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      Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

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      , , , , , , ,
      Cochrane Effective Practice and Organisation of Care Group
      The Cochrane Database of Systematic Reviews
      John Wiley & Sons, Ltd

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          Abstract

          Background

          Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low‐resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

          Objectives

          To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

          Search methods

          We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

          Selection criteria

          We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community‐based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non‐English records. Where translation was not feasible we categorised these records as studies awaiting classification.

          Data collection and analysis

          For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

          Main results

          The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross‐sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high‐income countries (HICs) and low‐ and middle‐income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle‐income countries, and Uganda for low‐income countries. Methods were mainly cross‐sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study.

          The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non‐communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

          Authors' conclusions

          This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision‐makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

          Plain language summary

          Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

          What is primary healthcare integration?

          Primary healthcare integration is a way of combining different primary healthcare services that have previously been delivered separately. The aim of this integration is usually to give people better access to healthcare and to make more efficient use of limited health resources.

          Why is it important to know about healthcare workers' views and experiences?

          Primary healthcare integration has been implemented in many different countries with varying success. Healthcare workers can influence the extent to which such changes in health services are implemented successfully. Learning about healthcare workers' views and experiences of primary healthcare integration can help us understand how healthcare workers might influence its implementation and its success or failure.

          What was the purpose of this scoping review?

          This scoping review searched for and mapped qualitative studies (studies with no numerical data) about healthcare workers' views and experiences of primary healthcare integration. We wanted to describe the available research to help inform future systematic reviews and research studies in this area.

          How did we identify and map the evidence?

          We searched for all published qualitative studies that reported on healthcare workers' views and experiences of primary healthcare integration up to 28 July 2020. We described the different study methods, countries, the scope and type of primary healthcare integration approaches, and the different types of healthcare workers and client groups involved. We then grouped the studies into categories.

          What did we find?

          We included 184 studies. The studies were from 37 countries. About half the studies took place in high‐income countries and half in low‐ and middle‐income countries.

          The studies we found in our review covered a variety of settings, participants, and types of primary healthcare integration. There were different configurations for which healthcare service programmes were being combined for integrated service delivery. These were categorised into the following six configurations: mental health; HIV, tuberculosis, and sexual reproductive health; maternal, woman, and child health; non‐communicable diseases (for example, heart disease, diabetes); general primary health integration, and allied and specialised services. We also explored whether integrated service delivery was fully or partially integrated, and the different integration strategies used to link and co‐ordinate services.

          The people participating in the implementation of integration interventions included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay health workers, and health system support staff. A wide range of clients were recipients of the integrated services.

          Author's conclusions

          This scoping review shows the variety of primary healthcare integration approaches that have been studied. Researchers and decision‐makers need to understand the relationship between different integration approaches and contexts, and the ways in which healthcare workers influence the impacts of this integration. The study categories we have developed can help researchers to understand these different types of integration approaches and to identify more focused questions for future systematic reviews.

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          PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation

          Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.
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            Scoping studies: towards a methodological framework

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              Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

              Background Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. Methods We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. Results The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. Conclusion The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
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                Author and article information

                Journal
                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                14651858
                10.1002/14651858
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                1469-493X
                19 July 2023
                2023
                19 July 2023
                : 2023
                : 7
                : CD013603
                Affiliations
                deptHealth Systems Research Unit South African Medical Research Council Cape TownSouth Africa
                Independent researcher Cape TownSouth Africa
                deptAlcohol Tobacco and Other Drug Research Unit The South African Medical Research Council Cape TownSouth Africa
                deptCochrane South Africa South African Medical Research Council Cape TownSouth Africa
                deptDepartment of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University StellenboschSouth Africa
                deptSocial & Behavioural Sciences Division, School of Public Health University of Cape Town Cape TownSouth Africa
                deptHIV and Other Infectious Diseases Research Unit South African Medical Research Council Cape TownSouth Africa
                deptDepartment of Psychiatry Stellenbosch University Cape TownSouth Africa
                deptCenter for Microbiology Research Kenya Medical Research Institute NairobiKenya
                deptDepartment of Global Health University of Washington SeattleWashingtonUSA
                deptDepartment of Epidemiology, School of Public Health Brown University ProvidenceRhode IslandUSA
                Article
                CD013603.pub3 CD013603
                10.1002/14651858.CD013603.pub3
                10355136
                57203701-0a0b-49d4-9e5f-c7fc099a672f
                Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.

                This is an open access article under the terms of the Creative Commons Attribution-Non-Commercial Licence, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                Categories
                Effective practice & health systems
                Delivery of healthcare services

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