Implementation of non-insulin-dependent diabetes self-management education (DSME) in LMICs: a systematic review of cost, adoption, acceptability, and fidelity in resource-constrained settings.

Background: Type II diabetes (T2D), is a serious health issue accounting for 10.7% of mortality globally. 80% of cases worldwide are found in low- and middle-income countries (LMIC), with rapidly increasing prevalence. Diabetes-self management education (DSME) is a cost-effective program that provides at-risk individuals with the knowledge and skills they need to adopt lifestyle changes that will improve their health and well-being. This systematic review examined the application of DSME in LMICs and identified the corresponding implementation results (cost, fidelity, acceptance, and adoption) associated with successful implementation in low-resource settings. Methods and analysis: The available research on T2D and the use of DSME in LMIC were systematically searched for using six electronic databases (PubMed, Embase, Cochrane, Web of Science, Google Scholar, PAIS, and EBSCO Discovery) between the months of October and November of 2022. The articles that met the search criteria were subsequently imported into EndNote and Covidence for analysis. The Cochrane RoB methodology for randomized trials was used to evaluate the risk of bias (RoB) in the included studies. A narrative synthesis was used to summarize the results. Results: A total of 773 studies were imported for screening, after 203 duplicates were removed, 570 remained. Abstract and title screenings resulted in the exclusion of 487 articles, leaving 83 for full-text review. Following a full-text review, 76 articles were excluded and seven were found to be relevant to our search. The most common reasons for exclusion were study design (n = 23), lack of results (n = 14), and wrong patient population (n = 12). Conclusion: Our systemic review found that DSME can be an acceptable and cost-effective solution in LMIC. While we intended to analyze cost, adoption, acceptability, and fidelity, our investigation revealed a gap in the literature on those areas, with most studies focusing on acceptability and cost and no studies identifying fidelity or adoption. To further evaluate the efficacy of DSME and enhance health outcomes for T2D in LMICs, more research is needed on its application. Systematic Review Registration: osf.io/7482t.

Analysis of the 2007-2018 National Health Interview Survey (NHIS): Examining Neurological Complications among Children with Sickle Cell Disease in the United States.

This study compared neurological complications among a national sample of United States children with or without sickle cell disease (SCD) and evaluated health status, healthcare and special education utilization patterns, barriers to care, and association of SCD status and demographics/socioeconomic status (SES) on comorbidities and healthcare utilization. Data was acquired from the National Health Interview Survey (NHIS) Sample Child Core questionnaire 2007-2018 dataset that included 133,542 children. An affirmation from the guardian of the child determined the presence of SCD. Regression analysis was used to compare the associations between SCD and demographics/SES on neurological conditions at p < 0.05. Furthermore, adjusted odds ratios (AORs) were estimated for having various neurological conditions. Of the 133,481 children included in the NHIS, the mean age was 8.5 years (SD: 0.02) and 215 had SCD. Of the children with SCD, the sample composition included male (n = 110), and Black (n = 82%). The SCD sample had higher odds of having neuro-developmental conditions (p < 0.1). Families of Black children (55% weighted) reported household incomes < 100% of federal poverty level. Black children were more likely to experience longer wait times to see the doctor (AOR, 0.3; CI 0.1-1.1). Compared to children without SCD, those with SCD had a greater chance of seeing a medical specialist within 12 months (AOR 2.3; CI 1.5-3.7). This representative sample of US children with SCD shows higher odds of developing neurological complications, increased healthcare and special education services utilization, with Black children experiencing a disproportionate burden. This creates the urgency to address the health burden for children with SCD by implementing interventions in healthcare and increasing education assistance programs to combat neurocognitive impairments, especially among Black children.

Assessing descriptions of scalability for hypertension control interventions implemented in low-and middle-income countries: A systematic review.

