Table 1
Search strategy.
| (integrat* OR linkag* OR combin* OR amalgamat* OR coordinat* OR unificat* OR manag* OR comprehensive* OR “co-ordinated” OR “disease control” OR care deliver* OR “healthcare deliver*” OR “health care deliver*” OR “collaborative care” OR “intersectional collaborat*” OR “interagency collaborat*” OR “care partner*”) | AND | (diabet* OR diabetes mellitus, type 2/OR diabetes, gestational/) | AND | (comorbid* OR co-morbid* OR multimorbid* OR multi-morbid* OR polymorbid* OR poly-morbid* OR codisease* OR co-disease* OR multidisease* OR multi-disease* OR polydisease* OR poly-disease* OR coillness* OR co-illness* OR multiillness* OR multi-illness* OR polyillness* OR poly-illness* OR copatholog* OR co-patholog* OR multipatholog* OR multi-patholog* OR polypatholog* OR poly-patholog* OR codisorder* OR co-disorder* OR multidisorder* OR multi-disorder* OR polydisorder* OR poly-disorder* OR cocondition* OR co-condition* OR multicondition* OR multi-condition* OR polycondition* OR poly-condition* OR cosyndrom* OR co-syndrom* OR multisyndrom* OR multi-syndrom* OR polysyndrom* OR poly-syndrom* OR ((coexisting OR co-existing OR multiple) W0 (morbidit* OR disease* OR illness* OR patholog* OR disorder* OR condition* OR syndrom*)) OR ((Charlson* OR Elixhauser*) W0 (index* OR score*))) OR OR “noncommunicable disease*” OR “non communicable disease*” OR ncd OR ncds OR “non infectious disease*” OR “non infectious illness*” OR “chronic disease*” OR “chronic illness*” OR “cardiovascular disease*” OR “vascular disease*” OR “heart disease*” OR “heart illness*” OR “cardiac disease*” OR “heart attack*” OR stroke* OR “heart failure” OR “heart rupture” OR “cardiac arrest” OR cancer* OR neoplasm* OR “chronic respiratory disease*” OR “chronic airflow obstruction*” OR “chronic obstructive airway disease*” OR “chronic obstructive lung disease*” OR “chronic obstructed pulmonary disease*” OR asthma OR “lung disease*” OR “communicable disease*” OR “infectious disease*” OR “human immunodeficiency virus” OR hiv OR “acquired immunodeficiency syndrome” OR aids OR “opportunistic infectious disease*” OR tuberculosis OR tb OR malaria OR pneumonia OR “diarrheal disease*”) | AND | Africa/OR “Africa South of the Sahara”/OR “Sub-Saharan Africa”/OR north Africa/OR Africa, Northern/Egypt or Libya OR Tunisia OR Algeria OR Morocco OR “Western Sahara” OR Angola/OR Benin/OR Botswana/OR Burkina Faso/OR Burundi/OR Cameroon/OR Cape Verde/OR Central African Republic/OR Chad/OR Comoros/OR Congo/OR Brazzaville/OR Cote d’Ivoire/OR Djibouti/OR Equatorial Guinea/OR Eritrea/OR Ethiopia/OR Gabon/OR Gambia/OR Ghana/OR Guinea/OR Bissau/OR Kenya/OR Lesotho/OR Liberia/OR Madagascar/OR Malawi/OR Mali/OR Mauritania/OR Mauritius/OR Mozambique/OR Namibia/OR Niger/OR Nigeria/OR Rwanda/OR Sao Tome e Principe/OR Senegal/OR Seychelles/OR Sierra Leone/OR Somalia/OR South Africa/OR South Sudan/OR Sudan/OR Swaziland/OR Eswatini OR Tanzania/OR Togo/OR Uganda/OR Western Sahara/OR Zaire/OR Zambia/OR Zimbabwe/ |
Figure 1
Flow diagram of the included studies for the systematic review of integrated management of type 2 diabetes mellitus and gestational diabetes mellitus in the context of multi-morbidity conditions in Africa.
