The role of context in implementation research for non-communicable diseases: Answering the 'how-to' dilemma.

INTRODUCTION: Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process. METHODS: Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level. RESULTS: Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process. CONCLUSIONS: Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.

Risk Factors and Current Health-Seeking Patterns of Migrants in Northeastern Mexico: Healthcare Needs for a Socially Vulnerable Population.

This study identified risk factors for health and access to healthcare services of migrants during their journey across Mexico to the United States. Data were collected in shelters located in Monterrey, the largest city of northeastern Mexico, through a basic clinical examination and a survey completed by 75 migrants; 92% of them were undocumented Central Americans. During their transit, they are at a high risk of contracting, developing, and transmitting diseases. The need of working to survive affects health-seeking behavior and a constant fear of being traced keeps migrants away from public health services, which delays diagnosis and treatment of diseases. Negligent lifestyles, such as smoking, drinking (31.8% of men and 11.1% of women), and drug abuse (13% of men and 11% of women), were found. Regarding tuberculosis (TB), undocumented migrants are usually not screened, even though they come from countries with a high TB burden. Besides, they might be overexposed to TB because of their living conditions in overcrowded places with deficient hygiene, protection, and malnutrition (54.7% of the sample). Possible comorbidities like acquired immune deficiency syndrome (AIDS; 4%) and diabetes (2.7%, but probably under-diagnosed) were referred. Migrants have little TB knowledge, which is independent of their level of education or a previous experience of deportation. About one-third of the migrants were totally unfamiliar with TB-related symptoms, while 36% had correct knowledge of basic TB symptoms. We conclude that a shortage of information on the highly vulnerable migratory population combined with a lack of social support and health education among migrants may play a significant role in the spread of communicable diseases. We recommend that health authorities address this urgent, binational, public health concern in order to prevent outbreaks of emerging infections.