Using a co-design process to develop an integrated model of care for delivering self-management intervention to multi-morbid COPD people in rural Nepal

Developing an integrated depression and tuberculosis care pathway using a co-design approach in a low-resource setting

BACKGROUND

Evidence suggests the use of a participatory approach for the improvement of TB care, however, there is limited evidence on how integrated depression screening and care could be delivered with TB services. Thus, this study co-designed an integrated care pathway for depression case finding and treatment in TB services, that can be delivered by non-mental health specialists within a low resourced settings.

METHODS

We conducted a total of 10 'co-design' workshops with people with TB, carers, tuberculosis and mental health healthcare providers between June and August 2021 in Dhaka, Bangladesh and Peshawar, Pakistan. We adapted the 'Hasso Plattner Institute of Design at Stanford University' for our codesign process. Information gathered during the workshop, through recordings and contemporaneous notes taking, was collated, and analysed to develop the integrated care pathways and materials for impmenting the carepathway.

RESULTS

We co-designed and developed a culturally adaptable care pathway that integrates depression screening into tuberculosis (TB) care, working closely with people affected by TB and healthcare workers in primary, secondary, and tertiary care settings in Bangladesh and Pakistan. We used PHQ-9 only to identify and screen for depression among people with TB in Bangladesh, whereas both PHQ-2 and PHQ-9 were used for depression screening among the Pakistani population. A trained paramedic or laboratory technologist (Bangladesh) and DOTS Facilitator (Pakistan), working within the TB facilities were identified and agreed to deliver the integrated depression screening services.

CONCLUSION

Stakeholders valued the opportunity to jointly design a care pathway. Iterative and coordinated working with these stakeholders enabled the researchers to understand better, explore and refine the co-design process. This approach assisted in mobilising knowledge about depression and integrating screening for depression within the existing usual TB care pathway, using the lived experience of people with TB and health workers' expertise.

'Community people are the most powerful resources': qualitative critical realist analysis and framework to support co-produced responses to zoonotic disease threats with(in) Nepali communities

BACKGROUND

Co-production between researchers, service providers, and members of affected communities is an old concept renewed by current efforts to decolonise global health, reduce exploitative practices, and develop more sustainable, context-relevant interventions to address global health issues. Working with communities- how ever defined- is central to healthcare improvement but engaging with communities and identifying priorities remains challenging for disease control professionals. Co-production aims to help ensure community members have some control over the design and implementation of any intervention, and greater ownership of processes and outcomes. We aimed to identify what would encourage co-production of activities to prevent potential transmission of zoonoses.

METHODS

In this qualitative study, we (British and Nepali researchers) interviewed 73 participants from six communities across Nepal, with 10 participating in photovoice. We also interviewed 20 healthcare professionals and policymakers, 14 representing human and six representing animal health. We interpreted data using reflexive thematic analysis.

RESULTS

Thirty-nine people in six communities participated in interviews, with another 34 in 5 focus groups. We generated three overarching themes: (i) constrained healthcare-seeking behaviours, (ii) experience of community programmes, and (iii) community priorities and co-production. Community participants, despite strong opinions and desire to participate in disease control interventions, had experienced little or no attempt by intervention organisers to engage them in design, implementation, evaluation, or accountability. Most had no experience of programmes at all. Participants highlighted the significance of working in 'local' languages, respecting religious and cultural realities, relating initiatives to lived experience, and ensuring that local leaders are involved.

CONCLUSIONS

Meaningful co-production requires recognising communities- through legitimate leadership/representation- as expert and equal partners who can 'work alongside' at all stages of any initiative. Implications from this research include the importance of promoting trust in communities through inclusion of influential community members (community health volunteers, traditional medicine practitioners, women's group leaders); the use of indigenous languages; the acceptability of different media for interventions (theatre, drama); and the need to be pragmatic about available resources, to manage the expectations of community members.

Development of a User-Centred Chronic Care Model for Patients With Heart Failure in a Limited-Resource Setting: A Codesign Study

BACKGROUND

Health service leaders in Thailand face substantial challenges in addressing the needs of a growing population of patients with moderate to severe Chronic Heart Failure (CHF) who require acute care management and ongoing supportive care in the community. The large number of CHF patients requiring readmission for high-level care places a significant burden on healthcare services.

METHODS

The design thinking model proposed by the Hasso-Plattner Institute of Design at Stanford University underpinned an approach to developing a co-designed, tailored, culturally acceptable model of chronic care for people with CHF. One consumer, 16 clinicians, and two organisational leaders participated in a codesign workshop that included three activities. The purpose of each activity was to (i) define the problem, (ii) brainstorm possible solutions and (iii) develop a prototype solution. The codesign workshop was one phase of a four-phase codesign project. Data collected included physical data such as sticky notes and storyboards and audio recordings of codesign group discussions. Data were analyses using content analysis.

