Systematic review process
Initially 829 studies were identified from three databases from which13 studies were considered for final analysis.
Figure:1 describes how studies were found and included by applying the inclusion and exclusion criteria.
Study setting and study characteristics
Majority (n = 7) of included studies were from India followed by Pakistan (n = 2), and Bangladesh, Nepal, and Sri Lanka (n = 1). No studies were found from Afghanistan, Bhutan, or the Maldives. Most of the (n = 10) intervention took place at the hospital or clinic level 21–30 whereas some (n = 3) were based on community setting 31–33.
Majority of the included studies (n = 8) were cross-sectional 22,23,25,26,28,29,31,33 followed by RCTs (n = 3) 21,30,32, non-randomized before-after intervention study (n = 1) (27) and qualitative study (n = 1) 24 (Table 1).
Table 1
Characteristics of included studies:
Study identifier
|
Study Design
|
Geographic Location,
Population age and
gender
|
NCD type
|
Intervention
|
Outcome/Result
|
Ali et al., 2016
|
Parallel, open-label, pragmatic RCT
|
- Diabetes clinics in India and Pakistan
− 35 + years
- Male & Female
|
Diabetes
|
Intervention: Regular physician’s care, diabetes specific care coordinator’s service through monthly phone call and follow-up visit
once in three months.
Control: Regular physician’s care only.
|
HbA1c level: Baseline: 9.9%,
Intervention and control group difference: HbA1c level < 7%:
12 month: 8.7% (P < 0.001)
30 month: 11.8% (P < 0.001)
Intervention vs. Control: 21.5% vs. 11.1%., (RR, 1.93 [95% CI, 1.52 to 2.45])
BP: Baseline: 143.3/81.7mm Hg,
Intervention and control group difference < 130/80 mm Hg:
12 month: 1.7% (P = 0.56)
30 month: 9.2% (P = 0.002)
Intervention vs. Control: 51.0% vs. 45.0%; (RR, 1.14 [CI, 1.04 to 1.26])
LDLc level: Baseline: 3.17 mmol/L (122.4 mg/dL)
Intervention and control group difference: LDLc level < 100 mg/dL (< 70 mg/dL for people with previous CVD):
12 month: 9.5% (P = 0.001)
30 month: 5.3% (P = 0.071)
Intervention vs. Control: 56.4% vs. 47.1%; (RR: 1.23 [CI, 1.13 to 1.34])
|
Upadhyay et al., 2015
|
Pre-post non-clinical
randomised controlled trial
|
- Pokhara, Nepal
− 16/+ years
- Male and female both
|
Diabetes mellitus
|
Test 1 group: Educational materials (diabetes information booklet, diabetes complication
chart, diabetic food chart, exercise, using insulin and glucometer) for increasing patients’ diabetes awareness and management.
Test 2 group: Educational materials and diabetic kit (includes glass tubing, chart of human anatomy with circulatory
system, daily medication calendar and calendar of antidiabetic medicines)
Control group: Usual service from nurse and doctor
|
Patients’ satisfaction scores:
Control group:
Baseline: 44
3month: 50
12 month: 47.7
Test 1 group:
Baseline: 45
3month: 66
12 month: 68
Test 2 group:
Baseline: 43
3month: 68
12 month: 73
|
Lewis and Newell et al, 2014
|
Qualitative study
|
- Dhaka metropolitan City & Sylhet division, Bangladesh
- Age group not mentioned
- Male and female
|
Type 2 Diabetes
|
Discussed about available diabetes care in different setting in Bangladesh.
Control group: N/A
|
- BIRDEM provides comprehensive education program (verbal and written) on diabetes care and patients have good awareness.
- Only the BIRDEM clinic situated in capital offered regular comprehensive check-ups (full cardiovascular, renal and eyesight examinations).
- Limited knowledge among patients who take service from specialist centres due to lack of getting proper diabetes guideline.
- Rural Upazilla-level clinics contains limited resources to manage diabetes.
-High service cost, resource limitation, long waiting line creates limitation to provide comprehensive treatment for service providers.
