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Community health workers (CHW) can play an active role in providing integrated HIV and harm reduction services. We used social media to create a virtual network among Vietnamese CHW. This paper reports CHW's social media engagement and the relationships with other work-related indicators. Sixty CHW participated in an intervention for integrated HIV/drug use service delivery. Following two in-person sessions, Facebook groups were established for CHW to share information, seek consultation, and refer patients. CHW's levels of online engagements were tracked for six months and linked to their service provision confidence, interaction with patients and other providers, and job satisfaction. The CHW made 181 posts, which received 557 comments and 1,607 reactions during the six months. Among the 60 CHW, 22 (36.6%) had three or more posts, 19 (31.7%) had one or two posts, and 19 (31.7%) had no post. Comparing the baseline and 6-month follow-up data, we observed that those who posted three or more times showed better service provision confidence (p = 0.0081), more interaction with providers in other settings (p = 0.0071), and higher job satisfaction (p = 0.0268). Our study suggests using social media to engage CHW in virtual communications to improve service provision in communities.

Background Addressing questions surrounding the feasibility of embedding exercise service units in clinical oncology settings is imperative for developing a sustainable exercise-oncology clinical pathway. We examined available literature and offered practical recommendations to support evidence-based practice, policymaking, and further investigations. Methods Four thousand eight hundred sixty-three unique records identified in Embase, CINAHL, MEDLINE, Web of Science Core Collection, and ProQuest (Health and Medicine) were screened for studies that recruited cancer patients, assessed the co-location of exercise service and cancer treatment units, and reported findings on service implementation. Evidence from six studies providing data from over 30 programs was integrated using narrative synthesis. Results Service implementation was relatively modest across the included studies. Exercise services were delivered by physiotherapists, exercise physiologists, and kinesiologists and funded mainly through grants and private donations, with staff salaries accruing as the major expense. Service penetration, adoption, and acceptability were generally low. However, studies recorded high clinician/patient satisfaction. Major barriers to service integration were limited funding, lack of detailed implementation plan, and low organizational buy-in. Common reasons for non-utilization, missed sessions, and dropouts were lack of interest, unwellness, hospital readmission, disease progression, and adverse skeletal events. Conclusion Implementing exercise services in clinical oncology settings seems an effective approach for increasing access to exercise-based rehabilitation for individuals on cancer treatment. While this model appears feasible for patients/clinicians, efforts are required to optimize service integration both in the short and long term. Key priorities include seeking [local] actions to address issues relating to funding and organizational buy-in. Important considerations may include developing an implementation plan to guide the implementation process, expanding the patient core management team to include staff from the exercise rehabilitation unit, and exploring the role of patient feedback in increasing clinician participation (e.g., treating oncologists and nurses) in the referral process. Future research should consider effective strategies to promote patients’ sense of self-efficacy and behavioral control and, further, the place of audit and feedback in improving exercise service delivery and overall service implementation.

Objective: To assess the feasibility and acceptability of integrating a contraception clinic within an opioid agonist treatment (OAT) service to improve access to contraception, especially long‐acting reversible methods of contraception (LARC), for women receiving OAT, who have increased risk of unplanned pregnancies and adverse pregnancy outcomes. Methods: A contraception clinic was established at a Sydney OAT service. Forty‐eight female OAT clients were surveyed regarding their contraception knowledge and needs. Interested and eligible women were referred to the contraception clinic. Results: Women were aged a median of 39 years (range 24–54 years). Most women (83%) agreed it was acceptable for their OAT clinician to discuss contraception with them. Eight women reported current LARC use and 21 reported they would consider using LARC. Twenty‐three women were eligible for contraception (sexually active, aged

Background In 2012, South Africa adopted the Contraception and Fertility Planning guidelines to incorporate safer conception services into care for HIV-affected couples trying to conceive. These guidelines lacked clear implementation and training recommendations. The objective of this study was to investigate factors influencing integration of safer conception services in a clinical setting. Methods Twenty in-depth interviews were conducted between October–November 2017 with providers and staff at Witkoppen Clinic in Johannesburg, where the Sakh’umndeni safer conception demonstration project had enrolled patients from July 2013–July 2017. Semi-structured interview guides engaged providers on their perspectives following the Sakh’umndeni project and possible integration plans to inform the translation of the stand-alone Sakh’umndeni services into a routine service. A grounded theory approach was used to code interviews and an adaptation of the Atun et al. (2010) ‘Integration of Targeted Interventions into Health Systems’ conceptual framework was applied as an analysis tool. Results Five themes emerged: (1) The need for safer conception training; (2) The importance of messaging and demand generation; (3) A spectrum of views around the extent of integration of safer conception services; (4) Limitations of family planning services as an integration focal point; and (5) Benefits and challenges of a “couples-based” intervention. In-depth interviews suggested that counselors, as the first point of contact, should inform patients about safer conceptions services, followed by targeted reinforcement of safer conception messaging by all clinicians, and referral to more intensively trained safer conception providers. Conclusion A safer conception counseling guide would facilitate consultations. While many providers felt that the services belonged in family planning, lack of HIV management skills, men and women trying to conceive within family planning may pose barriers.

Background Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania. Methods Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16–24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11). Results Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites. Conclusion Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.