RESULTS

Nine prototype storyboards aimed at enhancing continuity of care for CHF patients emerged from the workshop activities. The proposed solutions focused on improving consumer access to evidence-based information, multidisciplinary expertise and ongoing community support. Participants discussed and evaluated the viability and feasibility of each prototype before reaching a final decision on an optimal model. The preferred model was a nurse-led case management service supported by a multidisciplinary team.

CONCLUSION

Key stakeholders identified the importance of moving from a short-term model of care to an integrated, multidisciplinary approach to providing long-term support in the community. The final agreed prototype of a CHF Nurse Case Management service supported by a multidisciplinary team with a focus on community outreach addressed the key concerns of participants and was considered a feasible approach to developing a CHF chronic care service for the community in urban Bangkok, Thailand.

PATIENT OR PUBLIC CONTRIBUTION

The process of codesign involved the engagement and participation of individuals with CHF, clinicians and organisational leaders throughout the research process.

What mechanisms lead to the endurance of health and social care integration? A multiple case study in Italy

BACKGROUND

The rising complexity of the population's needs has made health and social care integration a priority for the future. Despite the presence of supporting policies and funding, the number of successful experiences that endure over time is limited.

OBJECTIVE

This work aims to investigate how health and social care integration occur and identify factors facilitating its endurance.

METHODS

We conducted a multiple case study on four long-lasting health and social care integration cases in Italy, where a new policy for enhancing integration was introduced. 20 senior managers employed in the four cases were interviewed and 33 official documents and websites were collected. The interviews' transcripts and documents were coded using an abductive approach.

RESULTS

The modalities of health and social care integration can vary according to the level of integration, type of network governance, and level of customization. There is no one predominant solution as the modalities depend on the specific context. To support policy-makers and health and social care providers in designing and implementing a sustainable health and social care integration in their contexts, this study provides six possible macro factors that clarify the priorities for integration.

CONCLUSIONS

This paper clarifies the modalities of integration and provides macro factors for enduring health and social care integration over time, providing avenues for future supporting policies.

Enablers and barriers of community health programs for improved equity and universal coverage of primary health care services: A scoping review

BACKGROUND

Community health programs (CHPs) are integral components of primary health care (PHC) systems and support the delivery of primary care and allied health and nursing care services. CHPs are necessary platforms for delivering health services toward universal health coverage (UHC). There are limited prior studies on comprehensive evidence synthesis on how CHPs strengthen community health systems for the demand and supply of PHC services. Therefore, this scoping review synthesized existing evidence on the interlinkage between CHPs and the community health system and beyond for delivering and utilising PHC services toward UHC.

METHODS

We conducted a scoping review of research articles on CHPs. We identified research articles in six databases (PubMed/Medline, CINAHL, Scopus, Cochrane, Web of Science, and Embase) and Google Scholar using search terms under three concepts: CHPs, PHC, and UHC. Of the 3836 records identified, 1407 duplicates were removed, and 2346 were removed based on titles and abstracts. A total of 83 articles were eligible for the full-text review; of them, 18 articles were removed with reasons, and the other 16 were included through hand search. Themes were identified and explained using Sacks and colleagues' "Beyond the Building Block" framework.

RESULTS

A total of 81 studies were included in the final review. Studies described CHPs as foundations for community health system readiness for PHC services, including decentralization in the health sector, community-controlled governance, resource mobilization, ensuring health commodities (e.g., through community pharmacies), and information evidence. These foundational inputs mediate the actions of CHPs by partnership with community organizations and health workforces (e.g., community health workers). CHPs contributed to improved access to health services by providing health services in public health emergencies, affordable and comprehensive care, and modifying social determinants of health.

CONCLUSIONS

CHPs are platforms for implementing and delivering PHC services close to communities. They help to modify social determinants of health, promote health and wellbeing, reduce care costs, prevent disease progression, and reduce hospitalisation rates. CHPs are integral parts of community health systems and require investment to improve access to PHC services. Gaps and challenges of CHPs include inadequate funding, limited engagement of the private sector, poor quality of health services, and limited focus on non-communicable diseases (NCDs). Further implementation research is needed to mitigate the burden of NCDs. Health systems efforts focus on increasing resources (e.g., financial and human) required in CHPs to ensure the quality of PHC services provided through CHPs toward better service access, and reaching the unreached and achieve equity and universality of PHC services.

Care pathways versus usual care for chronic obstructive pulmonary disease (COPD)

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of care pathways (CPs) compared to usual care/no CPs for people with chronic obstructive pulmonary disease (COPD).

