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Staton CA, Friedman K, Phillips AJ, Minnig MC, Sakita FM, Ngowi KM, Suffoletto B, Hirshon JM, Swahn M, Mmbaga BT, Vissoci JRN. Feasibility of a pragmatic randomized adaptive clinical trial to evaluate a brief negotiational interview for harmful and hazardous alcohol use in Moshi, Tanzania. PLoS One 2023; 18:e0288458. [PMID: 37535693 PMCID: PMC10399826 DOI: 10.1371/journal.pone.0288458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION Low-resourced settings often lack personnel and infrastructure for alcohol use disorder treatment. We culturally adapted a Brief Negotiational Interview (BNI) for Emergency Department injury patients, the "Punguza Pombe Kwa Afya Yako (PPKAY)" ("Reduce Alcohol For Your Health") in Tanzania. This study aimed to evaluate the feasibility of a pragmatic randomized adaptive controlled trial of the PPKAY intervention. MATERIALS AND METHODS This feasibility trial piloted a single-blind, parallel, adaptive, and multi-stage, block-randomized controlled trial, which will subsequently be used to determine the most effective intervention, with or without text message booster, to reduce alcohol use among injury patients. We reported our feasibility pilot study using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, with recruitment and retention rates being our primary and secondary outcomes. We enrolled adult patients seeking care for an acute injury at the Kilimanjaro Christian Medical Center in Tanzania if they (1) exhibited an Alcohol Use Disorder Identification Test (AUDIT) ≥8, (2) disclosed alcohol use prior to injury, or (3) had a breathalyzer ≥0.0 on arrival. Intervention arms were usual care (UC), PPKAY, PPKAY with standard text booster, or a PPKAY with a personalized text booster. RESULTS Overall, 181 patients were screened and 75 enrolled with 80% 6-week, 82.7% 3-month and 84% 6-month follow-up rates showing appropriate Reach and retention. Adoption measures showed an overwhelmingly positive patient acceptance with 100% of patients perceiving a positive impact on their behavior. The Implementation and trial processes were performed with high rates of PPKAY fidelity (76%) and SMS delivery (74%). Intervention nurses believed Maintenance and sustainability of this 30-minute, low-cost intervention and adaptive clinical trial were feasible. CONCLUSIONS Our intervention and trial design are feasible and acceptable, have evidence of good fidelity, and did not show problematic deviations in protocol. Results suggest support for undertaking a full trial to evaluate the effectiveness of the PPKAY, a nurse-driven BNI in a low-income country. TRIAL REGISTRATION Trial registration number NCT02828267. https://classic.clinicaltrials.gov/ct2/show/NCT02828267.
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Affiliation(s)
- Catherine A. Staton
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Kaitlyn Friedman
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Ashley J. Phillips
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | | | | | | | - Brian Suffoletto
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittbsurgh, PA, United States of America
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore MD, United States of America
| | - Monica Swahn
- Department of Epidemiology, Georgia State University School of Public Health, Atlanta, GA, United States of America
| | - Blandina T. Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Joao Ricardo Nickenig Vissoci
- Division of Emergency Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
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Assessment of substance use among injured persons seeking emergency care in Nairobi, Kenya. Afr J Emerg Med 2022; 12:321-326. [PMID: 35892006 PMCID: PMC9307445 DOI: 10.1016/j.afjem.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/24/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction Trauma is a leading cause of morbidity and mortality in Kenya. In many countries, substance use is common among patients presenting with injuries to an emergency center (EC). Objective To describe the epidemiology of self-reported substance use among adult injured patients seeking ED care in Nairobi, Kenya. Methods This prospective cross-sectional study, assessed patients presenting with injuries to the Kenyatta National Hospital ED in Nairobi, Kenya from March through June of 2021. Data on substance use, injury characteristics and ED disposition were collected. Substances of interest were alcohol, stimulants, marijuana, and opiates. The Alcohol Use Disorders Identification Test-Concise (AUDIT-C) tool was used to characterize hazardous alcohol use. Results A total of 1,282 patients were screened for participation, of which 646 were enrolled. Among participants, 322 (49.8%) reported substance use in the past month (AUDIT-C positive, stimulants, opiates, and/or marijuana). Hazardous alcohol use was reported by 271 (42.0%) patients who screened positive with AUDIT-C. Polysubstance use, (≥2 substances) was reported by 87 participants in the past month. Median time from injury to ED arrival was 13.1 h for all enrolees, and this number was significantly higher among substance users (median 15.4 h, IQR 5.5 - 25.5; p = 0.029). Conclusions In the population studied, reported substance use was common with a substantial proportion of injured persons screening positive for hazardous alcohol use. Those with substance use had later presentations for injury care. These data suggest that ED programming for substance use disorder screening and care linkage could be impactful in the study setting.