- Poor diabetes management in rural and peri-urban area due to high service cost.
- As basic diabetes services are unavailable in rural community clinic, so patients require extra money and time to travel to district hospital for service, which delayed care seeking for people.
|
Sing et al. 2014
|
Cross sectional study
|
- Chandigarh, India
- Mean age 31.49
- Gender not mentioned
|
Cardiovascular disease
|
Intervening mobile phone and Bluetooth operated handheld tele-ECG machine in community level.
Control group: N/A
|
− 100% accuracy of transmission rate of tele-ECG from handheld machine to mobile phone.
- Tele-ECG result was transmitted to expert physicians based in Postgraduate Institute of Medical Education and Research (PGIMER) from remote area
- Patients with acute myocardial infraction were screened through the tele-ECG machine and got immediate service from the specialized doctor.
- Patients reported ∼95% satisfaction about new tele-ECG machine as it ensured the availability of health care for people who lives in remote area.
|
Basu et al., 2006
|
Cross sectional study
|
- Rural district of Bengal, a state in
eastern India.
− 30–65 years
- Female
|
Cervical cancer
|
Community based cervical cancer screening test/ via-test for women aged 30–65 years.
Control group: N/A
|
- Immediate colposcopy for women with positive via screening: 100% compliance
- Cervical punch biopsies for women with abnormal colposcopy: 95.6% compliance, Biopsy was refused by 7 women.
- Satisfied and very satisfied with the service: 64.7% & 5.6% accordingly
- Accessibility and affordability mentioned by service recipient as it was community based and free screening.
|
Sankaranarayanan et al., 2012
|
Cluster randomized controlled trial
|
- Trivandrum district, Kerala, India.
− 35/+ years
- Male & Female
|
Oral Cancer
|
Intervention: Health worker provided screening facilities for oral cancer and health education to quit harmful practices +
further direction on treatment from specialist for those who are screened positive.
Control: Routine health care without screening facilities until 2006
|
- Cumulative advanced oral cancer mortality rate: RR 0.88, 95% CI (0.69–1.12)
- Incidence of advanced oral cancers among tobacco/alcohol user or both: RR 0.79, 95% CI (0.65–0.95)
- Advanced oral cancer mortality among tobacco/alcohol user or both: RR 0.76, 95% CI (0.60–0.97)
- Oral cancer incidence in result of four repeated screening among all eligible people: mortality HR 0.76,95% CI (0.49–1.17)
- Oral cancer mortality rate in result of four repeated screening among all eligible people: Mortality HR 0.21, 95% CI (0.13–0.35)
- Oral cancer incidence in result of four repeated screening among tobacco/alcohol user or both: mortality HR 0.62, 95% CI (0.41–0.92)
- Oral cancer mortality rate in result of four repeated screening among tobacco/alcohol user or both: mortality HR 0.19, 95% CI (0.11–0.31).
|
Mahapatra et al., 2016
|
Crosssectional study
|
- Odisha, India
− 21–40 years
- Male and female
|
Cancer
|
Oncology services provision in specialty hospitals in Odisha, India.
Control group: N/A
|
− 13 out of 22 patients reported about good interpersonal behaviour of doctors. However, negative behaviour from supporting staff was reported.
- Patient satisfaction on interpersonal manner 63% (3.2 ± 0.5).
- Patient satisfaction in overall communication 70% (3.3 ± 0.5).
- Few problems such as long waiting hours, shortage of bed for admission, long distance of specialized hospital etc. were reported.
|
Chiranthika et al., 2013
|
Cross-sectional study
|
- Gampaha, Western province of Sri Lanka
− 35–39 years
- Female
|
Breast cancer
|
Clinic based early detection service for breast cancer were provided. Then, assessment was done on coverage, quality and client satisfaction.
Control group: N/A
|
Coverage:
- Clinical Breast Examination coverage increased from 1.1% -2.2% between 2003–2007.
- Proportion of breast abnormalities detected on 2007: 1.8%.
