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Paniagua-Avila A, Shelton RC, Figueroa JC, Guzman AL, Gutierrez L, Hernandez-Galdamez DR, Ramirez JM, Rodriguez J, Irazola V, Ramirez-Zea M, Fort MP. Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: an application of the RE-AIM/PRISM extension for sustainability and health equity. Implement Sci Commun 2024; 5:23. [PMID: 38491376 PMCID: PMC10941412 DOI: 10.1186/s43058-024-00560-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/20/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala's public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals. METHODS Conducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic's onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of "Reach, Effectiveness, Adoption, Implementation and Maintenance," RE-AIM (Reach, Implementation delivery + adaptations), and "Practical Robust Implementation and Sustainability Model," PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019-July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations. RESULTS Contextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability. CONCLUSIONS Recognition of an EBI's benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation. TRIAL REGISTRATION NCT03504124.
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Affiliation(s)
- Alejandra Paniagua-Avila
- Epidemiology Department, Mailman School of Public Health, Columbia University, New York, NY, USA.
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Juan Carlos Figueroa
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
- Department of Epidemiology, Dornsife School of Public Health, Urban Health Collaborative, Drexel University, Philadelphia, PA, USA
| | - Ana Lissette Guzman
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Laura Gutierrez
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Diego Rolando Hernandez-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Juan Manuel Ramirez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Javier Rodriguez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
- Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
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Jolles MP, Fort MP, Glasgow RE. Aligning the planning, development, and implementation of complex interventions to local contexts with an equity focus: application of the PRISM/RE-AIM Framework. Int J Equity Health 2024; 23:41. [PMID: 38408990 PMCID: PMC10898074 DOI: 10.1186/s12939-024-02130-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/13/2024] [Indexed: 02/28/2024] Open
Abstract
For the fields of implementation science and health equity, understanding and being responsive to local contexts is of utmost importance to better inform the development, implementation, and evaluation of healthcare and public health interventions to increase their uptake and sustainment. Contexts are multi-level and include political, historical, economic, and social factors that influence health, as well as organizational characteristics, reflecting the richness of members' views, resources, values, and needs. Poor alignment between solutions and those contextual characteristics could have an impact on inequities. The PRISM (Practical Robust Implementation and Sustainability Model) is a context-based implementation science framework that incorporates RE-AIM outcomes (Reach, Effectiveness, Adoption, Implementation, Maintenance) and offers guidance to researchers, practitioners, and their patient and community partners on how to conceptualize, assess, and address contextual domains with a focus on health equity. Drawing from systems thinking, participatory engagement, and health equity principles, this commentary expands on previous work to 1) offer a novel perspective on how to align an intervention's core functions and forms with the PRISM's contextual domains, and 2) foster an ongoing and iterative engagement process with diverse partners throughout the research and practice process using a co-creation approach. We recommend intervention-to-context alignment through iterative cycles. To that end, we present the RE-AIM Framework's 'outcomes cascade' to illustrate touch points of opportunity and gaps within and across each of the five RE-AIM outcomes to illustrate 'where things go wrong'. We present a case study to illustrate and offer recommendations for research and practice efforts to increase contextual responsiveness, and enhance alignment with context before, during, and after implementation efforts and to ensure equity is being addressed. We strive to make a conceptual contribution to advance the field of pragmatic research and implementation of evidence-based practices through the application of the contextually-based PRISM framework with a focus on health equity.
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Affiliation(s)
- Monica Pérez Jolles
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Anschutz Medical Campus, Mailstop F443, 1890 North Revere Court, Aurora, CO, 80045, USA.
- Department of General Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Meredith P Fort
- Department of Health Systems, Management and Policy and Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Russell E Glasgow
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Anschutz Medical Campus, Mailstop F443, 1890 North Revere Court, Aurora, CO, 80045, USA
- Department of Family Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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Rakhra A, Hooley C, Fort MP, Weber MB, Price L, Nguyen HL, Ramirez M, Muula AS, Hosseinipour M, Apusiga K, Davila-Roman V, Gyamfi J, Adjei KGA, Andesia J, Fitzpatrick A, Launois P, Baumann AA. Training in eight low-and middle-income countries: lessons learned from a pilot study using the WHO-TDR dissemination and implementation massive open online course. Front Health Serv 2024; 3:1217619. [PMID: 38313329 PMCID: PMC10834670 DOI: 10.3389/frhs.2023.1217619] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 12/26/2023] [Indexed: 02/06/2024]
Abstract
Introduction Non-communicable diseases (NCDs) are a leading cause of morbidity and mortality in low-and middle- income countries (LMICs). Despite this, a lack of funding, training and mentorship for NCD investigators in LMICs exists. In an effort to gain knowledge and skills to address these gaps, participants from the Global Research on Implementation and Translation Science (GRIT), a consortium of studies in eight LMICs and their networks, attended the dissemination and implementation (D&I) massive open online course (MOOC) developed by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization to strengthen D&I capacity building. Here, we report on the pilot of this MOOC, which was implemented during the SARS COVID-19 pandemic from April- November 2020. Methods Participants completed pre-and post-training questionnaires to assess self-reported D&I competencies, general research skills, and research mentor access and quality. D&I competencies were measured by use of a scale developed for a US-based training program, with change in competency scores assessed by paired t test. We used univariate statistics to analyze the data for all other outcomes. Results Of the 247 participants enrolled, 32 (13%) completed all course requirements, 21 (9%) completed the pre-and post-surveys and are included in the analysis. D&I competency scores suggest improvement for those who had complete pre- and post-assessments. Trainee's average score on the full competency scale improved 1.45 points (0-5 scale) from pre- to post-test; all four subscales also showed evidence of improvements. There were small but not significant increases in competencies for grant writing, proposal/ manuscript writing and presentations from pre- to post-test assessment. 40% of trainees reported access to a research mentor and 12% reported access to a D&I specific mentor. Participants reported barriers (e.g., unstable internet access and challenges due to COVID-19) and facilitators (e.g., topical interests, collaboration with colleagues) to completing the MOOC. Conclusions Although COVID-19 affected program usage and completion, the MOOC was feasible. We also had signals of effectiveness, meaning among LMIC participants completing the course, there was improvement in self-report D&I competency scores. Recommendations for future D&I trainings in LMICs include (1) adding more topic specific modules (i.e., NCD research, general research skills) for scalability; (2) fostering more collaboration with participants across LMICs; and (3) establishing partnerships with D&I mentors for course participants.
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Affiliation(s)
- Ashlin Rakhra
- Department of Population Health, NYU Grossman School of Medicine, New York City, NY, United States
| | - Cole Hooley
- School of Social Work, Brigham Young University, Provo, UT, United States
| | - Meredith P. Fort
- Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Mary Beth Weber
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - LeShawndra Price
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Hoa L. Nguyen
- Epidemiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Manuel Ramirez
- Center for the Prevention of Chronic Diseases -CIIPEC, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | | | - Mina Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kingsley Apusiga
- Department of Physiology, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Victor Davila-Roman
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Joyce Gyamfi
- Global Health Program, New York University Global College of Public Health, New York City, NY, United States
| | | | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Moi University, Eldoret, Kenya
| | - Annette Fitzpatrick
- School of Public Health, University of Washington, Seattle, WA, United States
| | - Pascal Launois
- Research Capacity Strengthening (RCS) Unit, Special Programme for Research and Training in Tropical Diseases (TDR), WHO, Geneva, Switzerland
| | - Ana A. Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, MO, United States
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Guarchaj M, Tschida S, Milian Chew JP, Aguilar A, Flood D, Fort MP, Morales LC, Mendoza Montano C, Rodríguez Serrano SN, Rohloff P. Impact of COVID-19 on diabetes care: mixed methods study in an Indigenous area of Guatemala. BMJ Open 2024; 14:e079130. [PMID: 38167279 PMCID: PMC10773399 DOI: 10.1136/bmjopen-2023-079130] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION SARS-CoV-2 has impacted globally the care of chronic diseases. However, direct evidence from certain vulnerable communities, such as Indigenous communities in Latin America, is missing. We use observational data from a health district that primarily serves people of Maya K'iche' ethnicity to examine the care of type 2 diabetes in Guatemala during the pandemic. METHODS We used a parallel convergent mixed methods design. Quantitative data (n=142 individuals with diabetes) included glycated haemoglobin (HbA1c), blood pressure, body mass index and questionnaires on diabetes knowledge, self-care and diabetes distress. Quantitative data was collected at two points, at baseline and after COVID restrictions were lifted. For quantitative outcomes, we constructed multilevel mixed effects models with multiple imputation for missing data. Qualitative data included interviews with providers, supervisors and individuals living with diabetes (n=20). We conducted thematic framework analysis using an inductive approach. RESULTS Quantitative data was collected between June 2019 and February 2021, with a median of 487 days between data collection points. HbA1c worsened +0.54% (95% CI, 0.14 to 0.94) and knowledge about diabetes decreased -3.54 points (95% CI, -4.56 to -2.51). Qualitatively, the most important impact of the pandemic was interruption of the regular timing of home visits and peer group meetings which were the standard of care. CONCLUSIONS The deterioration of diabetes care was primarily attributed to the loss of regular contact with healthcare workers. The results emphasize the vulnerability of rural and Indigenous populations in Latin America to the suspension of chronic disease care.
