Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

Abstract

Background While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). Methods and findings On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. Conclusions Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Measurement of and training for NCD guideline implementation in LMICs: a scoping review protocol

“…Also, LMICs accounted for 77% of all global NCD deaths in 2022 1. Cardiovascular diseases, cancers, chronic respiratory diseases and diabetes are the leading causes of NCD mortality 1 2. Major risk factors for NCD include unhealthy diets, physical inactivity, tobacco and alcohol use 1 2.…”

“…Cardiovascular diseases, cancers, chronic respiratory diseases and diabetes are the leading causes of NCD mortality 1 2. Major risk factors for NCD include unhealthy diets, physical inactivity, tobacco and alcohol use 1 2. In 2015, 193 countries pledged to reduce premature NCD-related mortality and risk factors by 2030 in efforts to meet the Sustainable Development Goal (SDG) 3.4 targets 3.…”

“…In 2015, 193 countries pledged to reduce premature NCD-related mortality and risk factors by 2030 in efforts to meet the Sustainable Development Goal (SDG) 3.4 targets 3. SDG 3.4 encourages countries to reduce one-third of premature NCD-related deaths by 2030 through prevention and treatment 2. Despite the high burden of NCD-related morbidity and mortality in LMICs, recent evidence (including systematic reviews) reveals that no country in this geopolitical zone has made significant progress towards meeting SDG 3.4 target by 2030 4–6.…”

“…The COVID-19 pandemic has also complicated efforts to reduce NCD-related mortality since people living with NCD are more likely to die of COVID-19 7 8. Furthermore, global COVID-19 responses highlighted the social and economic inequities in NCD morbidity in both high-income countries and LMICs 2. Due to weak health systems, poverty and low human resources, LMICs are more susceptible to NCD, and they are less likely to adapt 2 3 9.…”

“…Furthermore, global COVID-19 responses highlighted the social and economic inequities in NCD morbidity in both high-income countries and LMICs 2. Due to weak health systems, poverty and low human resources, LMICs are more susceptible to NCD, and they are less likely to adapt 2 3 9. In addition, LMICs are four times less likely to have NCD covered by medical insurance than high-income countries 5.…”