- Proportion referred for further care detected with breast abnormalities: 86.8%.
Quality:
- Clients satisfaction with the infrastructure:
- Space in the clinic building: 83%,
- Overall cleanliness of clinic: 82.5%,
- Cleanliness of the toilets:58.5%,
- Availability of sitting facilities in the waiting area: 85.5%,
- Comfort in the waiting area: 84.5%
Satisfaction on service provision:
- Politeness displayed by the health care workers: 98%,
- Privacy while conducting CBE: 86%,
- Time spent on CBE: 97%,
- Health education on BSE: 98%
|
Mathew et al., 2017
|
Cross sectional study
|
- Mumbai, India
− 30–79 years
- Male and female
|
Lung Cancer
|
Telephonic follow-up for cancer patients with planned treatment was introduced.
Control group: N/A
|
- Agreement between the telephonic and physical impression of disease: Substantial strength
- Accuracy of telephonic versus physical follow-up: Among seven follow-up, five showed substantial strength (PABAK score: 0.67, CI:0.51–0.79; 0.66, CI: 0.48–0.79; 0.68, CI: 0.44–0.84; 0.74, CI: 0.46–0.89, 0.68, CI: 0.32–0.88).
- Satisfaction score:
Telephonic follow-up: 8
Physical follow-up: 9
- Negative correlation between time spent in telephonic follow-up and patient satisfaction: (r = − 0.147, P = 0.002).
- Anxiety reduction after physical follow-up: 70.27%
- Mean time spent for physical follow-up: 40.36 hour
- Expenditure for each physical follow-up: Rs. 5117.10 for travel and Rs. 3079.06 for lodging.
|
Ghoshal et al. 2019
|
Cross-sectional study
|
- India
- >= 18 years
- Male and female
|
Cancer
|
Advanced cancer patients' decision making about treatment were measured in a palliative care unit.
Control group: N/A
|
- Shared, active, and passive Decisional Control Preferences (DCP) was 20.7%, 26.7%, and 52.7%, respectively.
− 27.3% felt that the doctor should make a shared decision with the patient,
− 34% patients felt that the family should be involved in decision making.
− 32.7% make the decisions with the family after consulting with the doctor.
− 59.3% actual treatment decisions were passive, whereas 21.3% were actively taken by the patient.
|
Shams et al., 2018
|
Cross sectional study
|
- Karachi,
Pakistan.
− 20–60 + years
- Female
|
Breast and gynaecological cancer
|
Intervention group: Structured supportive care (physical and psychosocial
counselling, mind diversion activities) for patients taking chemotherapy for 6 weeks.
Control group: N/A
|
- Improved selfcare behaviour, physical and psychological health and satisfaction among the intervention participants.
- Almost all participants were satisfied with the program.
- Intervention gave emotional support and helps the participants to ventilate their feelings.
− 82.4% thinks program has positively influenced their life.
− 94.1% said program helped them in accepting the disease and its treatment.
− 94.1% said it helped them in controlling worrying thoughts.
− 82.4% said it helped them to control low moods.
− 94.1% participants’ outlook towards their lives have changed positively.
− 76.5% women's interest towards life has increased.
− 70.6% women have practiced positive coping strategies in their daily life, that they learned from weekly sessions.
- Knowledge enhanced: physical (82.4%), psychological (88.2%) and sexual health (76.5%)
|
Nayak et al., 2005
|
Nonrandomized Before-after intervention study
|
- Cuttack, India
- Pre: 28–79 years
- Post: 23–81 years
- Male and female
|
Cancer
|
Communication strategy for service providers developed and implemented
Control group: N/A
|
- Allowing enough time for the patient and families
1st step: 22%, 3rd step: 42% (p < .001)
- Doctor’s attitude towards clarification of issues
1st step: 26%, 3rd step: 56% (p < .001)
- Use of clear language
1st step: 14%, 3rd step: 57% ( p < .001)
-Privacy during consultation
1st step: 5%, 3rd step: 70% ( p < .001)
-No interruption during consultation
1st step: 42%, 3rd step: 82% ( p < .001)
- Overall satisfaction with communication
1st step: 13%, 3rd step: 33% ( p < .001).
|
Tovey et al., 2005
|
Cross-sectional study
|
- Lahore, Pakistan
- Age group not mentioned
- Male and female
|
Cancer
|
Cancer patients were asked in four different hospitals about their satisfaction towards using traditional medicine (TM) and
Complimentary Alternative Medicine (CAM) beside allopathic medicine.
