Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study

The acceptability of lifestyle medicine for the treatment of mental illness: perspectives of people with and without lived experience of mental illness

OBJECTIVE

While lifestyle medicine can be highly effective for treating a range of mental illnesses these approaches are grossly underutilised and have not been systematically implemented into health care systems. Understanding the acceptability of lifestyle medicine is a critical first step to remediate this. This study evaluated the acceptability of lifestyle medicine relative to pharmacotherapy and psychotherapy, and explore perspectives of people with and without lived experience of mental illness.

METHODS

Six hundred and forty-nine adult Australian residents (62.6% female; 53.6% with a lifetime diagnosis of mental illness) completed an online survey based on the Theoretical Framework of Acceptability assessing the acceptability of lifestyle medicine, pharmacotherapy and psychotherapy for treating mental illness.

RESULTS

Most participants felt positive about lifestyle medicine (76.9%) and felt that such approaches aligned with their personal values (74.9%). They understood how lifestyle medicine worked (86.4%) and believed it would be effective (69.6%). Lived experience of mental illness was associated with greater perceived burden and lower self-efficacy to engage in lifestyle medicine activities (both p < 0.001). While there was a clear preference for psychotherapy and lifestyle medicine over pharmacotherapy, pharmacotherapy was perceived as least effortful (p < .001) and participants were least confident in their ability to engage in lifestyle medicine (p < 0.05).

CONCLUSION

The findings indicate strong acceptability of lifestyle medicine for mental illness, a preference for non-pharmacological treatment approaches, and an understanding of the challenges associated with making long-term healthy lifestyle modifications amongst people who have lived experience of mental illness.

Design Research to Embed mHealth into a Community-Led Blood Pressure Management System in Uganda: Protocol for a Mixed Methods Study

BACKGROUND

Uncontrolled hypertension is a leading risk factor for cardiovascular diseases. In Uganda, such diseases account for approximately 10% of all deaths, with 1 in 5 adults having hypertension (>90% of the hypertensive cases are uncontrolled). Although basic health care in the country is available free of cost at government facilities, regularly accessing medication to control hypertension is difficult because supply chain challenges impede availability. Clients therefore frequently suspend treatment or buy medication individually at private facilities or pharmacies (incurring significant costs). In recent years, mobile health (mHealth) interventions have shown increasing potential in addressing health system challenges in sub-Saharan Africa, but the acceptability, feasibility, and uptake conditions of mobile money approaches to chronic disease management remain understudied.

OBJECTIVE

This study aims to design and pilot-test a mobile money-based intervention to increase the availability of antihypertensive medication and lower clients' out-of-pocket payments. We will build on existing local approaches and assess the acceptability, feasibility, and uptake of the designed intervention. Furthermore, rather than entering the study setting with a ready-made intervention, this research will place emphasis on gathering applied ethnographic insights early, which can then inform the parameters of the intervention prototype and concurrent trial.

METHODS

We will conduct a mixed methods study following a human-centered design approach. We will begin by conducting extensive qualitative research with a range of stakeholders (clients; health care providers; religious, cultural, and community leaders; academics; and policy makers at district and national levels) on their perceptions of hypertension management, money-saving systems, and mobile money in the context of health care. Our results will inform the design, iterative adaptation, and implementation of an mHealth-facilitated pooled financing intervention prototype. At study conclusion, the finalized prototype will be evaluated quantitatively via a randomized controlled trial.

RESULTS

As of August 2023, qualitative data collection, which started in November 2022, is ongoing, with data analysis of the first qualitative interviews underway to inform platform and implementation design. Recruitment for the quantitative part of this study began in August 2023.

CONCLUSIONS

Our results aim to inform the ongoing discourse on novel and sustainable pathways to facilitate access to medication for the management of hypertension in resource-constrained settings.

TRIAL REGISTRATION

German registry of clinical trials DRKS00030922; https://drks.de/search/en/trial/DRKS00030922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46614.

Challenges to Implementation of Community Health Worker-Led Chronic Obstructive Pulmonary Disease (COPD) Screening and Referral in Rural Uganda: A Qualitative Study using the Implementation Outcomes Framework

Background

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally. The burden of COPD is expected to increase in low- and middle-income countries (LMICs). COPD screening and diagnostics tools are often inaccessible in rural settings of LMICs. To contribute to the growing body of evidence on the effectiveness of Community Health Worker (CHW) interventions, this study aims to understand the facilitators and barriers of implementing a CHW-led COPD screening and referral program in rural Uganda.

