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Nganabashaka JP, Niyibizi JB, Umwali G, Rulisa S, M. Bavuma C, Byiringiro JC, Ntawuyirushintege S, Niyomugabo PC, Izerimana L, Tumusiime D. The effects of COVID-19 mitigation measures on physical activity (PA) participation among adults in Rwanda: An online cross-sectional survey. PLoS One 2023; 18:e0293231. [PMID: 37943889 PMCID: PMC10635554 DOI: 10.1371/journal.pone.0293231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 10/03/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION More than a third of the world's population was under full or partial lockdown during COVID-19 by April 2020. Such mitigation measures might have affected participation in various Physical activity (PA) and increased sedentary time. This study aimed to assess the effect of the COVID-19 mitigation measures on participation of adults in various PA types in Rwanda. METHODS We collected data from conveniently selected participants at their respective PA sites. We assessed the variation in time spent doing in four types of PA (Work related PA, PA in and around home, transportation PA and recreation, sport, and leisure purpose) across different pandemic period. We also evaluated the sedentary time over the weekdays and on the weekends. RESULTS A total of 1136 participants completed online assisted questionnaire. 71.4% were male, 83% of the study participants aged 18 to 35 years (mean = 29, (standard deviation = 7.79). Mean time spent doing vigorous PA as part of the work dropped from 84.5 minutes per day before COVID-19 to 58.6 minutes per day during lockdown and went back to 81.5 minutes per day after the lockdown. Time spent sitting on weekdays increased from 163 before COVID-19 to 244.5 minutes during lockdown and to 166.8 minutes after lockdown. Sitting time on weekend increased from 150 before COVID-19 to 235 minutes during lockdown and to 151 minutes after lockdown. Sleeping time on weekdays increased from 7.5 hours per day before COVID-19 to 9.9 hours during lockdown and to 7.5 hours after lockdown while it increased from 8 hours before COVID-19 to 10 hours during lockdown and to 8 hours per day after lockdown during weekends. CONCLUSION The study emphasizes the significance of diverse PA, including home-based programs, during pandemics like COVID-19. It suggests promoting PA types like work-related, transportation, and domestic works during lockdown and similar period.
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Affiliation(s)
| | - Jean Berchmans Niyibizi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Ghislaine Umwali
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Stephen Rulisa
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Charlotte M. Bavuma
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | | | - Lambert Izerimana
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - David Tumusiime
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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Rohwer A, Toews I, Uwimana-Nicol J, Nyirenda JLZ, Niyibizi JB, Akiteng AR, Meerpohl JJ, Bavuma CM, Kredo T, Young T. Models of integrated care for multi-morbidity assessed in systematic reviews: a scoping review. BMC Health Serv Res 2023; 23:894. [PMID: 37612604 PMCID: PMC10463690 DOI: 10.1186/s12913-023-09894-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 08/10/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND The prevalence of multi-morbidity is increasing globally. Integrated models of care present a potential intervention to improve patient and health system outcomes. However, the intervention components and concepts within different models of care vary widely and their effectiveness remains unclear. We aimed to describe and map the definitions, characteristics, components, and reported effects of integrated models of care in systematic reviews (SRs). METHODS We conducted a scoping review of SRs according to pre-specified methods (PROSPERO 2019 CRD42019119265). Eligible SRs assessed integrated models of care at primary health care level for adults and children with multi-morbidity. We searched in PubMed (MEDLINE), Embase, Cochrane Database of Systematic Reviews, Epistemonikos, and Health Systems Evidence up to 3 May 2022. Two authors independently assessed eligibility of SRs and extracted data. We identified and described common components of integrated care across SRs. We extracted findings of the SRs as presented in the conclusions and reported on these verbatim. RESULTS We included 22 SRs, examining data from randomised controlled trials and observational studies conducted across the world. Definitions and descriptions of models of integrated care varied considerably. However, across SRs, we identified and described six common components of integrated care: (1) chronic conditions addressed, (2) where services were provided, (3) the type of services provided, (4) healthcare professionals involved in care, (5) coordination and organisation of care and (6) patient involvement in care. We observed differences in the components of integrated care according to the income setting of the included studies. Some SRs reported that integrated care was beneficial for health and process outcomes, while others found no difference in effect when comparing integrated care to other models of care. CONCLUSIONS Integrated models of care were heterogeneous within and across SRs. Information that allows the identification of effective components of integrated care was lacking. Detailed, standardised and transparent reporting of the intervention components and their effectiveness on health and process outcomes is needed.
