foods, pulses, fruits and vegetables than male household heads, whereas men had larger FS:ES of animal-source foods. Pregnant women had the lowest MPA (37%) followed by their mothers-in-law (52%), and male household heads (57%). RDEARs between pregnant women and household heads were 31% higher (log-RDEAR coeff=0.27 (95% CI 0.12, 0.42), P < 0.001) when pregnant women earned more or the same as their spouse, and log-MPA ratios between pregnant women and mothers-in-law were positively associated with household-level calorie intakes (coeff=0.43 (0.23, 0.63), P < 0.001, per 1000 kcal).

Conclusions

Pregnant women receive inequitably lower shares of food and nutrients, but this could be improved by increasing pregnant women’s cash earnings and household food security.

Socioeconomic status and obesity in Cairo, Egypt: a heavy burden for all

Studies have generally shown a positive association between socioeconomic status (SES) and obesity in low-income countries, but few have tested this relationship in the Middle East where obesity prevalence is extraordinarily high and the nutrition profile more closely resembles developed world contexts. The objective of this study is to examine the SES-obesity association in Cairo, Egypt.

Multinomial regression analyses were conducted and predicted probabilities were found for overweight and obesity status among adult men and women in a stratified analysis. Data were taken from the 2007 Cairo Urban Inequity Study which collected information on 3993 individuals from 50 neighborhoods in the Cairo Governorate. Five different measures of SES were utilized – education, household expenditures, household assets, subjective wealth, and father’s education. No significant associations were found between most measures of SES and overweight/obesity in this population. Overweight and obesity are prevalent across the SES spectrum.

These findings suggest that obesity programs and policies should be targeted at all SES groups in Cairo, although specific mechanisms may vary by SES and should be explored further in future studies.

Meeting the mental health needs of low-income immigrants in primary care: a community adaptation of an evidence-based model

Low-income, uninsured immigrants are burdened by poverty and a high prevalence of trauma exposure and thus are vulnerable to mental health problems. Disparities in access to mental health services highlight the importance of adapting evidence-based interventions in primary care settings that serve this population. In 2005, the Montgomery Cares Behavioral Health Program began adapting and implementing a collaborative care model for the treatment of depression and anxiety disorders in a network of primary care clinics that serve low-income, uninsured residents of Montgomery County, Maryland, the majority of whom are immigrants. In its 6th year now, the program has generated much needed knowledge about the adaptation of this evidence-based model. The current article describes the adaptations to the traditional collaborative care model that were necessitated by patient characteristics and the clinic environment.

An examination of sociocultural factors associated with health and health care seeking among Latina immigrants

The purpose of this study was to examine the sociocultural factors associated with health maintenance and health care seeking among Latina immigrants. Data were collected from eight focus groups with 54 Latina immigrants between the ages of 19 and 62 (M=29.3+/-9.34). The PEN-3 model provided the framework for the study. Most of the participants came from Mexico; 46% had not completed high school; 85.2% had been in the United States for less than 7 years, and 73.6% reported not having health insurance coverage. Participants identified both positive and negative perceptions, enablers, and nurturers associated with health maintenance and health care seeking. Participants acknowledged the importance of physical, mental, and spiritual health and what they should do to be healthy. Despite such knowledge, they tended to engage in unhealthy behaviors due to a variety of nonstructural barriers such as lack of time, "tradition," and procrastination. They tended to use alternative/complementary medicine first, and then seek medical help if these practices are not effective. Many women believe that they do not have control over their own health attributing this lack of control to the "system." Participants also mentioned structural barriers to seeking health care such as lack of transportation, lack of proper documentation, lack of health insurance, language barriers, long waiting time at the clinics, and lack of knowledge on where to go for affordable care. Our study suggests that there are important structural and nonstructural barriers that hinder health maintenance and care seeking. The findings also lend support to the PEN-3 model, and suggest that positive perceptions, enablers, and nurturers associated with health maintenance and health care seeking, if properly reinforced, can counterbalance negative perceptions, enablers and nurturers in this population.