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Mutyambizi-Mafunda V, Myers B, Sorsdahl K, Chanakira E, Lund C, Cleary S. Economic evaluation of psychological treatments for common mental disorders in low- and middle-income countries: a systematic review. Health Policy Plan 2022; 38:239-260. [PMID: 36005943 PMCID: PMC9923379 DOI: 10.1093/heapol/czac069] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Common mental disorders (CMDs) constitute a major public health and economic burden on low- and middle-income countries (LMICs). Systematic reviews of economic evaluations of psychological treatments for CMDs are limited. This systematic review examines methods, reports findings and appraises the quality of economic evaluations of psychological treatments for CMDs in LMICs. We searched a range of bibliographic databases (including PubMed, EconLit, APA-PsycINFO and Cochrane library) and the African Journals Online (AJoL) and Google Scholar platforms. We used a pre-populated template to extract data and the Drummond & Jefferson checklist for quality appraisal. We present results as a narrative synthesis. The review included 26 studies, mostly from Asia (12) and Africa (9). The majority were cost-effectiveness analyses (12), some were cost-utility analyses (5), with one cost-benefit analysis or combinations of economic evaluations (8). Most interventions were considered either cost-effective or potentially cost-effective (22), with 3 interventions being not cost-effective. Limitations were noted regarding appropriateness of conclusions drawn on cost-effectiveness, the use of cost-effectiveness thresholds and application of 'societal' incremental cost-effectiveness ratios to reflect value for money (VfM) of treatments. Non-specialist health workers (NSHWs) delivered most of the treatments (16) for low-cost delivery at scale, and costs should reflect the true opportunity cost of NSHWs' time to support the development of a sustainable cadre of health care providers. There is a 4-fold increase in economic evaluations of CMD psychological treatments in the last decade over the previous one. Yet, findings from this review highlight the need for better application of economic evaluation methodology to support resource allocation towards the World Health Organization recommended first-line treatments of CMDs. We suggest impact inventories to capture societal economic gains and propose a VfM assessment framework to guide researchers in evaluating cost-effectiveness.
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Affiliation(s)
- Vimbayi Mutyambizi-Mafunda
- *Corresponding author. Health Economics Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa. E-mail:
| | - Bronwyn Myers
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Perth, WA 6102, Australia,Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg, Cape Town 7505, South Africa,Division of Addiction Psychiatry, Department of Psychiatry and Mental Health, 1st Floor, Neuroscience Institute, Groote Schuur Hospital, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town 7700, South Africa
| | - Esther Chanakira
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town 7700, South Africa,Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s Global Health Institute, King’s College London, De Crespigny Park, London, SE5 8AF, UK
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
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Addressing the substance use treatment gap in Africa using digital screening and brief interventions. Lancet Psychiatry 2022; 9:347-348. [PMID: 35429998 PMCID: PMC9168961 DOI: 10.1016/s2215-0366(22)00096-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/20/2022]
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van Ginneken N, Chin WY, Lim YC, Ussif A, Singh R, Shahmalak U, Purgato M, Rojas-García A, Uphoff E, McMullen S, Foss HS, Thapa Pachya A, Rashidian L, Borghesani A, Henschke N, Chong LY, Lewin S. Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries. Cochrane Database Syst Rev 2021; 8:CD009149. [PMID: 34352116 PMCID: PMC8406740 DOI: 10.1002/14651858.cd009149.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries. OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care. SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019). SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs. PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs). DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs). Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects. Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention. MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs). Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination. Intervention effects *Unless indicated, comparisons were usual care at T2. "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence. Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists); g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death); e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08); b. may have uncertain effects on symptoms/functioning/SU/AEs. Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11); d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects. Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11); b. may have uncertain effects on symptoms/functioning/SU/AEs. PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU. Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13); c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13); c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs; b. may have uncertain effects on recovery/symptoms(PTS)/functioning. AUTHORS' CONCLUSIONS PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.
