Integrating screening for non-communicable diseases and their risk factors in routine tuberculosis care in Delhi, India: A mixed-methods study

Tackling syndemics by integrating infectious and noncommunicable diseases in health systems of low- and middle-income countries: A narrative systematic review

The co-occurrence of infectious diseases (ID) and non-communicable diseases (NCD) is widespread, presenting health service delivery challenges especially in low-and middle-income countries (LMICs). Integrated health care is a possible solution but may require a paradigm shift to be successfully implemented. This literature review identifies integrated care examples among selected ID and NCD dyads. We searched PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, EMBASE, Global Health Database, and selected clinical trials registries. Eligible studies were published between 2010 and December 2022, available in English, and report health service delivery programs or policies for the selected disease dyads in LMICs. We identified 111 studies that met the inclusion criteria, including 56 on tuberculosis and diabetes integration, 46 on health system adaptations to treat COVID-19 and cardiometabolic diseases, and 9 on COVID-19, diabetes, and tuberculosis screening. Prior to the COVID-19 pandemic, most studies on diabetes-tuberculosis integration focused on clinical service delivery screening. By far the most reported health system outcomes across all studies related to health service delivery (n = 72), and 19 addressed health workforce. Outcomes related to health information systems (n = 5), leadership and governance (n = 3), health financing (n = 2), and essential medicines (n = 4)) were sparse. Telemedicine service delivery was the most common adaptation described in studies on COVID-19 and either cardiometabolic diseases or diabetes and tuberculosis. ID-NCD integration is being explored by health systems to deal with increasingly complex health needs, including comorbidities. High excess mortality from COVID-19 associated with NCD-related comorbidity prompted calls for more integrated ID-NCD surveillance and solutions. Evidence of clinical integration of health service delivery and workforce has grown-especially for HIV and NCDs-but other health system building blocks, particularly access to essential medicines, health financing, and leadership and governance, remain in disease silos.

Interactive effect of oral anti-hyperglycaemic or anti-hypertensive drugs on the inhibitory and bactericidal activity of first line anti-TB drugs against M. tuberculosis

Co-existence of life style disorders, like, Diabetes or Hypertension, increases risk of, treatment failure, deaths and developing drug-resistant TB. Concomitant administration of drugs to treat dual/multi-morbidities may alter their effectiveness, in additive/synergistic or adverse/antagonistic manner. We evaluated interactive effect of 7 anti-hyperglycaemic (HG) and 6 anti-hypertensive (HT) drugs on the inhibitory (MICs) and bactericidal (% killing of intracellular bacilli) activities of anti-TB drugs, Isoniazid (INH), Rifampicin (RFM), Ethambutol (EMB) and Streptomycin (STR) against M. tuberculosis. Five anti-HG drugs, namely, Acarbose, Acetohexamide, Glyburide, Repaglinide and Sitagliptin imparted either 'additive' or 'no effect' on the activities (inhibition or % killing) of all the four anti-TB drugs, as evident by their lower FICs (Fractional Inhibitory concentrations) and higher bacterial killing in combination. Metformin and Rosiglitazone, however, exerted adverse effect on the Ethambutol (FICs >2.0). All the six anti-HT drugs, namely, Atenolol, Hydrochlorothiazide, Ramipril, Valsartan, Nifedipine and Verapamil exerted either 'additive'/'synergistic' or 'no effect' on the activities of anti-TB drugs. These findings may help clinicians to select safe and helpful anti-HG or anti-HT drugs for TB patients, if, suffering with diabetes or hypertension like co-morbidities and receiving DOTs (a set regimen for the treatment of TB based on the WHO guidelines).

Integration Challenges and Opportunity of Implementing Non-Communicable Disease Screening Intervention with Tuberculosis Patient Care: A Mixed Implementation Study

Background

Despite the comorbidity, early detection and treatment of the two diseases are highly recommended; however, a few pilot studies were conducted, which are mainly focused on diabetes mellitus screening and the integration opportunity and challenges were not known. The study aimed to identify integrated implementation challenges and opportunities of non-communicable disease and risk factors screening intervention with tuberculosis patient care.