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Affiliation(s)
- Magdalena Guarchaj
- Center for Research in Indigenous Health, Maya Health Alliance | Wuqu' Kawoq, Tecpan, Chimaltenango, Guatemala
| | - Scott Tschida
- Center for Research in Indigenous Health, Maya Health Alliance | Wuqu' Kawoq, Tecpan, Chimaltenango, Guatemala
| | | | - Andrea Aguilar
- Center for Research in Indigenous Health, Maya Health Alliance | Wuqu' Kawoq, Tecpan, Chimaltenango, Guatemala
- Colectiva Guatemala Menstruante, Guatemala City, Guatemala
| | - David Flood
- Center for Research in Indigenous Health, Maya Health Alliance | Wuqu' Kawoq, Tecpan, Chimaltenango, Guatemala
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Meredith P Fort
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Carlos Mendoza Montano
- Centro de Investigación para la Prevención de las Enfermedades Crónicas, Instituto deNutrición de Centro América y Panamá, Guatemala City, Guatemala
| | | | - Peter Rohloff
- Center for Research in Indigenous Health, Maya Health Alliance | Wuqu' Kawoq, Tecpan, Chimaltenango, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Trinkley KE, Glasgow RE, D'Mello S, Fort MP, Ford B, Rabin BA. The iPRISM webtool: an interactive tool to pragmatically guide the iterative use of the Practical, Robust Implementation and Sustainability Model in public health and clinical settings. Implement Sci Commun 2023; 4:116. [PMID: 37726860 PMCID: PMC10508024 DOI: 10.1186/s43058-023-00494-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND To increase uptake of implementation science (IS) methods by researchers and implementers, many have called for ways to make it more accessible and intuitive. The purpose of this paper is to describe the iPRISM webtool (Iterative, Practical, Robust Implementation and Sustainability Model) and how this interactive tool operationalizes PRISM to assess and guide a program's (a) alignment with context, (b) progress on pragmatic outcomes, (c) potential adaptations, and (d) future sustainability across the stages of the implementation lifecycle. METHODS We used an iterative human-centered design process to develop the iPRISM webtool. RESULTS We conducted user-testing with 28 potential individual and team-based users who were English and Spanish speaking from diverse settings in various stages of implementing different types of programs. Users provided input on all aspects of the webtool including its purpose, content, assessment items, visual feedback displays, navigation, and potential application. Participants generally expressed interest in using the webtool and high likelihood of recommending it to others. The iPRISM webtool guides English and Spanish-speaking users through the process of iteratively applying PRISM across the lifecycle of a program to facilitate systematic assessment and alignment with context. The webtool summarizes assessment responses in graphical and tabular displays and then guides users to develop feasible and impactful adaptations and corresponding action plans. Equity considerations are integrated throughout. CONCLUSIONS The iPRISM webtool can intuitively guide individuals and teams from diverse settings through the process of using IS methods to iteratively assess and adapt different types of programs to align with the context across the implementation lifecycle. Future research and application will continue to develop and evaluate this IS resource.
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Affiliation(s)
- Katy E Trinkley
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO, 80045, USA.
- Adult and Child Center for Outcomes Research and Delivery Science Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Russell E Glasgow
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO, 80045, USA
- Adult and Child Center for Outcomes Research and Delivery Science Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sidney D'Mello
- Institute of Cognitive Science, University of Colorado Boulder, Boulder, CO, USA
| | - Meredith P Fort
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Bryan Ford
- Adult and Child Center for Outcomes Research and Delivery Science Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Borsika A Rabin
- Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave., Mail Stop F496, Aurora, CO, 80045, USA
- Adult and Child Center for Outcomes Research and Delivery Science Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
- ACTRI Dissemination and Implementation Science Center, University of California San Diego, La Jolla, CA, USA
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Weber MB, Baumann AA, Rakhra A, Akwanalo C, Gladys Amaning Adjei K, Andesia J, Apusiga K, Ha DA, Hosseinipour MC, Muula AS, Nguyen HL, Price LN, Ramirez-Zea M, Fitzpatrick AL, Fort MP. Global implementation research capacity building to address cardiovascular disease: An assessment of efforts in eight countries. PLOS Glob Public Health 2023; 3:e0002237. [PMID: 37708090 PMCID: PMC10501667 DOI: 10.1371/journal.pgph.0002237] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023]
Abstract
Cardiovascular diseases are the leading causes of morbidity and mortality worldwide, but implementation of evidence-based interventions for risk factors such as hypertension is lacking, particularly in low and middle income countries (LMICs). Building implementation research capacity in LMICs is required to overcome this gap. Members of the Global Research on Implementation and Translation Science (GRIT) Consortium have been collaborating in recent years to establish a research and training infrastructure in dissemination and implementation to improve hypertension care. GRIT includes projects in Ghana, Guatemala, India, Kenya, Malawi, Nepal, Rwanda, and Vietnam. We collected data from each site on capacity building activities using the Potter and Brough (2004) model, mapping formal and informal activities to develop (a) structures, systems and roles, (b) staff and infrastructure, (c) skills, and (d) tools. We captured information about sites' needs assessments and metrics plus program adaptations due to the COVID-19 pandemic. All sites reported capacity building activities in each layer of the Capacity Pyramid, with the largest number of activities in the Skills and Tools categories, the more technical and easier to implement categories. All sites included formal and informal training to build Skills. All sites included a baseline needs assessment to guide capacity building activities or assess context and inform intervention design. Sites implementing evidence-based hypertension interventions used common implementation science frameworks to evaluate implementation outcomes. Although the COVID-19 pandemic affected timelines and in-person events, all projects were able to pivot and carry out planned activities. Although variability in the activities and methods used existed, GRIT programs used needs assessments to guide locally appropriate design and implementation of capacity building activities. COVID-19 related changes were necessary, but strong collaborations and relationships with health ministries were maintained. The GRIT Consortium is a model for planning capacity building in LMICs.
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Affiliation(s)
- Mary Beth Weber
- Hubert Department of Global Health, Emory University, Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Ana A. Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Ashlin Rakhra
- Department of Population Health, NYU Grossman School of Medicine, New York City, New York, United States of America
| | | | - Kezia Gladys Amaning Adjei
- Department of Physiology, School of Medicine and Dentistry, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Kingsley Apusiga
- Department of Physiology, School of Medicine and Dentistry, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Duc A. Ha
- Health Strategy and Policy Institute, Vietnam Ministry of Health, Hanoi, Vietnam
| | - Mina C. Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Adamson S. Muula
- College of Medicine, University of Malawi and the Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Hoa L. Nguyen
- University of Massachusetts Chan Medical School, Boston, Massachusetts, United States of America
| | - LeShawndra N. Price
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Annette L. Fitzpatrick
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Meredith P. Fort
- Colorado School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora, Colorado, United States of America
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Bauer KL, Haapanen KA, Demeke N, Fort MP, Henderson KH. Increasing use of systems science in cardiovascular disease prevention to understand how to address geographic health disparities in communities with a disproportionate burden of risk. Front Cardiovasc Med 2023; 10:1216436. [PMID: 37522076 PMCID: PMC10374219 DOI: 10.3389/fcvm.2023.1216436] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
Objective Marginalized communities shoulder a disproportionate burden of cardiovascular disease (CVD) driven by concentrated neighborhood social risk factors. We provide a case study of systems science application to address geographic CVD health disparities at the community level - informing the science of CVD health disparities research. Methods We conducted a two-phased, multi-methods needs assessment in the Denver, Colorado area. Phase I consisted of a social network analysis to map a two-mode network of existing CVD prevention interventions and their implementing organizations. In Phase II, group model building (GMB) sessions with key community, public health, and healthcare provider stakeholders, were utilized to identify and visualize community factors contributing to disparities in CVD risk, producing a consensus-based causal loop diagram. Results Between May 2021 and June 2022, we conducted 24 virtual, semi-structured interviews in Phase I to describe CVD prevention interventions, and 7 virtual GMB sessions in Phase II to describe experiences of disparities in CVD risk. For the purposes of this paper, we focus on a subset of results for both phases. In Phase I we identified 89 active CVD prevention interventions, 29 of which addressed tobacco use. In Phase II, causal loop diagrams revealed root causes of disparities in CVD risk. We provide an example of a causal loop diagram that focuses on the community prevalence of tobacco use, identifying stress as a key underlying factor driving disparities. The integration of findings from both phases highlighted the alignment and misalignment between quit tobacco intervention goals and how they are being experienced in marginalized communities. Conclusion Systems science methods were useful to organize a large number of CVD prevention efforts, and evaluate the root causes of CVD health disparities in a high risk community. By integrating these two aspects, interventions may be reoriented to more effectively address the root causes of CVD health disparities.
