Design and feasibility of an implementation strategy to address Chagas guidelines engagement at the primary healthcare level in Argentina: a pilot study

doi:10.21203/rs.3.rs-1427996/v1

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Research article

Design and feasibility of an implementation strategy to address Chagas guidelines engagement at the primary healthcare level in Argentina: a pilot study

https://doi.org/10.21203/rs.3.rs-1427996/v1

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Background: Chagas is a public health problem, especially in Latin America, exacerbated by migratory movements and increasing urbanization. Argentina has the highest number of cases in the region, with 1,500,000 infected people, with mother-to-child as the primary mode of transmission. Vertical transmission has been significantly reduced by treating women of childbearing age; several guidelines in the region recommend treatment as a primary prevention strategy for the child and a secondary prevention strategy for women and their families. Despite recommendations, women of childbearing age are not always treated, and children do not receive timely diagnosis and treatment. The objective of this research was to design an implementation strategy to improve using Chagas guidelines at the primary healthcare level and pilot it to assess its feasibility and the factors that influence its implementation in three primary health care centers, Argentina.

Methods: We conducted a pilot feasibility study using the Consolidated Framework for Implementation Research. A qualitative process evaluation was conducted using semi-structured interviews with health care providers and observations in primary health care centers.

Results: We developed a multifaceted implementation strategy including training, flowcharts and reminders, a register of suspected and confirmed Chagas cases, and the selection of a management facilitator. The pilot study took place between September 2019 and May 2020. The implementation level was heterogeneous and varied depending on the components, being the facilitating factors, the simplicity of the intervention, professionals’ willingness to expand the indication of serologic tests, and staff commitment to the adoption of intervention components. The main barriers were the change of authorities at the local level, some professionals´ reluctance to administer etiological treatment, staff shortages, lack of diagnostic supplies (linked to contextual factors), and the health emergency caused by the COVID-19 pandemic.

Conclusions: Behavioral change strategies should be applied to improve implementation to address some of the main barriers, including support actions offered by opinion leaders, medical experts, and local health authorities. Rapid diagnostic tests should be readily available to maintain behavior changes. We suggest further refinement of the strategy and its implementation in more centers to assess outcomes prospectively with a hybrid implementation research design.

Chagas

primary health care

implementation strategy

feasibility

guideline

effective intervention.

Table 1. Components of the implementation strategy

Component	Description
Training	All health care providers working with the population of interest were trained on Chagas disease and resource management.
Flowcharts on Chagas management and approach	Flowcharts in poster format that included information on risk screening (questions to detect the population to be tested), procedures to manage people at risk and cases of Chagas disease, under national guidelines. The posters were tailored to the type of patient: for pediatric population, for prenatal controls and for women of reproductive age (see Additional files 1 to 3).
Reminders	Labels as reminders and easily locate medical records of infected or at risk people.
	Posters to remind professionals to ask questions to verify the risk of Chagas disease (risk screening), diagnose, follow-up results and treat positive cases (see Additional files 4 to 6).
Frequently asked questions for patient management and approach	This document summarized information to optimize the use of resources for managing Chagas disease at the first level of care, regarding notification of positive cases, access to etiological treatment, and coordination with other levels of care.
Identification of clinical records of people at risk and positive cases	The medical records of patients at risk of Chagas disease were identified (e.g., brightly coloured labels) to facilitate tracking results of diagnostic tests. Positive serologic tests results were recorded to facilitate routine practice. Family contacts needed to be followed up. Each healthcare center could design their own registration strategy.
Management facilitator	Central role in the dissemination and implementation of all components and liaison between key actors and levels of care, contributing to adequate healthcare.

Table 2. Level of implementation of the strategy

Component	Outcome measures	Details
Training	Adopted	Implemented in all PHCs. Some professionals were not trained because they were absent or worked on other duties on the training date.
Flowcharts	Partially adopted Low fidelity	Flowcharts were used in all PHCs, but risk screening was partially implemented. Indication of serology was increased without using risk assessment.
Reminders	Adopted	Reminder posters were used in all centres.
Frequently asked questions sheet	Not adopted	Few informants mentioned knowing or having used this component.
Register of at-risk persons and positive cases	Poorly adopted Low fidelity Low feasibility	No registers of persons at risk were implemented and, registers of positive cases were used in only one PHC. Clinical records of positive patients were labeled.
Management facilitators	Partially adopted Low fidelity Low feasibility	All PHCs appointed facilitators, but their performance and commitment were variable.

Table 3. Barriers to the implementation

Dimension	Barrier	Description
Inner setting	Insufficient human resources	Insufficient human resources and time due to demand for care and contextual factors.
	Low commitment	Lack of key actors (directors and/or facilitators) with a greater commitment to the intervention due to leave of absence or other reasons.
	Insufficient knowledge about intervention	Professionals with low knowledge of the intervention.
Outer setting and context	Lack of critical resources	Limited access to serology during much of the intervention period.
Outer setting and context	Health emergencies	Health emergencies (dengue outbreak and COVID-19 pandemic) absorbed time and resources and/or limited care activity in the centers.
Individuals involved	Beliefs and attitudes related to the intervention	Reluctance to starting treatment at the first level of care for fear of side effects or lack of knowledge.

Additionalfile1english.pdf
Additional file 1:Flowchart pregnant women.
Additionalfile2english.pdf
Additional file 2:Flowchart women of childbearing age.
Additionalfile3english.pdf
Additional file 3:Flowchart children and adolescents.
AdditionalFiles46english.docx
Additional file 4:Reminder: Poster women of childbearing age.Additional file 5:Reminder: Poster children and adolescents.Additional file 6:Reminder: stickers.
Additionalfile7.pdf
Additional file 7:Completed Standards for Reporting Implementation Studies (StaRI) checklist
LegendforAdditionalfiles16.docx
Additionalfile1.pdf
Additionalfile2.pdf
Additionalfile3.pdf
Additionalfile4.pdf
Additionalfile5.pdf
Additionalfile6.pdf

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Reviewers agreed at journal
22 Jun, 2022
Reviewer #1 agreed at journal
21 Jun, 2022
Reviewers invited by journal
20 Jun, 2022
Submission checks completed at journal
30 May, 2022
Editor invited by journal
04 May, 2022
Editor assigned by journal
20 Apr, 2022
First submitted to journal
07 Mar, 2022

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Design and feasibility of an implementation strategy to address Chagas guidelines engagement at the primary healthcare level in Argentina: a pilot study

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