Methods

A mixed implementation study design was used. Data were collected from a sample of 443 tuberculosis patients, 21 key informants and facility observations. For quantitative data, descriptive statistics for proportion were summarized in tables and figures. Four distinct implementation frame was adapted for thematic analysis of audio recordings, daily verbatim transcription, and descriptive field notes.

Results

The prevalence of hypertension and diabetes mellitus among tuberculosis patients were 6.55% and 5.64%, respectively. Totally 9 subthemes and 21 new codes were developed, of which 13 and 8 new codes were developed for integrated implementation challenges and opportunities, respectively. The absence of medical equipment, skill and knowledge training, record and report system, cooperative integration, feedback, referral system, shortage of supporting agencies, and services not free were external challenges, whereas lack of trained health workers, focal persons, and increased workload and absence of awareness creation were internal challenges. Despite the challenges, the presence of health extension programs, non-governmental organizations, community health care insurance and associations for diabetes mellitus were external opportunities. Availability of assigned focal persons, trained stakeholders, guidelines, information systems and compatible tuberculosis program structure were internal opportunities.

Conclusion

The majority of TB patients were not comorbid with NCDs. We build a favourable system for integrated implementation developing an integration platform and structural authority at a different organization by addressing identified challenges and applying facilitators is crucial.

Predictors of Tuberculosis and Non-Communicable Disease Comorbidities Among Newly Enrolled Tuberculosis Patients, Southern Ethiopia

Introduction

Non-communicable diseases are comorbid with tuberculosis, however only a few record review based studies have been conducted, which are more concentrated on elevated glucose levels. This study aimed to assess non-communicable disease comorbidity and its predictors among tuberculosis patients.

Methods

A prospective cross-sectional study design was used and the data were collected by a previously validated tool from a sample of 443 tuberculosis patients using cluster random sampling methods. Multinomial logistic regression was interpreted by relative risk to predict the association of comorbidity status with independent variables.

Results

The majority (87.81%) of TB patients were not comorbid with NCDs. The prevalence of hypertension and diabetes mellitus among tuberculosis patients were 6.55%, and 5.64%, respectively. The people who had a risk score >8 were 6.47 times more likely to have tuberculosis comorbid with one non-communicable disease compared to those with a risk score ≤8. The relative risk of tuberculosis patients with BMI >25 is 3.33 times compared to those with a BMI <23 of being comorbid with one non-communicable disease vs tuberculosis patients without non-communicable diseases. Those tuberculosis patients with an awareness of non-communicable disease comorbidities are 9.33 times more likely to have tuberculosis with multi-comorbidities compared to those who are unaware.

Conclusion

The majority of TB patients were not comorbid with NCDs. The person's weight, family size of more than five, monthly income >3000 birr, risk score >8 and BMI >25 significantly predict comorbidity with one non-communicable disease compared to those without a comorbidity. The presence of non-communicable disease comorbidity, treatment awareness, and being aged 50+ years significantly predict the presence of multi-comorbidities compared to those without comorbidity. For early detection and management of both diseases, establishing bidirectional screening platforms in tuberculosis care programs is urgently required.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Assessment of sensory and nutritional attributes of foxtail millet-based food products

Millets are a rich source of many health-promoting nutrients as well as bioactive compounds such as dietary fibers, antioxidants, macro and micronutrients etc., compared to other staple cereals such as rice, wheat and maize. These nutrients play a central role in the world nutritional security. Despite the inbuilt nutritional benefits, the production of millets has witnessed sharp decline owing to taste preferences, keeping quality and challenges associated with food preparation from millets. To sensitize the consumers about the nutritional benefits of foxtail millet, the present study was planned to formulate and nutritionally evaluate eight diversified foxtail millet-based food products namely rusk, kheer, pinni, sattu, vegetable dalia, cookies, bar and papad by replacing commonly used cereals such as wheat and rice. The products prepared from Foxtail millet were found to have high acceptability with mean score of more than 8.00. These diversified food products showed higher protein content ranging from 10.98 to 16.10 g/100 g, with the highest protein found in Foxtail millet kheer (16.01 g/100 g). The resistant starch content and predicted glycemic index (PGI) of these products ranged between 13.67 to 22.61 g/100 g and 46.12 to 57.55, respectively, with the highest resistant starch (22.61 ± 0.69 g/100 g) and lowest PGI (48.42 ± 0.20) found in millet bar. The high resistant starch and low PGI in foxtail millet products suggest that they could serve as an excellent food source suitable for diabetics. The obtained results suggest that all the Foxtail millet-based value-added products have superior nutrient profile and are highly acceptable than the traditional products. Inclusion of these foods in the diets of the population may help in the prevention of malnutrition and type 2 diabetes.