Methods

This qualitative study was conducted from September to October 2022 to explore Community Members, CHWs, and Healthcare Providers (HCPs) perceptions on the challenges of CHW-delivered COPD programming in Nakaseke, rural Uganda. In total, we held eight individual in-depth interviews with CHWs, ten in-depth interviews with HCPs and six focus group discussions with 34 Community Members. Research assistants audio-recorded and transcribed interviews verbatim. The implementation outcomes framework guided the thematic analysis.

Results

Implementation acceptability was constrained by a lack of COPD awareness, a lack of perceived utility in COPD screening as well as stigma around the diagnostic process. Limited spirometry adoption was also attributed to Community Member accessibility and willingness to participate in the COPD diagnostic referral process. The high patient volume and the complex, time-consuming diagnostic and referral process hindered successful implementation. To enhance program sustainability, all participants suggested increasing CHW support, medication access, decentralizing COPD care and upscaling follow-up of Community Members by CHWs.

Conclusion

CHW-led interventions remain a potentially critical tool to alleviate barriers to treatment and self-management in settings where access to care is limited. While community-based interventions can create sustainable infrastructure to improve health outcomes, formative assessments of the potential barriers prior to intervention are required. Evidence-based, localized approaches and sustained funding are imperative to achieve this.

Task-Shifting: Can Community Health Workers Be Part of the Solution to an Inactive Nation?

Background: In low-to-middle income countries (LMICs), there is a growing burden of non-communicable diseases (NCDs) placing strain on the facilities and human resources of healthcare systems. Prevention strategies that include lifestyle behavior counseling have become increasingly important. We propose a potential solution to the growing burden of NCDs through an expansion of the role for community health workers (CHWs) in prescribing and promoting physical activity in public health settings. This discussion paper provides a theoretical model for task-shifting of assessment, screening, counseling, and prescription of physical activity to CHWs. Five proposed tasks are presented within a larger model of service delivery and provide a platform for a structured, standardized, physical activity prevention strategy aimed at NCDs using CHWs as an integral part of reducing the burden of NCDs in LMICs. However, for effective implementation as part of national NCD plans, it is essential that CHWs received standardized, ongoing training and supervision on physical activity and other lifestyle behaviors to optimally impact community health in low resource settings.

Principles for task shifting hypertension and diabetes screening and referral: a qualitative study exploring patient, community health worker and healthcare professional perceptions in rural Uganda

BACKGROUND

A shortage of healthcare workers in low- and middle-income countries (LMICs) combined with a rising burden of non-communicable diseases (NCDs) like hypertension and diabetes mellitus has resulted in increasing gaps in care delivery for NCDs. As community health workers (CHWs) often play an established role in LMIC healthcare systems, these programs could be leveraged to strengthen healthcare access. The objective of this study was to explore perceptions of task shifting screening and referral for hypertension and diabetes to CHWs in rural Uganda.

METHODS

This qualitative, exploratory study was conducted in August 2021 among patients, CHWs and healthcare professionals. Through 24 in-depth interviews and ten focus group discussions, we investigated perceptions of task shifting to CHWs in the screening and referral of NCDs in Nakaseke, rural Uganda. This study employed a holistic approach targeting stakeholders involved in the implementation of task shifting programs. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically guided by the framework method.

RESULTS

Analysis identified elements likely to be required for successful program implementation in this context. Fundamental drivers of CHW programs included structured supervision, patients' access to care through CHWs, community involvement, remuneration and facilitation, as well as building CHW knowledge and skills through training. Additional enablers comprised specific CHW characteristics such as confidence, commitment and motivation, as well as social relations and empathy. Lastly, socioemotional aspects such as trust, virtuous behavior, recognition in the community, and the presence of mutual respect were reported to be critical to the success of task shifting programs.

CONCLUSION

CHWs are perceived as a useful resource when task shifting NCD screening and referral for hypertension and diabetes from facility-based healthcare workers. Before implementation of a task shifting program, it is essential to consider the multiple layers of needs portrayed in this study. This ensures a successful program that overcomes community concerns and may serve as guidance to implement task shifting in similar settings.

Evaluation of a Health Care Worker Training Intervention to Improve the Early Diagnosis and Referral of Childhood Cancers in Ghana: A Qualitative Descriptive Study

PURPOSE

This study sought to (1) evaluate the perceived effectiveness of an early childhood cancer warning signs and symptoms (EWSS) training intervention on health care worker (HCW) knowledge, attitudes, and clinical practice; (2) evaluate the ease of implementation of training received, including potential barriers and facilitators; and (3) provide insights into program improvements for future iterations of the intervention.