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Affiliation(s)
- Kyla L. Bauer
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Krista A. Haapanen
- Department of Human and Organizational Development, Vanderbilt University, Nashville, TN, United States
| | - Nathaniel Demeke
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Meredith P. Fort
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kamal H. Henderson
- Department of Cardiology, University of Colorado Denver School of Medicine, Aurora, CO, United States
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Walsh-Bailey C, Gilbert A, Shato T, Sandler B, Baumann AA, Bradley CD, McLoughlin GM, McGuire FH, Fort MP, Tabak RG. Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control. Syst Rev 2023; 12:83. [PMID: 37170261 PMCID: PMC10176929 DOI: 10.1186/s13643-023-02240-2] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 04/19/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science. METHODS We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project. DISCUSSION The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines. SYSTEMATIC REVIEW REGISTRATION Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.
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Affiliation(s)
- Callie Walsh-Bailey
- Brown School, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA.
- Implementation Science Center for Cancer Control and Prevention Research Center, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA.
| | - Amanda Gilbert
- Brown School, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA
| | - Thembekile Shato
- Implementation Science Center for Cancer Control and Prevention Research Center, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 600 S. Taylor Ave, St. Louis, MO, 63110, USA
| | - Brittney Sandler
- Division of Infectious Diseases, Washington University School of Medicine, 600 S. Taylor Ave, St. Louis, MO, 63110, USA
- Bernard Becker Medical Library, School of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 600 S. Taylor Ave, St. Louis, MO, 63110, USA
| | - Cory D Bradley
- Division of Infectious Diseases, Washington University School of Medicine, 600 S. Taylor Ave, St. Louis, MO, 63110, USA
| | - Gabriella M McLoughlin
- Implementation Science Center for Cancer Control and Prevention Research Center, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- College of Public Health, Temple University, 1800 N. Broad St, Philadelphia, PA, 19121, USA
| | - F Hunter McGuire
- Brown School, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA
| | - Meredith P Fort
- Department of Health Systems, Management and Policy, Colorado School of Public Health, 13055 E. 17Th Ave, Aurora, CO, 80045, USA
| | - Rachel G Tabak
- Brown School, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA
- Implementation Science Center for Cancer Control and Prevention Research Center, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
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Fort MP, Manson SM, Glasgow RE. Applying an equity lens to assess context and implementation in public health and health services research and practice using the PRISM framework. Front Health Serv 2023; 3:1139788. [PMID: 37125222 PMCID: PMC10137153 DOI: 10.3389/frhs.2023.1139788] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/13/2023] [Indexed: 05/02/2023]
Abstract
Dissemination and implementation science seeks to enhance the uptake, successful implementation, and sustainment of evidence-based programs and policies. While a focus on health equity is implicit in many efforts to increase access to and coverage of evidence-based programs and policies, most implementation frameworks and models do not explicitly address it. Disparities may in fact be increased by emphasizing high intensity interventions or ease of delivery over meeting need within the population, addressing deep-rooted structural inequities, and adapting to local context and priorities. PRISM (Practical, Robust Implementation and Sustainability Model), the contextual expansion of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework has several elements that address health equity, but these have not been explicated, integrated, or illustrated in one place. We present guidance for applying PRISM with an equity lens across its four context domains (external environment; multi-level perspectives on the intervention; characteristics of implementers and intended audience; and the implementation and sustainability infrastructure-as well as the five RE-AIM outcome dimensions. We then present an example with health equity considerations and discuss issues of representation and participation, representativeness and the importance of ongoing, iterative assessment of dynamic context and structural drivers of inequity. We also elaborate on the importance of a continuous process that requires addressing community priorities and responding to capacity and infrastructure needs and changes. We conclude with research and practice recommendations for applying PRISM with an increased emphasis on equity.
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Affiliation(s)
- Meredith P. Fort
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, United States
- Department of Health Systems, Management and Policy, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, United States
| | - Spero M. Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, United States
| | - Russell E. Glasgow
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus, and Eastern Colorado Veterans Administration, Aurora, CO, United States
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Paniagua-Avila A, Shelton RC, Guzman AL, Gutierrez L, Galdamez DH, Ramirez JM, Rodriguez J, Irazola V, Ramirez-Zea M, Fort MP. Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: An application of the RE-AIM/PRISM extension for sustainability and health equity. Res Sq 2023:rs.3.rs-2362741. [PMID: 36712105 PMCID: PMC9882599 DOI: 10.21203/rs.3.rs-2362741/v1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background The COVID-19 pandemic necessitated rapid changes in the delivery of care across public primary care settings in rural Guatemala in 2020. In response, a hypertension program implemented within the public primary care system required multiple adaptations, providing an illustrative example of dynamic implementation amidst changing context in an under-resourced setting. This study describes the evolvability of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care) during the COVID-19 pandemic and discusses implications for health equity and sustainability. Methods This convergent mixed methods analysis assessed implementation across five Ministry of Health districts during the initial phase of the pandemic. Qualitative and quantitative data were collected, analyzed, and integrated, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation Maintenance) Framework's extension for sustainability, and its contextual enhancement, PRISM (Pragmatic, Robust, Implementation and Sustainability Model). For RE-AIM, we focused on the "Implementation" domain, operationalizing it qualitatively as continued delivery and adaptations to the EBI and implementation strategy, and quantitatively as the extent of delivery over time. We conducted 18 in-depth interviews with health providers / administrators (n=8) and study staff (n=10) and performed a matrix-based thematic-analysis. Qualitative results informed the selection of quantitative implementation summarized as behavior over time graphs. Quantitative implementation data and illustrative quotes are presented as joint displays. Results In relation to implementation, several organic adaptations hindered delivery, threatened sustainability, and may have exacerbated health inequities. Planned adaptations enhanced program delivery and may have supported improved equity and sustainability. Salient PRISM factors that influenced implementation included "Organizational perspective of the EBI", "Fit" and "Implementation and sustainability infrastructure". Facilitators to continued delivery included the perception that the EBI is beneficial, program champions, and healthcare team organization. Barriers included the perception that the EBI is complicated, competition with other primary care activities, and temporary suspension of services due to COVID-19. Conclusions Multi-level contextual changes led to numerous adaptations of the EBI and implementation strategy. Systems thinking approaches may shed light on how a program's sustainability and its equitable delivery are influenced by adaptations over time in response to dynamic, multi-level contextual factors. Trial registration NCT03504124.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Meredith P Fort
- CU Anschutz Medical Campus: University of Colorado Anschutz Medical Campus
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11
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Figueroa JC, Paniagua-Avila A, Sub Cuc I, Cardona S, Ramirez-Zea M, Irazola V, Fort MP. Explanatory models of hypertension in Guatemala: recognizing the perspectives of patients, family members, health care providers and administrators, and national-level health system stakeholders. BMC Public Health 2022; 22:2320. [PMID: 36510216 PMCID: PMC9743515 DOI: 10.1186/s12889-022-14668-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Uncontrolled hypertension is a major public health burden and the most common preventable risk factor for cardiovascular diseases in Guatemala and other low- and middle-income countries. Prior to an initial trial that evaluated a hypertension intervention in rural Guatemala, we collected qualitative information on the needs and knowledge gaps of hypertension care within Guatemala's public healthcare system. This analysis applied Kleinman's Explanatory Models of Illness to capture how patients, family members, community-, district-, and provincial-level health care providers and administrators, and national-level health system stakeholders understand hypertension. METHODS: We conducted in-depth interviews with three types of participants: 1) national-level health system stakeholders (n = 17), 2) local health providers and administrators from district, and health post levels (25), and 3) patients and family members (19) in the departments of Sololá and Zacapa in Guatemala. All interviews were conducted in Spanish except for 6 Maya-Kaqchikel interviews. We also conducted focus group discussions with auxiliary nurses (3) and patients (3), one in Maya-Tz'utujil and the rest in Spanish. Through framework and matrix analysis, we compared understandings of hypertension by participant type using the Explanatory Model of Illness domains -etiology, symptoms, pathophysiology, course of illness, and treatment. RESULTS Health providers and administrators, and patients described hypertension as an illness that spurs from emotional states like sadness, anger, and worry; is inherited and related to advanced age; and produces symptoms that include a weakened body, nerves, pain, and headaches. Patients expressed concerns about hypertension treatment's long-term consequences, despite trying to comply with treatment. Patients stated that they combine biomedical treatment (when available) with natural remedies (teas and plants). Health providers and administrators and family members stated that once patients feel better, they often disengage from treatment. National-level health system stakeholders referred to lifestyle factors as important causes, considered patients to typically be non-compliant, and identified budget limitations as a key barrier to hypertension care. The three groups of participants identified structural barriers to limited hypertension care (e.g., limited access to healthy food and unaffordability of medications). CONCLUSION As understandings of hypertension vary between types of participants, it is important to describe their similarities and differences considering the role each has in the health system. Considering different perceptions of hypertension will enable better informed program planning and implementation efforts.