Background South Africa’s tuberculosis burden is the third highest globally and is closely associated with the country’s devastating HIV epidemic. The separation of HIV and TB services in primary healthcare services in South Africa hampers TB case finding in patients who are co-infected with HIV and TB. This operational proof of concept study assessed an approach to improving tuberculosis detection and treatment by integrating tuberculosis management into HIV care. Methods The intervention involved workforce re-engineering accompanied by changes to the physical environment in three primary healthcare facilities in Gert Sibande district, Mpumalanga Province, that allowed HIV providers to test their HIV patients for TB and initiate and monitor TB treatment when indicated. To assess the proof of concept we compared the management of TB patients by HIV and TB providers, by reviewing the records of all facility patients who tested positive for tuberculosis between July 2015 and February 2016. We also considered the perceptions of healthcare providers and facility managers about the intervention through structured interviews. Results Approximately 30% of the 1855 patients with presumed TB in the three clinics had been identified by HIV providers. The percentage of patients consecutively tested for TB was 81.0% and 85.0% (p = 0.0551) for HIV and TB providers, respectively. Of the patients identified with TB by HIV and TB providers, 75.4% and 79.2% (p = 0.2876), respectively, were initiated on treatment. The defaulter rate was higher among HIV, compared to TB, providers (12.8% versus 4.2%). Overall, healthcare providers and facility managers had positive views of the intervention but raised concerns regarding potential increase in workload and administrative issues, as well as infection control. Conclusions The results of this proof-of-concept study indicate that the full spectrum of TB services can be easily and effectively integrated into existing HIV care programs. However, a possible shift in the service providers’ workload, including administrative tasks, must be tackled and effective infection control must be ensured. Further research is needed to assess the impact of TB service integration into the scope of HIV care (or other chronic care programs) on patient outcomes, including analysis of routine data. Electronic supplementary material The online version of this article (10.1186/s12913-018-3524-9) contains supplementary material, which is available to authorized users.

Summary The purpose of this qualitative study was to understand the knowledge, attitudes, and practices among key Rwandan policymakers and stakeholders related to family planning (FP) and integrated HIV/FP services. Motivational in-depth interview format and content was developed after an extensive policy review. A convenience sample of 10 high-level HIV and FP Rwandan policymakers and stakeholders completed the interview. Stakeholders demonstrated strong foundational knowledge of HIV and FP. Given the choice, stakeholders would allocate more monies to FP and less to HIV than currently distributed. Respondents felt that improved FP method knowledge, especially long-acting reversible contraception, among clients/couples and providers, was needed to address myths, misconceptions, and biases. The most often cited way to integrate HIV/FP services was development of integrated tools (eg, training materials, data collection tools, and advocacy and policy guidance). We recommend strategies for policy advancement supportive of HIV/FP service integration inclusive of couples and long-acting reversible contraception methods.

We investigated self-reported mental health during the first three months of the COVID-19 pandemic (March-May 2020), using a survey of HIV-testing and sexual health service clients from British Columbia, Canada (N = 1198). Over half (55%) reported their mental health as poor at the beginning of the COVID-19 pandemic, more than double that of the general Canadian population in the same time frame (22%). Acknowledging that this burden of poor mental health that is likely to persist in the coming years, we propose that sexual health clinics should facilitate access to mental health supports as a low-barrier point of primary care contact.

Background Given the close connection between human immunodeficiency virus (HIV) infection and substance use disorder (SUD), access to integrated HIV and SUD services is critical for individuals experiencing both challenges and their biopsychosocial conditions. Method Adopting an integrative method, this systematic review included 23 empirical studies published between 2000 and 2018. Articles investigated providers’ and clients’ perspectives on barriers to accessing integrated HIV and SUD services in various service settings (e.g., HIV primary care, SUD treatment, pharmacy). Results Using a client-centered relational framework, we identified barriers in three relational domains with “the client” as the focus of each: client-provider, client-organization, and client-system. The review shows that (1) barriers to HIV and SUD services do not exist in isolation, but in the dynamics within and across three relational domains; (2) service providers and clients often have different perceptions about what constitutes a barrier and the origin of such barriers; and (3) interprofessional and interorganizational collaborations are crucial for integrating HIV and SUD services. Conclusion This review points out the limitations of the conventional paradigm grouping barriers to service integration into isolated domains (client, provider, organization, or system). Reforms in service arrangements and provider training are recommended to address barriers to integrated services.

Social media can potentially serve as a platform to coordinate medical care among fragmented health sectors. This paper describes procedures of using social media to enhance antiretroviral therapy (ART) and methadone maintenance treatment (MMT) providers' virtual network for integrated service for HIV-positive people who inject drugs (PWID) in Vietnam. A total of 88 ART and MMT treatment providers participated in person group sessions followed by online virtual support to improve service integration. In-person reunions were held to reinforce Facebook participation and network activities. Content analysis was used to identify keywords and topic categories of the online information exchange. Both MMT and ART providers were actively engaged in online communications. Referral and treatment adherence were the two most frequently discussed topic areas by both the MMT and ART providers. Frequent cross-agency connections were observed. Online provider networks and communities could be built and useful to support treatment providers to improve service integration.

