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.

A large scale multi-laboratory suspect screening of pesticide metabolites in human biomonitoring: From tentative annotations to verified occurrences

Within the Human Biomonitoring for Europe initiative (HBM4EU), a study to determine new biomarkers of exposure to pesticides and to assess exposure patterns was conducted. Human urine samples (N = 2,088) were collected from five European regions in two different seasons. The objective of the study was to identify pesticides and their metabolites in collected urine samples with a harmonized suspect screening approach based on liquid chromatography coupled to high resolution mass spectrometry (LC-HRMS) applied in five laboratories. A combined data processing workflow included comprehensive data reduction, correction of mass error and retention time (RT) drifts, isotopic pattern analysis, adduct and elemental composition annotation, finalized by a mining of the elemental compositions for possible annotations of pesticide metabolites. The obtained tentative annotations (n = 498) were used for acquiring representative data-dependent tandem mass spectra (MS2) and verified by spectral comparison to reference spectra generated from commercially available reference standards or produced through human liver S9 in vitro incubation experiments. 14 parent pesticides and 71 metabolites (including 16 glucuronide and 11 sulfate conjugates) were detected. Collectively these related to 46 unique pesticides. For the remaining tentative annotations either (i) no data-dependent MS2 spectra could be acquired, (ii) the spectral purity was too low for sufficient matching, or (iii) RTs indicated a wrong annotation, leaving potential for more pesticides and/or their metabolites being confirmed in further studies. Thus, the reported results are reflecting only a part of the possible pesticide exposure.

Harmonized Quality Assurance/Quality Control Provisions for Nontargeted Measurement of Urinary Pesticide Biomarkers in the HBM4EU Multisite SPECIMEn Study

A set of quality assurance/quality control (QA/QC) criteria for nontargeted measurement of pesticide exposure markers in a large-scale study of human urine has been proposed and applied across five laboratories within the HBM4EU project. Quality control material, including reference standards and fortified pooled urine samples (QC urine) were prepared in a centralized way and distributed across participants to monitor analytical performance and consistency of the liquid chromatography coupled to high-resolution mass spectrometry data generated with a harmonized workflow. Signal intensities, mass accuracy, and retention times of selected QA/QC markers covering a broad range of physicochemical properties were monitored across QC solvent standards, QC urine samples, study urine samples, and procedural blanks, setting acceptance thresholds for repeatability and accuracy. Overall, results showed high repeatability of the collected data. The RSDs of the signal intensities were typically below 20-30% in QC and study samples, with good stability of the chromatographic separation (retention time drift within 2-4 s intrabatch and 5 s interbatch) and excellent mass accuracy (average error < 2 ppm). The use of the proposed criteria allowed for the identification of handling errors, instrumental issues, and potential batch effects. This is the first elaboration of harmonized QA/QC criteria applied across multiple laboratories to assess the quality of data generated by nontargeted analysis of human samples.

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial

Background

Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes.

Methods

StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals.

Results

The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (− 0.08% (− 0.31 to 0.16) (IFCC − 0.82 mmol/mol (− 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was − 0.71% (− 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful.

Conclusions

Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes.

Trial registration

Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11874-7.

Process evaluation of a brief messaging intervention to improve diabetes treatment adherence in sub-Saharan Africa

Background

The SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention is a pragmatic randomised controlled trial, testing the effectiveness of brief text messaging for improving clinical outcomes and medication adherence. The intervention did not impact glycaemic control. We conducted a pre-and post-trial process evaluation alongside the StAR2D study in Malawi and South Africa, exploring the experiences and perceptions of patient participants, to better understand potential underlying reasons for the trial outcomes.

Methods

We employed a qualitative research design, including conducting semi structured in-depth interviews and focus groups at both trial sites. Purposive sampling was used to ensure representation of a wide range of patients with type 2 diabetes with regards to age, gender, ethnicity, language, and duration of diabetes. We interviewed the same participants at baseline and at the end of the trial. We used within-case and across-case thematic analysis to identify key themes.

