Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis.

BACKGROUND: Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings. METHODS AND FINDINGS: The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1-4, low-high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007-2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007-2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35-140.18]), the non-JADE group had higher (145.32 [95% CI 138.68-152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12-74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15-1.30) and 0.70 (95% CI 0.66-0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score-matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias. CONCLUSIONS: ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings.

Effects of Work-Related Stressors and Mindfulness on Mental and Physical Health Among Australian Nurses and Healthcare Workers.

PURPOSE: To examine the relative impact of work-related stressors and the personal resource of mindfulness on employees' mental and physical health. DESIGN: A cross-sectional survey design with nursing and healthcare workers in Victoria, Australia. METHODS: Data were collected from 702 respondents. Mean scores for work-related stressors and employee mental and physical health were compared with population norms. We used hierarchical linear regressions to examine the relative impact of demographics, work-related stressors, and mindfulness on employee mental and physical health. FINDINGS: Employees in this sample reported higher levels of work-related stress and poorer mental health compared to available norms, while their levels of physical health were within the normal range. Regression analyses showed that work-related stressors were important predictors of employee mental health, but mindfulness was the stronger predictor. There was a slightly stronger relationship between employee physical health and work-related stress compared to mindfulness. Furthermore, being younger and employed in a non-nursing role were associated with better physical health. CLINICAL RELEVANCE: Encouraging mindfulness as a health behavior practice among nurses and other healthcare workers could improve employee well-being and potentially enable them to more effectively fulfill the requirements of their demanding roles.

Individualized Fracture Risk Feedback and Long-term Benefits After 10 Years.

INTRODUCTION: This study aimed to determine if beneficial effects of individualized feedback of fracture risk on osteoporosis preventive behaviors and bone mineral density observed in a 2-year trial were sustained long-term. METHODS: This was a 10-year follow-up of a 2-year RCT in 470 premenopausal women aged 25-44 years, who were randomized to one of two educational interventions (the Osteoporosis Prevention and Self-Management Course [OPSMC] or an osteoporosis information leaflet) and received tailored feedback of their relative risk of fracture in later life (high versus normal risk groups). Bone mineral density of lumbar spine and femoral neck were measured by dual-energy X-ray absorptiometry. Physical activity, dietary calcium intake, calcium and vitamin D supplements, and smoking status were measured by questionnaires. RESULTS: From 2 to 12 years, the high-risk group had a smaller decrease in femoral neck bone mineral density (ß=0.023, 95% CI=0.005, 0.041 g/cm2) but similar lumbar spine bone mineral density change as the normal-risk group. They were more likely to use calcium (relative risk=1.66, 95% CI=1.22, 2.24) and vitamin D supplements (1.99, 95% CI=1.27, 3.11). The OPSMC had no effects on bone mineral density change. Both high-risk (versus normal-risk) and the OPSMC groups (versus leaflet) had a more favorable pattern of smoking behavior change (relative risk=1.85, 95% CI=0.70, 4.89 and relative risk=2.27, 95% CI=0.86, 6.01 for smoking cessation; relative risk=0.33, 95% CI=0.13, 0.80 and relative risk=0.28, 95% CI=0.10, 0.79 for commenced or persistent smoking). CONCLUSIONS: Feedback of high fracture risk to younger women was associated with long-term improvements in osteoporosis preventive behaviors and attenuated femoral neck bone mineral density loss. Therefore, this could be considered as a strategy to prevent osteoporosis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) NCT00273260.

Prevalence of non-communicable disease risk factors in three sites across Papua New Guinea: a cross-sectional study.

Papua New Guinea (PNG) is a culturally, environmentally and ethnically diverse country of 7.3 million people experiencing rapid economic development and social change. Such development is typically associated with an increase in non-communicable disease (NCD) risk factors. AIM: To establish the prevalence of NCD risk factors in three different regions across PNG in order to guide appropriate prevention and control measures. METHODS: A cross-sectional survey was undertaken with randomly selected adults (15-65 years), stratified by age and sex recruited from the general population of integrated Health and Demographic Surveillance Sites in West Hiri (periurban), Asaro (rural highland) and Karkar Island (rural island), PNG. A modified WHO STEPS risk factor survey was administered along with anthropometric and biochemical measures on study participants. RESULTS: The prevalence of NCD risk factors was markedly different across the three sites. For example, the prevalences of current alcohol consumption at 43% (95% CI 35 to 52), stress at 46% (95% CI 40 to 52), obesity at 22% (95% CI 18 to 28), hypertension at 22% (95% CI 17 to 28), elevated levels of cholesterol at 24% (95% CI 19 to 29) and haemoglobin A1c at 34% (95% CI 29 to 41) were highest in West Hiri relative to the rural areas. However, central obesity at 90% (95% CI 86 to 93) and prehypertension at 55% (95% CI 42 to 62) were most common in Asaro whereas prevalences of smoking, physical inactivity and low high-density lipoprotein-cholesterol levels at 52% (95% CI 45 to 59), 34% (95% CI 26 to 42) and 62% (95% CI 56 to 68), respectively, were highest in Karkar Island. CONCLUSION: Adult residents in the three different communities are at high risk of developing NCDs, especially the West Hiri periurban population. There is an urgent need for appropriate multisectoral preventive interventions and improved health services. Improved monitoring and control of NCD risk factors is also needed in all regions across PNG.