Background The Floresco integrated service model was designed to address the fragmentation of community mental health treatment and support services. Floresco was established in Queensland, Australia, by a consortium of non-government organisations that sought to partner with general practitioners (GPs), private mental health providers and public mental health services to operate a ‘one-stop’ mental health service hub. Methods We conducted an independent mixed-methods evaluation of client outcomes following engagement with Floresco (outcome evaluation) and factors influencing service integration (process evaluation). The main data sources were: (1) routinely-collected Recovery Assessment Scale — Domains and Stages (RAS–DS) scores at intake and review (n = 108); (2) RAS–DS scores, mental health inpatient admissions and emergency department (ED) presentations among clients prospectively assessed at intake and six-month follow-up (n = 37); (3) semi-structured interviews with staff from Floresco, consortium partners, private practitioners and the local public mental health service (n = 20); and (4) program documentation. Results Interviews identified staff commitment, co-location of services, flexibility in problem-solving, and anecdotal evidence of positive client outcomes as important enablers of service integration. Barriers to integration included different organisational practices, difficulties in information-sharing and in attracting and retaining GPs and private practitioners, and systemic constraints on integration with public mental health services. Of 1129 client records, 108 (9.6%) included two RAS–DS measurements, averaging 5 months apart. RAS–DS ‘total recovery’ scores improved significantly (M = 63.3%, SD = 15.6 vs. M = 69.2%, SD = 16.1; p p p p = 0.001). Corresponding improvements, except in ‘Connecting and belonging’, were seen in the 37 follow-up study participants. Decreases in inpatient admissions (20.9% vs. 7.0%), median length of inpatient stay (8 vs. 3 days), ED presentations (34.8% vs. 6.3%) and median duration of ED visits (187 vs. 147 min) were not statistically significant. Conclusions Despite the lack of a control group and small follow-up sample size, Floresco’s integrated service model showed potential to improve client outcomes and reduce burden on the public mental health system. Horizontal integration of non-government and private services was achieved, and meaningful progress made towards integration with public mental health services.

BackgroundIn return-to-work (RTW) programs, coordinators are often provided in order to integrate services. However, models of coordinating services vary widely internationally, and across different programs, where one distinction is between vertical and horizontal integration (i.e. between levels/institutions, or within one service/level). The aim of this study was therefore to explore and describe if and how a coordinator was provided in RTW-programs, and whether the provision of a coordinator was associated with certain personal or intervention characteristics.MethodsThe study was designed as a cohort study following employees participating in a variety of Rapid-RTW-programs in Norway (n = 39). Employees (n = 494) answered a self-administered questionnaire, which was linked to register-data on diagnoses and sickness-absence. Employees who replied yes/no to the question “Did the program provide a person who tailored or coordinated your services?” were included in this analysis. Associations for being provided with a coordinator were tested in adjusted logistic regression models.ResultsSixty-nine percent of the employees reported having a coordinator. These coordinators were mainly responsible for coordinating treatment within own programs (i.e. horizontal coordination, 68%). As expected, rehabilitation programs more often provided a coordinator compared to treatment programs (OR 3.87 95% CI 2.42–6.24). The odds for being provided with a coordinator were reduced for each additional year of age of the employee (OR 0.97, 95% CI 0.96–0.99). More professions were involved in programs that provided coordinators, also more contact with other stakeholders like leaders and social insurance services (NAV), but only contact with supervisor remained statistically significant in adjusted analysis (OR 1.69 95% CI 0.31–9.27). The programs with a coordinator more often provided adaptations at the workplace for the individual employee (OR 0.08 95% CI 0.01–0.60). However, these signs of vertical integration were only evident for a limited number of employees.ConclusionIn this study, seven of ten employees reported to have a coordinator, which was associated with more professions and stakeholder involvement in the RTW-process. Most of these coordinators did not coordinate vertically between the service levels and types of intervention arenas for sick listed employees (i.e. workplace, social security, and health care services), as recommended in earlier research.

Background Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously. Methods We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017. Results Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes. Conclusions Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors. Electronic supplementary material The online version of this article (10.1186/s12978-019-0714-9) contains supplementary material, which is available to authorized users.

Background Tanzania remains among the countries with the highest burden of infectious diseases (notably HIV, Malaria and Tuberculosis) during pregnancy. In response, the country adopted World Health Organization’s (WHO) latest antenatal care (ANC) guidelines which recommend comprehensive services including diagnostic screening and treatment for pregnant women during antenatal. However, as Tanzania makes efforts to scale up these services under the existing health system resources, it is crucial to understand its capacity to deliver these services in an integrated fashion. Using the WHO’s service availability and readiness assessment(SARA) framework, this study assesses the capacity of the Tanzanian Health System to provide integrated Malaria, Tuberculosis and HIV services. Methods Composite indicators of the five components of integration were constructed from primary datasets of the Tanzanian Service Provision Assessments (SPA) under the Demographic and Health Survey (DHS) programs. Chi-squared analysis was conducted to determine the associations of each of the defined components and background characteristics of facilities/health workers. A logistic regression model was further used to explore strength of relationships between availability of service readiness components and a pregnant women’s receipt of HIV, Malaria and TB services by reporting adjusted odds ratios. Results Generally, capacity to integrate malaria services was significantly higher (72.3 95% CI 70.3–74.4 p = 0.02) compared to Tuberculosis (48.9 95% CI 48.4–50.7) and HIV (54.8 95% CI 53.1–56.9) services. Diagnostic capacity was generally higher than treatment commodities. Regarding the components of SARA integration, logistic regression found that the adjusted odds ratio of having all five components of integration and receiving integrated care was 1.9 (95% CI 0.8–2.7). Among these components, the strongest determinant (predictor) to pregnant women’s receipt of integrated care was having trained staff on site (AOR 2.6 95% CI 0.6–4.5). Conclusion Toward a successful integration of these services under the new WHO guidelines in Tanzania, efforts should be channelled into strengthening infectious disease care especially HIV and TB. Channelling investments into training of health workers (the strongest determinant to integrated care) is likely to result in positive outcomes for the pregnant woman and unborn child.