BACKGROUND: The prevalence of hypertension continues to rise in low- and middle-income- countries (LMICs) where scalable, evidence-based interventions (EBIs) that are designed to reduce morbidity and mortality attributed to hypertension have yet to be fully adopted or disseminated. We sought to evaluate evidence from published randomized controlled trials using EBIs for hypertension control implemented in LMICs, and identify the WHO/ExpandNet scale-up components that are relevant for consideration during "scale-up" implementation planning. METHODS: Systematic review of RCTs reporting EBIs for hypertension control implemented in LMICs that stated "scale-up" or a variation of scale-up; using the following data sources PubMed/Medline, Web of Science Biosis Citation Index (BCI), CINAHL, EMBASE, Global Health, Google Scholar, PsycINFO; the grey literature and clinicaltrials.gov from inception through June 2021 without any restrictions on publication date. Two reviewers independently assessed studies for inclusion, conducted data extraction using the WHO/ExpandNet Scale-up components as a guide and assessed the risk of bias using the Cochrane risk-of-bias tool. We provide intervention characteristics for each EBI, BP results, and other relevant scale-up descriptions. MAIN RESULTS: Thirty-one RCTs were identified and reviewed. Studies reported clinically significant differences in BP, with 23 studies reporting statistically significant mean differences in BP (p < .05) following implementation. Only six studies provided descriptions that captured all of the nine WHO/ExpandNet components. Multi-component interventions, including drug therapy and health education, provided the most benefit to participants. The studies were yet to be scaled and we observed limited reporting on translation of the interventions into existing institutional policy (n = 11), cost-effectiveness analyses (n = 2), and sustainability measurements (n = 3). CONCLUSION: This study highlights the limited data on intervention scalability for hypertension control in LMICs and demonstrates the need for better scale-up metrics and processes for this setting. TRIAL REGISTRATION: Registration PROSPERO (CRD42019117750).

Utilization of Pneumococcal Vaccine and Penicillin Prophylaxis in Sickle Cell Disease in Three African Countries: Assessment among Healthcare Providers in SickleInAfrica.

Sickle cell disease is a genetic disease with a predisposition to infections caused by encapsulated organisms, especially Streptococcus pneumoniae. Pneumococcal vaccines and prophylactic penicillin have reduced the rate of this infection and mortality in sickle cell disease. However, implementation of these interventions is limited in Africa. The objectives of the study were to assess health care providers' behaviors with the implementation of pneumococcal vaccination and penicillin prophylaxis and to identify barriers to their use. A 25-item online questionnaire was administered through SickleinAfrica: a network of researchers, and healthcare providers, in Ghana, Nigeria, and Tanzania, working to improve health outcomes of sickle cell disease in Africa. Data was collected and managed using the Research Electronic Data Capture (REDCap), tools and data analysis was done using STATA version 13 and R statistical software. Eighty-two medical practitioners responded to the questionnaire. Only 54.0 and 48.7% of respondents indicated the availability of published guidelines on sickle cell disease management and pneumococcal vaccine use, respectively, at their facilities. The majority (54.0%) perceived that the vaccines are effective but over 20.0% were uncertain of their usefulness. All respondents from Ghana and Tanzania affirmed the availability of guidelines for penicillin prophylaxis in contrast to 44.1% in Nigeria. Eighty-five percent of respondents affirmed the need for penicillin prophylaxis but 15.0% had a contrary opinion for reasons including the rarity of isolation of Streptococcus pneumoniae in African studies, and therefore, the uncertainty of its benefit. Lack of published guidelines on the management of sickle cell disease and doubts about the necessity of prophylactic measures are potential barriers to the implementation of effective interventions.

Proactive prevention: Act now to disrupt the impending non-communicable disease crisis in low-burden populations.

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.

Implementation of the therapeutic use of hydroxyurea for sickle cell disease management in resource-constrained settings: a systematic review of adoption, cost and acceptability.