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Affiliation(s)
- Anke Rohwer
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Jeannine Uwimana-Nicol
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - John L Z Nyirenda
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | | | - Ann R Akiteng
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Charlotte M Bavuma
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Kigali University Teaching Hospital, Kigali, Rwanda
| | - Tamara Kredo
- South African Medical Research Council, Cochrane South Africa, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Ng'ang'a L, Ngoga G, Dusabeyezu S, Hedt-Gauthier BL, Harerimana E, Niyonsenga SP, Bavuma CM, Bukhman G, Adler AJ, Kateera F, Park PH. Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda. BMC Endocr Disord 2022; 22:244. [PMID: 36209209 PMCID: PMC9547423 DOI: 10.1186/s12902-022-01162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated the effectiveness of self-monitoring of blood-glucose (SMBG) in controlling blood glucose levels. However, there are limited studies describing the implementation of SMBG in rural SSA. This study explores the feasibility and effectiveness of implementing SMBG among patients diagnosed with insulin-dependent type 2 diabetes in rural Rwanda. METHODS Participants were randomized into intervention (n = 42) and control (n = 38) groups. The intervention group received a glucose-meter, blood test-strips, log-book, waste management box and training on SMBG in addition to usual care. The control group continued with their usual care consisting of, routine monthly medical consultation and health education. The primary outcomes were adherence to the implementation of SMBG (testing schedule and recording data in the log-book) and change in hemoglobin A1c. Descriptive statistics and a paired t-test were used to analyze the primary outcomes. RESULTS In both the intervention and control arms, majority of the participants were female (59.5% vs 52.6%) and married (71.4% vs 73.7%). Most had at most a primary level education (83.3% vs. 89.4%) and were farmers (54.8% vs. 50.0%). Among those in the intervention group, 63.4% showed good adherence to implementing SMBG based on the number of tests recorded in the glucose meter. Only 20.3% demonstrated accurate recording of the glucose level tests in log-books. The mean difference of the HbA1C from baseline to six months post-intervention was significantly better among the intervention group -0.94% (95% CI -1.46, -0.41) compared to the control group 0.73% (95% CI -0.09, 1.54) p < 0.001. CONCLUSION Our study showed that among patients with insulin-dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log-book. TRIAL REGISTRATION The trial was registered retrospectively on the Pan African Clinical Trial Registry, on 17th May 2019. The registration number is PACTR201905538846394.