Process evaluation of complex interventions in non-communicable and neglected tropical diseases in low- and middle-income countries: a scoping review

OBJECTIVES

The aim of this review is to map out the use of process evaluation (PE) in complex interventions that address non-communicable diseases (NCDs) and neglected tropical diseases (NTDs) to identify gaps in the design and conduct, as well as strengths, limitations and implications, of this type of research in low- and middle-income countries (LMICs).

DESIGN

Scoping review of PE studies of complex interventions implemented in LMICs. Six databases were searched focused on studies published since 2008.

DATA SOURCES

Embase, PubMed, EbscoHost, Web of Science (WOS), Virtual Health Library (VHL) Regional Portal and Global Index Medicus: Regional Indexes AIM (AFRO), LILACS (AMRO/PAHO), IMEMR (EMRO), IMSEAR (SEARO), WPRIM (WPRO) Global Index Regional Indexes, MEDLINE, SciELO.

ELIGIBILITY CRITERIA

Studies conducted in LMICs on PEs of randomised controlled trials (RCTs) and non-RCTs published between January 2008 and January 2020. Other criteria were studies of interventions for people at risk or having physical and mental NCDs, and/or NTDs, and/or their healthcare providers and/or others related to achieve better health for these two disease groups. Studies were excluded if they were not reported in English or Spanish or Portuguese or French, not peer-reviewed articles, not empirical research and not human research.

DATA EXTRACTION AND SYNTHESIS

Data extracted to be evaluated were: available evidence in the utilisation of PE in the areas of NCDs and NTDs, including frameworks and theories used; methods applied to conduct PEs; and in a subsample, the barriers and facilitators to implement complex interventions identified through the PE. Variables were extracted and categorised. The information was synthesised through quantitative analysis by reporting frequencies and percentages. Qualitative analysis was also performed to understand facilitators and barriers presented in these studies. The implications for PEs, and how the information from the PE was used by researchers or other stakeholders were also assessed in this approach.

RESULTS

303 studies were identified, 79% were for NCDs, 12% used the label 'PE', 27% described a theory or framework for the PE, and 42% used mixed methods to analyse their findings. Acceptability, barriers and facilitators to implement the interventions, experiences and perceptions, and feasibility were the outcomes most frequently evaluated as part of the PEs. Barriers and facilitators themes identified were contextual factors, health system factors, human resources, attitudes and policy factors.

CONCLUSIONS

PEs in NCDs and NTDs are used in LMICs with a wide variety of methods. This review identified many PEs that were not labelled by the authors as such, as well as a limited application of PE-related theories and frameworks, and heterogeneous reporting of this type of study.

Readiness of the primary health care units and associated factors for the management of hypertension and type II diabetes mellitus in Sidama, Ethiopia

Background

In low-income nations such as Ethiopia, noncommunicable diseases (NCDs) are becoming more common. The Ethiopian Ministry of Health has prioritized NCD prevention, early diagnosis, and management. However, research on the readiness of public health facilities to address NCDs, particularly hypertension and type II diabetes mellitus, is limited.

Methods

The study used a multistage cluster sampling method and a health facility-based cross-sectional study design. A total of 83 health facilities were evaluated based on WHO's Service Availability and Readiness Assessment (SARA) tool to investigate the availability of services and the readiness of the primary health care unit (PHCU) to manage type II diabetes and Hypertension. Trained data collectors interviewed with PHCU head or NCD focal persons. The study tried to investigate (1) the availability of basic amenities and the four domains: staff and guidelines, basic equipment, diagnostic materials, and essential medicines used to manage DM and HPN, (2) the readiness of the PHCU to manage DM and HPN. The data were processed by using SPSS version 24. Descriptive statistics, including frequency and percentage, inferential statistics like the chi-square test, and logistic regression models were used to analyze the data.