Table 2
Study characteristics.
| AUTHOR | YEAR | COUNTRY | STUDY AIM | STUDY DESIGN | SAMPLING STRATEGY |
|---|---|---|---|---|---|
| Labhardt N.D et al. | 2010 | Cameroon | To examine the effectiveness of integrating care for HT and T2DM by task shifting to non-physician clinician (NPC) facilities in eight rural health districts in Cameroon. | Cohort | Purposive |
| Segafredo G. et al. | 2016 | Angola | To estimate the double burden of DM, HT and TB and to pilot the integration of the screening for DM and HT in the TB national programs in six TB centers in Luanda. | Cross-sectional or Interventional | Purposive |
| Wroe E.B. et al. | 2015 | Malawi | To increase access to care for NCD patients, to maximize efficiency given the severe human resource shortages, and to replicate strong HIV outcomes for patients with other chronic conditions. | Cross-sectional | Purposive |
| Chamie G.et al. | 2012 | Uganda | To test the feasibility and diagnostic yield of integrating NCD and other communicable disease services into a rapid, high-throughput, community-based HIV testing and referral campaign for all residents of a rural Ugandan parish, and to determine rates and predictors of post-campaign linkage to care by disease. | Cross-sectional | Community based campaign (census) |
| Jerene D. et al. 2017 Ethiopia | 2017 | Ethiopia | To demonstrate the feasibility of integrated care for TB, HIV and DM in a pilot project. | Cross-sectional | Purposive |
| Almossawi HJ et al. | 2019 | South Africa | To assess the readiness of the PHC system to provide integrated TB and DM services. | Cross-sectional | Random for patients records, convenience for respondents |
| Pfaff C. et al. 2018 Malawi | 2018 | Malawi | To describe the experience of this pilot initiative, where all adults accessing care in the HIV clinic are screened and treated for HT and DM during the same visit. | Cross-sectional | Purposive |
| Pastakia S.D et al. | 2017 | Kenya | To assess the impact of the implementation of a patient-centered rural NCD care delivery model called Bridging Income Generation through grouP Integrated Care (BIGPIC). | Cohort or Interventional | Voluntary |
| Govindasamy D. et al. 2013 | 2013 | South Africa | To determine the yield of newly-diagnosed HIV, TB symptoms, DM and HT, and to assess CD4 count testing, linkage to care as well as correlates of linkage and barriers to care from a mobile testing unit. | Cohort or Interventional | Voluntary |
| Kachimanga C. et al. | 2017 | Malawi | To increase case detection for NCDs in the community, at the facility for acute outpatient care, and at Integrated Chronic Care Clinic (IC3) itself. | Cross-sectional | Voluntary |
| Manne-Goehler J. et al. | 2017 | South Africa | To assess the relationship between ART use and utilization of health care services for DM and HT. | Cross-sectional | Random |
| Golovaty I. et al. | 2018 | South Africa | To conduct a cost analysis to determine the per-person incremental costs associated with integrating NCD screening and counseling to a home-based HIV counseling and testing program in KwaZulu-Natal. | Cross-sectional | Quota from an old enrolled cohort |
| Venables A. et al. | 2016 | Kenya | To assess patient and health-care worker perceptions and experiences of medicines adherence clubs (MACs) in the urban informal settlement of Kibera. | Cross-sectional | Purposive |
Table 3
Results of the assessment of risk of bias in included studies by using the ROBINS-I assessment tool.