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Affiliation(s)
| | - Gedeon Ngoga
- Non-Communicable Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda
- NCD Synergies, Partners In Health, Boston, MA, USA
| | | | | | | | | | - Charlotte M Bavuma
- Kigali University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Gene Bukhman
- NCD Synergies, Partners In Health, Boston, MA, USA
- Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Alma J Adler
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Paul H Park
- NCD Synergies, Partners In Health, Boston, MA, USA
- Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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Nganabashaka JP, Ntawuyirushintege S, Niyibizi JB, Umwali G, Bavuma CM, Byiringiro JC, Rulisa S, Burns J, Rehfuess E, Young T, Tumusiime DK. Population-Level Interventions Targeting Risk Factors for Hypertension and Diabetes in Rwanda: A Situational Analysis. Front Public Health 2022; 10:882033. [PMID: 35844869 PMCID: PMC9283981 DOI: 10.3389/fpubh.2022.882033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background Eighty percent (80%) of global Non-Communicable Diseases attributed deaths occur in low- and middle-income countries (LMIC) with hypertension and diabetes being key contributors. The overall prevalence of hypertension was 15.3% the national prevalence of diabetes in rural and urban was 7.5 and 9.7%, respectively among 15–64 years. Hypertension represents a leading cause of death (43%) among hospitalized patients at the University teaching hospital of Kigali. This study aimed to identify ongoing population-level interventions targeting risk factors for diabetes and hypertension and to explore perceived barriers and facilitators for their implementation in Rwanda. Methods This situational analysis comprised a desk review, key informant interviews, and stakeholders' consultation. Ongoing population-level interventions were identified through searches of government websites, complemented by one-on-one consultations with 60 individuals nominated by their respective organizations involved with prevention efforts. Semi-structured interviews with purposively selected key informants sought to identify perceived barriers and facilitators for the implementation of population-level interventions. A consultative workshop with stakeholders was organized to validate and consolidate the findings. Results We identified a range of policies in the areas of food and nutrition, physical activity promotion, and tobacco control. Supporting program and environment interventions were mainly awareness campaigns to improve knowledge, attitudes, and practices toward healthy eating, physical activity, and alcohol and tobacco use reduction, healthy food production, physical activity infrastructure, smoke-free areas, limits on tobacco production and bans on non-standardized alcohol production. Perceived barriers included limited stakeholder involvement, misbeliefs about ongoing interventions, insufficient funding, inconsistency in intervention implementation, weak policy enforcement, and conflicts between commercial and public health interests. Perceived facilitators were strengthened multi-sectoral collaboration and involvement in ongoing interventions, enhanced community awareness of ongoing interventions, special attention paid to the elderly, and increased funds for population-level interventions and policy enforcement. Conclusion There are many ongoing population-level interventions in Rwanda targeting risk factors for diabetes and hypertension. Identified gaps, perceived barriers, and facilitators provide a useful starting point for strengthening efforts to address the significant burden of disease attributable to diabetes and hypertension.
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Affiliation(s)
- Jean Pierre Nganabashaka
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- *Correspondence: Jean Pierre Nganabashaka
| | | | | | - Ghislaine Umwali
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Charlotte M. Bavuma
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Stephen Rulisa
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Eva Rehfuess
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig Maximilian University of Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Taryn Young
- Centre for Evidence-Based Health Care, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - David K. Tumusiime
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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Niyibizi JB, Okop KJ, Nganabashaka JP, Umwali G, Rulisa S, Ntawuyirushintege S, Tumusiime D, Nyandwi A, Ntaganda E, Delobelle P, Levitt N, Bavuma CM. Perceived cardiovascular disease risk and tailored communication strategies among rural and urban community dwellers in Rwanda: a qualitative study. BMC Public Health 2022; 22:920. [PMID: 35534821 PMCID: PMC9088034 DOI: 10.1186/s12889-022-13330-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 04/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background In Rwanda, cardiovascular diseases (CVDs) are the third leading cause of death, and hence constitute an important public health issue. Worldwide, most CVDs are due to lifestyle and preventable risk factors. Prevention interventions are based on risk factors for CVD risk, yet the outcome of such interventions might be limited by the lack of awareness or misconception of CVD risk. This study aimed to explore how rural and urban population groups in Rwanda perceive CVD risk and tailor communication strategies for estimated total cardiovascular risk. Methods An exploratory qualitative study design was applied using focus group discussions to collect data from rural and urban community dwellers. In total, 65 community members took part in this study. Thematic analysis with Atlas ti 7.5.18 was used and the main findings for each theme were reported as a narrative summary. Results Participants thought that CVD risk is due to either financial stress, psychosocial stress, substance abuse, noise pollution, unhealthy diets, diabetes or overworking. Participants did not understand CVD risk presented in a quantitative format, but preferred qualitative formats or colours to represent low, moderate and high CVD risk through in-person communication. Participants preferred to be screened for CVD risk by community health workers using mobile health technology. Conclusion Rural and urban community members in Rwanda are aware of what could potentially put them at CVD risk in their respective local communities. Community health workers are preferred by local communities for CVD risk screening. Quantitative formats to present the total CVD risk appear inappropriate to the Rwandan population and qualitative formats are therefore advisable. Thus, operational research on the use of qualitative formats to communicate CVD risk is recommended to improve decision-making on CVD risk communication in the context of Rwanda. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13330-6.