Tanzania has high fertility, low contraceptive prevalence and low exclusive breastfeeding (EBF). The Lake Zone, including Mara and Kagera regions, leads the country in total fertility, use of the lactational amenorrhea method (LAM) is negligible. This pre-/post-study explored the effects of a multi-level facility and community intervention (service delivery support, community engagement, media and LAM tracking) to integrate maternal and infant nutrition and postpartum family planning (FP) within existing health contacts. Mixed methods were used, including service statistics, exit interviews, patient-tracking tools for community health workers, client self-tracking tools, supervision data, focus group discussions and in-depth interviews. Results are presented using the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) implementation science framework. The intervention reached primarily the second and fourth wealth quintiles, increased FP and EBF at six weeks postpartum. LAM was very acceptable, provided an entry point for FP conversations and for addressing misconceptions, and reinforced EBF practices. Partners felt encouraged to support spousal nutrition, breastfeeding and FP. Higher adoption in Kagera may be influenced by performance-based financing. The intervention was implemented with generally high fidelity. Maintenance data reflected stakeholder interest in continuing the intervention. A multi-level facility and community intervention was feasible to implement and likely contributed to improved EBF practices and FP uptake, including LAM use.

Introduction strong PMTCT-ART service linkages ensure continuity of care for healthier mothers and children born HIV free. Program data showed weak PMTCT- ART linkages in military health facilities. We conducted a study to assess the PMTCT-adult ART service linkage in two Nigerian military health facilities in Kaduna State. Methods we conducted a cross-sectional study using mixed methods (interviews and FGDs) in 44 Nigeria Army Reference Hospital (NARH) and 1 Division Hospital, Kaduna. We studied 372 HIV-positive mothers after a delivery of their babies, referred for ART services from January 2009 to December 2013. We conducted FGDs among ANC, PMTCT and ART clinics staff. We analysed data using descriptive and inferential methods. A p-value of < 0.05 was considered significant with 95% confidence intervals (CI) for estimates. Results of the 372 respondents studied, 320 (86%) accessed PMTCT services from the 44 NARH. Most respondents (206,55.4%) respondents aged < 25 years. One in six (16.7%) respondents had no record of referral. Delivering baby in a separate facility from where PMTCT services were accessed, increased the likelihood of not accessing ART services (odd ratio [OR]: 6.7, 95% CI= 3.3 -13.6). The qualitative study identified poor service integration between PMTCT and ANC clinics. Conclusion the key factors hindering PMTCT-ART linkage in military health facilities included poor service integration, clients delivering of a baby in a facility separate from where PMTCT services were accessed. The Ministry of Defence HIV programme should strengthen ANC-PMTCT-ART service integration through a centrally coordinated client information management system.

Background: Since the publication of the White Paper for the Transformation of the Health System in South Africa in 1997, which included Policy on Integration of Mental Health Care into primary health care (PHC), there has been an emphasis on the promotion of health as well as the re-engineering of PHC to include the integration of mental health care into PHC. Although South Africa has made significant advances at the level of health-related policy development and legislation in trying to bring the country in line with international trends, there have been challenges with regard to implementation of policies, including that of integration of mental health care into PHC. Objectives: The aim of this study was to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KwaZulu-Natal (KZN) province of South Africa and to seek possible solutions. Method: A qualitative exploratory descriptive design was used to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KZN. The sample consisted of 42 participants of whom 4 were PHC managers, 6 were operational managers and 22 were professional nurses who were directly involved in implementing the policy at the operational level. Results: The challenges identified included lack of training in mental healthcare services for staff working in PHC, unavailability of mental health policies, inadequate resources, poor communication between management and staff, lack of skills among PHC nurses in identifying signs of mental illness and misdiagnosis of patients. Conclusion: Considering the challenges pertaining to PHC nurses’ abilities and skills to implement the Policy on Integration of Mental Health Care into PHC, PHC-trained nurses should engage in lifelong learning and be encouraged to develop their knowledge, skills and competence throughout their professional lives.

Background Youth with concurrent substance use and mental health concerns have diverse psychosocial needs and may present to a multitude of clinical and social service sectors. By integrating service sectors at a system level, the diversity of needs of youth with concurrent disorders can be addressed in a more holistic way. The objective of the present study was to quantify the level of cross-sectoral integration in youth-focused services in Canada. Methods Social network analysis (SNA) was used to examine the relationships between eight sectors: addictions, child welfare, education, physical health, housing, mental health, youth justice, and other social services. A total of 597 participants representing twelve networks of youth-serving agencies across Canada provided information on their cross-sectoral contacts and referrals. Results Overall, results suggested a moderate level of integration between sectors. The mental health and the addictions sectors demonstrated only moderate integration, while the addictions sector was strongly connected with the youth justice sector. Conclusions Despite evidence of moderate integration, increased integration is called for to better meet the needs of youth with concurrent mental health and substance use concerns across youth-serving sectors. Ongoing efforts to enhance the integration between youth-serving sectors should be a primary focus in organizing networks serving youth with concurrent mental health and substance use needs.

