Background: The burden of non-communicable diseases (NCDs) is increasing in low-and middle-income countries (LMICs) where NCDs cause 4:5 deaths, disproportionately affect poorer populations, and carry a large economic burden. Digital interventions can improve NCD management for these hard-to-reach populations with inadequate health systems and high cell-phone coverage; however, there is limited research on whether digital health is reaching this potential. We conducted a process evaluation to understand challenges and successes from a digital health intervention trial to support Cambodians living with NCDs in a peer educator (PE) program.Methods: MoPoTsyo, a Cambodian non-governmental organization (NGO), trains people living with diabetes and/or hypertension as PEs to provide self-management education, support, and healthcare linkages for better care management among underserved populations. We partnered with MoPoTsyo and InSTEDD in 2016-2018 to test tailored and targeted mHealth mobile voice messages and eHealth tablets to facilitate NCD management and clinical-community linkages. This cluster randomized controlled trial (RCT) engaged 3,948 people and 75 PEs across rural and urban areas. Our mixed methods process evaluation was guided by RE-AIM to understand impact and real-world implications of digital health. Data included patient (20) and PE interviews (6), meeting notes, and administrative datasets. We triangulated and analyzed data using thematic analysis, and descriptive and complier average causal effects statistics (CACE).Results: Reach: intervention participants were more urban (66% vs. 44%), had more PE visits (39 vs. 29), and lower uncontrolled hypertension [12% and 7% vs. 23% and 16% uncontrolled systolic blood pressure (SBP) and diastolic blood pressure (DBP)]. Adoption: patients were sent mean [standard deviation (SD)] 30 [14] and received 14 [8] messages; 40% received no messages due to frequent phone number changes.Effectiveness: CACE found clinically but not statistically significant improvements in blood pressure and sugar for mHealth participants who received at least one message vs. no messages. Implementation: main barriers were limited cellular access and that mHealth/eHealth could not solve structural barriers to NCD control faced by people in poverty. Maintenance: had the intervention been universally effective, it could be paid for from additional revolving drug fund revenue, new agreements with mobile networks, or the mHealth, 2020
Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.
While university students are potential human resources, this population group is particularly involved in health risk behaviours. Preventing risky sexual behaviours among them would contribute to prevention of HIV, sexually transmitted infections (STIs), and unwanted pregnancies, which have posed a great burden on population health. This study was therefore conducted to identify social and behavioural factors associated with risky sexual behaviours among university students in nine ASEAN countries. A multi-country, cross-sectional study was conducted in 2015 among university students by a network of researchers in the selected countries. A convenient sampling method and stratified random sampling procedures were employed to select universities and students, respectively. A structured questionnaire was translated into national languages of the participating countries and used to collect data from the selected students in the classrooms. Using STATA, Chi-square test was used to test differences in proportions, and multinomial logistic regression analyses were performed to obtain relative risk ratios and 95% confidence intervals. Multivariate logistic regression analysis was performed with to identify independent social and behavioural factors associated with non-condom use at last sexual intercourse. In total, 8,836 students with a mean age of 20.6 (SD = 2.0) participated in the study. Most of them (98.5%) were unmarried. In all countries, male students were significantly more likely to have two or more sexual partners in the past 12 months compared to female students (4.8% vs. 1.1%, p < 0.001). Female students were significantly more likely to report unprotected sex compared to male students (50.5% vs. 58.8%, p = 0.01). Results of multivariable logistic regression analyses showed that students who reported having two or more partners in the past 12 months were significantly more likely to be male, be aged between 20–30, be current tobacco smokers, be binge drinkers, have severe depressive symptoms, and have been in a physical fight in the past 12 months, compared to students who reported having less than two sexual partners in the past 12 months. Health intervention programmes to prevent and control STIs, especially HIV infection, should focus on university students having the social and behavioural characteristics that are associated with risky sexual behaviours.
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