OBJECTIVES: Mortality associated with sickle cell disease (SCD) is high in many low- and middle-income countries (LMICs). Hydroxyurea, a medicine to effectively manage SCD, is not widely available in resource-constrained settings. We identified and synthesised the reported implementation outcomes for the therapeutic use of hydroxyurea for SCD in these settings. DESIGN: Systematic review. DATA SOURCES: PubMed, Embase, Cochrane, Web of Science Plus, Global Health, CINAHL, and PsycINFO were searched February through May 2019 without any restrictions on publication date. ELIGIBILITY CRITERIA: We included empirical studies of hydroxyurea for management of SCD that were carried out in LMICs and reported on implementation outcomes. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently assessed studies for inclusion, carried out data extraction using Proctor et al.'s implementation and health service outcomes, and assessed the risk of bias using ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions). RESULTS: Two cross-sectional surveys (n=2) and one cohort study (n=1) reported implementation of hydroxyurea for SCD management, namely regarding outcomes of adoption (n=3), cost (n=3) and acceptability (n=1). These studies were conducted exclusively among paediatric and adults populations in clinical settings in Nigeria (n=2) or Jamaica (n=1). Adoption is low, as observed through reported provider practices and patient adherence, in part shaped by misinformation and fear of side effects among patients, provider beliefs regarding affordability and organisational challenges with procuring the medicine. There was no difference in the cost of hydroxyurea therapy compared with blood transfusion in the paediatric population in urban Jamaica. Risk of bias was low or moderate across the included studies. CONCLUSIONS: This review rigorously and systematically assessed the evidence on implementation of hydroxyurea in resource-constrained settings such as LMICs. Findings suggest that knowledge regarding implementation is low. To address the know-do gap and guide clinical practice, implementation research is needed. Integrating effective interventions into existing health systems to improve hydroxyurea uptake is essential to reducing SCD-associated mortality. PROSPERO REGISTRATION NUMBER: CRD42020155953.

Implementation outcomes of policy and programme innovations to prevent obstetric haemorrhage in low- and middle-income countries: a systematic review.

Globally, obstetric haemorrhage (OH) remains the leading cause of maternal mortality. Much of the associated mortality is ascribed to challenges surrounding deployment of innovations rather than lack of availability. In low- and middle-income countries (LMICs), where the burden is highest, there is a growing interest in implementation research as a means to bridge the 'know-do' gap between proven interventions and their reliable implementation at scale. In this systematic review, we identified and synthesized qualitative and quantitative data across the implementation outcomes of OH prevention innovations in LMICs using a taxonomy developed by Proctor et al. We also identified service outcomes for the included innovations, as well as implementation strategies and implementation facilitators and barriers. Eligible studies were empirical, focused on the implementation of OH prevention programmes or policies and occurred in an LMIC. Eight databases were searched. Two authors independently assessed studies for selection and extracted data; the first author resolved discrepancies. Narrative synthesis was used to analyse and interpret the findings. Studies were predominantly focused in Africa and on primary prevention. Interventions included prophylactic use of uterotonics (n = 7), clinical provider skills training (n = 4) and provision of clinical guidelines (n = 1); some (n = 3) were also part of a multi-component quality improvement bundle. Various barriers were reported, including challenges among intervention beneficiaries, providers and within the health system; however, studies reported the development and testing of practical implementation solutions. These included training and monitoring of implementers, community and stakeholder engagement and guidance by external mentors. Some studies linked successful delivery to implementation outcomes, most commonly adoption and acceptability, but also feasibility, penetration and sustainability. Findings suggest that innovations to prevent OH can be acceptable, appropriate and feasible in LMIC settings; however, more research is needed to better evaluate these and other under-reported implementation outcomes.

Addressing gaps in international blood availability and transfusion safety in low- and middle-income countries: a NHLBI workshop.