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Affiliation(s)
- Juan Carlos Figueroa
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala.
- Dornsife School of Public Health, Department of Epidemiology and Biostatistics, Drexel University, Urban Health Collaborative, Philadelphia, PA, USA.
| | - Alejandra Paniagua-Avila
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York City, New York, USA
| | - Ingrid Sub Cuc
- Department of Native American Studies, University of California, Davis, Davis, CA, , USA
| | - Sayra Cardona
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Calzada Roosevelt 6-25 Zona 11, 01011, Guatemala City, Guatemala
- Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
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12
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Glasgow RE, Battaglia C, McCreight M, Ayele R, Maw AM, Fort MP, Holtrop JS, Gomes RN, Rabin BA. Use of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to guide iterative adaptations: Applications, lessons learned, and future directions. Front Health Serv 2022; 2:959565. [PMID: 36925843 PMCID: PMC10012751 DOI: 10.3389/frhs.2022.959565] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/23/2022] [Indexed: 02/07/2023]
Abstract
Introduction Implementation science frameworks have been used widely for planning and evaluation, but seldom to guide adaptations during program implementation. There is great potential for these frameworks to be used to inform conceptual and data-driven decisions about adaptations. Methods We summarize recent applications using Iterative RE-AIM to capture and guide adaptations. Iterative RE-AIM can be repeated at multiple time points customized to each project and involves the following activities: identification of key implementation partners; rating importance of and progress on each RE-AIM dimension (reach, effectiveness, adoption, implementation, and maintenance); use of summary data on ratings to identify one or two RE-AIM dimensions for adaptations and implementation strategies; and evaluation of progress and impact of adaptations. We summarize recent and ongoing Iterative RE-AIM applications across multiple care coordination and pain management projects within the Veterans Health Administration, a hypertension control trial in Guatemala, a hospital-based lung ultrasound implementation pilot, and a colorectal cancer screening program in underserved communities. Results Iterative RE-AIM appears feasible, helpful, and broadly applicable across diverse health care issues, interventions, contexts, and populations. In general, the RE-AIM dimension showing the largest gap between importance and progress has been Reach. The dimensions most frequently selected for improvement have been Reach and Implementation. We discuss commonalities, differences and lessons learned across these various applications of Iterative RE-AIM. Challenges include having objective real time data on which to make decisions, having key implementation staff available for all assessments, and rapidly scoring and providing actionable feedback. We discuss print and online resources and materials to support Iterative RE-AIM. Conclusions The use of Iterative RE-AIM to guide and support understanding of adaptations has proven feasible across diverse projects and in multiple case studies, but there are still questions about its strengths, limitations, essential components, efficiency, comparative effectiveness, and delivery details. Future directions include investigating the optimal frequency and timing for iterative applications; adding contextual assessments; developing more continuous and rapid data on which to make adaptation decisions; identifying opportunities to enhance health equity; and determining the level of facilitation that is most cost-effective.
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Affiliation(s)
- Russell E. Glasgow
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Catherine Battaglia
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veteran Affairs, VA Eastern Colorado Health Care System, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veteran Affairs, VA Eastern Colorado Health Care System, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veteran Affairs, VA Eastern Colorado Health Care System, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Anna M. Maw
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Meredith P. Fort
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Health Systems, Management and Policy Department, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jodi Summers Holtrop
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Rebekah N. Gomes
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Borsika Adrienn Rabin
- Colorado Implementation Science Center for Cancer Control, Dissemination and Implementation Science Program, Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Dissemination and Implementation Science Center, Altman Clinical and Translational Research Center, Herbert Wertheim School of Public Health and Human Longevity in Science, University of California, San Diego, CA, United States
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13
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Fort MP, Reid M, Russell J, Santos CJ, Running Bear U, Begay RL, Smith SL, Morrato EH, Manson SM. Diabetes Prevention and Care Capacity at Urban Indian Health Organizations. Front Public Health 2021; 9:740946. [PMID: 34900897 PMCID: PMC8661087 DOI: 10.3389/fpubh.2021.740946] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
American Indian and Alaska Native (AI/AN) people suffer a disproportionate burden of diabetes and cardiovascular disease. Urban Indian Health Organizations (UIHOs) are an important source of diabetes services for urban AI/AN people. Two evidence-based interventions-diabetes prevention (DP) and healthy heart (HH)-have been implemented and evaluated primarily in rural, reservation settings. This work examines the capacity, challenges and strengths of UIHOs in implementing diabetes programs. Methods: We applied an original survey, supplemented with publicly-available data, to assess eight organizational capacity domains, strengths and challenges of UIHOs with respect to diabetes prevention and care. We summarized and compared (Fisher's and Kruskal-Wallis exact tests) items in each organizational capacity domain for DP and HH implementers vs. non-implementers and conducted a thematic analysis of strengths and challenges. Results: Of the 33 UIHOs providing services in 2017, individuals from 30 sites (91% of UIHOs) replied to the survey. Eight UIHOs (27%) had participated in either DP (n = 6) or HH (n = 2). Implementers reported having more staff than non-implementers (117.0 vs. 53.5; p = 0.02). Implementers had larger budgets, ~$10 million of total revenue compared to $2.5 million for non-implementers (p = 0.01). UIHO strengths included: physical infrastructure, dedicated leadership and staff, and community relationships. Areas to strengthen included: staff training and retention, ensuring sufficient and consistent funding, and data infrastructure. Conclusions: Strengthening UIHOs across organizational capacity domains will be important for implementing evidence-based diabetes interventions, increasing their uptake, and sustaining these interventions for AI/AN people living in urban areas of the U.S.