METHOD

Using a qualitative descriptive study design, we conducted in-depth, semistructured interviews with 23 purposively sampled Ghanaian HCW recipients of the EWSS training intervention. We undertook iterative thematic analysis of data concurrently with interviews and used a modified version of the theoretical framework of acceptability to guide the evaluation of the training intervention.

RESULTS

We identified six themes-affective attitude, burden, intervention coherence, perceived effectiveness, self-efficacy, and quality improvement-that structure participant perceptions of the effectiveness of the EWSS training. Participants generally had a positive attitude to the training intervention, found the content relatively easy to understand, and communicated the positive impacts of the training on their day-to-day practice. However, they also identified patient- and system-level challenges to the real-world implementation of intervention components, including patients' cultural and religious beliefs about illnesses, patients' financial constraints, and inadequately funded health systems.

CONCLUSION

Our findings suggest that although an HCW-focused training intervention has the potential to improve timely diagnosis and referral for childhood cancers in Ghana and comparable health system contexts, complementary interventions to address patient- and system-level implementation challenges are required to translate improvements in HCW knowledge to sustained impact on health outcomes for children with cancer.

Approaches and outcomes of community health worker's interventions for hypertension management and control in low-income and middle-income countries: systematic review

OBJECTIVES

To critically appraise the scope, content and outcomes of community health worker (CHW) interventions designed to reduce blood pressure (BP) in low-income and middle-income countries (LMICs).

METHOD

We performed a database search (PUBMED, EMBASE, CINAHL, PsycINFO, OpenGrey, Cochrane Central Trials Register and Cochrane Database of Systematic Reviews) to identify studies in LMICs from 2000 to 2020. Eligible studies were interventional studies published in English and reporting CHW interventions for management of BP in LMICs. Two independent reviewers screened the titles, abstracts and full texts of publications for eligibility and inclusion. Relevant information was extracted from these studies using a tailored template. Risk of bias was assessed using the Cochrane collaboration risk of bias tool. Qualitative synthesis of results was done through general summary of the characteristics and findings of each study. We also analysed the patterns of interventions and their outcomes across the studies. Results were presented in form of narrative and tables.

RESULTS

Of the 1557 articles identified, 14 met the predefined criteria. Of these, 12 were cluster randomised trials whereas two were pretest/post-test studies. The CHW interventions were mainly community-based and focused on behaviour change for promoting BP control among hypertensive patients as well as healthy individuals. The interventions had positive effects in the BP reduction, linkage to care, treatment adherence and in reducing cardivascular-disease risk level.

DISCUSSION AND CONCLUSION

The current review is limited in that, a meta-analysis to show the overall effect of CHW interventions in the management of hypertension was not possible due to the diversity of the interventions, and outcomes of the studies included in the review. Summarised outcomes of individual studies showed CHW enhanced the control and management of hypertension. Further studies are needed to indicate the impact and cost-effectiveness of CHW-led interventions in the control and management of hypertension in LMICs.

Understanding factors influencing uptake of healthy lifestyle practices among adults following a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: A qualitative study

Introduction

Healthy lifestyle practices including physical activity, healthy diets, non-smoking, reduced alcohol consumption and stress reduction are important in the prevention of metabollic CVD risk factors such as hypertension, overweight and obesity, diabetes and hyperlipidaemia. Owing to current lifestyle changes, the increasing burden of CVD and importance of healthy behaviours, the need for strategies to increase uptake of healthy lifestyles among sub-Saharan African populations are apparent. This study explored the factors influencing uptake of healthy lifestyle practices among adults following implementation of a community CVD prevention programme.

Methods

This was a descriptive qualitative study conducted among purposively selected adults who had engaged in a community CVD prevention programme. Data were collected using in-depth interviews, which were audio recorded and transcribed verbatim. Study transcripts were read into NVIVO 12.6 software for coding and analysis guided by thematic analysis following the semantic approach.

Results

This study found variations in uptake of healthy lifestyle practices for CVD prevention with most changes reported for dietary behaviour especially in vegetable and fruit intake, reduction of salt intake and fats and oils consumption. Changes in physical activity were also notable. On the other hand, participants were slow in making changes in alcohol consumption, smoking behaviours and stress reduction. The barriers to uptake of healthy lifestyle practices were individual such as limited capability or skills, structural such as limited physical activity facilities, and social such as cultural and peer influence. Relatedly, the facilitators of practices uptake were individual including knowledge and personal determination to change, and social including social support from family and the community.

Conclusions

Insights from understanding the uptake of lifestyle practices should guide planning and design of community programmes with an emphasis on removing barriers and strengthening facilitators building on the intermediate motivating factors and considering individual needs and expectations.