Using policy codesign to achieve multi-sector alignment in adolescent behavioral health: a study protocol

BACKGROUND

Policymaking is quickly gaining focus in the field of implementation science as a potential opportunity for aligning cross-sector systems and introducing incentives to promote population health, including substance use disorders (SUD) and their prevention in adolescents. Policymakers are seen as holding the necessary levers for realigning service infrastructure to more rapidly and effectively address adolescent behavioral health across the continuum of need (prevention through crisis care, mental health, and SUD) and in multiple locations (schools, primary care, community settings). The difficulty of aligning policy intent, policy design, and successful policy implementation is a well-known challenge in the broader public policy and public administration literature that also affects local behavioral health policymaking. This study will examine a blended approach of coproduction and codesign (i.e., Policy Codesign), iteratively developed over multiple years to address problems in policy formation that often lead to poor implementation outcomes. The current study evaluates this scalable approach using reproducible measures to grow the knowledge base in this field of study.

METHODS

This is a single-arm, longitudinal, staggered implementation study to examine the acceptability and short-term impacts of Policy Codesign in resolving critical challenges in behavioral health policy formation. The aims are to (1) examine the acceptability, feasibility, and reach of Policy Codesign within two geographically distinct counties in Washington state, USA; (2) examine the impact of Policy Codesign on multisector policy development within these counties using social network analysis; and (3) assess the perceived replicability of Policy Codesign among leaders and other staff of policy-oriented state behavioral health intermediary organizations across the USA.

DISCUSSION

This study will assess the feasibility of a specific approach to collaborative policy development, Policy Codesign, in two diverse regions. Results will inform a subsequent multi-state study measuring the impact and effectiveness of this approach for achieving multi-sector and evidence informed policy development in adolescent SUD prevention and treatment.

Preferences and perspectives regarding telehealth exercise interventions for adults with cystic fibrosis: A qualitative study

OBJECTIVE

Physical activity and exercise are key components in the management of cystic fibrosis (CF). Completing exercise programs online may minimize the risk of cross-infection and increase access for people with CF. This study aimed to understand the perspectives of people with CF regarding intervention content for a telehealth exercise program.

METHODS

Individual semistructured qualitative interviews were conducted in adults with CF purposefully sampled for age, disease severity, and social demographics. Interviews were recorded, transcribed verbatim, and analyzed thematically by two researchers independently.

RESULTS

Participants were 23 adults with CF (14 females) aged from 21 to 60 years. Three major themes (subthemes) were generated: "Personalizing components to an exercise program" (customizing an exercise program to the individual person and their unique health and exercise needs, enjoyment and variety of exercise activities, accessibility and exercise fitting around competing demands or commitments), "The importance of maintaining connections" (challenges regarding face-to-face interactions for people with CF, accountability of scheduled exercise sessions with others, shared experiences between people with CF and specialist support from the CF care team), and "Monitoring health and exercise" (perception of health status and monitoring and recording exercise participation and health).

CONCLUSION

This study provides important information regarding the preferences of adults with CF for telehealth exercise interventions. Interventions should be tailored to the individual person with CF, include an opportunity to maintain connections with peers and the CF multidisciplinary team, and provide a method to monitor progress over time.

Readiness of primary care centres for a community-based intervention to prevent and control noncommunicable diseases in the Caribbean: A participatory, mixed-methods study

INTRODUCTION

Epidemiological transition to NCDs is a challenge for fragile health systems in the Caribbean. The Congregations Taking Action against NCDs (CONTACT) Study intervention proposes that trained health advocates (HAs) from places of worship (PoWs), supervised by nurses at nearby primary healthcare centres (PHCs), could facilitate access to primary care among vulnerable communities. Drawing on participatory and systems thinking, we explored the capacity of local PHCs in three Caribbean countries to support this intervention.

METHODS

Communities in Jamaica (rural, urban), Guyana (rural) and Dominica (Indigenous Kalinago Territory) were selected for CONTACT because of their differing socio-economic, cultural, religious and health system contexts. Through mixed-method concept mapping, we co-developed a list of perceived actionable priorities (possible intervention points ranked highly for feasibility and importance) with 48 policy actors, healthcare practitioners and civic society representatives. Guided in part by the concept mapping findings, we assessed the readiness of 12 purposefully selected PHCs for the intervention, using a staff questionnaire and an observation checklist to identify enablers and constrainers.

RESULTS

Concept mapping illustrated stakeholder optimism for the intervention, but revealed perceptions of inadequate primary healthcare service capacity, resources and staff training to support implementation. Readiness assessments of PHCs identified potential enablers and constrainers that were consistent with concept mapping results. Staff support was evident. Constraints included under-staffing, which could hinder supervision of HAs; and inadequate essential NCD medicines, training in NCDs and financial and policy support for embedding community interventions. Despite a history of socio-political disadvantage, the most enabling context was found in the Kalinago Territory, where ongoing community engagement activities could support joint development of programmes between churches and PHCs.