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Affiliation(s)
- Meredith P Fort
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Margaret Reid
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jenn Russell
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Cornelia J Santos
- Environmental Studies-Indigenous Sustainability Studies Program, Bemidji State University, Bemidji, MN, United States
| | - Ursula Running Bear
- Department of Population Health, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Rene L Begay
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Savannah L Smith
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, United States
| | - Spero M Manson
- Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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14
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Tschida S, Flood D, Guarchaj M, Milian J, Aguilar A, Fort MP, Guetterman T, Montano CM, Miller A, Morales L, Rohloff P. Implementation of a Diabetes Self-Management Education and Support Intervention in Rural Guatemala: A Mixed-Methods Evaluation Using the RE-AIM Framework. Prev Chronic Dis 2021; 18:E100. [PMID: 34882536 PMCID: PMC8673946 DOI: 10.5888/pcd18.210259] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION To address the global diabetes epidemic, lifestyle counseling on diet, physical activity, and weight loss is essential. This study assessed the implementation of a diabetes self-management education and support (DSMES) intervention using a mixed-methods evaluation framework. METHODS We implemented a culturally adapted, home-based DSMES intervention in rural Indigenous Maya towns in Guatemala from 2018 through 2020. We used a pretest-posttest design and a mixed-methods evaluation approach guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative data included baseline characteristics, implementation metrics, effectiveness outcomes, and costs. Qualitative data consisted of semistructured interviews with 3 groups of stakeholders. RESULTS Of 738 participants screened, 627 participants were enrolled, and 478 participants completed the study. Adjusted mean change in glycated hemoglobin A1c was -0.4% (95% CI, -0.6% to -0.3%; P < .001), change in systolic blood pressure was -5.0 mm Hg (95% CI, -6.4 to -3.7 mm Hg; P < .001), change in diastolic blood pressure was -2.6 mm Hg (95% CI, -3.4 to -1.9 mm Hg; P < .001), and change in body mass index was 0.5 (95% CI, 0.3 to 0.6; P < .001). We observed improvements in diabetes knowledge, distress, and most self-care activities. Key implementation factors included 1) recruitment barriers for men, 2) importance of patient-centered care, 3) role of research staff in catalyzing health worker involvement, 4) tradeoffs between home and telephone visits, and 5) sustainability challenges. CONCLUSION A community health worker-led DSMES intervention was successfully implemented in the public health system in rural Guatemala and resulted in significant improvements in most clinical and psychometric outcomes. Scaling up sustainable DSMES in health systems in rural settings requires careful consideration of local barriers and facilitators.
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Affiliation(s)
- Scott Tschida
- Center for Research in Indigenous Health, Wuqu' Kawoq, Tecpán, Chimaltenango, Guatemala
- Wuqu' Kawoq, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala.
| | - David Flood
- Center for Research in Indigenous Health, Wuqu' Kawoq, Tecpán, Chimaltenango, Guatemala
- Department of Internal Medicine, National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan
| | - Magdalena Guarchaj
- Center for Research in Indigenous Health, Wuqu' Kawoq, Tecpán, Chimaltenango, Guatemala
| | - Juanita Milian
- Instituto de Salud Incluyente, San Lucas Sacatepéquez, Sacatepéquez, Guatemala
| | - Andrea Aguilar
- Center for Research in Indigenous Health, Wuqu' Kawoq, Tecpán, Chimaltenango, Guatemala
| | - Meredith P Fort
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Timothy Guetterman
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carlos Mendoza Montano
- Centro de Investigación para la Prevención de las Enfermedades Crónicas, Instituto de Nutrición de Centro América y Panamá, Guatemala City, Guatemala
| | - Ann Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lidia Morales
- Instituto de Salud Incluyente, San Lucas Sacatepéquez, Sacatepéquez, Guatemala
| | - Peter Rohloff
- Center for Research in Indigenous Health, Wuqu' Kawoq, Tecpán, Chimaltenango, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Hernández-Galdamez D, Mansilla K, Peralta AL, Rodríguez-Szaszdi J, Ramírez JM, Roche D, Gulayin P, Ramirez-Zea M, He J, Irazola V, Fort MP. Monitoring Study Participants and Implementation with Phone Calls to Support Hypertension Control During the COVID-19 Pandemic: The Case of a Multicomponent Intervention Trial in Guatemala. Glob Heart 2021; 16:77. [PMID: 34900568 PMCID: PMC8622336 DOI: 10.5334/gh.954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 10/30/2021] [Indexed: 11/20/2022] Open
Abstract
Background The COVID-19 pandemic presents a challenge to health care for patients with chronic diseases, especially hypertension, because of the important association and increased risk of these patients with a severe presentation of COVID-19 disease. The Guatemalan Ministry of Health has been implementing a multi-component program aimed at improving hypertension control in rural communities since 2019 as a part of an intervention research cluster randomized trial. When the first cases of COVID-19 were reported (March 13, 2020) in Guatemala, our study paused all study field activities, and began monitoring participants through phone calls. The objective of this paper is to describe the approach used to monitor study participants during the COVID-19 pandemic and compare data obtained during phone calls for intervention and control group participants. Methods We developed a cross-sectional study within the HyTREC (Hypertension Outcomes for T4 Research within Lower Middle-Income Countries) project 'Multicomponent Intervention to Improve Hypertension Control in Central America: Guatemala' in which phone calls were made to participants from both intervention and control groups to monitor measures important to the study: delivery of antihypertensive medications in both groups, receipt of coaching sessions and use of a home blood pressure monitor by intervention group participants, as well as reasons that they were not implemented. Results Regarding the delivery of antihypertensive drugs by the MoH to participants, those in the intervention group had a higher level of medication delivery (73%) than the control group (51%), p<0.001. Of the total participants in the intervention group, 62% had received at least one health coaching session in the previous three months and 81% used a digital home blood pressure monitor at least twice a week. Intervention activities were lower than expected due to restricted public transportation on top of decreased availability of health providers. Conclusion In Guatemala, specifically in rural settings, access to antihypertensive medications and health services during pandemic times was impaired and less than expected, even after accounting for the program's implementation activities and actions.
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Affiliation(s)
- Diego Hernández-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Kristyne Mansilla
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Ana Lucía Peralta
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Javier Rodríguez-Szaszdi
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Juan Manuel Ramírez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Dina Roche
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Pablo Gulayin
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, AR
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Jiang He
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, US
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, AR
| | - Meredith P. Fort
- Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, US
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16
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Fort MP, Mundo W, Paniagua-Avila A, Cardona S, Figueroa JC, Hernández-Galdamez D, Mansilla K, Peralta-García A, Roche D, Palacios EA, Glasgow RE, Gulayin P, Irazola V, He J, Ramirez-Zea M. Hypertension in Guatemala's Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework. BMC Health Serv Res 2021; 21:908. [PMID: 34479559 PMCID: PMC8414027 DOI: 10.1186/s12913-021-06889-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/29/2020] [Accepted: 08/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. Methods We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. Results Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. Conclusions This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06889-0.
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Affiliation(s)
- Meredith P Fort
- Department of Health Systems, Management and Policy, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA. .,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA. .,INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.
| | - William Mundo
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Alejandra Paniagua-Avila
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Sayra Cardona
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Juan Carlos Figueroa
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Diego Hernández-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Kristyne Mansilla
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Ana Peralta-García
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Dina Roche
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | | | - Russell E Glasgow
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Pablo Gulayin
- South American Center of Excellence for Cardiovascular Health, Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Vilma Irazola
- South American Center of Excellence for Cardiovascular Health, Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Jiang He
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.,Tulane University Translation Science Institute, New Orleans, LA, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
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Fort MP, Steiner JF, Santos C, Moore KR, Villaverde MD, Nease DE, Ortega D, Manson SM. Opportunities, Challenges, and Strategies for Engaging Family in Diabetes and Hypertension Management: A Qualitative Study. J Health Care Poor Underserved 2021; 31:827-844. [PMID: 33410810 DOI: 10.1353/hpu.2020.0063] [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: 11/11/2022]
Abstract
Family engagement may improve disease management, yet little is known about this topic as it relates to underrepresented minorities who receive care in low-resource primary care settings. This study aimed to explore family engagement in diabetes and hypertension management at an Urban Indian Health Organization to identify opportunities and challenges, and inform care strategies. We employed semi-structured interviews, genograms, eco-maps, and timelines, among 23 English- and Spanish-speaking American Indian and Latino adults with a dual diagnosis of type 2 diabetes and hypertension and 13 family members. Using thematic analysis, we found that family support is not always available, patients have difficulty sharing medical information, and family often live far away. Conversely, opportunities to leverage included a desire for increased engagement, motivation from the younger generation, prevention within the family, outreach to family members with the same conditions, and learning from elders and ancestors. Implications for programs, clinical care, and research are discussed.