Perceptions of benefit of complementary therapy use among people with diabetes and cardiovascular disease.

BACKGROUND: Little is known about why and how people with type 2 diabetes and cardiovascular disease (CVD) use CAM, or of the perceived benefits of CAM use. The CAMELOT study explored care-seeking, self-management, costs, barriers and benefits of CAM use among this population. We report here on CAM used for treatment of diabetes and CVD, and non-clinical outcomes of CAM use. METHODS: Data were collected in 2009-2010 via in-depth interviews (n = 69) and a self-report questionnaire (n = 2,915) among people with diabetes and/or CVD, throughout an Australian state. Analysis included contingency tables, chi-square analysis and thematic coding of interview and long answer survey data. RESULTS: CAM use was generally part of a multi-component approach to chronic condition management. Choice of CAM practitioners and products varied and included CAM not usually associated with diabetes or CVD treatment, such as massage or manipulative therapies (44%). Most survey respondents perceived that CAM consultations resulted in symptom relief, improved general health and increased knowledge, understanding and confidence in condition management. Few people reported that they experienced any side effects from CAM. Economic barriers were significant in limiting access to CAM. CONCLUSION: More research is required to understand how the appropriate use and perceived benefits of CAM can be reinforced by stronger interaction or integration with mainstream health service delivery for chronic condition management and illness prevention.

Developing an action model for integration of health system response to HIV/AIDS and noncommunicable diseases (NCDs) in developing countries.

INTRODUCTION: Although there are several models of integrated architecture, we still lack models and theories about the integration process of health system responses to HIV/AIDS and NCDs. OBJECTIVE: The overall purpose of this study is to design an action model, a systematic approach, for the integration of health system responses to HIV/AIDS and NCDs in developing countries. METHODS: An iterative and progressive approach of model development using inductive qualitative evidence synthesis techniques was applied. As evidence about integration is spread across different fields, synthesis of evidence from a broad range of disciplines was conducted. RESULTS: An action model of integration having 5 underlying principles, 4 action fields, and a 9-step action cycle is developed. The INTEGRATE model is an acronym of the 9 steps of the integration process: 1) Interrelate the magnitude and distribution of the problems, 2) Navigate the linkage between the problems, 3) Testify individual level co-occurrence of the problems, 4) Examine the similarities and understand the differences between the response functions, 5) Glance over the health system's environment for integration, 6) Repackage and share evidence in a useable form, 7) Ascertain the plan for integration, 8) Translate the plan in to action, 9) Evaluate and Monitor the integration. CONCLUSION: Our model provides a basis for integration of health system responses to HIV/AIDS and NCDs in the context of developing countries. We propose that future empirical work is needed to refine the validity and applicability of the model.

Co-occurrence of diabetes and depression: conceptual considerations for an emerging global health challenge.

BACKGROUND: Considering the relationships between diabetes and depression may enhance programs to reduce their individual and shared disease burden. METHODS: This paper discusses relationships between diabetes and depression, the range of influences on each, conceptual issues central to their definition, and interventions including comprehensive, population approaches to their prevention and management. Foundational and exemplary literature was identified by the writing team according to their areas of expertise. RESULTS: Diabetes and depression influence each other while sharing a broad range of biological, psychological, socioeconomic and cultural determinants. They may be viewed as: (a) distinct but sometimes comorbid entities, (b) dimensions, (c) parts of broader categories, e.g., metabolic/cardiovascular abnormalities or negative emotions, or (d) integrated so that comprehensive treatment of diabetes includes depression or negative emotions, and that of depression routinely considers possible diabetes or other chronic diseases. LIMITATIONS: The choice of literature relied primarily on the authors' knowledge of the issues addressed. Some important perspectives and research may have been overlooked. CONCLUSIONS AND CLINICAL IMPLICATIONS: Collaboration among primary care and specialist clinicians as well as program and public health managers should reflect the commonalities among diabetes, depression, and other chronic mental and physical disorders. Interventions should include integrated clinical care and self-management programs along with population approaches to prevention and management. Self management and problem solving may provide a coherent framework for integrating the diverse tasks and objectives of those living with diabetes and depression or many other varieties of multi-morbidity.

Bone density testing: an under-utilised and under-researched health education tool for osteoporosis prevention?