CONCLUSION

Multi-sectoral stakeholder consultation and direct PHC assessments revealed viability of the proposed POW-PHC partnership for NCD prevention and control. However, structural and policy support will be key for implementing change.

Collaborative design of a health research training programme for nurses and midwives in Tshwane district, South Africa: a study protocol

INTRODUCTION

Nurses are essential for implementing evidence-based practices to improve patient outcomes. Unfortunately, nurses lack knowledge about research and do not always understand research terminology. This study aims to develop an in-service training programme for health research for nurses and midwives in the Tshwane district of South Africa.

METHODS AND ANALYSIS

This protocol outlines a codesign study guided by the five stages of design thinking proposed by the Hasso-Plattner Institute of Design at Stanford University. The participants will include nurses and midwives at two hospitals in the Tshwane district, Gauteng Province. The five stages will be implemented in three phases: Phase 1: Stage 1-empathise and Stage 2-define. Exploratory sequential mixed methods including focus group discussions with nurses and midwives (n=40), face-to-face interviews (n=6), and surveys (n=330), will be used in this phase. Phase 2: Stage 3-ideate and Stage 4-prototype. A team of research experts (n=5), nurses and midwives (n=20) will develop the training programme based on the identified learning needs. Phase 3: Stage 5-test. The programme will be delivered to clinical nurses and midwives (n=41). The training programme will be evaluated through pretraining and post-training surveys and face-to-face interviews (n=4) following training. SPSS V.29 will be used for quantitative analysis, and content analysis will be used to analyse qualitative data.

ETHICS AND DISSEMINATION

The protocol was approved by the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria (reference number 123/2023). The protocol is also registered with the National Health Research Database in South Africa (reference number GP_202305_032). The study findings will be disseminated through conference presentations and publications in peer-reviewed journals.

A rapid review of opportunities and challenges in the implementation of social prescription interventions for addressing the unmet needs of individuals living with long-term chronic conditions

BACKGROUND

People with long-term chronic conditions often struggle to access and navigate complex health and social services. Social prescription (SP) interventions, a patient-centred approach, help individuals identify their holistic needs and increase access to non-clinical resources, thus leading to improved health and well-being. This review explores existing SP interventions for people with long-term chronic conditions and identifies the opportunities and challenges of implementing them in primary healthcare settings.

METHODS

This rapid review followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and searched relevant articles in three databases (PubMed/MEDLINE, EMBASE, and Web of Science) by using subject headings and keywords combined with Boolean operators. The search encompassed articles published between January 2010 and June 2023. Two authors independently conducted study screening and data abstraction using predefined criteria. A descriptive synthesis process using content analysis was performed to summarise the literature.

RESULTS

Fifteen studies were included, with all but one conducted in the United Kingdom, and revealed that social prescribers help guide patients with long-term chronic conditions to various local initiatives related to health and social needs. Effective implementation of SP interventions relies on building strong relationships between social prescribers and patients, characterised by trust, empathy, and effective communication. A holistic approach to addressing the unmet needs of people with long-term chronic conditions, digital technology utilisation, competent social prescribers, collaborative healthcare partnerships, clinical leadership, and access to local resources are all vital components of successful SP intervention. However, the implementation of SP interventions faces numerous challenges, including accessibility and utilisation barriers, communication gaps, staffing issues, an unsupportive work environment, inadequate training, lack of awareness, time management struggles, coordination and collaboration difficulties, and resource constraints.

CONCLUSION

The present review emphasises the importance of addressing the holistic needs of people with long-term chronic conditions through collaboration and coordination, training of social prescribers, community connections, availability of local resources, and primary care leadership to ensure successful interventions, ultimately leading to improved patient health and well-being outcomes. This study calls for the need to develop or utilise appropriate tools that can capture people's holistic needs, as well as an implementation framework to guide future contextual SP interventions.

Transforming Integrated Care Through Co-production: A Systematic Review Using Meta-ethnography

Introduction

There is a requirement for health and care systems and services to work on an equitable basis with people who use and provide integrated care. In response, co-production has become essential in the design and transformation of services. Globally, an array of approaches have been implemented to achieve this. This unique review explores multi-context and multi-method examples of co-production in integrated care using an exceptional combination of methods.

Aim

To review and synthesise evidence that examines how co-production with service users, unpaid carers and members of staff can affect the design and transformation of integrated care services.

Methods

Systematic review using meta-ethnography with input from a patient and public involvement (PPI) co-production advisory group. Meta-ethnography can generate theories by interpreting patterns between studies set in different contexts. Nine academic and four grey literature databases were searched for publications between 2012-2022. Data were extracted, analysed, translated and interpreted using the seven phases of meta-ethnography and PPI.