Results

Brief messages delivered by text were acceptable and useful for addressing informational and support needs for participants. Some participants reported behaviour changes because of the text reminders and advice on a healthy lifestyle. Both participating in the trial and the messages were experienced as a source of support, caring, and motivation. Participants’ ability to act on the messages was limited. A common theme was frustration over the lack of ability to effectively control one’s blood glucose level. They reported a range of routinised, partial diabetes care adherence behaviours, shaped by complex and interacting individual, social, and health service factors. Participant responses and intervention impact were similar across sites, despite differences in health services.

Conclusion

This process evaluation provided context and insight into the factors influencing participants’ engagement with the text messaging intervention. The complex context in which patients take their diabetes medication, may explain in part, why brief text messaging may have been insufficient to bring about changes in health outcomes. The scale of need for self-management and health service support, suggests that health system strengthening, and other forms of self-management support should accompany digital communication interventions. (Current Controlled Trials ISRCTN70768808, registered 03/08/2015.)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11552-8.

Risk assessment of exposure to phthalates in breastfeeding women using human biomonitoring

In this study, we assessed the presence of 14 phthalate metabolites in the urine of 104 lactating mothers from Valencia (Spain) who took part in the human biomonitoring project BETTERMILK. Nine of the metabolites studied showed detection frequencies >80%, whereas the rest of the metabolites presented low detection frequencies (<5%). The concentrations ranged from <LoQ to 1291 ng/mL with monoethyl phthalate showing the highest concentration, with a geometric mean of 34.90 ng/mL. In general, the phthalate metabolite levels quantified in the present study were lower than the urinary levels found in previous studies that involved lactating mothers. The consumption of packaged juices and the frequency of deodorant usage were predictors of some phthalate metabolite levels in urine. In order to put the biomonitoring data in a risk assessment context, guide values for the different phthalates were used and the respective hazard quotients were calculated, which ranged from 0.0036 (benzylbutyl phthalate) to 0.49 (di-2-ethylhexyl phthalate) at the 95th percentile level. Consequently, no risk was appreciated in the studied population.

Global-to-local policy transfer in the introduction of new molecular tuberculosis diagnostics in South Africa

SETTING

Lack of innovation in diagnostics has contributed to tuberculosis (TB) remaining a global health challenge. It is critical to understand how new diagnostic technologies are translated into policies and how these are implemented.

OBJECTIVE

To examine policy transfer for two rapid molecular diagnostic tests, GenoType(®) MDRTBplus and Xpert(®) MTB/RIF, to understand policy development, uptake and implementation in South Africa.

METHODS

A policy transfer analysis framework integrating the key dimensions of policy transfer into one coherent model was used. Two phases of key informant interviews were undertaken with a wide range of stakeholders.

RESULTS

Both tests were developed through innovative partnerships and responded to urgent public health needs. GenoType was introduced through a process that was more inclusive than that for Xpert. National policy and planning processes were opaque for both tests. Their implementation, maintenance and expansion suffered from poor communication and coordination, insufficient attention to resource implications, technical challenges and a lack of broader health systems thinking.

CONCLUSION

Our analysis identified the risks and benefits of partnerships for technological innovation, the complex intersections between global and national actors and the impact of health systems on policy transfer, and the risks of rescue- and technology-focused thinking in addressing public health challenges.

Effect of intrathecal baclofen on evoked pain perception: an evoked potentials and quantitative thermal testing study

BACKGROUND AND OBJECTIVES

Somatic antinociceptive effects of baclofen have been demonstrated in animal models. We hypothesized that if enhanced thermal or pain sensitivity is produced by loss of gamma-aminobutyric acid (GABA)-ergic tone in the central nervous system, spinal administration of GABA agonists might be predicted to be effective in thermal and/or pain perception changes and pain-related evoked potentials in candidates for intrathecal baclofen (ITB) treatment.