Feedback of fracture risk based on bone mineral density (BMD) is an under-explored potential osteoporosis education intervention. We performed a randomised controlled trial of either an osteoporosis information leaflet or small group education (the Osteoporosis Prevention and Self-Management Course (OPSMC)), combined with individualised fracture risk feedback in premenopausal women over two years. Women with a mean T-score at spine and hip of <0 were informed they were at higher risk of fracture in later life and those with T-score ≥ 0 were informed they were not. Women receiving feedback of high fracture risk had a greater increase in femoral neck, but not lumbar spine, BMD compared to the low risk group (1.6% p.a. vs. 0.7% p.a., p = 0.0001). Participation in the OPSMC had no greater effect on BMD than receiving the leaflet. Femoral neck BMD change was associated with starting calcium supplements (1.3% p.a., 95% CI +0.49, +2.17) and self-reported physical activity change (0.7% p.a., 95% CI +0.22, +1.22). Mother's report of increasing their children's calcium intake was associated with receiving the OPSMC (OR 2.3, 95% CI 1.4, 3.8) and feedback of high fracture risk (OR 2.0, 95% CI 1.2, 3.3). Fracture risk feedback based on BMD could potentially make an important contribution to osteoporosis prevention but confirmation of long-term benefits and cost effectiveness is needed before implementation can be recommended.

The effect on behavior and bone mineral density of individualized bone mineral density feedback and educational interventions in premenopausal women: a randomized controlled trial [NCT00273260].

BACKGROUND: Limited information is available on ways to influence osteoporosis risk in premenopausal women. This study tested four hypotheses regarding the effects of individualized bone density (BMD) feedback and different educational interventions on osteoporosis preventive behavior and BMD in pre-menopausal women, namely: that women are more likely to change calcium intake and physical activity if their BMD is low; that group education will be more efficacious at changing behavior than an information leaflet; that BMD feedback and group education have independent effects on behavior and BMD; and, that women who improve their physical activity or calcium intake will have a change in bone mass over 2 years that is better than those who do not alter their behavior. METHODS: We performed a 2-year randomized controlled trial of BMD feedback according to T-score and either an osteoporosis information leaflet or small group education in a population-based random sample of 470 healthy women aged 25-44 years (response rate 64%). Main outcome measures were dietary calcium intake, calcium supplement use, smoking behavior, physical activity, endurance fitness, lower limb strength and BMD. We used paired t-tests, one-way ANOVA and linear regression techniques for data analysis. RESULTS: Women who had feedback of low BMD had a greater increase in femoral neck BMD than those with normal BMD (1.6% p.a. vs. 0.7% p.a., p = 0.0001), but there was no difference in lumbar spine BMD change between these groups (0.1% p.a. vs. 0.08% p.a., p = 0.9). Both educational interventions had similar increases in femoral neck BMD (Leaflet = +1.0% p.a., Osteoporosis self-management course = + 1.3% p.a., p = 0.4). Femoral neck BMD change was only significantly associated with starting calcium supplements (1.3 % p.a, 95%CI +0.49, +2.17) and persistent self-reported change in physical activity levels (0.7% p.a., 95%CI +0.22, +1.22). CONCLUSION: Individualized BMD feedback combined with a minimal educational intervention is effective at increasing hip but not spine bone density in premenopausal women. The changes in behavior through which this was mediated are potentially important in the prevention of other diseases, thus measuring BMD at a young age may have substantial public health benefits, particularly if these changes are sustained.

Utilisation of general practitioner services by socio-economic disadvantage and geographic remoteness.

OBJECTIVE: To examine the association between socio-economic status (SES) and GP utilisation across Statistical Local Areas (SLAs) that differed in their geographic remoteness, and to assess whether Indigenous status and GP availability modified the association. DESIGN: Retrospective analysis of Medicare data for all unreferred GP consultations (1996/97) for 952 SLAs comprising the six Australian States. Geographic remoteness was ascertained using the Area Remoteness Index of Australia (ARIA), and SES was measured by grouping SLAs into tertiles based on their Index of Relative Socioeconomic Disadvantage score. MAIN OUTCOME MEASURE: Age/sex standardised rates of GP utilisation for each SLA. MAIN RESULTS: In SLAs classified as 'highly accessible', rates of GP use were 10.8% higher (95% CI 5.7-16.0) in the most socio-economically disadvantaged tertile after adjustment for Indigenous status and GP availability. A very different pattern of GP utilsation was found in 'remote/very remote' SLAs. After adjustment, rates of GP use in the most socio-economically disadvantaged tertile were 25.3% lower (95% CI 5.9-40.7) than in the most advantaged tertile. CONCLUSIONS: People in socio-economically disadvantaged metropolitan SLAs have higher rates of GP utilisation, as would be expected due to their poorer health. This is not true for people living in disadvantaged remote/very remote SLAs: in these areas, those most in need of GP services are least likely to receive them. Australia may lay claim to having a primary health care system that provides universal coverage, but we are still some way from having a system that is economically and geographically accessible to all.