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Affiliation(s)
- Jean Berchmans Niyibizi
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda.
| | - Kufre Joseph Okop
- Chronic Diseases Initiative for Africa (CDIA), Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jean Pierre Nganabashaka
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda
| | - Ghislaine Umwali
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda
| | - Stephen Rulisa
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda.,Kigali University Teaching Hospital, Kigali, Rwanda
| | - Seleman Ntawuyirushintege
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda
| | - David Tumusiime
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda
| | | | | | - Peter Delobelle
- Chronic Diseases Initiative for Africa (CDIA), Department of Medicine, University of Cape Town, Cape Town, South Africa.,Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Naomi Levitt
- Chronic Diseases Initiative for Africa (CDIA), Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Charlotte M Bavuma
- College of Medicine and Health Sciences (CMHS), University of Rwanda, Kicukiro Campus, KK19 Av 101, P.O. Box 4285, Kigali, Rwanda.,Kigali University Teaching Hospital, Kigali, Rwanda
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Niyibizi JB, Nganabashaka JP, Ntawuyirushintege S, Tumusiime D, Umwali G, Rulisa S, Nyandwi A, Okop KJ, Ntaganda E, Sell K, Levitt N, Jessani NS, Bavuma CM. Using Citizen Science Within an Integrated Knowledge Translation (IKT) Approach to Explore Cardiovascular Disease Risk Perception in Rwanda. Front Trop Dis 2021. [DOI: 10.3389/fitd.2021.752357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BackgroundCollaborative approaches to generating knowledge between knowledge users (KUs) and researchers as a means of enhancing evidence-informed decision making have been gaining ground over the last few years. The principal study targeted rural and urban communities within the catchment areas of Cyanika health centre (Burera district, Northern Province) and Kacyiru health centre (Gasabo district, in City of Kigali), respectively to understand perceptions and preferences of communication with respect to cardiovascular disease (CVD) risk in Rwanda. This paper describes the integration of citizen science within an integrated knowledge translation (IKT) approach for this study.MethodsThe citizen science approach included deliberate, selective and targeted engagement of KUs at various steps throughout the study. It incorporated national and district levels stakeholders, primary health care stakeholders, local community leaders and influencers, and local community members (selected and trained to be termed citizen scientists) in the process of implementation. Data for this paper included minutes, reports and notes from meetings and workshops which were perused to report the immediate outcomes and challenges of citizen science within an IKT approach for a study such as described for Rwanda.ResultsAs a result of a deliberate IKT strategy, key national stakeholders attended and contributed to all phases of citizen science implementation. Project-based and relationship-based immediate outcomes were documented. In line with local community health issues reported by the citizen scientists, the local community stakeholders pledged home grown solutions. These included enhancement of compliance to implement the “kitchen garden per household” policy, teaching local residents on preparation of healthy diet from locally available food items, organizing collective physical activity, fighting against locally made substandard beverages and teaching local residents on CVD (risk factors). As an indicator of the probable uptake of research evidence, district officials appreciated citizen scientists’ work and decided to consider presented results in their next fiscal year action plan.ConclusionCitizen science proved to be an important strategy for research co-production in Rwanda. While this strategy falls within the remit of a larger IKT approach it focuses on the role and ownership of research by local community residents. This study demonstrated that to improve the relevance and impact of research in local community a deliberate IKT approach that incorporates citizen science can be invaluable.
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Rohwer A, Uwimana Nicol J, Toews I, Young T, Bavuma CM, Meerpohl J. Effects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open 2021; 11:e043705. [PMID: 34253658 PMCID: PMC8276295 DOI: 10.1136/bmjopen-2020-043705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes. DESIGN Systematic review. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019. ELIGIBILITY CRITERIA We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care. DATA EXTRACTION AND SYNTHESIS Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation. RESULTS Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty). CONCLUSIONS Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations. PROSPERO REGISTRATION NUMBER CRD42018099314.
