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.

ANTECEDENTES: La integración de la atención primaria de salud (APS) se ha promovido en todo el mundo como herramienta para la mejora del sector sanitario y la cobertura sanitaria universal (CSU), especialmente en contextos con pocos recursos. Sin embargo, por diversas razones, la aplicación y el impacto todavía son variables. La integración de la APS, en su forma más simple, se puede considerar una forma de prestar conjuntamente servicios de APS que en ocasiones se han prestado como una serie de programas sanitarios separados o "verticales". Se sabe que el personal sanitario determina el éxito de la aplicación de las intervenciones de mejora. Por lo tanto, conocer las percepciones y experiencias de los trabajadores sanitarios sobre la integración de la APS puede ayudar a comprender la función que desempeñan en la configuración de los esfuerzos para la aplicación y el impacto de la integración de la APS. Sin embargo, la heterogeneidad de la base de evidencia complica la comprensión de su función en la configuración de la aplicación, la prestación y el impacto de la integración de la APS, así como el papel de los factores contextuales que influyen en sus respuestas. OBJETIVOS: Identificar la literatura cualitativa sobre las percepciones y experiencias del personal sanitario en relación con la integración de la APS para caracterizar la base de evidencia, con vistas a informar mejor las futuras síntesis sobre el tema. MÉTODOS DE BÚSQUEDA: Se utilizaron los métodos exhaustivos estándar de búsqueda de Cochrane. La última fecha de búsqueda fue el 28 de julio de 2020. No se buscó literatura gris debido a los numerosos registros publicados identificados. CRITERIOS DE SELECCIÓN: Se incluyeron estudios con diseños cualitativos y de métodos mixtos que informaran sobre las percepciones y experiencias de los profesionales sanitarios sobre la integración de la APS de cualquier país. Se excluyeron los contextos distintos de la APS y la atención sanitaria comunitaria, los participantes que no fueran profesionales sanitarios y las intervenciones que abarcaran más que los servicios sanitarios. Para revisar los registros que no estaban en inglés se contó con la traducción realizada con la ayuda de colegas y el programa Google Translate. En los casos en que la traducción no fue posible, estos registros se clasificaron como estudios pendientes de clasificación. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Para la extracción de los datos, se utilizó un formulario de extracción de datos personalizado que contenía ítems elaborados mediante enfoques inductivos y deductivos. La extracción independiente por duplicado de una muestra del 10% de los estudios permitió alcanzar un acuerdo suficiente entre los autores de la revisión. Los datos extraídos se analizaron cuantitativamente contando el número de estudios por indicador y convirtiéndolos en proporciones con información descriptiva cualitativa adicional. Los indicadores incluían descripciones de los métodos de estudio, el contexto del país, el tipo de intervención, el alcance y las estrategias, el personal sanitario encargado de aplicarla y la población destinataria. RESULTADOS PRINCIPALES: La revisión incluyó 184 estudios para el análisis sobre la base de 191 documentos incluidos. La mayoría de los estudios se publicaron en los últimos 12 años, con un fuerte aumento en los últimos cinco. La mayoría de los estudios emplearon métodos con un diseño cualitativo transversal (principalmente entrevistas y debates en grupos de discusión), y pocos utilizaron diseños longitudinales o etnográficos (o ambos). Los estudios abarcaron 37 países, con una proporción casi equitativa de países de ingresos altos (PIA) y países de ingresos bajos y medios (PIBM). Tanto en los PIA como en los PIBM, la distribución geográfica presentaba carencias y algunos países eran más dominantes, como EE. UU. en los países de ingresos altos, Sudáfrica en los de ingresos medios y Uganda en los de ingresos bajos. Los métodos fueron principalmente estudios observacionales transversales con pocos estudios longitudinales. Una minoría de estudios utilizó un modelo conceptual analítico para orientar el diseño, la aplicación y la evaluación del estudio de integración. El principal hallazgo fue los distintos niveles de diversidad encontrados en la base de evidencia sobre estudios de integración de la APS que examinaron las percepciones y experiencias de los trabajadores sanitarios. La revisión identificó seis configuraciones diferentes de flujos de servicios sanitarios que se estaban integrando y que se clasificaron como: salud mental y del comportamiento; VIH, tuberculosis (TB) y salud sexual y reproductiva; salud materna, de la mujer y del niño; enfermedades no transmisibles; y dos categorías más amplias, a saber, servicios generales de APS y servicios afines y especializados. Dentro de los flujos sanitarios, la revisión clasificó el alcance de las intervenciones como integración total o parcial. La revisión identificó el uso de tres estrategias de integración diferentes y las clasificó como estrategias de integración horizontal, ampliación de los servicios y vinculación de los servicios. Se identificó el amplio abanico de profesionales sanitarios que participaron en la aplicación de las intervenciones de integración: responsables de políticas sanitarias, altos directivos, directivos intermedios y de primera línea, médicos, profesionales sanitarios asociados, trabajadores sanitarios no técnicos y personal de apoyo de los sistemas sanitarios. Se identificó la variedad de poblaciones destinatarias. CONCLUSIONES DE LOS AUTORES: Esta revisión sistemática exploratoria proporciona una revisión global sistemática y descriptiva de la heterogeneidad de la bibliografía cualitativa sobre las percepciones y experiencias de los profesionales sanitarios con respecto a la integración de la APS, señalando la diversidad con respecto a los contextos nacionales, los tipos de estudio, las poblaciones de clientes, las poblaciones de profesionales sanitarios y el enfoque, el alcance y las estrategias de la intervención. Sería importante que los investigadores y los responsables de la toma de decisiones comprendieran cómo la diversidad en el diseño, la aplicación y el contexto de la intervención de integración de la APS podría influir en la forma en que los trabajadores sanitarios conciben el impacto de la integración de la APS. La clasificación de los estudios en función de las distintas dimensiones (p. ej., enfoque de la integración, alcance, estrategia y tipo de trabajadores sanitarios y poblaciones de clientes) puede ayudar a los investigadores a orientarse en la forma en que varía la bibliografía y especificar posibles preguntas para futuras síntesis de evidencia cualitativa.