Objectives: This study explores the implementation processes of integrating specialized diabetes teams into primary care in southern Ontario, Canada. Methods: In-depth qualitative interviews were conducted with 23 patients, 20 diabetes educators and 16 primary care physicians. In addition, group debriefing sessions were conducted and field notes were collected from diabetes educators and diabetes education program managers to further explore the day-to-day issues of implementation. Data were analyzed using an inductive content analysis approach. Results: Analysis revealed 3 main themes: Right Place, Right Time, Right Service: the convenience and comfort of local care, timely, preventive management and delivering person-centred care; Creating Partnerships: generating intervention buy-in, formal discussion, service agreements, site orientation and team development; Operational Complexities and Strategies: access to electronic medical records and documentation, referral and scheduling procedures, and costs and resources. Conclusions: Because situating diabetes teams in primary care currently involves using existing healthcare structures and human resources, pragmatic methods of fostering successful implementation of this model of practice are required. The utility of this model was perceived as being viable, and benefits were visible to all study participants. Strategies to facilitate implementation include outlining roles and expectations by educators and the primary care providers' team in the beginning, investment in the intervention by all stakeholders, and clear channels of communication that allow educators to perform their roles and leverage opportunities for team collaboration in patient care. Further evaluation of implementation processes can serve to expand this model of practice, which has proven so far to be favourable to the players involved.

The growing burden of HIV and tuberculosis (TB) coinfection has prompted enhanced collaboration or integration of services between HIV and TB programs in high-burden countries. The disparate paradigms or cultures of HIV and TB care, however, have challenged integration efforts. Historically, TB programs have been based in a traditional, public health approach whereas HIV programs have been rooted in an individualized, patient-centred approach. While these distinct approaches may be a product of their diverse social and clinical epidemiologies, and the disparate levels of political support and advocacy tied to HIV and TB disease control, they may influence the ways in which dual services are accepted and utilized by affected communities. We urge HIV and TB programs to recognize and address their cultural differences in integration efforts to build a more cohesive and successful framework of HIV/TB care.

Background In Bangladesh, abortion is restricted except to save the life of a woman, but menstrual regulation is allowed to induce menstruation and return to non-pregnancy after a missed period. MR services are typically provided through the Directorate General of Family Planning, while postabortion care services for incomplete abortion are provided by facilities under the Directorate General of Health Services. The bifurcated health system results in reduced quality of care, particularly for postabortion care patients whose procedures are often performed using sub-optimal uterine evacuation technology and typically do not receive postabortion contraceptive services. This study evaluated the success of a pilot project that aimed to integrate menstrual regulation, postabortion care and family planning services across six Directorate General of Health Services and Directorate General of Family Planning facilities by training providers on woman-centered abortion care and adding family planning services at sites offering postabortion care. Methods A pre-post evaluation was conducted in the six large intervention facilities. Structured client exit interviews were administered to all uterine evacuation clients presenting in the 2-week data collection period for each facility at baseline (n = 105; December 2011–January 2012) and endline (n = 107; February–March 2013). Primary outcomes included service integration indicators such as provision of menstrual regulation, postabortion care and family planning services in both facility types, and quality of care indicators such as provision of pain management, provider communication and women’s satisfaction with the services received. Outcomes were compared between baseline and endline for Directorate General of Family Planning and Directorate General of Health Services facilities, and chi-square tests and t-tests were used to test for differences between baseline and endline. Results At the end of the project there was an increase in menstrual regulation service provision in Directorate General of Health Services facilities, from none at baseline to 44.1% of uterine evacuation services at endline (p

Objectives. The Massachusetts Department of Public Health (MDPH) and the Barnstable County Sheriff's Department (BCSD) in Massachusetts initiated a pilot program in July 2009 offering education and hepatitis C virus (HCV) antibody testing to inmates and detainees, concurrent with routine HIV testing. The initiative was implemented to assess the feasibility of integrating HCV screening into an HIV screening program in a correctional setting and the efficacy of linking HCV antibody-positive inmates to clinical care upon release. Methods. Through the Screening for Hepatitis C as a Prevention Enhancement initiative, HCV and HIV testing were offered to inmates and detainees shortly after admission, and by request at any time during incarceration. In preparation for release, referrals were made to community-based medical providers for HCV follow-up care. Data from BCSD were compared with routine surveillance data received by MDPH. Confirmatory HCV test results received by April 15, 2012, were considered indicators of appropriate post-release clinical care. Results. From July 2009 through December 2011, 22% ( n=596) and 25% (n=667) of 2,716 inmates/detainees accepted HCV and HIV testing, respectively. Of those tested for HCV antibody, 20.5% ( n=122) were positive. Of those tested for HIV antibody, 0.8% (n=5) were positive. Of the inmates who tested HCV positive at BCSD and had been released, 37.8% were identified as receiving post-release medical care. Conclusions. We determined that integration of HCV education and screening into correctional facilities is feasible and reveals high rates of HCV infection. Although this model presupposes programmatic infrastructure, elements of the service design and integration could inform a range of correctional programs. Effective linkage to care, while substantial, was not routine based on our analysis, and may require additional resources given its cost and complexity.

