Self-management of diabetes in Sub-Saharan Africa: a systematic review.

BACKGROUND: The prevalence of diabetes in sub-Saharan Africa has increased rapidly over the last years. Self-management is a key element for the proper management, but strategies are currently lacking in this context. This systematic review aims to describe the level of self-management among persons living with type 2 diabetes mellitus in sub-Saharan Africa. METHOD: Relevant databases including PubMed, Web of Science and Google Scholar were searched up to September 2016. Studies reporting self-management behavior of people with type 2 diabetes mellitus and living in sub-Saharan Africa were included. RESULTS: A total of 550 abstracts and 109 full-text articles were assessed. Forty-three studies, mainly observational, met the inclusion criteria. The studies showed that patients rarely self-monitored their glucose levels, had low frequency/duration of physical activity, moderately adhered to recommended dietary and medication behavior, had poor level of knowledge regarding diabetes related complications and sought traditional or herbal medicines beside of their biomedical treatment. The analysis also revealed a lack of studies on psychosocial aspects. CONCLUSION: Except for the psychosocial area, there is a good amount of recent studies on self-management behavior of type 2 diabetes mellitus sub-Saharan Africa. These studies indicate that self-management in sub-Saharan Africa is poor and therefore a serious threat to the health of individuals and the health systems capacity.

A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa.

BACKGROUND: The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa. METHODS: Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework. RESULTS: The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies. CONCLUSIONS: Policy makers and program managers should consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. Researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.

Non-communicable diseases: mapping research funding organisations, funding mechanisms and research practices in Italy and Germany.

BACKGROUND: Evidence shows that territorial borders continue to have an impact on research collaboration in Europe. Knowledge of national research structural contexts is therefore crucial to the promotion of Europe-wide policies for research funding. Nevertheless, studies assessing and comparing research systems remain scarce. This paper aims to further the knowledge on national research landscapes in Europe, focusing on non-communicable disease (NCD) research in Italy and Germany. METHODS: To capture the architecture of country-specific research funding systems, a three-fold strategy was adopted. First, a literature review was conducted to determine a list of key public, voluntary/private non-profit and commercial research funding organisations (RFOs). Second, an electronic survey was administered qualifying RFOs. Finally, survey results were integrated with semi-structured interviews with key opinion leaders in NCD research. Three major dimensions of interest were investigated - funding mechanisms, funding patterns and expectations regarding outputs. RESULTS: The number of RFOs in Italy is four times larger than that in Germany and the Italian research system has more project funding instruments than the German system. Regarding the funding patterns towards NCD areas, in both countries, respiratory disease research resulted as the lowest funded, whereas cancer research was the target of most funding streams. The most reported expected outputs of funded research activity were scholarly publication of articles and reports. CONCLUSIONS: This cross-country comparison on the Italian and German research funding structures revealed substantial differences between the two systems. The current system is prone to duplicated research efforts, popular funding for some diseases and intransparency of research results. Future research will require addressing the need for better coordination of research funding efforts, even more so if European research efforts are to play a greater role.

A systematic review of randomized controlled trials of mHealth interventions against non-communicable diseases in developing countries.

BACKGROUND: The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones (mHealth interventions) is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs). METHODS: A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed. RESULTS: The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions (ranging from health promotion over appointment reminders and medication adjustments to clinical decision support systems), and included patients with different diseases (diabetes, asthma, hypertension). Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures. Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs. CONCLUSIONS: Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.

Costs of delivering human papillomavirus vaccination using a one- or two-dose strategy in Tanzania.

OBJECTIVE: As part of the Dose Reduction Immunobridging and Safety Study of Two HPV Vaccines in Tanzanian Girls (DoRIS; NCT02834637), the current study is one of the first to evaluate the financial and economic costs of the national rollout of an HPV vaccination program in school-aged girls in sub-Saharan Africa and the potential costs associated with a single dose HPV vaccine program, given recent evidence suggesting that a single dose may be as efficacious as a two-dose regimen. METHODS: The World Health Organization's (WHO) Cervical Cancer Prevention and Control Costing (C4P) micro-costing tool was used to estimate the total financial and economic costs of the national vaccination program from the perspective of the Tanzanian government. Cost data were collected in 2019 via surveys, workshops, and interviews with local stakeholders for vaccines and injection supplies, microplanning, training, sensitization, service delivery, supervision, and cold chain. The cost per two-dose and one-dose fully immunized girl (FIG) was calculated. RESULTS: The total financial and economic costs were US$10,117,455 and US$45,683,204, respectively, at a financial cost of $5.17 per two-dose FIG, and an economic cost of $23.34 per FIG. Vaccine and vaccine-related costs comprised the largest proportion of costs, followed by service delivery. In a one-dose scenario, the cost per FIG reduced to $2.51 (financial) and $12.18 (economic), with the largest reductions in vaccine and injection supply costs, and service delivery. CONCLUSIONS: The overall cost of Tanzania's HPV vaccination program was lower per vaccinee than costs estimated from previous demonstration projects in the region, especially in a single-dose scenario. Given the WHO Strategic Advisory Group of Experts on Immunization's recent recommendation to update dosing schedules to either one or two doses of the HPV vaccine, these data provide important baseline data for Tanzania and may serve as a guide for improving coverage going forward. The findings may also aid in the prioritization of funding for countries that have not yet added HPV vaccines to their routine immunizations.

Benefit Assessment and Reimbursement of Digital Health Applications: Concepts for Setting Up a New System for Public Coverage.

In Germany, some digital health applications (DiHA) became reimbursable through the statutory health insurance system with the adoption of the Digital Healthcare Act in 2019. Approaches and concepts for the German care context were developed in an iterative process, based on existing concepts from international experience. A DiHA categorization was developed that could be used as a basis to enable the creation of a reimbursed DiHA repository, and to derive evidence requirements for coverage and reimbursement for each DiHA. The results provide an overview of a possible classification of DiHA as well as approaches to assessment and evaluation. The structure of remuneration and pricing in connection with the formation of groups is demonstrated.

How Denmark, England, Estonia, France, Germany, and the USA Pay for Variable, Specialized and Low Volume Care: A Cross-country Comparison of In-patient Payment Systems.

BACKGROUND: Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]). METHODS: Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries. RESULTS: Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers. CONCLUSION: Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.

Determining the potential of mobilephone-based health interventions in Kumasi, Ghana.

BACKGROUND: Numerous reviews have reported generally positive outcomes of mobile phone-based health (mHealth) interventions in the sub-Saharan African countries, especially for people with non-communicable diseases. At the same time, the mHealth landscape is burdened by a lack of sustainability. A recently published review has identified several context factors that influence the successful implementation of mHealth. Therefore, the aim is to use these contextual factors to assess the potential for mHealth in a particular clinical setting. DESIGN: The study used a cross-sectional, descriptive design. SETTING: The clinical setting of the study was the 'Komfo Anokye Teaching Hospital' in Kumasi, Ghana. PARTICIPANTS: 150 patients attending the diabetes clinic were surveyed. MAIN OUTCOME MEASURES: Context factors that influence the perceived usefulness and ease of use of mHealth. RESULTS: The survey revealed that patients at the diabetes centre had a positive attitude towards mobile phones, but also a low familiarity. Whereas patients faced several access barriers to care, most enabling resources for the successful and sustainable implementation of mHealth interventions such as access to mobile phones and electricity were available. CONCLUSIONS: There is a high potential for mHealth in the setting of the diabetes clinic in Kumasi, Ghana. FUNDING: None Declared.