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Affiliation(s)
- Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | | | - Amin Ussif
- Norwegian Institute of Public Health, Oslo, Norway
| | - Rakesh Singh
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Ujala Shahmalak
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Antonio Rojas-García
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders, Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah McMullen
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | | | - Ambika Thapa Pachya
- Department of Community Health Sciences, School of Medicine and School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Anna Borghesani
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Lee-Yee Chong
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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van der Westhuizen C, Malan M, Naledi T, Roelofse M, Myers B, Stein DJ, Lahri S, Sorsdahl K. Patient outcomes and experience of a task-shared screening and brief intervention service for problem substance use in South African emergency centres: a mixed methods study. Addict Sci Clin Pract 2021; 16:31. [PMID: 33980314 PMCID: PMC8117325 DOI: 10.1186/s13722-021-00239-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background Screening, brief intervention and referral to treatment (SBIRT) programmes have resulted in generally positive outcomes in healthcare settings, particularly for problem alcohol use, yet implementation is hampered by barriers such as concerns regarding the burden on healthcare professionals. In low-resourced settings, task-sharing approaches can reduce this burden by using non-professional healthcare workers, yet data are scarce regarding the outcomes and acceptability to patients within a SBIRT service. This study aims to evaluate patient-reported outcomes, patient acceptability, perceived benefits and recommendations for improving a task-shared SBIRT service in South African emergency centres (ECs). Methods This mixed methods study incorporates quantitative substance use screening and patient satisfaction data collected routinely within the service at three hospitals, and qualitative semi-structured interviews with 18 EC patient beneficiaries of the programme exploring acceptability and perceived benefits of the programme, as well as recommendations to improve the service. Approximately three months after the acute EC visit, a sub-sample of patients were followed up telephonically to assess patient-reported satisfaction and substance use outcomes. Results Of the 4847 patients eligible for the brief intervention, 3707 patients (76%) used alcohol as their primary substance and 794 (16%) used cannabis. At follow-up (n = 273), significant reductions in substance use frequency and severity were noted and over 95% of patients were satisfied with the service. In the semi-structured interviews, participants identified the non-judgemental caring approach of the counsellors, and the screening and psychoeducation components of the intervention as being the most valuable, motivating them to decrease substance use and make other positive lifestyle changes. Study participants made recommendations to include group sessions, market the programme in communities and extend the programme’s reach to include a broader age group and a variety of settings. Conclusions This task-shared SBIRT service was found to be acceptable to patients, who reported several benefits of a single SBIRT contact session delivered during an acute EC visit. These findings add to the SBIRT literature by highlighting the role of non-professional healthcare workers in delivering a low-intensity SBIRT service feasible to implement in low-resourced settings.
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Affiliation(s)
- Claire van der Westhuizen
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Megan Malan
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Tracey Naledi
- Public Health Medicine Division, University of Cape Town, Cape Town, South Africa
| | | | - Bronwyn Myers
- Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- Department of Psychiatry and Neuroscience Institute, SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Sa'ad Lahri
- Department of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Khayelitsha Hospital Emergency Services, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
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Curtis K, Qian S, Yu P, White J, Ruperto K, Balzer S, Munroe B. Does electronic medical record redesign increase screening of risk for pressure injury, falls and substance use in the Emergency Department? An implementation evaluation. Australas Emerg Care 2020; 24:20-27. [PMID: 32376117 DOI: 10.1016/j.auec.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Following the provision of urgent care, screening for risks known to impact patient outcomes is an extension of safe emergency nursing care, in particular for falls, pressure injury and substance use. Screening is a process that primarily aims to identify people at increased risk for specific complications. This study aimed to describe and evaluate the implementation of a consolidated electronic checklist on the screening completion rates for falls, pressure injury and substance use in a regional health district. METHODS This pre-post study used emergency data from four Emergency Departments (EDs) in southern NSW, Australia between November 2016 and February 2019. Patient characteristics, triage category, discharge diagnosis, arrival date and time, screening completion date and time and treatment location were extracted. Descriptive statistics were used to describe the characteristics of the presentations. Z test with adjusted p-values using Bonferroni Correction method was used to compare the characteristics of the presentations and the rates of screening completion. The Theoretical Domains Framework was used to identify any deficits in the implementation. RESULTS There were 33,561 patients in the pre and 35,807 in the post group. There were no differences in patient characteristics between the two groups. The mean emergency department (ED) length of stay was unchanged (490.5min pre vs 489.9min post). The proportion of patients who had all three screens completed increased from 1.3% to 5.5% (p<0.001). Pressure injury risk screening increased from 46.6% (pre) to 53.1% (post) (p<0.001) as did substance use screening (1.7% vs 12.4%, p<0.001). Screening was strongly associated to which hospital the patient was admitted, their age and ED length of stay. Of the 51 mapped intervention functions, 20 (39%) were used in the implementation. CONCLUSIONS The introduction of a consolidated electronic checklist for use by emergency nurses to complete fall, pressure injury and substance use screening resulted in an overall increase in risk screening. However screening rates remained poor. Implementation that considers the capability, opportunity and motivation of those that need to alter their behaviour would likely improve the overall compliance.