Findings

A total of 2,097 studies were identified. 10 met the inclusion criteria. Studies demonstrated a variety of integrated care provisions for diverse populations. Co-production was most successful through person-centred design, innovative planning, and collaboration. Key impacts on service transformation were structural changes, accessibility, and acceptability of service delivery. The methods applied organically drew out new interpretations, namely a novel cyclic framework for application within integrated care.

Conclusion

Effective co-production requires a process with a well-defined focus. Implementing co-delivery, with peer support, facilitates service user involvement to be embedded at a higher level on the 'ladder of co-production'. An additional step on the ladder is proposed; a cyclic co-delivery framework. This innovative and operational development has potential to enable better-sustained person-centred integrated care services.

Understanding barriers to participation in group chronic disease self-management (CDSM) programs: A scoping review

OBJECTIVE

To identify factors that influence enrollment in and attendance of chronic disease self-management (CDSM) group programs.

METHODS

A scoping review of peer-reviewed publications that reported on factors of enrollment or attendance in group CDSM programs for adults with any type of chronic condition. Screening was completed by two reviewers and data extraction was checked for accuracy. Data were summarized and key themes were identified in collaboration with the study team.

RESULTS

Following screening, 52 of 2774 articles were included. Attendance rates that varied from 10.4-98.5% (mean =72.5%). There is considerable overlap between enrollment and attendance factors. These included Competing Commitments, Logistics, Personal characteristics, Perception of illness/health status, Health service provision, and Group dynamics.

CONCLUSIONS

Varied and individualized factors can facilitate or impede enrollment or attendance in group CDSM programs. Consideration of these factors and tailoring of programs is needed to facilitate patient ability to take part. Participatory co-design is a growing approach to ensure programs meet individual and community needs. More research is needed to identify the specific impact of using codesign on enrollment and attendance in group CDSM programs.

PRACTICE IMPLICATIONS

Including community members and service users in design and implementation may enhance CDSM program access.

How a co-design process led to more contextually relevant family planning interventions in emerging urban settings in Eastern Uganda

Voluntary, rights-based family planning upholds women's right to determine freely the number and spacing of their children. However, low-resource settings like Uganda still face a high unmet need for family planning. And, while urban areas are often indicated to have better access to health services, emerging evidence is revealing intra-urban socio-economic differentials in family planning utilization. To address the barriers to contraceptive use in these settings, understanding community-specific challenges and involving them in tailored intervention design is crucial. This paper describes the use of co-design, a human-centred design tool, to develop context-specific interventions that promote voluntary family planning in urban settings in Eastern Uganda. A five-stage co-design approach was used: 1) Empathize: primary data was collected to understand the problem and people involved, 2) Define: findings were shared with 56 participants in a three-day in-person co-design workshop, including community members, family planning service providers and leaders, 3) Ideate: workshop participants generated potential solutions, 4) Prototype: participants prioritized prototypes, and 5) Testing: user feedback was sought about the prototypes. A package of ten interventions was developed. Five interventions targeted demand-side barriers to family planning uptake, four targeted supply-side barriers, and one addressed leadership and governance barriers. Involving a diverse group of co-creators provided varied experiences and expertise to develop the interventions. Participants expressed satisfaction with their involvement in finding solutions to challenges in their communities. However, power imbalances and language barriers were identified by the participants as potential barriers to positive group dynamics and discussion quality. To address them, participants were separated into groups, and medical terminologies were simplified during brainstorming sessions. These changes improved participation and maximized the contributions of all participants. It is therefore important to consider participant characteristics and their potential impact on the process, especially when engaging diverse participant groups, and implement measures to mitigate their effects.

Community centred co-design methodology for designing and implementing socio-behavioural interventions to counter COVID-19 related misinformation among marginalized population living in the squatter settlements of Karachi, Pakistan: a methodology paper

BACKGROUND

Misinformation regarding COVID-19 pandemic and vaccination is damaging COVID-19 vaccine trust and acceptance in Low- and Middle-Income Countries (LMIC). Identification of misinformation and designing locally acceptable solutions are needed to improve COVID-19 vaccine acceptance. This study aimed to utilize community-led co-design methodology to evaluate misinformation regarding COVID-19 and develop contextual interventions to address misinformation in a marginalized peri urban slum communities of Landhi town Karachi, Pakistan.

METHODS

This study was conducted between January and December 2021, in marginalized peri-urban slum dwellers of Muslimabad Colony, Landhi Town Karachi, Pakistan. We used a community-centred co-design methodology embedded within mixed study design to identify misinformation, co-design, test and implement locally acceptable solutions. The co-design methodology involved five stages of the design thinking model: (1) Empathize, (2) Define, (3) Ideate, (4) Prototype, and (5) Test. The project involved active engagement and participation of wide range of stakeholders and community beneficiaries (end users) including local EPI vaccinators, informal healthcare workers, religious leaders (male and female), schoolteachers (male and female), local government representatives, community leaders, housewives, youth, and general population. To develop a trusting relationship, and understand local culture, values, practices, and traditions, we allowed one month of observation period (observe, engage, watch, and listen) in the beginning, followed by door-to-door survey along with focus group discussions (FGD) and in-depth interviews (IDI) at baseline. Co-design workshops (separate for male and female) were conducted at each stage of co-design methodology to design and test locally acceptable solutions.

