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.

Burden of disease and barriers to comprehensive care for rheumatic heart disease in South Africa: an updated systematic review protocol.

INTRODUCTION: Rheumatic heart disease (RHD) is responsible for a significant burden of cardiovascular morbidity and mortality, and remains the most common cause of acquired heart disease among children and young adults in low-income and middle-income countries. Additionally, the global COVID-19 pandemic has forced the emergency restructuring of many health systems, which has had a broad impact on health in general, including cardiovascular disease. Despite significant cost to the health system and estimates from 2015 indicating both high incidence and prevalence of RHD in South Africa, no cohesive national strategy exists. An updated review of national burden of disease estimates, as well as literature on barriers to care for patients with RHD, will provide crucial information to assist in the development of a national RHD programme. METHODS AND ANALYSIS: Using predefined search terms that capture relevant disease processes from Group A Streptococcal (GAS) infection through to the sequelae of RHD, a search of PubMed, Scopus, ISI Web of Science, Sabinet African Journals, SA Heart and Current and Completed Research databases will be performed. All eligible studies on RHD, acute rheumatic fever and GAS infection published from April 2014 to December 2022 will be included. Vital registration data for the same period from Statistics South Africa will also be collected. A standardised data extraction form will be used to capture results for both quantitative and qualitative analyses. All studies included in burden of disease estimates will undergo quality assessment using standardised tools. Updated estimates on mortality and morbidity as well as a synthesis of work on primary, secondary and tertiary prevention of RHD will be reported. ETHICS AND DISSEMINATION: No ethics clearance is required for this study. Findings will be disseminated in a peer-reviewed journal and submitted to national stakeholders in RHD. PROSPERO REGISTRATION NUMBER: CRD42023392782.

Understanding the local and international stakeholders in rheumatic heart disease field in Tanzania and Uganda: A systematic stakeholder mapping.

BACKGROUND: Our study aimed to systematically identify RHD stakeholders and categories of stakeholders to consider when developing a scorecard that reflects a broad stakeholder input. METHOD: We used the Schiller et al.(2013) framework to identify RHD stakeholders and stakeholder categories in Tanzania and Uganda. The process involved identifying stakeholders by searching literature related to incidence, prevalence, morbidity, mortality, health services, or health outcomes of Group A streptococcus, acute rheumatic fever, or rheumatic heart disease in these countries. The strategy was completed for two electronic databases in 2016 and in 2020 to update the results. We also engaged known stakeholders to obtain practice-based insight. We then categorised and visually represented the identified stakeholders. RESULTS: We identified 139 stakeholders in Uganda, with 68% being from 15 different countries across 31 locations. In comparison, local Ugandan stakeholders were dispersed in six locations across the country. In Tanzania, we identified 128 stakeholders, with 66% being locally based and dispersed in seven locations across the country and stakeholders from different countries were situated in 18 countries across 28 locations. We categorised all identified stakeholders into one or more of five categories 1) Civil Society and General Public, 2) Education Sector, 3) Research, Training and Capacity Building, 4) Healthcare service delivery, and 5) Health Policy and Administration. CONCLUSION: The stakeholder categories identified include multiple sectors and stakeholders from multiple countries, this reflects the complexities of RHD. This also highlights the need for collaboration and partnership as a critical action for preventing and controlling RHD.

How do we measure the implementation of the World Health Assembly resolution on rheumatic fever and rheumatic heart disease in African countries? Rationale and design of an evidence-based scorecard.

BACKGROUND: This article aims to explain the rationale and design for developing an evidence-based scorecard to monitor country-level implementation of the 71st World Health Assembly resolution on rheumatic fever and rheumatic heart disease (RHD) in Africa. RATIONALE: A scorecard provides a simple and reliable tool for tracking progress over time and establishing accountability mechanisms. METHODS: Development of the scorecard will incorporate engaging RHD stakeholders identified and categorised at a country level. We will conduct individual interviews to understand the barriers and facilitators to implementing the resolution. The Delphi technique will facilitate structured group discussions to develop appropriate indicators. Indicators will be linked to the resolution's goals to create strategic lines of action, to inform the scorecard. The scorecard will be quantitatively validated in real-life settings. DISCUSSION: We deem that the rigor of the development process of this study will produce an evidence-based scorecard that is fit for purpose across Africa.

A Comprehensive Needs Assessment Tool for Planning RHD Control Programs in Limited Resource Settings.

Rheumatic heart disease (RHD) is an important cause of disability and death in low- and middle-income countries. However, evidence-based interventions have not been implemented systematically in many countries. We present a RHD Needs Assessment Tool (NAT) that can be used at country or regional levels to systematically develop and plan comprehensive RHD control programs and to provide baseline data for program monitoring and evaluation. The RHD NAT follows a mixed-methods approach using quantitative and qualitative data collection instruments. Evidence is mapped to a conceptual model that follows a patient through the natural history of RHD. The NAT has 4 phases: 1) situational assessment; 2) facility-based assessment of epidemiology and health system capacity; 3) patient and provider experience of RHD using ethnographic methods; and 4) intervention planning, including stakeholder mapping and development of a monitoring and evaluation framework. The RHD NAT is designed to paint a comprehensive picture of RHD care in an endemic setting and to identify the major gaps to disseminating and implementing evidence-based interventions.