Results

Of the 82 health facilities, only 29% and 28% of the PHCU identified as ready to manage HPN and DM. Facility type, facility location, presence of guidelines, trained staff, groups of antihypertensive and antidiabetic medicines had a significant impact (P < 0.05) on the readiness of the PHCU to manage HPN and DM at a 0.05 level of significance. Facilities located in urban were 8.2 times more likely to be ready to manage HPN cases than facilities located in rural (AOR = 8.2, 95% CI [2.4-28.5]) and P < 0.05.

Conclusion and recommendation

The results identified comparatively poor and deprived readiness to offer HPN and DM services at lower-level health facilities(health centers). Equipping the lower-level health facilities with screening and diagnostic materials, essential medicines, and provision of basic training for the health care providers and NCD guidelines should be available, especially in the lower health care facilities.

Integrating tuberculosis and noncommunicable diseases care in low- and middle-income countries (LMICs): A systematic review

BACKGROUND

Low- and middle-income countries (LMICs) are facing a combined affliction from both tuberculosis (TB) and noncommunicable diseases (NCDs), which threatens population health and further strains the already stressed health systems. Integrating services for TB and NCDs is advantageous in tackling this joint burden of diseases effectively. Therefore, this systematic review explores the mechanisms for service integration for TB and NCDs and elucidates the facilitators and barriers for implementing integrated service models in LMIC settings.

METHODS AND FINDINGS

A systematic search was conducted in the Cochrane Library, MEDLINE, Embase, PubMed, Bibliography of Asian Studies, and the Global Index Medicus from database inception to November 4, 2021. For our search strategy, the terms "tuberculosis" AND "NCDs" (and their synonyms) AND ("delivery of healthcare, integrated" OR a range of other terms representing integration) were used. Articles were included if they were descriptions or evaluations of a management or organisational change strategy made within LMICs, which aim to increase integration between TB and NCD management at the service delivery level. We performed a comparative analysis of key themes from these studies and organised the themes based on integration of service delivery options for TB and NCD services. Subsequently, these themes were used to reconfigure and update an existing framework for integration of TB and HIV services by Legido-Quigley and colleagues, which categorises the levels of integration according to types of services and location where services were offered. Additionally, we developed themes on the facilitators and barriers facing integrated service delivery models and mapped them to the World Health Organization's (WHO) health systems framework, which comprises the building blocks of service delivery, human resources, medical products, sustainable financing and social protection, information, and leadership and governance. A total of 22 articles published between 2011 and 2021 were used, out of which 13 were cross-sectional studies, 3 cohort studies, 1 case-control study, 1 prospective interventional study, and 4 were mixed methods studies. The studies were conducted in 15 LMICs in Asia, Africa, and the Americas. Our synthesised framework explicates the different levels of service integration of TB and NCD services. We categorised them into 3 levels with entry into the health system based on either TB or NCDs, with level 1 integration offering only testing services for either TB or NCDs, level 2 integration offering testing and referral services to linked care, and level 3 integration providing testing and treatment services at one location. Some facilitators of integrated service include improved accessibility to integrated services, motivated and engaged providers, and low to no cost for additional services for patients. A few barriers identified were poor public awareness of the diseases leading to poor uptake of services, lack of programmatic budget and resources, and additional stress on providers due to increased workload. The limitations include the dearth of data that explores the experiences of patients and providers and evaluates programme effectiveness.

CONCLUSIONS

Integration of TB and NCD services encourages the improvement of health service delivery across disease conditions and levels of care to address the combined burden of diseases in LMICs. This review not only offers recommendations for policy implementation and improvements for similar integrated programmes but also highlights the need for more high-quality TB-NCD research.

Implementation of the WHO's collaborative framework for the management of tuberculosis and diabetes: a scoping review

OBJECTIVE

To map evidence on the implementation of the WHO's collaborative framework for the management of tuberculosis (TB) and diabetes mellitus (DM) comorbidity, globally.

DESIGN

Scoping review.