Enhancing Performance and Sustainability of Community Health Worker Programs in Uganda: Lessons and Experiences From Stakeholders

We conducted a 1-day workshop—a unique opportunity to engage stakeholders at all levels of community health worker (CHW) program involvement—to discuss learned experiences and strategies to enhance and sustain the CHW program in Uganda.

Background:

Community health worker (CHW) programs in Uganda have contributed to improved health outcomes in recent years. However, opportunities for engaging the various stakeholders supporting CHW programs have been limited. This article presents workshop findings where several stakeholders shared their lessons and experiences that can enhance performance and sustainability of CHW programs in Uganda.

Methods:

We collected qualitative data from stakeholders from government, private, and community organizations, as well as CHWs, involved in CHW programs in Uganda during a 1-day workshop. The workshop involved plenary presentations and group discussions on critical aspects of CHW programs. All proceedings from the workshop were audio-recorded, transcribed, and analyzed by thematic content analysis.

Results:

Four major themes emerged from the workshop: lessons learned in implementing CHW programs, challenges affecting CHW programs, performance of CHWs, and ensuring sustainability of CHW programs. Key lessons learned related to 3 main subthemes: capacity building and use of technology, supervision and motivation, and stakeholder engagement and collaboration. Challenges affecting CHW programs identified included poor coordination, fragmented data collection systems, high program expectations, inadequate support mechanisms, and high dropout rates. Mechanisms for improving the performance of CHWs emphasized the need to: strengthen recruitment, training, and retention strategies; improve motivation; streamline coordination mechanisms; and develop and strengthen community health policies. The sustainability of CHW programs requires institutionalization; sustainable funding; economic empowerment of CHWs; local ownership; and a strengthened research agenda.

Conclusion:

To improve the performance and sustainability of CHWs programs, stakeholders such as policy makers and implementing partners need to consider CHW needs, existing structures and policies, as well as local support.

Community health workers' involvement in the prevention and control of non-communicable diseases in Wakiso District, Uganda

Background

Community health workers (CHWs) are an important cadre of the global health workforce as they are involved in providing health services at the community level. However, evidence on the role of CHWs in delivering interventions for non-communicable diseases (NCDs) in Uganda is limited. This study, therefore, assessed the involvement of CHWs in the prevention and control of NCDs in Wakiso District, Uganda with a focus on their knowledge, attitudes and practices, as well as community perceptions.

Methods

A cross-sectional study using mixed methods was conducted which involved a structured questionnaire among 485 CHWs, and 6 focus group discussions (FGDs) among community members. The study assessed knowledge, perceptions including the importance of the various risk factors, and the current involvement of CHWs in NCDs, including the challenges they faced. Quantitative data were analysed in STATA version 13.0 while thematic analysis was used for the qualitative data.

Results

The majority of CHWs (75.3%) correctly defined what NCDs are. Among CHWs who knew examples of NCDs (87.4%), the majority mentioned high blood pressure (77.1%), diabetes (73.4%) and cancer (63.0%). Many CHWs said that healthy diet (86.2%), physical activity (77.7%), avoiding smoking/tobacco use (70.9%), and limiting alcohol consumption (63.7%) were very important to prevent NCDs. Although more than half of the CHWs (63.1%) reported being involved in NCDs activities, only 20.9 and 20.6% had participated in community mobilisation and referral of patients respectively. The majority of CHWs (80.1%) who were involved in NCDs prevention and control reported challenges including inadequate knowledge (58.4%), lack of training (37.6%), and negative community perception towards NCDs (35.1%). From the FGDs, community members were concerned that CHWs did not have enough training on NCDs hence lacked enough information. Therefore, the community did not have much confidence in them regarding NCDs, hence rarely consulted them concerning these diseases.

Conclusions

Despite CHWs having some knowledge on NCDs and their risk factors, their involvement in the prevention and control of the diseases was low. Through enhanced training and community engagement, CHWs can contribute to the prevention and control of NCDs, including health education and community mobilisation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-020-00653-5.

Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research

Background

In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have explored the implementation processes of such interventions to inform their scale up and sustainability. Using the consolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencing the implementation of a community CVD programme led by community health workers (CHWs) in Mukono and Buikwe districts in Uganda.

Methods

This qualitative study is a process evaluation of an ongoing type II hybrid stepped wedge cluster trial guided by the CFIR. Data for this analysis were collected through regular meetings and focus group discussions (FGDs) conducted during the first cycle (6 months) of intervention implementation. A total of 20 CHWs participated in the implementation programme in 20 villages during the first cycle. Meeting reports and FGD transcripts were analysed following inductive thematic analysis with the aid of Nvivo 12.6 to generate emerging themes and sub-themes and thereafter deductive analysis was used to map themes and sub-themes onto the CFIR domains and constructs.