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.

A narrative analysis positioning HIV relative to personal (sexual) relationship challenges in an agony aunt column in the Western Cape, South Africa - Aunty Mona's "love advice".

HIV prevalence and incidence in South Africa remain high, making HIV a part of everyday life. Community narratives on HIV treatment and prevention are important and influence official and unofficial health messaging and community perceptions and understandings of HIV. We explore how contributors and the columnist of an agony aunt column position HIV relative to choices made about love, partnership, and sex over three years. We analysed all columns of an agony aunt series (Antie Mona) published between December 2012 and November 2015. The column is published in a South African, Afrikaans-language newspaper "Son", prioritising sensationalist news items. Trends were identified through narrative analysis. Data were managed in ATLAS.ti and inductive, iterative coding conducted. It was found that letters to the agony aunt rarely refer to HIV directly (less than 7%). Euphemisms such as diseases of the flesh and the great flu were more commonly used instead of HIV or AIDS. Letters addressed HIV in three ways: direct references to experiences living with HIV; direct questions about HIV prevention; and scenarios where HIV could (from a public health perspective) have been the main concern, but everyday issues took precedence. The majority of letters fell into this latter category where the writers focused on the immediate concerns of good sexual relations, problems related to love and romantic relationships, good moral behaviour of others, and issues of oppressive life conditions rather than on HIV directly. The findings illustrate that informal, public contributions to health information, such as agony aunts, are important narratives that inform popular perspectives on HIV and health. A better appreciation of this context would allow health implementers to ensure that these role players receive updated health messaging to avoid the risk of HIV-related stigma where HIV is used as a moral rod to punish perceived moral transgressions.

Hair cortisol as a biomarker of stress and resilience in South African mixed ancestry females.

BACKGROUND: Hair cortisol concentrations (HCC) are increasingly used as a biomarker of stress, however limited research exists regarding the relationship between HCC and protective factors, such as resilience. Additionally, studies measuring HCC need to account for possible confounders, and these factors have not been examined in sufficiently diverse settings. OBJECTIVES: Our objectives were to identify determinants of HCC in a sample of mixed ancestry adults and investigate the association of HCC with measures of self-perceived stress and resilience. METHODS: Our sample comprised 164 females (mean age 46.5 years, SD = 15.0), self-identifying as mixed ancestry, who were control participants in a case-control study (SHARED ROOTS), conducted in Cape Town, South Africa from May 2014 until June 2017. We examined which socio-demographic, hair related, clinical and behavioural factors were associated with HCC in both unadjusted and adjusted linear regression models. Furthermore, the relationship of HCC with self-perceived stress and resilience scores were also examined. RESULTS: HCC (Mdn 4.4 pg/ml; IQR 2.8; 11.4) were significantly positively associated with hair product use and breastfeeding, and significantly negatively associated with age, level of education, duration of sun exposure, duration of storage, and demonstrated a trend towards significance with frequency of hair washing, in adjusted models. HCC were inversely associated with CD-RISC scores (adj ß = -0.179, p =  0.012) but were not significantly associated with PSS scores (adj ß = -0.001, p =  0.989). CONCLUSIONS: We identified specific determinants of HCC in our sample, including the first indication that sun exposure has an effect on HCC under naturalistic conditions. These potential confounders need to be controlled for in the design and analysis of future studies. HCC may be a biomarker of resilience to stress, rather than perceived stress. Further research measuring HCC in more diverse settings and populations and including constructs related to resilience are needed.