Injection drug users are at a high risk for a number of preventable diseases and complications of drug use. This article describes the implementation of a nurse-led health promotion and disease prevention program in New Jersey's syringe access programs. Initially designed to target women as part of a strategy to decrease missed opportunities for perinatal HIV prevention, the program expanded by integrating existing programs and funding streams available through the state health department. The program now offers health and prevention services to both men and women, with 3,488 client visits in 2011. These services extend the reach of state health department programs, such as adult vaccination and hepatitis and tuberculosis screening, which clients would have had to seek out at multiple venues. The integration of prevention, treatment, and health promotion services in syringe access programs reaches a vulnerable and underserved population who otherwise may receive only urgent and episodic care.

BackgroundUsing methadone maintenance therapy (MMT) clinics to deliver antiretroviral therapy (ART) has proven to be effective for promoting treatment initiation and adherence in drug users living with HIV.ObjectivesThe objective of this study was to investigate the HIV-positive client acceptability of integrated ART services and to identify the reasons for and factors associated with service acceptability.MethodsA total of 86 HIV-positive MMT clients were recruited from 12 MMT clinics in Sichuan Province, China. They participated in a cross-sectional survey that queried their willingness to receive seven different types of MMT-based ART services. The reasons for their willingness/unwillingness to accept these services were documented. The association between service acceptability and background characteristics was examined.ResultsThe most accepted integrated services were ART-related counseling (75.6%) and referral (73.2%). Concerns regarding the provider's lack of ART expertise and confidentiality issues were common barriers for the acceptance of MMT-based ART services. A trust relationship with MMT providers was a reason for service acceptance. Service acceptability was associated with a poorer perceived health status. Conclusions/Importance: ART-related services, based on the client perspective, can be delivered at MMT clinics. However, service provider training and the protection of confidentiality must be strengthened for the effective implementation of integrated service delivery.

No abstract available. Keywords: HIV/AIDS; antiretroviral therapy; methadone; people who inject drugs; service integration; implementation science. (Published: 21 July 2015) Citation: Lambdin BH et al. Journal of the International AIDS Society 2015, 18 :19936 http://www.jiasociety.org/index.php/jias/article/view/19936 | http://dx.doi.org/10.7448/IAS.18.1.19936

Integration of health education and welfare services in primary care systems is a key strategy to solve the multiple determinants of chronic diseases, such as Human Immunodeficiency Virus Infection and Acquired Immune Deficiency Syndrome (HIV/AIDS). However, there is a scarcity of conceptual models from which to build integration strategies. We provide a model based on cross-sectional data from 168 Community Health Agents, 62 nurses, and 32 physicians in two municipalities in Brazil’s Unified Health System (UHS). The outcome, service integration, comprised HIV education, community activities (e.g., health walks and workshops), and documentation services (e.g., obtainment of working papers and birth certificates). Predictors included individual factors (provider confidence, knowledge/skills, perseverance, efficacy); job characteristics (interprofessional collaboration, work-autonomy, decision-making autonomy, skill variety); and organizational factors (work conditions and work resources). Structural equation modeling was used to identify factors associated with service integration. Knowledge and skills, skill variety, confidence, and perseverance predicted greater integration of HIV education alongside community activities and documentation services. Job characteristics and organizational factors did not predict integration. Our study offers an explanatory model that can be adapted to examine other variables that may influence integration of different services in global primary healthcare systems. Findings suggest that practitioner trainings to improve integration should focus on cognitive constructs—confidence, perseverance, knowledge, and skills.

Background Effective prevention against cancers depends heavily on sustained individual efforts practicing protective behaviors and avoiding risk factors in a complex sociocultural context, which requires continuous and personalized supports. Contemporary prevention relies primarily on strategies targeting general population with limited attention being paid to individualized approaches. This study tests a novel package called, in acronym of core intervention components, eCROPS-CA that leverages protective behaviors against over 80% leading cancers among high risk individuals via continuous and tailored counseling by village doctors. Methods/Design The study utilizes a quesi-RCT design involving 4320 high risk individuals selected, via rapid and detailed risk assessments, from about 72,000 farmers aged 35+ in 36 administrative villages randomized into equal intervention and delayed intervention arms. The intervention arm receives baseline and semiannual follow up evaluations plus eCROPS-CA for 5 years; while the control arm, only the baseline and follow-up evaluations for the first 5 years and eCROPS-CA starting from the 6th year if the intervention is proved effective. eCROPS-CA comprises electronic supports and supervision (e), counseling cancer prevention (C), recipe for objective behaviors (R), operational toolkit (O), performance-based incentives (P), and screening and assessment (S). Evaluation measures include: incidence and stage of the leading cancers, cancer-related knowledge, attitudes and practices; easy biophysical indicators (e.g., body mass index, blood pressure); intervention compliance, acceptance of the package. Discussion The prevention package incorporates key success factors in a synergetic way toward cost-effectiveness and long-term sustainability. It targets a set rather than any single cancer; choses village doctors as key solution to the widespread lack of professional manpower in implementing personalized and thus relatively sophisticated prevention; adopts real-time monitoring in reaching continuous improvement; utilizes smart web aids to enable prioritizing complex determinants of objective behaviors, linking counseling sessions happened at different time points and hence delivering highly coordinated prevention; uses 2-stage risk assessment models in identifying high risk individuals so as to focus on the most needed; applies standardized operation procedures in simplifying and smoothing behavior intervention yet ensuring delivery of essential steps and key elements. Trials registry ISRCTN33269053 Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1253-6) contains supplementary material, which is available to authorized users.

