Process Evaluation of a Clustered Randomized Control Trial of a Comprehensive Intervention to Reduce the Risk of Cardiovascular Events in Primary Health Care in Rural China

Relationship Between Social Support and Clinical Outcomes: An Evaluation of Participant-Nominated Treatment Supporters in the HOPE 4 Intervention

BACKGROUND

The HOPE 4 trial (Heart Outcomes Prevention and Evaluation 4) investigated the effectiveness of a comprehensive, collaborative model of care, implemented in Colombia and Malaysia, which aimed to reduce cardiovascular disease risk in individuals with hypertension. One component of this intervention was the nomination of a treatment supporter, where participants could select a family member or friend to assist them with their care. The purpose of this study was to investigate the impact of these individuals on participant outcomes, as well as the relationship dynamics between participants and their treatment supporter.

METHODS

Participants in the HOPE 4 intervention group with baseline and 12 months of follow-up were included for analysis. They were divided into Every Visit (n=339) and

RESULTS

Groups were majority female (53% versus 62%) with a mean age of 63 and 66 years. Country of origin differed between groups (22% versus 86%; Colombia). A 15.5% ([95% CI, 6.2%-24.8%] P=0.004) greater increase in statin medication use was reported in the Every Visit group at 12 months compared with the

CONCLUSIONS

Long-term support from a nominated treatment supporter was associated with improved adherence, risk factor management, and medication use among individuals with hypertension.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01826019.

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Key Words

• cardiovascular diseases
• hypertension
• medical adherence
• risk factors
• social support

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MESH Headings

• Humans
• Female
• Middle Aged
• Aged
• Hypertension/diagnosis
• Hypertension/drug therapy
• Hypertension/epidemiology
• Blood Pressure
• Medication Adherence
• Risk Factors
• Social Support

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Affiliation(s)

Anastasia Drakos Faculty of Medicine, University of Ottawa, ON, Canada (A.D.) Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Tara McCready Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Patricio Lopez-Jaramillo Research Institute, Fundación Oftalmológica de Santander, Floridablanca, Colombia (P.L.-J.) Masira Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.)
Shofiqul Islam Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Martin McKee Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom (M.M.)
Salim Yusuf Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.) Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada (S.Y.)
J D Schwalm Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)

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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.

Implementation considerations for non-communicable disease-related integration in primary health care: a rapid review of qualitative evidence

BACKGROUND

Integrated delivery of primary health care (PHC) services is a health reform recommended for achieving ambitious targets of the Sustainable Development Goals and Universal Health Coverage, responding to growing challenges of managing non-communicable and multimorbidity. However, more evidence is needed on effective implementation of PHC integration in different country settings.

OBJECTIVE

This rapid review synthesized qualitative evidence on implementation factors affecting integration of non-communicable disease (NCD) into PHC, from the perspective of implementers. The review contributes evidence to inform the World Health Organizations' guidance on integration of NCD control and prevention to strengthen health systems.

METHOD

The review was guided by standard methods for conducting rapid systematic reviews. Data analysis was guided by the SURE and WHO health system building blocks frameworks. We used Confidence in the Evidence of Reviews of Qualitative Research (GRADE-CERQual) to assess the confidence of the main findings.

RESULTS

The review identified 81 records eligible for inclusion, from 595 records screened. We sampled 20 studies for analysis (including 3 from expert recommendations). Studies covered a wide range of countries (27 countries from 6 continents), the majority from low-and middle-income countries (LMICs), with a diverse set of NCD-related PHC integration combinations and implementation strategies. The main findings were categorised into three overarching themes and several sub-themes. These are, A: Policy alignment and governance, B: Health systems readiness, intervention compatibility and leadership, and C: Human resource management, development, and support. The three overarching findings were assessed as each having a moderate level of confidence.

CONCLUSION

The review findings present insights on how health workers responses may be shaped by the complex interaction of individual, social, and organizational factors that may be specific to the context of the intervention, the importance of cross-cutting influences such as policy alignment, supportive leadership and health systems constraints, knowledge that can inform the development of future implementation strategies and implementation research.

Migration and diabetes incidence among Chinese adults in Canada, China, Hong Kong, and Taiwan: An international population-based comparative study from 2000 to 2017

AIMS

We conducted an international population-based study comparing the incidence of young- (age 20-39 years) and usual- (age ≥ 40 years) onset diabetes among Chinese-Canadian immigrants; their source populations (mainland China, Hong Kong, Taiwan); and other Canadians.