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Affiliation(s)
- Anke Rohwer
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jeannine Uwimana Nicol
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Charlotte M Bavuma
- Kigali University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Joerg Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Bavuma CM, Musafiri S, Rutayisire PC, Ng'ang'a LM, McQuillan R, Wild SH. Socio-demographic and clinical characteristics of diabetes mellitus in rural Rwanda: time to contextualize the interventions? A cross-sectional study. BMC Endocr Disord 2020; 20:180. [PMID: 33302939 PMCID: PMC7731466 DOI: 10.1186/s12902-020-00660-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/30/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Existing prevention and treatment strategies target the classic types of diabetes yet this approach might not always be appropriate in some settings where atypical phenotypes exist. This study aims to assess the socio-demographic and clinical characteristics of people with diabetes in rural Rwanda compared to those of urban dwellers. METHODS A cross-sectional, clinic-based study was conducted in which individuals with diabetes mellitus were consecutively recruited from April 2015 to April 2016. Demographic and clinical data were collected from patient interviews, medical files and physical examinations. Chi-square tests and T-tests were used to compare proportions and means between rural and urban residents. RESULTS A total of 472 participants were recruited (mean age 40.2 ± 19.1 years), including 295 women and 315 rural residents. Compared to urban residents, rural residents had lower levels of education, were more likely to be employed in low-income work and to have limited access to running water and electricity. Diabetes was diagnosed at a younger age in rural residents (mean ± SD 32 ± 18 vs 41 ± 17 years; p < 0.001). Physical inactivity, family history of diabetes and obesity were significantly less prevalent in rural than in urban individuals (44% vs 66, 14.9% vs 28.7 and 27.6% vs 54.1%, respectively; p < 0.001). The frequency of fruit and vegetable consumption was lower in rural than in urban participants. High waist circumference was more prevalent in urban than in rural women and men (75.3% vs 45.5 and 30% vs 6%, respectively; p < 0.001). History of childhood under-nutrition was more frequent in rural than in urban individuals (22.5% vs 6.4%; p < 0.001). CONCLUSIONS Characteristics of people with diabetes in rural Rwanda appear to differ from those of individuals with diabetes in urban settings, suggesting that sub-types of diabetes exist in Rwanda. Generic guidelines for diabetes prevention and management may not be appropriate in different populations.
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Affiliation(s)
- Charlotte M Bavuma
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
| | - Sanctus Musafiri
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | - Ruth McQuillan
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah H Wild
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Ng'ang'a L, Ngoga G, Dusabeyezu S, Hedt-Gauthier BL, Ngamije P, Habiyaremye M, Harerimana E, Ndayisaba G, Rusangwa C, Niyonsenga SP, Bavuma CM, Bukhman G, Adler AJ, Kateera F, Park PH. Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial. BMJ Open 2020; 10:e036202. [PMID: 32718924 PMCID: PMC7389513 DOI: 10.1136/bmjopen-2019-036202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Most patients diagnosed with diabetes in sub-Saharan Africa (SSA) present with poorly controlled blood glucose, which is associated with increased risks of complications and greater financial burden on both the patients and health systems. Insulin-dependent patients with diabetes in SSA lack appropriate home-based monitoring technology to inform themselves and clinicians of the daily fluctuations in blood glucose. Without sufficient home-based data, insulin adjustments are not data driven and adopting individual behavioural change for glucose control in SSA does not have a systematic path towards improvement. METHODS AND ANALYSIS This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group-participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group-participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG. The primary outcomes are change in haemoglobin A1c, fidelity to SMBG protocol by patients, appropriateness and adverse effects resulting from SMBG. Secondary outcomes include reliability and acceptability of SMBG and change in the quality of life of the participants. ETHICS AND DISSEMINATION This study has been approved by the Rwanda National Ethics Committee (Kigali, Rwanda No.102/RNEC/2018). We will disseminate the findings of this study through presentations within our study settings, scientific conferences and publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER PACTR201905538846394; pre-results.