Objectives. We identified the level and type of program collaboration and service integration (PCSI) among HIV prevention programs in 59 CDC-funded health department jurisdictions. Methods. Annual progress reports (APRs) completed by all 59 health departments funded by CDC for HIV prevention activities were reviewed for collaborative and integrated activities reported by HIV programs for calendar year 2009. We identified associations between PCSI activities and funding, AIDS diagnosis rate, and organizational integration. Results. HIV programs collaborated with other health department programs through data-related activities, provider training, and providing funding for sexually transmitted disease (STD) activities in 24 (41%), 31 (53%), and 16 (27%) jurisdictions, respectively. Of the 59 jurisdictions, 57 (97%) reported integrated HIV and STD testing at the same venue, 39 (66%) reported integrated HIV and tuberculosis testing, and 26 (44%) reported integrated HIV and viral hepatitis testing. Forty-five (76%) jurisdictions reported providing integrated education/outreach activities for HIV and at least one other disease. Twenty-six (44%) jurisdictions reported integrated partner services among HIV and STD programs. Overall, the level of PCSI activities was not associated with HIV funding, AIDS diagnoses, or organizational integration. Conclusions. HIV programs in health departments collaborate primarily with STD programs. Key PCSI activities include integrated testing, integrated education/outreach, and training. Future assessments are needed to evaluate PCSI activities and to identify the level of collaboration and integration among prevention programs.

Objectives. We evaluated emergency department (ED) provider adherence to guidelines for concurrent HIV-sexually transmitted disease (STD) testing within an expanded HIV testing program and assessed demographic and clinical factors associated with concurrent HIV-STD testing. Methods. We examined concurrent HIV-STD testing in a suburban academic ED with a targeted, expanded HIV testing program. Patients aged 18–64 years who were tested for syphilis, gonorrhea, or chlamydia in 2009 were evaluated for concurrent HIV testing. We analyzed demographic and clinical factors associated with concurrent HIV-STD testing using multivariate logistic regression with a robust variance estimator or, where applicable, exact logistic regression. Results. Only 28.3% of patients tested for syphilis, 3.8% tested for gonorrhea, and 3.8% tested for chlamydia were concurrently tested for HIV during an ED visit. Concurrent HIV-syphilis testing was more likely among younger patients aged 25–34 years (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [CI] 0.78, 2.10) and patients with STD-related chief complaints at triage (AOR=11.47, 95% CI 5.49, 25.06). Concurrent HIV-gonorrhea/chlamydia testing was more likely among men (gonorrhea: AOR=3.98, 95% CI 2.25, 7.02; chlamydia: AOR=3.25, 95% CI 1.80, 5.86) and less likely among patients with STD-related chief complaints at triage (gonorrhea: AOR=0.31, 95% CI 0.13, 0.82; chlamydia: AOR=0.21, 95% CI 0.09, 0.50). Conclusions. Concurrent HIV-STD testing in an academic ED remains low. Systematic interventions that remove the decision-making burden of ordering an HIV test from providers may increase HIV testing in this high-risk population of suspected STD patients.

Background: A majority of patients prefer to die at home. Specialist palliative care aims to improve quality of life. Hospice assist at home is a Dutch model of general/specialised palliative care within primary care, collaboratively built by general practitioners and a hospice. Aim: The aims of this study are to explore whether hospice assist at home service enables patients at hometo express end-of-life preferences and die in their preferred location. In addition, this study provides insight into symptomburden, stability and early referral. Design: A retrospective cross-sectional evaluation study was performed (December 2014–March 2015), using hospice assist at home patient records and documentation. Primary outcome includes congruence between preferred and actual place of death. Secondary outcomes include symptom burden, (in)stability and early identification. Setting/participants: Between June 2012 and December 2014, 130 hospice assist at home patients, living at home with a life expectancy Results: A total of 130 patients (62 (48%) men; mean age, 72 years) were enrolled, of whom 107/130 (82%) died and 5 dropped out. Preferred place of death was known for 101/107 (94%) patients of whom 91% patients died at their preferred place of death. Conclusion: Hospice assist at home service supports patients to die in their preferred place of death. Shared responsibility of proactive care in primary care collaboration enabled patients to express preferences. Hospice care should focus on local teamwork, to contribute to shared responsibilities in providing optimal palliative care.