CONCLUSION

Community-centred co-design methodology was not only successful in designing, testing, and evaluating locally acceptable solutions but it also actively engaged and empowered the marginalized population living in peri urban slum communities of Karachi, Pakistan.

Potentials and challenges of using co-design in health services research in low- and middle-income countries

Co-design with people having poor access to health services and fragile health systems in low- and middle-income countries can be momentous in bringing service users and other stakeholders together to improve the delivery and utilisation of health services. There is ample of evidence from high-income countries regarding how co-design can translate available evidence into developing acceptable, feasible, and adaptable health solutions in different settings. However, there is limited literature on co-design in health research in the context of low- and middle-income countries. Therefore, it is crucial to understand how knowledge about collaborative working can be translated into policy and practice in the context of low- and middle-income countries. Thus, this paper discusses the concept of co-design, co-production, and co-creation in health and the potentiality and challenges of using co-design in health services research in low- and middle-income countries. Despite the challenges, the co-design research has considerable potential to encourage the meaningful engagement of service users and other stakeholders in developing, implementing, and evaluating real-world solutions in low- and middle-income countries. It is essential to balance power dynamics in a co-design process through mutual recognition and respect, participant diversity, and reciprocity and flexibility in sharing. The inclusive and collaborative approach to working is complex due to existing rigid hierarchical structures, socio-cultural beliefs, political interference and working practices. However, this could be minimised by developing transparent terms of reference that reflect the value and benefits of equal partnership in particular co-design work.

Engaging Ethnically Diverse Populations in Self-Management Interventions for Chronic Respiratory Diseases: A Narrative Review

The burden of chronic respiratory diseases continues to rise globally. Comprehensive management relies on a combination of treatment approaches including patient self-management, where health professionals are required to educate and support patients to take control of their disease. When self-management interventions are suitably directed and effectively executed, outcomes point to increases in quality of life and a reduction in unscheduled or emergency consultations for people living with chronic respiratory disease. However, despite these positive gains, the literature reveals poor trends of engagement with this management approach and reduced access to appropriately designed programs for people from ethnically diverse populations, including migrants and refugees. The purpose of this review article is to discuss factors influencing engagement in chronic respiratory disease self-management among people from ethnically diverse backgrounds and to propose strategies to improve the participation of this population in these interventions in the future.

Learning from a codesign exercise aimed at developing a navigation intervention in the general practice setting

OBJECTIVES

In this study, we aimed to describe and evaluate the codesign of an intervention in general practice setting to help address navigation problems faced by the patients from the culturally and linguistically diverse (CALD) community in Australia.

METHODS

An experience-based codesign (EBCD) methodology was adopted using the Double Diamond design process. Two codesign workshops were conducted online with 13 participants including patients, their caregivers, health service providers, researchers, and other stakeholders. Workshops were audio-recorded, transcribed, and thematically analyzed.

RESULTS

The codesign participants identified several navigation problems among CALD patients such as inadequate health literacy, cultural and language barriers, and difficulties with navigating health and social services. They believed that bilingual community navigators (BCNs; lay health workers from the same language or cultural background) could help them address these problems. However, this depended on BCNs being trained and supervised, with a clear role definition and manageable workloads, and not used as an interpreter. In undertaking the codesign process, we found that pre-workshop consultations were useful to ensure engagement, especially for consumers who participated more actively in group activities with service providers after these and their own separate small group discussions during the workshop.

CONCLUSION

Overall, participants identified that BCNs could offer help in addressing the problems faced by the CALD patients in accessing care in general practice setting. The codesign process provided new insights into the navigation problems faced by CALD patients in accessing care and collaboratively developed a strategy for further testing and evaluation.

How to co-design a health literacy-informed intervention based on a needs assessment study in chronic obstructive pulmonary disease

OBJECTIVE

To develop a co-designed health literacy (HL)-informed intervention for people with chronic obstructive pulmonary disease (COPD) that enables them to find, understand, remember, use and communicate the health information needed to promote and maintain good health.

DESIGN

This study used a co-design approach informed by the programme logic of the Ophelia (Optimising Health Literacy and Access) process. The co-design included workshops where possible solutions for an HL-informed intervention were discussed based on an HL needs assessment study.

SETTINGS

Five workshops were performed in a local community setting in the specialist and municipality healthcare services in Oslo, Norway.