In April 2017, a workshop sponsored by the National Heart, Lung, and Blood Institute, Division of Blood Diseases and Resources, and the Center for Translation Research and Implementation Science was held to discuss blood availability and transfusion safety in low- and middle-income countries (LMICs). The purpose of the workshop was to identify research opportunities for implementation science (IS) to improve the availability of safe blood and blood components and transfusion practices in LMICs. IS describes the late stages of the translational research spectrum and studies optimal and sustainable strategies to deliver proven-effective interventions. Regional working groups were formed to focus on opportunities and challenges in East Africa, Central/West Africa, Middle East and North Africa, Latin America and the Caribbean, Southeast Asia, Western Pacific Asia, Eastern Europe, and Central Asia. The need for an "adequate supply of safe blood" emerged as the major overriding theme. Among the regional working groups, common cross-cutting themes were evident. The majority of research questions, priorities, and strategies fell into the categories of blood availability, blood transfusion safety, appropriate use of blood, quality systems, health economics and budgeting, and training and education in IS. The workshop also brought into focus inadequate country-level data that can be used as the basis for IS initiatives. A mixed approach of needs assessment and targeted interventions with sufficient evidence base to move toward sustainment is an appropriate next step for blood availability and transfusion safety research in LMICs.

Foreword: Big Data and Its Application in Health Disparities Research.

The articles presented in this special issue advance the conversation by describing the current efforts, findings and concerns related to Big Data and health disparities. They offer important recommendations and perspectives to consider when designing systems that can usefully leverage Big Data to reduce health disparities. We hope that ongoing Big Data efforts can build on these contributions to advance the conversation, address our embedded assumptions, and identify levers for action to reduce health care disparities.

Big Data Science: Opportunities and Challenges to Address Minority Health and Health Disparities in the 21st Century.

Addressing minority health and health disparities has been a missing piece of the puzzle in Big Data science. This article focuses on three priority opportunities that Big Data science may offer to the reduction of health and health care disparities. One opportunity is to incorporate standardized information on demographic and social determinants in electronic health records in order to target ways to improve quality of care for the most disadvantaged populations over time. A second opportunity is to enhance public health surveillance by linking geographical variables and social determinants of health for geographically defined populations to clinical data and health outcomes. Third and most importantly, Big Data science may lead to a better understanding of the etiology of health disparities and understanding of minority health in order to guide intervention development. However, the promise of Big Data needs to be considered in light of significant challenges that threaten to widen health disparities. Care must be taken to incorporate diverse populations to realize the potential benefits. Specific recommendations include investing in data collection on small sample populations, building a diverse workforce pipeline for data science, actively seeking to reduce digital divides, developing novel ways to assure digital data privacy for small populations, and promoting widespread data sharing to benefit under-resourced minority-serving institutions and minority researchers. With deliberate efforts, Big Data presents a dramatic opportunity for reducing health disparities but without active engagement, it risks further widening them.

A Strategic Framework for Utilizing Late-Stage (T4) Translation Research to Address Health Inequities.

Achieving health equity requires that every person has the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances. Inequity experienced by populations of lower socioeconomic status is reflected in differences in health status and mortality rates, as well as in the distribution of disease, disability and illness across these population groups. This article gives an overview of the health inequities literature associated with heart, lung, blood and sleep (HLBS) disorders. We present an ecological framework that provides a theoretical foundation to study late-stage T4 translation research that studies implementation strategies for proven effective interventions to address health inequities.

Reducing Health Inequities in the U.S.: Recommendations From the NHLBI's Health Inequities Think Tank Meeting.

The National, Heart, Lung, and Blood Institute convened a Think Tank meeting to obtain insight and recommendations regarding the objectives and design of the next generation of research aimed at reducing health inequities in the United States. The panel recommended several specific actions, including: 1) embrace broad and inclusive research themes; 2) develop research platforms that optimize the ability to conduct informative and innovative research, and promote systems science approaches; 3) develop networks of collaborators and stakeholders, and launch transformative studies that can serve as benchmarks; 4) optimize the use of new data sources, platforms, and natural experiments; and 5) develop unique transdisciplinary training programs to build research capacity. Confronting health inequities will require engaging multiple disciplines and sectors (including communities), using systems science, and intervening through combinations of individual, family, provider, health system, and community-targeted approaches. Details of the panel's remarks and recommendations are provided in this report.