METHODS

Guided by Arksey and O'Malley's scoping review framework, this review mapped literature on the global implementation of the framework for the management of TB and DM comorbidity, globally. An extensive literature search for peer-reviewed studies, theses, studies in the press and a list of references from the selected studies was conducted to source-eligible studies. PubMed, Google Scholar, Web of Science, Science Direct, the EBSCOhost platform (academic search complete, health source: nursing/academic edition, CINAHL with full text), Scopus and the WHO library were used to source the literature. We performed title screening of articles using keywords in the databases, after which two independent reviewers (RS and PV) screened abstracts and full articles. Studies from August 2011 to May 2021 were included in this review and the screening was guided by the inclusion and exclusion criteria. Findings were analysed using the thematic content analysis approach and results presented in the form of a narrative report. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension was used as a checklist and for explaining the scoping review process.

RESULTS

This review found evidence of the WHO TB-DM collaborative framework's implementation in 35 countries across the globe. TB-DM comorbidity was identified in patients through bidirectional screening of both patients with TB and patients with DM in rural and urban settings.

CONCLUSION

Due to the paucity of evidence on mechanisms of collaboration, we recommend further research in other implementing countries to identify techniques used for diagnosis and integration of TB and DM services, in order to ensure that effective and joint management of TB-DM comorbidity in populations is achieved.

Frontline healthcare workers' experiences in implementing the TB-DM collaborative framework in Northern Ghana

Background

Over the past decade, global health policy has increased its focus on measures to halt further increase in tuberculosis (TB) incidence and management of diabetes mellitus (DM). However, the vertical management of these two diseases have not achieved much in addressing the adverse effects of the rising tuberculosis-diabetes co-epidemic. This necessitated the World Health Organisation and the International Union Against Tuberculosis and Lung Disease to develop a framework to manage this dual disease burden.

TB-DM co-epidemic is a public health concern in Ghana, adversely threatening the country’s fragile health systems. Since frontline healthcare workers are critical in health policy implementation, this study used Lipsky’s theoretical framework of street-level bureaucracy to explore their experiences in implementing the collaborative framework at the health facility level in Ghana.

Methods

This qualitative study was conducted between July to September 2019 using an exploratory design. Data was generated using a semi-structured interview guide designed to elicit information on knowledge of TB-DM comorbidity as well as systems for co-management. Twenty-three in-depth interviews were conducted among purposively selected frontline healthcare workers (doctors, nurses, TB task- shifting officers, TB institutional coordinators and hospital managers) from three health facilities in the Northern Region of Ghana. The lead author also conducted observations and document reviews, in order to fully address the study objectives. Thematic analysis was guided by the Lipsky’s theoretical framework of street level bureaucracy.

Results

The findings revealed three main themes and six sub-themes. Main themes were Prioritisation of TB/HIV co-infection while negating TB-DM comorbidity, Poor working conditions, and Coping mechanisms, whereas sub-themes were Low knowledge and awareness of TB-DM comorbidity, Limited awareness of the collaborative framework, High workload in TB & DM Clinics, Multiple roles, Inadequate training, and Space shortage.

Conclusions

Frontline healthcare workers had limited knowledge of TB-DM comorbidity and the collaborative framework, which, in turn adversely affected the effectiveness in implementing the framework. The effective implementation of the framework begins with raising awareness about the framework through in service training amongst the frontline healthcare workers. Additionally, an integrated screening tool to detect both TB and DM would help achieve early detection of TB-DM comorbidity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06883-6.

Models of care for patients with hypertension and diabetes in humanitarian crises: a systematic review

Care for non-communicable diseases, including hypertension and diabetes (HTN/DM), is recognized as a growing challenge in humanitarian crises, particularly in low- and middle-income countries (LMICs) where most crises occur. There is little evidence to support humanitarian actors and governments in designing efficient, effective, and context-adapted models of care for HTN/DM in such settings. This article aimed to systematically review the evidence on models of care targeting people with HTN/DM affected by humanitarian crises in LMICs. A search of the MEDLINE, Embase, Global Health, Global Indexus Medicus, Web of Science, and EconLit bibliographic databases and grey literature sources was performed. Studies were selected that described models of care for HTN/DM in humanitarian crises in LMICs. We descriptively analysed and compared models of care using a conceptual framework and evaluated study quality using the Mixed Methods Appraisal Tool. We report our findings according to PRISMA guidelines. The search yielded 10 645 citations, of which 45 were eligible for this review. Quantitative methods were most commonly used (n = 34), with four qualitative, three mixed methods, and four descriptive reviews of specific care models were also included. Most studies detailed primary care facility-based services for HTN/DM, focusing on health system inputs. More limited references were made to community-based services. Health care workforce and treatment protocols were commonly described framework components, whereas few studies described patient centredness, quality of care, financing and governance, broader health policy, and sociocultural contexts. There were few programme evaluations or effectiveness studies, and only one study reported costs. Most studies were of low quality. We concluded that an increasing body of literature describing models of care for patients with HTN/DM in humanitarian crises demonstrated the development of context-adapted services but showed little evidence of impact. Our conceptual framework could be used for further research and development of NCD models of care.