PARTICIPANTS

People with COPD, multidisciplinary healthcare professionals (HCPs) from the municipality and specialist healthcare services, and researchers (n=19) participated in the workshops. The co-designed HL-informed intervention was based on seven focus groups with people with COPD (n=14) and HCPs (n=21), and a cross-sectional study of people with COPD using the Health Literacy Questionnaire (n=69).

RESULTS

The workshop co-design process identified 45 action points and 51 description points for possible intervention solutions to meet the HL needs of people with COPD. The final recommendation for an HL-informed intervention focused on tailored follow-up after hospitalisation, which uses motivational interviewing techniques, is based on the individual's HL, self-management and quality of life needs and is implemented in cooperation with HCPs in both the specialist and municipality healthcare services.

CONCLUSION

During the codesign process, the workshop group generated several ideas for how to help patients find, understand, remember, use and communicate health information in order to promote and maintain good health. People with COPD need tailored follow-up based on their individual HL needs by HCPs that have knowledge of COPD and are able to motivate them for self-management tasks and help them to improve their quality of life (QOL) and decrease hospitalisation.

Using a Taxonomy to Systematically Identify and Describe Self-Management Interventions Components in Randomized Trials for COPD

Self-management interventions (SMIs) may improve outcomes in Chronic Obstructive Pulmonary Disease (COPD). However, accurate comparisons of their relative effectiveness are challenging, partly due to a lack of clarity and detail regarding the intervention content being evaluated. This study systematically describes intervention components and characteristics in randomized controlled trials (RCTs) related to COPD self-management using the COMPAR-EU taxonomy as a framework, identifying components that are insufficiently incorporated into the design of the intervention or insufficiently reported. Overall, 235 RCTs published between 2010 and 2018, from a systematic review were coded using the taxonomy, which includes 132 components across four domains: intervention characteristics, expected patient (or caregiver) self-management behaviours, patient relevant outcomes, and target population characteristics. Risk of bias was also assessed. Interventions mainly focused on physical activity (67.4%), and condition-specific behaviours like breathing exercise (63.5%), self-monitoring (50.8%), and medication use (33.9%). Support techniques like education and skills-training, self-monitoring, and goal setting (over 35% of the RCTs) were mostly used for this. Emotional-based techniques, problem-solving, and shared decision-making were less frequently reported (less than 15% of the studies). Numerous SMIs components were insufficiently incorporated into the design of COPD SMIs or insufficiently reported. Characteristics like mode of delivery, intensity, location, and providers involved were often not described. Only 8% of the interventions were tailored to the target population's characteristics. Outcomes that are considered important by patients were hardly taken into account. There is still a lot to improve in both the design and description of SMIs for COPD. Using a framework such as the COMPAR-EU SMI taxonomy may contribute to better reporting and to better informing of replication efforts. In addition, prospective use of the taxonomy for developing and reporting intervention content would further aid in building a cumulative science of effective SMIs in COPD.

Preventing Drift through Continued Co-Design with a First Nations Community: Refining the Prototype of a Tiered FASD Assessment

As part of the broader Yapatjarrathati project, 47 remote health providers and community members attended a two-day workshop presenting a prototype of a culturally-safe, tiered neurodevelopmental assessment that can identify fetal alcohol spectrum disorder (FASD) in primary healthcare. The workshop provided a forum for broad community feedback on the tiered assessment process, which was initially co-designed with a smaller number of key First Nations community stakeholders. Improvement in self-reported attendee knowledge, confidence, and perceived competence in the neurodevelopmental assessment process was found post-workshop, assessed through self-report questionnaires. Narrative analysis described attendee experiences and learnings (extracted from the workshop transcript), and workshop facilitator experiences and learnings (extracted from self-reflections). Narrative analysis of the workshop transcript highlighted a collective sense of compassion for those who use alcohol to cope with intergenerational trauma, but exhaustion at the cyclical nature of FASD. There was a strong desire for a shared responsibility for First Nations children and families and a more prominent role for Aboriginal Health Workers in the assessment process. Narrative analysis from workshop facilitator reflections highlighted learnings about community expertise, the inadvertent application of dominant cultural approaches throughout facilitation, and that greater emphasis on the First Nation's worldview and connection to the community was important for the assessment process to be maintained long-term. This study emphasised the benefit of continued co-design to ensure health implementation strategies match the needs of the community.

Analyzing the Implementation of Policies and Guidelines for the Prevention and Management of Type 2 Diabetes at Primary Health Care Level in Nepal

Background

Nepal, in recent years, is witnessing an increasing problem of type 2 diabetes that has resulted significant premature deaths and disability. Prevention and management of non-communicable diseases (NCDs) including diabetes have been prioritized in the national policies and guidelines of the Nepal Government. However, research looking at the overview of the implementation of the existing policies and guidelines for diabetes prevention and control is scarce. Hence, this study reviewed diabetes related existing policies and its implementation process at the primary health care level in Nepal.