Control group: N/A
|
- Most used CAM/TMs by cancer patients’ in Pakistan are Dam Darood (70.4%), and spiritual healing (47.2%) and Hakeem (35%).
− 84% of the cancer patients had used 1 or more forms of TM in combination with conventional treatments.
- To the patients, CAM/TMs are also thought to be effective and very effective (Dam Darood 57%, spiritual healing 26% and Hakeem 22%) beside medical specialists (94%) and general practitioners (78%).
− 58% patients were satisfied with the cancer treatment of homeopathy.
|
Quality assessment
Among the RCTs, allocation concealment was found “unclear” for two studies 30,32 random sequence generation, performance bias, detection bias, and attrition bias was found as low risk of bias for two studies. All studies reported a low risk of reporting bias 21,30,32. The absence of allocation concealment and attrition rate resulted in the unclear risk of bias for one study 32. The remaining RCT did not mention any of the bias except the primary outcome and attrition rate 30. The risk of bias of RCTs has been demonstrated in Fig. 2.
In overall grading, among eight cross-sectional studies, four studies 22,23,26,31 were of good quality, three 25,28,33 were of moderate quality and one study 29 was found to have poor quality. As per the adapted grading system, the qualitative study 24 and non-randomized before-after intervention study 27 were graded as the good quality study as well. Studies that were assessed as a good quality study had an adequate answer for study setting, sample size and sampling method, valid and reliable statistical analysis, and reporting system, ethical consideration and managing confounding.
Intervention and outcome:
Intervention related to cancer and its outcome
9 out of 13 studies that were included in this review focused on interventions to improve QoC in cancer services. Here, two studies discussed community-based 31,32, and one study discussed clinic-based screening services 22 to improve QoC for cancer patients.
A community-based cervical cancer screening program by trained health workers (HW) was discussed in one study where Visual Inspection with Acetic Acid (VIA) test, colposcopy, punch biopsy, treatment, and advice were provided consecutively which increases the availability of service provision to village women and treatment compliance and reduce the incidence and severity of advanced cervical cancer. 64.7% of women were satisfied while 5.6% were very satisfied with the services. Women with positive results on the VIA test were immediately scheduled for colposcopy and women with abnormal colposcopy were referred for cervical punch biopsies which result in 100% and 95.6% compliance to treatment in both cases 31.
15 years long RCT on community-based oral cancer screening program was run by trained HW where awareness rising through home visits, screening services, further treatment for positively screened patients, referrals, etc. were provided to the community people to increase treatment facilities and awareness 32. This intervention significantly reduced the mortality rate of oral cancer among tobacco/ alcohol users and non-users. Through community-based care and health education, the incidence of advanced oral cancer among tobacco/alcohol users reduced significantly (RR 0.79, 95% CI: 0.65–0.95) 32.
A clinic-based screening and early detection program was conducted in Gampaha district, Sri Lanka, where clinical breast examination (CBE) and breast self-examination (BSE) was done by public health midwives/HW for early detection of breast cancer. Women were found satisfied with clinic space (83%), privacy (86%) and time spent (97%) during CBE, toilet cleanliness (58.5%), availability and comfort of sitting facilities in the waiting area (85.5% and 84.5%). Clinic-based breast cancer detection program has helped to increase breast cancer detection and service coverage from 1.1% -2.2% between 2003–2007. Referral service increase and 86.8% of women who were detected with breast abnormalities were referred for further care 22.