METHODS

Eleven patients with severe spinal cord injury (SCI) who suffered from severe spasticity were evaluated during a 50-μg ITB bolus test. Warm and heat pain thresholds, evoked heat pain perception, and contact heat-evoked potentials (CHEPs) were determined above SCI level from the right and left sides. Nine age- and gender-matched healthy volunteers undergoing repeat testing without any placebo injection served as control group.

RESULT

In patients, heat pain perception threshold increased, and evoked pain perception and amplitude of CHEPs decreased significantly after ITB bolus application in comparison with baseline (p < 0.005), with no change in warm perception threshold. In controls, no significant changes were observed in repeat testing over time.

CONCLUSION

Our findings indicate that ITB modulates heat pain perception threshold, evoked heat pain perception and heat pain-related evoked potentials without inducing warm perception threshold changes in SCI patients. This phenomenon should be taken into account in the clinical evaluation and management of pain in patients receiving baclofen.

Clinical and financial benefits of rapid detection of respiratory viruses: an outcomes study

To assess the expected benefits of rapid reporting of respiratory viruses, we compared patients whose samples were processed using standard techniques such as enzyme immunoassays, shell vial assays, and culture tube assays (year 1) to patients whose samples were processed with the same standard techniques in addition to immunofluorescent testing (FA) directly on cytocentrifuged samples (year 2). The cytospin FA screened for influenza A and B viruses, respiratory syncytial virus (RSV), parainfluenza viruses 1 to 3, and adenovirus (DAKO Diagnostics Ltd.). The specificity of the cytospin FA for all viruses was 100%. The sensitivities for influenza A virus and RSV were 90 and 98%, respectively, but the sensitivities for influenza B virus and adenovirus were unacceptable (14.3 and 0%, respectively). However, since the former viruses account for >85% of our isolates from clinical specimens, the cytospin FA is an excellent screening test since the positive result was available within hours. The mean turnaround time for all positive viruses was 4.5 days in year 1 and 0.9 day in year 2 (P = 0.001). This rapid reporting resulted in physicians having access to information sooner, enabling more appropriate treatment. The mean length of stay in the hospital for inpatients with respiratory viral isolates was 10.6 days for year 1 versus 5.3 days for year 2. Mean variable costs for these patients was $7,893 in year 1 and $2,177 in year 2. After subtracting reagent costs and technological time, the savings in variable costs was $144,332/year. Summarizing, the cytospin FA markedly decreased turnaround time and was associated with decreased mortality, length of stay, and costs and with better antibiotic stewardship.

Neurobehavioral outcomes among farm and nonfarm rural Ecuadorians

International researchers have urged greater use of simple neurobehavioral batteries in developing country settings where higher levels of exposure and a variety of cultural and demographic factors may both occur. We conducted a cross-sectional survey of 144 farm members and 72 age and education frequency-matched controls from rural Ecuador, using an amplified Neurobehavioral Core Test Battery. Farm members ranged from those with only indirect pesticide contact to applicators regularly applying organophosphate and carbamate insecticides by backpack sprayer. The distributors of scores showed those with less than 4 years of formal education and at the extremes of age (< 16 or > 65 years old) contributed sufficiently to nonnormality that they had to be excluded from subsequent analyses (resultant n = 170). After adjustment for age and education, language-based IQ test scores and farm membership were the most consistent determinants of neurobehavioral outcomes. Visual-spatial tasks were the most sensitive to the effects of farm membership. Gender (women better than men), alcohol problems, and solvent use were also important for some neurobehavioral tests.

Precocious puberty in a case of Klinefelter's syndrome

An 11 year old male with Klinefelter syndrome and precocious puberty showed an XY/XXY/XXXY chromosomal constitution in his peripheral blood. The meiotic non-disjunction considered as responsible for the syndrome is probably of maternal origin as suggested by the glucose-6-phosphate dehydrogenase levels. It is difficult to decide whether the relationship between the two disorders is casual or not. The effects of longacting progesterone on the patient are described.