While the emergency department (ED) is often a first point of entry for children and youth with mental health (MH) concerns, there is a limited capacity to respond to MH needs in this setting. Child MH systems are typically fragmented among multiple ministries, organizations, and providers. Communication among these groups is often poor, resulting in gaps, particularly in transitions of care, for this vulnerable population. The evidence-based Emergency Department Mental Health Clinical Pathway (EDMHCP) was created with two main goals: (1) to guide risk assessment and disposition decision-making for children and youth presenting to the ED with MH concerns and (2) to provide a streamlined transition to follow-up services with community MH agencies (CMHAs) and other providers. The purpose of this paper is to describe our study protocol to implement and evaluate the EDMHCP. This mixed methods health services research project will involve implementation and evaluation of the EDMHCP in four exemplar ED-CMHA dyads. The Theoretical Domains Framework will be used to develop a tailored intervention strategy to implement the EDMHCP. A multiple baseline study design and interrupted time-series analysis will be used to determine if the EDMHCP has improved health care utilization, medical management of the MH problems, and health sector coordination. The primary process outcome will be the proportion of patients with MH-specific recommendations documented in the health record. The primary service outcome will be the proportion of patients receiving the EDMHCP-recommended follow-up at 24-h or at 7 days. Data sources will include qualitative interviews, health record audits, administrative databases, and patient surveys. A concurrent process evaluation will be conducted to assess the degree of variability and fidelity in implementation across the sites. This paper presents a novel model for measuring the effects of the EDMHCP. Our development process will identify how the EDMHCP is best implemented among partner organizations to deliver evidence-based risk management of children and youth presenting with MH concerns. More broadly, it will contribute to the body of evidence supporting clinical pathway implementation within novel partnerships. ClinicalTrials.gov ( NCT02590302 )

Background Families with low incomes experience an array of health and social challenges that compromise their resilience and lead to negative family outcomes. Along with financial constraints, there are barriers associated with mental and physical health, poorer education and language. In addition, vulnerable populations experience many services as markedly unhelpful. This combination of family and service barriers results in reduced opportunities for effective, primary-level services and an increased use of more expensive secondary-level services (e.g., emergency room visits, child apprehensions, police involvement). A systematic review of effective interventions demonstrated that promotion of physical and mental health using existing service was critically important. Methods/Design The Families First Edmonton Trial (FFE) tests four service integration approaches to increase use of available health and social services for families with low-income. It is a randomized, two-factor, single-blind, longitudinal effectiveness trial where low-income families (1168) were randomly assigned to receive either (1) Family Healthy Lifestyle plus Family Recreation service integration (Comprehensive), (2) Family Healthy Lifestyle service integration, (3) Family Recreation service integration, or (4) existing services. To be eligible families needed to be receiving one of five government income assistance programs. The trial was conducted in the City of Edmonton between January 2006 and August 2011. The families were followed for a total of three years of which interventional services were received for between 18 and 24 months. The primary outcome is the number of family linkages to health and social services as measured by a customized survey tool “Family Services Inventory”. Secondary outcomes include type and satisfaction with services, cost of services, family member health, and family functioning. Where possible, the measures for secondary outcomes were selected because of their standardization, the presence of published norming data, and their utility as comparators to other studies of low-income families. As an effectiveness trial, community and government partners participated in all committees through a mutually agreed upon governance model and helped manage and problem solve with researchers. Discussion Modifications were made to the FFE trial based on the pragmatics of community-based trials. Trial registration number ClinicalTrials.gov NCT00705328

Objective/Background The Global Fund to Fight AIDS, Tuberculosis & Malaria (GF) strives for high value for money, encouraging countries to integrate synergistic services and systems strengthening to maximize investments. The GF needs to show how, and how much, its grants support more than just HIV/AIDS, TB and malaria. Sexual and Reproductive Health (SRH) has been part of HIV/AIDS grants since 2007. Previous studies showed the GF PBF system does not allow resource tracking for SRH integration within HIV/AIDS grants. We present findings from a resource tracking case study using primary data collected at country level. Methods Ethiopia was the study site. We reviewed data from four HIV/AIDS grants from January 2009-June 2011 and categorized SDAs and activities as directly, indirectly, or not related to SRH integration. Data included: GF PBF data; financial, performance, in-depth interview and facility observation data from Ethiopia. Results All HIV/AIDS grants in Ethiopia support SRH integration activities (12-100%). Using activities within SDAs, expenditures directly supporting SRH integration increased from 25% to 66% for the largest HIV/AIDS grant, and from 21% to 34% for the smaller PMTCT-focused grant. Using SDAs to categorize expenditures underestimated direct investments in SRH integration; activity-based categorization is more accurate. The important finding is that primary data collection could not resolve the limitations in using GF GPR data for resource tracking. The remedy is to require existing activity-based budgets and expenditure reports as part of PBF reporting requirements, and make them available in the grant portfolio database. The GF should do this quickly, as it is a serious shortfall in the GF guiding principle of transparency. Conclusions Showing high value for money is important for maximizing impact and replenishments. The Global Fund should routinely track HIV/AIDs grant expenditures to disease control, service integration, and overall health systems strengthening. The current PBF system will not allow this. Real-time expenditure analysis could be achieved by integrating existing activity-based financial data into the routine PBF system. The GF’s New Funding Model and the 2012-2016 strategy present good opportunities for over-hauling the PBF system to improve transparency and allow the GF to monitor and maximize value for money. Electronic supplementary material The online version of this article (doi:10.1186/s12992-015-0106-z) contains supplementary material, which is available to authorized users.