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Affiliation(s)
- Loise Ng'ang'a
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | - Gedeon Ngoga
- Non-Communicable Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
| | - Symaque Dusabeyezu
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Patient Ngamije
- Kirehe District Hospital, Ministry of Health, Kigali, Rwanda
| | | | | | - Gilles Ndayisaba
- Non-Communicable Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Christian Rusangwa
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | | | - Charlotte M Bavuma
- Internal Medicine, University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Gene Bukhman
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alma J Adler
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Fredrick Kateera
- Research, Inshuti Mu Buzima, Partners In Health-Rwanda, Rwinkwavu, Rwanda
| | - Paul H Park
- NCD Synergies, Partners in Health, Boston, Massachusetts, United States
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
BACKGROUND Hypertension is a major public health challenge affecting more than one billion people worldwide; it disproportionately affects populations in low- and middle-income countries (LMICs), where health systems are generally weak. The increasing prevalence of hypertension is associated with population growth, ageing, genetic factors, and behavioural risk factors, such as excessive salt and fat consumption, physical inactivity, being overweight and obese, harmful alcohol consumption, and poor management of stress. Over the long term, hypertension leads to risk for cardiovascular events, such as heart disease, stroke, kidney failure, disability, and premature mortality. Cardiovascular events can be preventable when high-risk populations are targeted, for example, through population-wide screening strategies. When available resources are limited, taking a total risk approach whereby several risk factors of hypertension are taken into consideration (e.g. age, gender, lifestyle factors, diabetes, blood cholesterol) can enable more accurate targeting of high-risk groups. Targeting of high-risk groups can help reduce costs in that resources are not spent on the entire population. Early detection in the form of screening for hypertension (and associated risk factors) can help identify high-risk groups, which can result in timely treatment and management of risk factors. Ultimately, early detection can help reduce morbidity and mortality linked to it and can help contain health-related costs, for example, those associated with hospitalisation due to severe illness and poorly managed risk factors and comorbidities. OBJECTIVES To assess the effectiveness of different screening strategies for hypertension (mass, targeted, or opportunistic) to reduce morbidity and mortality associated with hypertension. SEARCH METHODS An Information Specialist searched the Cochrane Register of Studies (CRS-Web), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American Caribbean Health Sciences Literature (LILACS) Bireme, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) without language, publication year, or publication status restrictions. The searches were conducted from inception until 9 April 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) and non-RCTs (NRCTs), that is, controlled before and after (CBA), interrupted time series (ITS), and prospective analytic cohort studies of healthy adolescents, adults, and elderly people participating in mass, targeted, or opportunistic screening of hypertension. DATA COLLECTION AND ANALYSIS Screening of all retrieved studies was done in Covidence. A team of reviewers, in pairs, independently assessed titles and abstracts of identified studies and acquired full texts for studies that were potentially eligible. Studies were deemed to be eligible for full-text screening if two review authors agreed, or if consensus was reached through discussion with a third review author. It was planned that at least two review authors would independently extract data from included studies, assess risk of bias using pre-specified Cochrane criteria, and conduct a meta-analysis of sufficiently similar studies or present a narrative synthesis of the results. MAIN RESULTS We screened 9335 titles and abstracts. We identified 54 potentially eligible studies for full-text screening. However, no studies met the eligibility criteria. AUTHORS' CONCLUSIONS There is an implicit assumption that early detection of hypertension through screening can reduce the burden of morbidity and mortality, but this assumption has not been tested in rigorous research studies. High-quality evidence from RCTs or programmatic evidence from NRCTs on the effectiveness and costs or harms of different screening strategies for hypertension (mass, targeted, or opportunistic) to reduce hypertension-related morbidity and mortality is lacking.
