What is primary healthcare integration?
Primary healthcare integration is a way of combining different primary healthcare services that have previously been delivered separately. The aim of this integration is usually to give people better access to healthcare and to make more efficient use of limited health resources.
Why is it important to know about healthcare workers' views and experiences?
Primary healthcare integration has been implemented in many different countries with varying success. Healthcare workers can influence the extent to which such changes in health services are implemented successfully. Learning about healthcare workers' views and experiences of primary healthcare integration can help us understand how healthcare workers might influence its implementation and its success or failure.
What was the purpose of this scoping review?
This scoping review searched for and mapped qualitative studies (studies with no numerical data) about healthcare workers' views and experiences of primary healthcare integration. We wanted to describe the available research to help inform future systematic reviews and research studies in this area.
How did we identify and map the evidence?
We searched for all published qualitative studies that reported on healthcare workers' views and experiences of primary healthcare integration up to 28 July 2020. We described the different study methods, countries, the scope and type of primary healthcare integration approaches, and the different types of healthcare workers and client groups involved. We then grouped the studies into categories.
What did we find?
We included 184 studies. The studies were from 37 countries. About half the studies took place in high-income countries and half in low- and middle-income countries.
The studies we found in our review covered a variety of settings, participants, and types of primary healthcare integration. There were different configurations for which healthcare service programmes were being combined for integrated service delivery. These were categorised into the following six configurations: mental health; HIV, tuberculosis, and sexual reproductive health; maternal, woman, and child health; non-communicable diseases (for example, heart disease, diabetes); general primary health integration, and allied and specialised services. We also explored whether integrated service delivery was fully or partially integrated, and the different integration strategies used to link and co-ordinate services.
The people participating in the implementation of integration interventions included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay health workers, and health system support staff. A wide range of clients were recipients of the integrated services.
Author's conclusions
This scoping review shows the variety of primary healthcare integration approaches that have been studied. Researchers and decision-makers need to understand the relationship between different integration approaches and contexts, and the ways in which healthcare workers influence the impacts of this integration. The study categories we have developed can help researchers to understand these different types of integration approaches and to identify more focused questions for future systematic reviews.
This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.
To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.
We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.
We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.
For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.
The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study.
The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.