Results

The barriers to intervention implementation were the complexity of the intervention (complexity), compatibility with community culture (culture), the lack of an enabling environment for behaviour change (patient needs and resources) and mistrust of CHWs by community members (relative priority). In addition, the low community awareness of CVD (tension for change), competing demands (other personal attributes) and unfavourable policies (external policy and incentives) impeded intervention implementation. On the other hand, facilitators of intervention implementation were availability of inputs and protective equipment (design quality and packaging), training of CHWs (Available resources), working with community structures including leaders and groups (process—opinion leaders), frequent support supervision and engagements (process—formally appointed internal implementation leaders) and access to quality health services (process—champions).

Conclusion

Using the CFIR, we identified drivers of implementation success or failure for a community CVD prevention programme in a low-income context. These findings are key to inform the design of impactful, scalable and sustainable CHW programmes for non-communicable diseases prevention and control.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-020-01065-0.

Patient barrier acceptance during airway management among anesthesiologists: a simulation pilot study

BACKGROUND

Protection of healthcare providers (HCP) has been a serious challenge in the management of patients during the coronavirus 2019 (COVID-19) pandemic. Additional physical barriers have been created to enhance personal protective equipment (PPE). In this study, user acceptability of two novel barriers was evaluated and the performance of airway management using PPE alone versus PPE plus the additional barrier were compared.

METHODS

An open-label, double-armed simulation pilot study was conducted. Each participant performed bag-mask ventilation and endotracheal intubation using a GlideScope in two scenarios: 1) PPE donned, followed by 2) PPE donned plus the addition of either the isolation chamber (IC) or aerosol box (AB). Endotracheal intubation using videolaryngoscopy was timed. Participants completed pre- and post-simulation questionnaires.

RESULTS

Twenty-nine participants from the Department of Anesthesia were included in the study. Pre- and post-simulation questionnaire responses supported the acceptance of additional barriers. There was no significant difference in intubating times across all groups (PPE vs. IC 95% CI, 26.3, 35.1; PPE vs. AB 95% CI, 25.9, 35.5; IC vs. AB 95% CI, 23.6, 39.1). Comparison of post-simulation questionnaire responses between IC and AB showed no significant difference. Participants did not find the additional barriers negatively affected communication, visualization, or maneuverability.

CONCLUSIONS

Overall, the IC and AB were comparable, and there was no negative impact on performance under testing conditions. Our study suggests the positive acceptance of additional patient protection barriers by anesthesia providers during airway management.

Cardiovascular disease prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda

Background

With the growing epidemic of Cardiovascular Disease (CVD) in sub-Saharan Africa, behavioural change interventions are critical in supporting populations to achieve better cardiovascular health. Population knowledge regarding CVD is an important first step for any such interventions. This study examined CVD prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda.

Methods

The study was cross-sectional in design conducted among adults aged 25 to 70 years as part of the baseline assessment by the Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa (SPICES) – project. Data were collected using pretested semi-structured questionnaires, and respondents categorized as knowledgeable if they scored at least five out of six in the knowledge questions. Data were exported into STATA version 15.0 statistical software for analysis conducted using mixed-effects Poisson regression with fixed and random effects and robust standard errors.

Results

Among the 4372 study respondents, only 776 (17.7%) were knowledgeable on CVD prevention. Most respondents were knowledgeable about foods high in calories 2981 (68.2%), 2892 (66.1%) low fruit and vegetable intake and high salt consumption 2752 (62.9%) as CVD risk factors. However, majority 3325 (76.1%) thought the recommended weekly moderate physical activity was 30 min and half 2262 (51.7%) disagreed or did not know that it was possible to have hypertension without any symptoms. Factors associated with high CVD knowledge were: post-primary education [APR = 1.55 (95% CI: 1.18–2.02), p = 0.002], formal employment [APR = 1.69 (95% CI: 1.40–2.06), p < 0.001] and high socio-economic index [APR = 1.35 (95% CI: 1.09–1.67), p = 0.004]. Other factors were: household ownership of a mobile phone [APR = 1.35 (95% CI: 1.07–1.70), p = 0.012] and ever receiving advice on healthy lifestyles [APR = 1.38 (95% CI: 1.15–1.67), p = 0.001].

Conclusions

This study found very low CVD knowledge with major gaps around recommended physical activity duration, diet and whether hypertension is asymptomatic. Observed knowledge gaps should inform suitable interventions and strategies to equip and empower communities with sufficient information for CVD prevention.

Trial registration

ISRCTN Registry ISRCTN15848572, January 2019, retrospectively registered.