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Affiliation(s)
- Bey-Marrié Schmidt
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Solange Durao
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Ingrid Toews
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte M Bavuma
- College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda
| | - Ameer Hohlfeld
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Edris Nury
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
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11
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Bahendeka S, Kaushik R, Swai AB, Otieno F, Bajaj S, Kalra S, Bavuma CM, Karigire C. EADSG Guidelines: Insulin Storage and Optimisation of Injection Technique in Diabetes Management. Diabetes Ther 2019; 10:341-366. [PMID: 30815830 PMCID: PMC6437255 DOI: 10.1007/s13300-019-0574-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 02/07/2023] Open
Abstract
To date, insulin therapy remains the cornerstone of diabetes management; but the art of injecting insulin is still poorly understood in many health facilities. To address this gap, the Forum for Injection Technique and Therapy Expert Recommendations (FITTER) published recommendations on injection technique after a workshop held in Rome, Italy in 2015. These recommendations are generally applicable to the majority of patients on insulin therapy, athough they do not explore alternative details that may be suitable for low- and middle-income countries. The East Africa Diabetes Study Group sought to address this gap, and furthermore to seek consensus on some of the contextual issues pertaining to insulin therapy within the East African region, specifically focusing on scarcity of resources and its adverse effect on the quality of care. A meeting of health care professionals, experts in diabetes management and patients using insulin, was convened in Kigali, Rwanda on 11 March 2018, and the following recommendations were made: (1) insulin should be transported safely, without undue shaking and exposure to high (> 32 °C) temperature environments. (2) Insulin should not be transported below 0 °C. (3) If insulin is to be stored at home for over 2 months, it should be stored at the recommended temperature of 2-8 °C. (4) Appropriate instructions should be given to patients while dispensing insulin. (5) Insulin in use should be kept at room temperature and should never be kept immersed under water. Immersing insulin under water after the vial has been pierced carries a high risk of contamination, leading to loss of potency and likelihood of causing injection abscesses. (6) The shortest available needles (4 mm for pen and 6 mm for insulin syringe) should be preferred for all patients. (7) In routine care, intramuscular injections should be avoided, especially with long-acting insulins, as it may result in severe hypoglycaemia. (8) The practice of slanting the needle excessively should be avoided as it results in sub-epidermal injection of insulin which leads to poor absorption and may cause "tattooing" of the skin and scarring. (9) In patients presenting in a wasted state, with "paper-like skin", injections should, if possible, be initiated with pen injection devices, so as to utilise the 4-mm needle without lifting a skin fold (pinching the skin); otherwise lifting of a skin fold is required, if longer needles are utilised. (10) Reuse of needles and syringes is not recommended. However, as the reuse of syringes and needles is practiced for various reasons, and by many patients, individuals should not be given alarming messages; and usage should be limited to discarding when injections become more painful; but at any rate not to exceed reusing a needle more than 5 times.
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Affiliation(s)
- Silver Bahendeka
- Department of Internal Medicine, Mother Kevin Post Graduate Medical School, Uganda Martyrs University, Kampala, Uganda.
- St. Francis Hospital, Kampala, Uganda.
| | | | - Andrew Babu Swai
- Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania
| | - Fredrick Otieno
- Department of Clinical Medicine and Therapeutics School of Medicine, College of Health Science, University of Nairobi, Nairobi, Kenya
| | - Sarita Bajaj
- Department of Clinical Medicine and Therapeutics School of Medicine, College of Health Science, University of Nairobi, Nairobi, Kenya
| | - Sanjay Kalra
- Moti Lal Nehru Medical College, Allahabad, India
- Bharti Research Institute of Diabetes and Endocrinology, Karnal, Haryana, India
| | - Charlotte M Bavuma
- Department of Internal Medicine, College of Medicine and Health Sciences, Kigali University Teaching HospitalUniversity of Rwanda, Kigali, Rwanda
| | - Claudine Karigire
- Department of Internal Medicine, Rwanda Military Hospital, Kigali, Rwanda
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Nicol JU, Rohwer A, Young T, Bavuma CM, Meerpohl JJ. Correction to: Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs): Protocol for a systematic review. Syst Rev 2019; 8:36. [PMID: 30704523 PMCID: PMC6354368 DOI: 10.1186/s13643-019-0943-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractFollowing publication of the original article [1], the author reported that their family name was misspelled.