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Paniagua-Avila A, Fort MP, Glasgow RE, Gulayin P, Hernández-Galdamez D, Mansilla K, Palacios E, Peralta AL, Roche D, Rubinstein A, He J, Ramirez-Zea M, Irazola V. Evaluating a multicomponent program to improve hypertension control in Guatemala: study protocol for an effectiveness-implementation cluster randomized trial. Trials 2020; 21:509. [PMID: 32517806 PMCID: PMC7281695 DOI: 10.1186/s13063-020-04345-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 03/17/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypertension is a major risk factor for cardiovascular disease (CVD). Despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (LMICs). We will evaluate an adapted version of a multilevel and multicomponent hypertension control program in Guatemala, previously proven effective and feasible in Argentina. The program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback. METHODS Using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in Guatemala over an 18-month period. Through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 to enhanced usual care across five departments, enrolling 44 participants per health district and 1584 participants in total. The clinical outcomes are (1) the difference in the proportion of patients with controlled hypertension (< 130/80 mmHg) between the intervention and control groups at 18 months and (2) the net change in systolic and diastolic blood pressure from baseline to 18 months. The context-enhanced Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM)/Practical Robust Implementation and Sustainability Model (PRISM) framework will guide the evaluation of the implementation at the level of the patient, provider, and health system. Using a mixed-methods approach, we will evaluate the following implementation outcomes: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost-effectiveness. DISCUSSION We will disseminate the study findings, and promote scale up and scale out of the program, if proven effective. This study will generate urgently needed data on effective, adoptable, and sustainable interventions and implementation strategies to improve hypertension control in Guatemala and other LMICs. TRIAL REGISTRATION ClinicalTrials.gov: NCT03504124. Registered on 20 April 2018.
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Affiliation(s)
- Alejandra Paniagua-Avila
- Mailman School of Public Health, Columbia University, New York, NY, USA.,INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala.,Colorado School of Public Health, Aurora, CO, USA
| | - Russell E Glasgow
- Department of Family Medicine, and Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, USA
| | - Pablo Gulayin
- Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Diego Hernández-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Kristyne Mansilla
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Eduardo Palacios
- Programa Nacional de Enfermedades Crónicas, Ministerio de Salud y Asistencia Social (MSPAS), Guatemala City, Guatemala
| | - Ana Lucia Peralta
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Dina Roche
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Adolfo Rubinstein
- Programa Nacional de Enfermedades Crónicas, Ministerio de Salud y Asistencia Social (MSPAS), Guatemala City, Guatemala
| | - Jiang He
- Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, LA, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala.
| | - Vilma Irazola
- Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, LA, USA
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Schroeder EB, Moore KR, Manson SM, Baldwin MA, Goodrich GK, Malone AS, Pieper LE, Xu S, Fort MP, Son‐Stone L, Johnson D, Steiner JF. A randomized clinical trial of an interactive voice response and text message intervention for individuals with hypertension. J Clin Hypertens (Greenwich) 2020; 22:1228-1238. [DOI: 10.1111/jch.13909] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Emily B. Schroeder
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
- Department of Medicine University of Colorado Anschutz Medical Campus Aurora CO USA
- Parkview Health Fort Wayne IN USA
| | - Kelly R. Moore
- Centers for American Indian and Alaska Native Health University of Colorado Anschutz Medical Campus Aurora CO USA
| | - Spero M. Manson
- Centers for American Indian and Alaska Native Health University of Colorado Anschutz Medical Campus Aurora CO USA
| | - Megan A. Baldwin
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
| | - Glenn K. Goodrich
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
| | - Allen S. Malone
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
| | - Lisa E. Pieper
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
| | - Stanley Xu
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
| | - Meredith P. Fort
- Centers for American Indian and Alaska Native Health University of Colorado Anschutz Medical Campus Aurora CO USA
| | | | - David Johnson
- First Nations Community HealthSource Albuquerque NM USA
| | - John F. Steiner
- Kaiser Permanente Colorado Institute for Health Research Aurora CO USA
- Department of Medicine University of Colorado Anschutz Medical Campus Aurora CO USA
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20
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Fort MP, Paniagua-Avila A, Beratarrechea A, Cardona S, Figueroa JC, Martinez-Folgar K, Moyano D, Barrios E, Mazariegos BE, Palacios E, Irazola V, He J, Ramirez-Zea M. Stakeholder Engagement in the Translation of a Hypertension Control Program to Guatemala's Public Primary Health Care System: Lessons Learned, Challenges, and Opportunities. Glob Heart 2020; 14:155-163. [PMID: 31324370 DOI: 10.1016/j.gheart.2019.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/25/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is an urgent need to define appropriate intervention strategies to control blood pressure in low- and middle-income countries. In 2018, a program proven effective in Argentina was translated to Guatemala's public primary health care system in rural and primarily indigenous communities. OBJECTIVES This paper describes the stakeholder engagement process used to adapt the program to the Guatemalan rural context prior to implementing a type II hybrid effectiveness-implementation trial and shares lessons learned. METHODS We identified key differences in the 2 contexts that are relevant to translating the intervention to the Guatemalan context. Alongside interviews and focus group discussions, we conducted consultation workshops in July and August 2018, applying a participatory translation process involving patients, family members, community members, health care providers, and Ministry of Health officials. The process consisted of multiple meetings in Guatemala City, as well as meetings in each of the 5 departments where the study will be implemented, and 1 district per department. During the workshops, we presented the evidence-based experience from Argentina and then focused on the challenges and recommended solutions that the participants identified for each of the intervention's 6 components. The process concluded with a meeting in which the research team and Ministry of Health officials defined specific details of the intervention. RESULTS The outcome of the process is an adapted approach appropriate to integrate into Guatemala's public primary health care system in the trial phase. The approach considers the challenges and recommended strategies for each of the 6 intervention components. CONCLUSIONS We identified lessons learned, challenges, and opportunities during the adaptation process. Findings will inform ongoing stakeholder engagement during the study implementation and future scale-up and efforts to translate evidence-based hypertension control strategies to low- and middle-income countries globally.
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Affiliation(s)
- Meredith P Fort
- Department of Health Systems, Management and Policy, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Aurora, CO, USA; Institute of Nutrition of Central America and Panama (INCAP) Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
| | - Alejandra Paniagua-Avila
- Institute of Nutrition of Central America and Panama (INCAP) Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Andrea Beratarrechea
- Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Sayra Cardona
- Institute of Nutrition of Central America and Panama (INCAP) Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Juan Carlos Figueroa
- Institute of Nutrition of Central America and Panama (INCAP) Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Kevin Martinez-Folgar
- Institute of Nutrition of Central America and Panama (INCAP) Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Daniela Moyano
- Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Edgar Barrios
- Ministry of Health and Social Welfare, Guatemala City, Guatemala
| | | | - Eduardo Palacios
- Ministry of Health and Social Welfare, Guatemala City, Guatemala
| | - Vilma Irazola
- Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Manuel Ramirez-Zea
- Institute of Nutrition of Central America and Panama (INCAP) Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
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21
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Maw AM, Galvin B, Henri R, Yao M, Exame B, Fleshner M, Fort MP, Morris MA. Stakeholder Perceptions of Point-of-Care Ultrasound Implementation in Resource-Limited Settings. Diagnostics (Basel) 2019; 9:diagnostics9040153. [PMID: 31635219 PMCID: PMC6963438 DOI: 10.3390/diagnostics9040153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Nearly half of the world lacks access to diagnostic imaging. Point of care ultrasound (POCUS) is a versatile and relatively affordable imaging modality that offers promise as a means of bridging the radiology gap and improving care in low resource settings. Methods: We performed semi-structured interviews of key stakeholders at two diverse hospitals where POCUS implementation programs had recently been conducted: one in a rural private hospital in Haiti and the other in a public referral hospital in Malawi. Questions regarding the clinical utility of POCUS, as well as barriers and facilitators of its implementation, were asked of study participants. Using the Framework Method, analysis of interview transcripts was guided by the WHO ASSURED criteria for point of care diagnostics. Results: Fifteen stakeholders with diverse roles in POCUS implementation were interviewed. Interviewees from both sites considered POCUS a valuable diagnostic tool that improved clinical decisions. They perceived barriers to adequate training as one of the most important remaining barriers to POCUS implementation. Conclusions: In spite of the increasing affordability and portability of ultrasounds devices, there are still important barriers to the implementation of POCUS in resource-limited settings.