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Affiliation(s)
- Kate Curtis
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Health and Medical Research Institute, Australia; Faculty of Science, Medicine and Health, University of Wollongong, Australia.
| | - Siyu Qian
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia; Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Australia
| | - Ping Yu
- Centre for Digital Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Janet White
- eMR Application Support-FirstNet, Health ICT, NSW Health, Australia
| | - Kate Ruperto
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia
| | - Sharyn Balzer
- Emergency Department, Shoalhaven District Memorial Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Belinda Munroe
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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Werner K, Risko N, Burkholder T, Munge K, Wallis L, Reynolds T. Cost-effectiveness of emergency care interventions in low and middle-income countries: a systematic review. Bull World Health Organ 2020; 98:341-352. [PMID: 32514199 PMCID: PMC7265944 DOI: 10.2471/blt.19.241158] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries. METHODS Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. RESULTS Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied. CONCLUSION We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.
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Affiliation(s)
- Kalin Werner
- Department of Surgery, Division of Emergency Medicine, F51-62, Old Main Building, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Nicholas Risko
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, United States of America (USA)
| | - Taylor Burkholder
- Department of Emergency Medicine, University of Southern California, Los Angeles, USA
| | - Kenneth Munge
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Lee Wallis
- Department of Surgery, Division of Emergency Medicine, F51-62, Old Main Building, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Teri Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
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Wagenaar BH, Hammett WH, Jackson C, Atkins DL, Belus JM, Kemp CG. Implementation outcomes and strategies for depression interventions in low- and middle-income countries: a systematic review. Glob Ment Health (Camb) 2020; 7:e7. [PMID: 32346482 PMCID: PMC7176918 DOI: 10.1017/gmh.2020.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/07/2020] [Accepted: 01/22/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage. METHODS PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019. RESULTS A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3). CONCLUSIONS Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.
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Affiliation(s)
- Bradley H. Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Wilson H. Hammett
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Courtney Jackson
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Dana L. Atkins
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jennifer M. Belus
- Department of Psychology, University of Maryland, College Park, MD, USA
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Mutyambizi-Mafunda V, Myers B, Sorsdahl K, Lund C, Naledi T, Cleary S. Integrating a brief mental health intervention into primary care services for patients with HIV and diabetes in South Africa: study protocol for a trial-based economic evaluation. BMJ Open 2019; 9:e026973. [PMID: 31092660 PMCID: PMC6530312 DOI: 10.1136/bmjopen-2018-026973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Depression and alcohol use disorders are international public health priorities for which there is a substantial treatment gap. Brief mental health interventions delivered by lay health workers in primary care services may reduce this gap. There is limited economic evidence assessing the cost-effectiveness of such interventions in low-income and middle-income countries. This paper describes the proposed economic evaluation of a health systems intervention testing the effectiveness, cost-effectiveness and cost-utility of two task-sharing approaches to integrating services for common mental disorders with HIV and diabetes primary care services. METHODS AND ANALYSIS This evaluation will be conducted as part of a three-armed cluster randomised controlled trial of clinical effectiveness. Trial clinical outcome measures will include primary outcomes for risk of depression and alcohol use, and secondary outcomes for risk of chronic disease (HIV and diabetes) treatment failure. The cost-effectiveness analysis will evaluate cost per unit change in Alcohol Use Disorder Identification Test and Centre for Epidemiological Studies scale on Depression scores as well as cost per unit change in HIV RNA viral load and haemoglobin A1c, producing results of provider and patient cost per patient year for each study arm and chronic disease. The cost utility analyses will provide results of cost per quality-adjusted life year gained. Additional analyses relevant for implementation including budget impact analyses will be conducted to inform the development of a business case for scaling up the country's investment in mental health services. ETHICS AND DISSEMINATION The Western Cape Department of Health (WCDoH) (WC2016_RP6_9), the South African Medical Research Council (EC 004-2/2015), the University of Cape Town (089/2015) and Oxford University (OxTREC 2-17) provided ethical approval for this study. Results dissemination will include policy briefs, social media, peer-reviewed papers, a policy dialogue workshop and press briefings. TRIAL REGISTRATION NUMBER PACTR201610001825405.
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Affiliation(s)
- Vimbayi Mutyambizi-Mafunda
- Health Economics Unit, University of Cape Town School of Public Health and Family Medicine, Cape Town, Western Cape, South Africa
| | - Bronwyn Myers
- Alcohol and Drug Abuse Research Unit, South African Medical Research Council, Tygerburg, Western Cape, South Africa
| | - Katherine Sorsdahl
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Crick Lund
- Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, Western Cape, South Africa
- Institute of Psychiatry, Psychology and Neuroscience, Health Services and Population Research, King's College London, London, UK
| | - Tracey Naledi
- Desmond Tutu HIV Research Centre, University of Cape Town School of Public Health and Family Medicine, Observatory, Western Cape, South Africa
- Western Cape Department of Health, Cape Town, Western Cape, South Africa
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Observatory, Western Cape, South Africa
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