Opportunistic screening for diabetes mellitus and hypertension in primary care settings in Karnataka, India: a few steps forward but still some way to go

Background: Opportunistic screening for individuals aged ≥30 years at all levels of healthcare for early detection of diabetes mellitus (DM) and hypertension (HTN) is an integral strategy under the national program to control non-communicable diseases. There has been no systematic assessment of the screening process in primary care settings since its launch. The objective was to determine the number and proportion eligible for screening, number screened, diagnosed and treated for DM and HTN among persons aged ≥30 years in two selected primary health centres (PHCs) in Dakshina Kannada district, Karnataka, India during March-May 2019 and to explore the enablers and barriers in the implementation of screening from the perspective of the health care providers (HCPs) and beneficiaries . Methods: This was a sequential explanatory mixed-methods study with a quantitative (cohort design) and a descriptive qualitative component (in-depth interviews and focus group discussions) with HCPs and persons seeking care. Those that were not known DM/HTN and not screened for DM/HTN in one year were used to estimate persons eligible for screening. Results: Of 2697 persons, 512 (19%) were eligible for DM screening, 401 (78%) were screened; 88/401 (22%) were diagnosed and 67/88 (76%) were initiated on treatment. Of 2697, 337 (13%) were eligible for HTN screening, 327 (97%) were screened, 55 (17%) were diagnosed with HTN; of those diagnosed, 44/55 (80%) were initiated on treatment.  The documentation changes helped in identifying the eligible population. Patient willingness to undergo screening and recognition of relevance of screening were screening enablers.  Overworked staff, logistical and documentation issues, inadequate training were the barriers. Conclusion: Nearly 19% were eligible for DM screening and 13% were eligible for HTN screening. The yield of screening was high. We noted several enablers and barriers. The barriers require urgent attention to reduce the gaps in delivery and uptake of services.

Mapping evidence on the implementation of the WHO's collaborative framework for the management of tuberculosis and diabetes: a scoping review protocol

INTRODUCTION

The emergence of tuberculosis (TB) and diabetes mellitus (DM) coepidemic threatens the gains made in fighting the prevalence of these two diseases. As a result, in 2011, WHO and the International Union Against Lung Disease launched a framework to address the growing TB-DM coepidemic across the world. The aim of the proposed review study is mapping evidence on the implementation of the WHO collaborative framework for the management of TB-DM using a scoping review.

METHODOLOGY AND ANALYSIS

This study will map literature on the global implementation of the WHO collaborative framework for the management of TB-DM, using Arksey and O'Malley's scoping review framework. An extensive literature search for the peer-reviewed articles, grey literature, unpublished studies, thesis, studies in the press and a list of references from the selected studies will be conducted to find eligible studies. PubMed, Google Scholar, Web of Science, Science Direct, the EBSCOhost platform (Academic search complete, health source: nursing/academic edition, CINAHL with full text) and the WHO library will be used to source literature. The researcher will perform title screening of articles using keywords in the databases, and two independent reviewers will then screen abstracts and full articles. The screening will be guided by the inclusion and exclusion criteria. The Mixed Method Appraisal Tool V.2018 will be used to examine the quality of studies to be included. The findings will be analysed using the thematic content analysis approach and the results presented in the form of a narrative report.

ETHICS AND DISSEMINATION

The study did not require ethics approval because it is a scoping review protocol. Findings from this study will be disseminated by print and electronic mediums.

Diabetes in developing countries

There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro- and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost-effective, but targeted high-risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, "fatalistic attitudes", high cost and non-availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low-cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non-medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.