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Affiliation(s)
- Anna M Maw
- Division of Hospital Medicine, University of Colorado, Aurora, CO 80045, USA.
| | | | | | - Micheal Yao
- Division of Engineering and Applied Science, California Institute of Technology, Pasadena, CA 91125, USA.
| | - Bruno Exame
- Alma Mater Hospital, Gros Morne 4210, Haiti.
| | - Michelle Fleshner
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA.
| | - Meredith P Fort
- Department of Health Systems, Management and Policy, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Aurora, CO 80045, USA.
| | - Megan A Morris
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO 80045, USA.
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Abstract
Health in All Policies (HiAP) encourage health-conscious policymaking in
non-health sectors; however, there are no standardized measures or guides for
assessing progress in HiAP implementation. The purpose of this study was to
describe how HiAP in local public health agencies (LPHAs) are implemented at the
local level in Colorado and identify challenges and opportunities for
implementation. We conducted semi-structured interviews with 13 key informants
identified through purposive sampling. Interviews were recorded, double-coded,
and analyzed using thematic analysis. The themes we identified relating to the
implementation of different HiAP approaches were as follows: the importance of
building trusting relationships, a need to understand the work of LPHAs and
public health, and LPHA structure and role clarity. Tools and tactics that
respondents identified in their implementation and practice of HiAP are sharing
data and data platforms, community dashboarding, providing services to partners,
sharing programs or services, attending meetings regularly, and measurement
instruments. This study demonstrates HiAP approach variation and the need for a
state-wide standardized framework for initiatives and progress. Future HiAP
implementation research should focus on county-level analysis using outcomes
that LPHAs are targeting based on their health priorities and should also
capture the activities of sectors outside of public health.
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Affiliation(s)
- William Mundo
- University of Colorado Anschutz Medical
Campus, Aurora, USA,William Mundo, Department of Health Systems,
Management & Policy, University of Colorado Anschutz Medical Campus, 13120
E. 19th Avenue, Box A-049, Room 5223-1, Aurora, CO 80045, USA.
| | - Peter Manetta
- University of Colorado Anschutz Medical
Campus, Aurora, USA,Colorado Association of Local Public
Health Officials, Denver, USA
| | | | - Angela Sauaia
- University of Colorado Anschutz Medical
Campus, Aurora, USA
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Fort MP, Namba LM, Dutcher S, Copeland T, Bermingham N, Fellenz C, Lantz D, Reusch JJ, Bayliss EA. Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area. Perm J 2017; 21:16-022. [PMID: 28241908 DOI: 10.7812/tpp/16-022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In response to limited access to specialty care in safety-net settings, an integrated delivery system and three safety-net organizations in the Denver, CO, metropolitan area launched a unique program in 2013. The program offers safety-net providers the option to electronically consult with specialists. Uninsured patients may be seen by specialists in office visits for a defined set of services. This article describes the program, identifies aspects that have worked well and areas that need improvement, and offers lessons learned. METHODS We quantified electronic consultations (e-consults) between safety-net clinicians and specialists, and face-to-face specialist visits between May 2013 and December 2014. We reviewed and categorized all e-consults from November and December 2014. In 2015, we interviewed 21 safety-net clinicians and staff, 12 specialists, and 10 patients, and conducted a thematic analysis to determine factors facilitating and limiting optimal program use. RESULTS In the first 20 months of the program, safety-net clinicians at 23 clinics made 602 e-consults to specialists, and 81 patients received face-to-face specialist visits. Of 204 primary care clinicians, 103 made e-consults; 65 specialists participated in the program. Aspects facilitating program use were referral case managers' involvement and the use of clear, concise questions in e-consults. Key recommendations for process improvement were to promote an understanding of the different health care contexts, support provider-to-provider communication, facilitate hand-offs between settings, and clarify program scope. CONCLUSION Participants perceived the program as responsive to their needs, yet opportunities exist for continued uptake and expansion. Communitywide efforts to assess and address needs remain important.
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Affiliation(s)
- Meredith P Fort
- Research Assistant Professor in the Department of Health Systems, Management and Policy and the Centers for American Indian and Alaska Native Health at the University of Colorado Denver in Aurora.
| | - Lynnette M Namba
- Senior Community Health Specialist in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Sarah Dutcher
- Community Health Center Advocate and a former Senior Manager in the Quality Initiatives Division of the Colorado Community Health Network in Denver.
| | - Tracy Copeland
- Project Coordinator for Community Care in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Neysa Bermingham
- Former Access to Care Manager in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Chris Fellenz
- Physician Lead for Safety Net Partnerships and Access to Care in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Deborah Lantz
- Clinical Services Director for the Department of Neurology and Community Patient Access for Kaiser Permanente Colorado in Denver.
| | - John J Reusch
- Cardiologist with the Colorado Permanente Medical Group in Denver.
| | - Elizabeth A Bayliss
- Clinician Investigator for the Institute for Health Research of Kaiser Permanente Colorado in Denver and a Professor of Family Medicine at the University of Colorado School of Medicine.
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Fort MP, Murillo S, López E, Dengo AL, Alvarado-Molina N, de Beausset I, Castro M, Peña L, Ramírez-Zea M, Martínez H. Impact evaluation of a healthy lifestyle intervention to reduce cardiovascular disease risk in health centers in San José, Costa Rica and Chiapas, Mexico. BMC Health Serv Res 2015; 15:577. [PMID: 26711290 PMCID: PMC4693408 DOI: 10.1186/s12913-015-1248-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/19/2015] [Indexed: 11/24/2022] Open
Abstract
Background Previous healthy lifestyle interventions based on the Salud para Su Corazón curriculum for Latinos in the United States, and a pilot study in Guatemala, demonstrated improvements in patient knowledge, behavior, and clinical outcomes for adults with hypertension. This article describes the implementation of a healthy lifestyle group education intervention at the primary care health center level in the capital cities of Costa Rica and Chiapas, Mexico for patients with hypertension and/or type 2 diabetes and presents impact evaluation results. Methods Six group education sessions were offered to participants at intervention health centers from November 2011 to December 2012 and participants were followed up for 8 months. The study used a prospective, longitudinal, nonequivalent pretest-posttest comparison group design, and was conducted in parallel in the two countries. Cognitive and behavioral outcome measures were knowledge, self-efficacy, stage-of-change, dietary behavior and physical activity. Clinical outcomes were: body mass index, systolic and diastolic blood pressure, and fasting blood glucose. Group by time differences were assessed using generalized estimating equation models, and a dose–response analysis was conducted for the intervention group. Results The average number of group education sessions attended in Chiapas was 4 (SD: 2.2) and in Costa Rica, 1.8 (SD: 2.0). In both settings, participation in the study declined by 8-month follow-up. In Costa Rica, intervention group participants showed significant improvements in systolic and diastolic blood pressure and borderline significant improvement for fasting glucose, and significant improvement in the stages-of-change measure vs. the comparison group. In Chiapas, the intervention group showed significant improvement in the stages-of-change measure in relation to the comparison group. Significant improvements were not observed for knowledge, self-efficacy, dietary behavior or physical activity. In Chiapas only, a significant dose–response relationship was observed for systolic and diastolic blood pressure. Conclusion Group education interventions at health centers have the potential to improve stage-of-change activation, and may also improve clinical outcomes. In the future, it will be essential to dedicate resources to understand ways to reach a representative group of the patient population, tailor the intervention so that patients are engaged to participate, and consider the broader family and community context that influences patients’ capacity to manage their condition.
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Affiliation(s)
- Meredith P Fort
- Department of Family Medicine, University of Colorado, 13055 East 17th Avenue, Aurora, CO, 80045, USA. .,INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala.
| | - Sandra Murillo
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala.
| | - Erika López
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Ana Laura Dengo
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala.
| | - Nadia Alvarado-Molina
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala. .,School of Nutrition, University of Costa Rica, San José, Costa Rica.
| | - Indira de Beausset
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala. .,School of Nutrition, University of Costa Rica, San José, Costa Rica.
| | - Maricruz Castro
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Liz Peña
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Manuel Ramírez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala.
| | - Homero Martínez
- INCAP Research Center for the Prevention of Chronic Diseases, Guatemala City, Guatemala. .,RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. .,Hospital Infantil de México "Dr. Federico Gómez", Mexico City, Mexico.