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Affiliation(s)
- Jeannine Uwimana Nicol
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa. .,School of Public Health, College of Medicine and Health Science, University of Rwanda, Kicukiro, Kigali, Rwanda.
| | - Anke Rohwer
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa
| | - Taryn Young
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa
| | - Charlotte M Bavuma
- College of Medicine and Health Science, University of Rwanda, Kicukiro, Kigali, Rwanda
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Breisacher Strasse 153, 79110, Freiburg, Germany
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Abstract
INTRODUCTION It is unclear whether early detection of hypertension, through screening, leads to healthier behaviours and better control of blood pressure levels. There is a need to learn from studies that have assessed the impact of different screening approaches on patient important outcomes. This systematic review protocol outlines the methods that will be used to assess the comparative effectiveness of different screening strategies (mass, targeted or opportunistic) for hypertension to reduce morbidity and mortality associated with hypertension. METHODS AND ANALYSIS We will primarily search Cochrane Central Register of Controlled Trials, Medline, Embase and Latin American and Caribbean Health Sciences Literature (LILACS). Relevant randomised controlled trials, controlled before and after, interrupted time series and prospective analytic cohort studies regardless of publication date, language and geographic location, will be included. We are interested in clinical, adverse event and health system outcomes. Two reviewers will independently screen titles, abstracts and full-text articles against inclusion criteria; perform data extraction and assess risk of bias in included studies. We will assess the certainty of the overall evidence using the Grading of Recommendations Assessment, Development and Evaluation approach and report findings accordingly. ETHICS AND DISSEMINATION No ethics approval will be sought, as only secondary studies will be used. Findings will be disseminated through peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER CRD42018093046.
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Affiliation(s)
- Bey-Marrié Schmidt
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Solange Durão
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center—University of Freiburg, Freiburg, Germany
| | - Charlotte M Bavuma
- College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center—University of Freiburg, Freiburg, Germany
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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14
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Affiliation(s)
- Bey-Marrié Schmidt
- South African Medical Research Council; Cochrane South Africa; Cape Town South Africa
| | - Solange Durao
- South African Medical Research Council; Cochrane South Africa; Cape Town South Africa
| | - Ingrid Toews
- Medical Center, Faculty of Medicine, University of Freiburg; Evidence in Medicine / Cochrane Germany; Breisacher Straße 153 Freiburg Baden-Württemberg Germany 79110
| | - Charlotte M Bavuma
- University of Rwanda; College of Medicine and Health Science; Kigali Rwanda
| | - Joerg J Meerpohl
- Medical Center - University of Freiburg; Institute for Evidence in Medicine (for Cochrane Germany Foundation); Breisacher Straße 153 Freiburg Germany 79110
| | - Tamara Kredo
- South African Medical Research Council; Cochrane South Africa; Cape Town South Africa
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Uwimana Nicol J, Rohwer A, Young T, Bavuma CM, Meerpohl JJ. Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs) : Protocol for a systematic review. Syst Rev 2018; 7:203. [PMID: 30458841 PMCID: PMC6247752 DOI: 10.1186/s13643-018-0865-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/31/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs. METHODS We will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χ 2 and I 2 tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table. DISCUSSION In light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018099314 .
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Affiliation(s)
- Jeannine Uwimana Nicol
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa.
- School of Public Health, College of Medicine and Health Science, University of Rwanda, Kicukiro, Kigali, Rwanda.
| | - Anke Rohwer
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa
| | - Taryn Young
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl drive, Parow, Cape Town, 7500, South Africa
| | - Charlotte M Bavuma
- College of Medicine and Health Science, University of Rwanda, Kicukiro, Kigali, Rwanda
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Breisacher Strasse 153, 79110, Freiburg, Germany
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