In one study, telephonic follow-up beside physical follow-up was arranged for the patients with cancer who were already under planned treatment. An unchanged questionnaire was used to compare the patient's physical condition, satisfaction, cost, and time associated with both types of follow-up. A negative correlation was found between time spent in telephonic follow-up and patient satisfaction (r = − 0.147, P = 0.002). Patients preferred a physical follow-up even though it required a higher financial investment. 70.27% of study participants acknowledged the reduction in anxiety when they attended a physical follow-up 26.
Due to a structured five weeklong hospital-based physical and psychological supportive care for women undergoing chemotherapy for six weeks, patient’s ability to control their mood (82.4%), acceptance of the disease and its treatment (94.1%), positive outlook toward life (76.5% women’s interest toward life grows and 70.6% of women to practice positive coping strategies in their daily life), etc. increases. This intervention was packed with group therapy where physical and psychosocial counselling and mind diversion activities for improving psychological and emotional wellbeing were provided 28.
It was explored through one study that improved communication skills of service providers can increase patient’s satisfaction around their behaviour. Three staged-intervention of this study included investigation of the patient’s perception of doctor-patient communication, dissemination of results with service providers, and development of a communication strategy for service providers and provision of training for them 27.
Two studies discussed how a specialized hospital and palliative care centre for cancer could serve patients in a more engaging way 25 and how the decision-making process around treatment could be influenced 34. Services from a specialized cancer hospital had increased patient satisfaction (63%) related to the interpersonal relationship with their service provider (3.2 ± 0.5). 70% of patients were also satisfied with the overall communication (3.3 ± 0.5) even though issues such as long waiting times, shortage of beds and, long-distance to a specialized hospital are present 25. It was identified that a specialized palliative care unit could help patients with making decisions related to treatment by consulting with the specialized doctor 34.
- Intervention related to diabetes and its outcome:
Three among thirteen studies discussed interventions that ensure QoC around diabetic care. For maintaining QoC in service provision the included studies discussed different approaches such as employing diabetic care specific HW, providing diabetic education and care, and initiating specialized service for diabetes 21,24,30.
It was found through a 2.5-year-long RCT 21, that HWs specialized in diabetic care resulted in improved and continuous care. This RCT employed diabetes care specific HW who communicated with a diabetic patient from the intervention group every month over the phone and organized a follow-up visit once every three months, in addition to regular visits to the physician. HWs also developed a management plan for patients by looking at patients’ laboratory tests, treatment plans, and discuss them with the doctors. Because of diabetes care specific HW’s patient follow-up and care, patients of the intervention group achieved the study objective 21.
Another RCT conducted in Nepal had three arms where two were intervention arms (named as test 1 and test 2 group) and one was a control arm 30. Both intervention groups received diabetes-related education materials, whereas participants in test 2 received diabetic kits along with educational materials. Due to this intervention, the satisfaction score among the intervention group has increased after 12 months when compared to the control group. The second intervention group received an extra diabetic kit along with education materials, which increased their satisfaction scores even more 30.
Through a qualitative study conducted by Lewis and Newell discussed the available diabetic care from BIRDEM, BADAS, district health complexes, community clinics in the rural area, and the slums of Bangladesh 24. Unlike BADAS, BIRDEM provides a comprehensive awareness program, written and verbal information. It also discussed the limitations of a specialized center for diabetes care in Bangladesh and the high cost of diabetes care outside of BIRDEM. They emphasized the lack of access to clinics with appropriate facilities for diabetic care for people living in rural areas and subdistrict level. Specialized diabetes center could raise awareness on diabetes management and the availability of comprehensive check-ups (full cardiovascular, renal, and eyesight examinations) and proper health education, could minimize the risk for future complications in diabetic patients 24.
- Intervention related to CVD and its outcome:
To maintain QoC around CVD a study included in this review discussed a community-based screening service where a unique handheld tele-ECG machine was used. As early diagnosis and screening of CVD are difficult for people living in rural areas, community-based screening services with tele-ECG machines screened patients with acute myocardial infarction and they got immediate service from a specialized doctor. It achieved a 95% satisfaction rate for people living in remote areas as well 33.