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Fort MP, Castro M, Peña L, López Hernández SH, Arreola Camacho G, Ramírez-Zea M, Martínez H. Opportunities for involving men and families in chronic disease management: a qualitative study from Chiapas, Mexico. BMC Public Health 2015; 15:1019. [PMID: 26438195 PMCID: PMC4595112 DOI: 10.1186/s12889-015-2361-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/28/2015] [Indexed: 12/03/2022] Open
Abstract
Background A healthy lifestyle intervention was implemented in primary care health centers in urban parts of Tuxtla Gutiérrez, Chiapas, Mexico with an aim of reducing cardiovascular disease risk for patients with type 2 diabetes and/or hypertension. During implementation, research questions emerged. Considerably fewer men participated in the intervention than women, and an opportunity was identified to increase the reach of activities aimed at improving disease self-management through strategies involving family members. A qualitative study was conducted to identify strategies to involve men and engage family members in disease management and risk reduction. Methods Nine men with hypertension and/or type 2 diabetes with limited to no participation in disease self-management and health promotion activities, six families in which at least one family member had a diagnosis of one or both conditions, and nine health care providers from four different government health centers were recruited for the study. Participants took part in semi-structured interviews. During interviews with families, genograms and eco-maps were used to diagram family composition and structure, and capture the nature of patients’ relationships to the extended family and community resources. Transcripts were coded and a general inductive analytic approach was used to identify themes related to men’s limited participation in health promotion activities, family support and barriers to disease management, and health care providers’ recommendations. Results Participants reported barriers to men’s participation in chronic disease management and healthy lifestyle education activities that can be grouped into two categories: internal and external factors. Internal factors are those for which they are able to make the decision on their own and external factors are those that are not related solely to their decision to take part or not. Four primary aspects were identified related to families’ relationships with disease: different roles within the family, types of support provided to patients, the opportunity to prevent disease among family members without a diagnosis, and - in some cases - lack of family support or stress-induced by other family members. There was an overlap in recommended strategies for engaging men and family members in chronic disease management activities. Conclusions There is an opportunity to increase the reach of interventions aimed at improving disease self-management by engaging men and family members. The proposed strategies presented by patients, family members, and providers have implications for health education and service provision at primary care health centers and for future research.
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Affiliation(s)
- Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,Department of Family Medicine, University of Colorado - Denver, Denver, CO, USA.
| | - Maricruz Castro
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Liz Peña
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | | | - Gabriel Arreola Camacho
- School of Nutrition, University of Sciences and Arts of Chiapas, Tuxtla Gutiérrez, Chiapas, Mexico.
| | - Manuel Ramírez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala.
| | - Homero Martínez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala. .,RAND Corporation, 1776 Main Street, Santa Monica, CA, USA. .,Hospital Infantil de México, "Dr. Federico Gómez", Mexico City, Mexico.
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Cerón A, Fort MP, Morine CM, Lou-Meda R. Chronic kidney disease among children in Guatemala. Rev Panam Salud Publica 2014; 36:376-382. [PMID: 25711748] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/31/2014] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVE To describe the distribution of pediatric chronic kidney disease (CKD) in Guatemala, estimate incidence and prevalence of pediatric end-stage renal disease (ESRD), and estimate time to progress to ESRD. METHODS This study analyzed the registry of the only pediatric nephrology center in Guatemala, from 2004-2013. Incidence and prevalence were calculated for annual periods. Moran's index for spatial autocorrelation was used to determine significance of geographic distribution of incidence. Time to progress to ESRD and associated risk factors were calculated with multivariate Cox regression. RESULTS Of 1 545 patients from birth to less than 20 years of age, 432 had chronic renal failure (CRF). Prevalence and incidence of ESRD were 4.9 and 4.6 per million age-related population, respectively. Incidence was higher for the Pacific coast and Guatemala City. The cause of CRF was undetermined in 43% of patients. Average time to progress to ESRD was 21.9 months; factors associated with progression were: older age, diagnosis of glomerulopathies, and advanced-stage CKD at consultation. CONCLUSIONS Prevalence and incidence of ESRD in Guatemala are lower than in other countries. This may reflect poor access to diagnosis. Areas with higher incidence and large proportion of CKD of undetermined cause are compatible with other studies from the geographic subregion. Findings on progression to ESRD may reflect delayed referral.
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Affiliation(s)
- Alejandro Cerón
- Department of Anthropology, University of Denver, Denver, Colorado, United States of America,
| | | | - Chris M Morine
- Department of Anthropology, University of Denver, Denver, Colorado, United States of America,
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Fort MP, Alvarado-Molina N, Peña L, Mendoza Montano C, Murrillo S, Martínez H. Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San José, Costa Rica and Tuxtla Gutiérrez, Mexico. BMC Fam Pract 2013; 14:131. [PMID: 24007205 PMCID: PMC3846574 DOI: 10.1186/1471-2296-14-131] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 08/29/2013] [Indexed: 11/10/2022]
Abstract
Background The burden of cardiovascular disease is growing in the Mesoamerican region. Patients’ disease self-management is an important contributor to control of cardiovascular disease. Few studies have explored factors that facilitate and inhibit disease self-management in patients with type 2 diabetes and hypertension in urban settings in the region. This article presents patients’ perceptions of barriers and facilitating factors to disease self-management, and offers considerations for health care professionals in how to support them. Methods In 2011, 12 focus groups were conducted with a total of 70 adults with type 2 diabetes and/or hypertension who attended urban public health centers in San José, Costa Rica and Tuxtla Gutiérrez, Chiapas, Mexico. Focus group discussions were transcribed and coded using a content analysis approach to identify themes. Themes were organized using the trans-theoretical model, and other themes that transcend the individual level were also considered. Results Patients were at different stages in their readiness-to-change, and barriers and facilitating factors are presented for each stage. Barriers to disease self-management included: not accepting the disease, lack of information about symptoms, vertical communication between providers and patients, difficulty negotiating work and health care commitments, perception of healthy food as expensive or not filling, difficulty adhering to treatment and weight loss plans, additional health complications, and health care becoming monotonous. Factors facilitating disease self-management included: a family member’s positive experience, sense of urgency, accessible health care services and guidance from providers, inclusive communication, and family and community support. Financial difficulty, gender roles, differences by disease type, faith, and implications for families and their support were identified as cross-cutting themes that may add an additional layer of complexity to disease management at any stage. These factors also relate to the broader family and societal context in which patients live. Conclusions People living with type 2 diabetes and hypertension present different barriers and facilitating factors for disease self-management, in part based on their readiness-to-change and also due to the broader context in which they live. Primary care providers can work with individuals to support self-management taking into consideration these different factors and the unique situation of each patient.
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Affiliation(s)
- Meredith P Fort
- Comprehensive Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panamá, Calzada Roosevelt 6-25, Zona 11, Guatemala City, Guatemala.
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Kanter R, Fort MP, Ramirez M, Martorell R. The changing influence of wealth, education and urbanization on overweight and obesity in Guatemalan women between 1995 and 2008. FASEB J 2013. [DOI: 10.1096/fasebj.27.1_supplement.1055.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rebecca Kanter
- INCAP Research Center for the Prevention of Chronic Diseases ‐CIIPECInstitute of Nutrition of Central American and PanamaGuatemala CityGuatemala
| | - Meredith P. Fort
- INCAP Research Center for the Prevention of Chronic Diseases ‐CIIPECInstitute of Nutrition of Central American and PanamaGuatemala CityGuatemala
| | - Manuel Ramirez
- INCAP Research Center for the Prevention of Chronic Diseases ‐CIIPECInstitute of Nutrition of Central American and PanamaGuatemala CityGuatemala
| | - Reynaldo Martorell
- Hubert Department of Global HealthRollins School of Public HealthEmory UniversityAtlantaGA
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Fort MP, Grembowski DE, Verdugo JC, Morales LC, Arriaga CA, Mercer MA, Lim SS. Implementation and progress of an inclusive primary health care model in Guatemala: coverage, quality, and utilization. Rev Panam Salud Publica 2012; 30:217-24. [PMID: 22069068 DOI: 10.1590/s1020-49892011000900005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 06/02/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0% at both sites contrasts with the national average of 25.6%. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6% at site 1 (Bocacosta, Sololá) and 92.7% at site 2 (San Juan Ostuncalco), compared with the national average of 71.2%. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5% of families at site 1 and 11.2% of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.
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Affiliation(s)
- Meredith P Fort
- Health Services, University of Washington, Seattle, United States of America
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