Methods

This study involved two phases: Phase I: situation analyses through review of documents and Phase II: qualitative exploratory study. In phase I, four databases (Medline, Web of Science, Embase and PubMed) were systematically searched using key search terms related to diabetes care and policies between January 2000 and June 2021. Also, relevant gray literature was reviewed to understand the trajectory of policy development and its translation with regards to diabetes prevention and management at primary health care level in Nepal. Following the phase I, we conducted in-depth interviews (IDI) and key informant interviews (KII) with health care providers, policy makers, and managers (IDI = 13, and KII = 7) at peripheral and central levels in Kavrepalanchowk and Nuwakot districts of Nepal. The in-depth interviews were audio recorded, transcribed, and coded. The triangulation of data from document review and interviews was done and presented in themes.

Results

Four key themes were identified through triangulating findings from the document review and interviews including (i) limited implementation of policies into practices; (ii) lack of coordination among the different levels of service providers; (iii) lack of trained human resources for health and inadequate quality services at the primary health care level, and (iv) inadequate access and utilization of diabetes care services at primary health care level. Specifically, this study identified some key pertinent challenges to the implementation of policies and programs including inadequate resources, limited engagement of stakeholders in service design and delivery, lack of trained health care providers, lack of financial resources to strengthen peripheral health services, fragmented health governance, and weak reporting and monitoring systems.

Conclusion

This study revealed that the policies, plans, and strategies for prevention and management of NCDs in Nepal recognized the importance of diabetes prevention and control. However, a major gap remains with adequate and lack of clarity in terms of implementation of available policies, plans, strategies, and programs to address the problem of diabetes. We suggest the need for multisectoral approach (engaging both health and non-health sectors) at central as well as peripheral levels to strengthen the policies implementation process, building capacity of health care providers, ensuring adequate financial and non-financial resources, and improving quality of services at primary health care levels.

Healthcare providers' perspectives on integrating NCDs into primary healthcare in Thailand: a mixed method study

BACKGROUND

In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand's PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement.

METHODS

This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews.

RESULTS

Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs.

CONCLUSION

PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.

Older adults with non-communicable chronic conditions and their health care access amid COVID-19 pandemic in Bangladesh: Findings from a cross-sectional study

BACKGROUND

Burgeoning burden of non-communicable disease among older adults is one of the emerging public health problems. In the COVID-19 pandemic, health services in low- and middle-income countries, including Bangladesh, have been disrupted. This may have posed challenges for older adults with non-communicable chronic conditions in accessing essential health care services in the current pandemic. The present study aimed at exploring the challenges experienced by older Bangladeshi adults with non-communicable chronic conditions in receiving regular health care services during the COVID-19 pandemic.

MATERIALS AND METHODS

The study followed a cross-sectional design and was conducted among 1032 Bangladeshi older adults aged 60 years and above during October 2020 through telephone interviews. Self-reported information on nine non-communicable chronic conditions (osteoarthritis, hypertension, heart disease, stroke, hypercholesterolemia, diabetes, chronic respiratory diseases, chronic kidney disease, cancer) was collected. Participants were asked if they faced any difficulties in accessing medicine and receiving routine medical care for their medical conditions during the COVID-19 pandemic. The association between non-communicable chronic conditions and accessing medication and health care was analysed using binary logic regression model.

RESULTS

Most of the participants aged 60-69 years (77.8%), male (65.5%), married (81.4%), had no formal schooling (58.3%) and resided in rural areas (73.9%). Although more than half of the participants (58.9%) reported having a single condition, nearly one-quarter (22.9%) had multimorbidity. About a quarter of the participants reported difficulties accessing medicine (23%) and receiving routine medical care (27%) during the pandemic, and this was significantly higher among those suffering from multimorbidity. In the adjusted analyses, participants with at least one condition (AOR: 1.95, 95% CI: 1.33-2.85) and with multimorbidity (AOR: 4.75, 95% CI: 3.17-7.10) had a higher likelihood of experiencing difficulties accessing medicine. Similarly, participants with at least one condition (AOR: 3.08, 95% CI: 2.11-4.89) and with multimorbidity (AOR: 6.34, 95% CI: 4.03-9.05) were significantly more likely to face difficulties receiving routine medical care during the COVID-19 pandemic.

CONCLUSIONS

Our study found that a sizeable proportion of the older adults had difficulties in accessing medicine and receiving routine medical care during the pandemic. The study findings highlight the need to develop an appropriate health care delivery pathway and strategies to maintain essential health services during any emergencies and beyond. We also argue the need to prioritise the health of older adults with non-communicable chronic conditions in the centre of any emergency response plan and policies of Bangladesh.

Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level.

Method

This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV₁) and FEV₁/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes.

Discussion

This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal.

Trial registration

ClinicalTrials.gov NCT03797768. Registered on January 9, 2019.