| STUDY ID | 1. BIAS CAUSED BY CONFOUNDING | 2. BIAS CAUSED BY SELECTION OF PARTICIPANTS | 3. BIAS CAUSED BY CLASSIFICATION OF INTERVENTIONS | 4. BIAS CAUSED BY DEVIATIONS FROM INTENDED INTERVENTIONS | 5. ATTRITION BIAS CAUSED BY MISSING DATA | 6. DETECTION BIAS CAUSED BY MEASUREMENT OF OUTCOMES | 7. REPORTING BIAS CAUSED BY SELECTION OF THE REPORTED RESULTS | OVERALL JUDGEMENT |
|---|---|---|---|---|---|---|---|---|
| Labhardt N.D et al. 2010 Cameroon | Low | Low | Low | No information | Low information on reasons for missing data provided) | Low | Low | Low |
| Segafredo G. et al. 2016 Angola | Serious | Low | No information | No information | No information | Serious | No information | Serious |
| Wroe E.B. et al. 2015 Malawi | Serious | Serious | No information | No information | Serious | Serious | Serious | Serious |
| Chamie G.et al. 2012 Uganda | Serious | Serious | No information | No information | Serious | No information | No information | Serious |
| Jerene D. et al. 2017 Ethiopia | Serious | Serious | No information | No information | Low (information on reasons for missing data provided) | No information | No information | Serious |
| Almossawi HJ et al. 2019 South Africa | Serious | Low | No information | No information | Low (information on reasons for missing data provided) | No information | Low | Serious |
| Pfaff C. et al. 2018 Malawi | Serious | Low | Low | No information | Low (information on reasons for missing data provided | No information | No information | Serious |
| Pastakia S.D et al. 2017 Kenya | Serious | Serious | Serious | Low | No information | Serious | Serious | Serious |
| Govindasamy D. et al. 2013 South Africa | Low | Low | No information | No information | No information | No information | No information | Serious |
| Kachimanga C. et al. 2017 Malawi | Serious | Serious | No information | No information | No information | No information | No information | Serious |
| Manne-Goehler J. et al. 2017 South Africa | Serious | Low | No information | No information | Low (information on reasons for missing data provided | Serious | No information | Serious |
| Golovaty I. et al. 2018 South Africa | Low | Low | No information | No information | No information | No information | No information | Serious |
| Venables A. et al. 2016 Kenya | Serious | Serious | No information | No information | Serious | No information | No information | Serious |
Table 4
Cost effectiveness outcomes and integration levels.
| AUTHOR | YEAR | COUNTRY | COST-EFFECTIVENESS OUTCOME | INTEGRATION LEVEL: PARTIAL*/FULL** |
|---|---|---|---|---|
| Labhardt et al. | 2010 | Cameroon | Affordable drugs from the national essential drug list were available and used | Full |
| Segafredo et al. 2016 | 2016 | Angola | Not measured | Partial |
| Wroe et al. | 2015 | Malawi | All patients were seen in one day, at the nearest health center, for all of their chronic conditions. | Full |
| Chamie G.et al. | 2012 | Uganda | Cost-effectiveness of adding NCD screening was not the aim of the study but the relatively low cost of $2.41/person makes it likely to be cost-effective. | Partial |
| Jerene et al. | 2017 | Ethiopia | Not measured | Partial |
| Almossawi et al. | 2019 | South Africa | Not measured | Partial |
| Pfaff et al. | 2018 | Malawi | Not measured but its advantages discussed and its evaluation recommended | Partial |
| Pastakia et al. | 2017 | Kenya | group care model resulted in 72.4% of screen-positive participants returning for subsequent care, of which 70.3% remained in care through the 12 months of the evaluation period. | Partial |
| Govindasamy et al. | 2013 | South Africa | Not measured | Partial |
| Kachimanga et al. | 2017 | Malawi | Not measured | Partial |
| Manne-Goehler et al. | 2017 | South Africa | Not measured | Partial |
| Golovaty et al. | 2018 | South Africa | Comprehensive home-based HIV-NCD testing and counseling results in a modest increase in costs with the potential to avert NCD death and disability. The additional time burden of NCD screening and testing was the major driver of costs, emphasizing the need for a targeted approach that bridges to an integrated public health model. 20% increase in testing and counseling time was revealed in time assessment | Partial |
| Venables et al. | 2016 | Kenya | MACs allow for the efficient management of co-morbidities and enable large numbers of stable patients to collect their chronic medication efficiently, whilst simultaneously enabling patients to benefit from peer support and health education. | Partial |
[i] Partial *: Integration through co-location of services (same room or same clinic).
Full **: Integration of services OR integration into PHC-mainstreaming.