Self-management of chronic, non-communicable diseases in South Asian settings: A systematic mixed-studies review

Self-management is crucial in mitigating the impacts of a growing non-communicable disease (NCD) burden, particularly in Low and Middle-Income countries. What influences self-management in these settings, however, is poorly understood. We aimed to identify the determinants of self-management in the high NCD region of South Asia and explore how they influence self-management. A systematic mixed-studies review was conducted. Key electronic databases [MEDLINE (1946+), Embase (1974+), PsycInfo (1967+) and CINAHL (EBSCOhost)] in March 2022 (and updated in April 2023) were searched for studies on the self-management of four high-burden NCD groups: cardiovascular diseases, type 2 diabetes, chronic respiratory diseases and depression. Study characteristics and quantitative data were extracted using a structured template, and qualitative information was extracted using NVivo. Quality appraisal was done using the Mixed Methods Assessment Tool (MMAT). Quantitative findings were organised using the Commission on Social Determinants of Health (CSDH) framework and synthesised narratively, supported by effect direction plots. Qualitative findings were thematically synthesised. Both were integrated in a mixed synthesis. Forty-four studies (26 quantitative, 16 qualitative and 2 mixed-methods studies) were included, the majority of which were conducted in urban settings and among individuals with diabetes and cardiovascular diseases. Higher age, education, and income (structural determinants), health-related knowledge, social support and self-efficacy (psychosocial determinants), longer illness duration and physical comorbidity (biologic determinants), and the affordability of medicine (health-system determinants) were key determinants of self-management. Qualitative themes highlighted the role of financial adversity and the social and physical environment in shaping self-management.A complex interplay of structural and intermediary social determinants shapes self-management in South Asian settings. Multi-component, whole-systems approaches could boost self-management in these settings. Key areas include empowerment and education of patients and wider community, design and delivery of bespoke behavioural interventions and a stronger emphasis on supporting self-management in healthcare settings.

Perspectives of health workers engaging in task shifting to deliver health care in low-and-middle-income countries: a qualitative evidence synthesis

BACKGROUND

Low- and middle-income countries (LMICs) are experiencing growing demand for healthcare services yet face a persistent shortage in access to specialist health workers (SHWs). Task shifting is an approach used to address this gap in service provision. Specific healthcare tasks are shifted to other, larger cadres of non-specialist health workers (NSHWs), including lay health workers with SHWs potentially taking on supervisory roles. Previous studies demonstrate that task shifting is both clinically and economically effective, however the impact of task shifting on health workers (HWs) is not fully understood.

OBJECTIVE

The aim of this synthesis is to generate new knowledge about what influences HWs perspectives of benefits and costs of engaging in task shifting.

METHODS

A qualitative evidence synthesis (QES) of peer-reviewed literature using databases CINAHL, the Cochrane Database of Systematic Reviews, Psych INFO, MEDLINE, EMBASE, Epistimonikos, Web of Science (science and social science citation index), Scopus LILACS, the African Index Medicus and Google Scholar. Eligible studies were those that included qualitative data about HWs perspectives of task shifting in LMICs. Information from eligible studies was extracted into a Google Sheet, and the data gathered were analysed thematically.

RESULTS

Fifty-four studies were included in the QES. Results were organised under three themes, 'the cultural environment in which task shifting is employed', 'access to resources for task shifting' and 'alignment with personal values and beliefs, self-efficacy and personal emotional resilience'.

CONCLUSION

This is the first review bringing together views about task shifting from the perspective of different cadres of HWs drawn from diverse healthcare, geographical and country settings in LMICs. Task shifting is a complex process which relies upon the active engagement of HWs. Taking into consideration factors that influence HWs perspectives, such as their personal characteristics, preparatory training, and ongoing access to resources, is important for informing how task shifted healthcare initiatives are designed and delivered to successfully widen access to healthcare in LMICs.

Behavioral Activation for Comorbid Depression in People With Noncommunicable Disease in India: Protocol for a Randomized Controlled Feasibility Trial

BACKGROUND

The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated.

OBJECTIVE

Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care.

METHODS

Following well-established frameworks for intervention adaptation, we first adapted BA (to fit the linguistic, cultural, and resource context) for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters (eg, recruitment and retention rates and completeness of follow-up) needed to design a future definitive trial.

RESULTS

Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation (qualitative data) collection is ongoing. Both the qualitative and quantitative data analyses are ongoing.

CONCLUSIONS

This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program.

TRIAL REGISTRATION

Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41127.

Effectiveness and implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: Systematic review and meta-analysis

We evaluate the effectiveness of psychological interventions for depression in people with NCDs in South Asia and explore the individual, organizational, and policy-level barriers and facilitators for the implementation and scaling up of these interventions. Eight databases (and local web pages) were searched in May 2022. We conducted random effects models to evaluate the pooled effect of psychological interventions on depression in people with NCDs. We extracted the individual, organizational, and policy level barriers and facilitators. We found five randomized control trials, nine qualitative studies, and 35 policy documents that fitted the inclusion criteria. The pooled standardized mean difference in depression comparing psychological interventions with usual care was -2.31 (95% CI, -4.16 to -0.45; p = .015, I2 = 96.0%). We found barriers and facilitators to intervention delivery, mental health appears in the policy agenda in Bangladesh and Pakistan. However, there is a lack of policies relating to training in mental health for NCD health providers and a lack of integration of mental health care with NCD care. All of the psychological interventions reported to be effective in treating depression in this population. There are important delivery and policy barriers to the implementation and scaling up of psychological interventions for people with NCDs.

‘Now you see it, now you do not’: sensory–motor re-education in complex regional pain syndrome

The patient with complex regional pain syndrome (CRPS) commonly describes a lack of ownership of their painful limb, poor definition of that body part and difficulty with localization of the limb when performing daily activities. These descriptions suggest that sensory input from the limb may be reduced leading to neglect of the limb and poor motor control. However, the cardinal symptom of CRPS is pain, commonly severe, which demands a high level of attention. Patients are highly protective of the painful region and hypervigilant to any potential threats to their affected limb. These seemingly conflicting behavioural responses and sensory descriptions are confusing for the patient and health-care professional. In recent years our understanding has greatly advanced on how altered sensory perception of a CRPS affected limb relates to changes in the central representation of that body part, and how this may interact with motor planning and autonomic function. Excitingly, this increased knowledge has directly informed clinical practice via a new evaluation of sensory–motor re-education techniques and the development of novel interventions to enhance sensory discrimination. We review the common sensory problems seen in CRPS, the mechanisms that may be behind these clinical symptoms, and how sensory, motor and autonomic systems interact. Therapies designed to enhance sensory discrimination and motor planning are discussed, supported by the results of a small case series undergoing sensory re-education for CRPS. The clinical protocol and two case studies are available as additional online material to illustrate how all of this is applied in practice.