METHODS

Using population-based data (2000-17; n = 3.4 million cases), we calculated incidence rates and incidence rate ratios comparing the average incidence for each cohort.

RESULTS

The average incidence of young-onset diabetes (YOD) among immigrants from China, Hong Kong, and Taiwan was 165.5, 121.0, and 78.4 per 100,000 person-years respectively. Immigrants from China and Hong Kong had higher YOD incidence than their source populations (RR China: 2.59, 2.44-2.74; Hong Kong: 1.64, 1.49-1.81), while immigrants from Taiwan had lower rates versus Taiwan (RR 0.63, 0.45-0.86). YOD incidence among immigrants from China increased sharply by 8.3% (3.3-13.6%) per year from 2011 onward-over twice the annual increase among non-Chinese Canadians. The average incidence rates of usual-onset diabetes among immigrants from China, Hong Kong, and Taiwan were higher than (RR 1.77, 1.73-1.81), similar to (0.98, 0.96-1.01), and lower than (0.36, 0.32-0.40) those in each source population respectively.

CONCLUSIONS

Diabetes incidence among Chinese migrants is unexpectedly heterogeneous, varying according age at migration, territory of origin, and the occurrence of diabetes in the source population.

Evaluation of a package of risk-based pharmaceutical and lifestyle interventions in patients with hypertension and/or diabetes in rural China: A pragmatic cluster randomised controlled trial

BACKGROUND

Primary prevention of cardiovascular disease (CVD) requires adequate control of hypertension and diabetes. We designed and implemented pharmaceutical and healthy lifestyle interventions for patients with diabetes and/or hypertension in rural primary care, and assessed their effectiveness at reducing severe CVD events.

METHODS AND FINDINGS

We used a pragmatic, parallel group, 2-arm, controlled, superiority, cluster trial design. We randomised 67 township hospitals in Zhejiang Province, China, to intervention (34) or control (33). A total of 31,326 participants were recruited, with 15,380 in the intervention arm and 15,946 in the control arm. Participants had no known CVD and were either patients with hypertension and a 10-year CVD risk of 20% or higher, or patients with type 2 diabetes regardless of their CVD risk. The intervention included prescription of a standardised package of medicines, individual advice on lifestyle change, and adherence support. Control was usual hypertension and diabetes care. In both arms, as usual in China, most outpatient drug costs were out of pocket. The primary outcome was severe CVD events, including coronary heart disease and stroke, during 36 months of follow-up, as recorded by the CVD surveillance system. The study was implemented between December 2013 and May 2017. A total of 13,385 (87%) and 14,745 (92%) participated in the intervention and control arms, respectively. Their mean age was 64 years, 51% were women, and 90% were farmers. Of all participants, 64% were diagnosed with hypertension with or without diabetes, and 36% were diagnosed with diabetes only. All township hospitals and participants completed the 36-month follow-up. At 36 months, there were 762 and 874 severe CVD events in the intervention and control arms, respectively, yielding a non-significant effect on CVD incidence rate (1.92 and 2.01 per 100 person-years, respectively; crude incidence rate ratio = 0.90 [95% CI: 0.74, 1.08; P = 0.259]). We observed significant, but small, differences in the change from baseline to follow-up for systolic blood pressure (-1.44 mm Hg [95% CI: -2.26, -0.62; P < 0.001]) and diastolic blood pressure (-1.29 mm Hg [95% CI: -1.77, -0.80; P < 0.001]) in the intervention arm compared to the control arm. Self-reported adherence to recommended medicines was significantly higher in the intervention arm compared with the control arm at 36 months. No safety concerns were identified. Main study limitations include all participants being informed about their high CVD risk at baseline, non-blinding of participants, and the relatively short follow-up period available for judging potential changes in rates of CVD events.

CONCLUSIONS

The comprehensive package of pharmaceutical and healthy lifestyle interventions did not reduce severe CVD events over 36 months. Improving health system factors such as universal coverage for the cost of essential medicines is required for successful risk-based CVD prevention programmes.

TRIAL REGISTRATION

ISRCTN registry ISRCTN58988083.