Design and methodological standards

Our study will be conducted as a systematic review of qualitative, quantitative, and mixed-methods evidence examining implementation strategies for integrating NCD care into PHC in SSA. The review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 [21] guidelines for the final manuscript, while this protocol has been developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 statement to ensure transparency and reproducibility [22] S1 Table.

Given the anticipated heterogeneity in study designs, intervention types, and outcome measures, synthesis and reporting will align with the Synthesis Without Meta-analysis (SWiM) guidance to ensure clarity and transparency in narrative reporting [23]. The conduct of the review, including literature searching, study selection, data extraction, and synthesis, will be guided by methodological principles outlined in the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [24]. Any amendments to the registered protocol during the course of the review will be documented, justified, and reported transparently in both the PROSPERO record and the final publication.

Study dates

The review commenced on 15 March 2026, with protocol registration and database searches. Preliminary database searches have been initiated; however, study screening, data extraction, and analysis have not yet commenced. We anticipate completing study screening, data extraction, and analysis by 28 May 2026, with final manuscript submission expected by June 2026.

Eligibility criteria

Time window and language

We will review studies published in English between 1 January 1990 and 31 December 2025. This timeframe has been selected to capture both early and contemporary efforts toward integrating NCD care into PHC systems.

PEO framework

Exposure

Our exposure of interest will be implementation strategies or delivery models aimed at integrating NCD care into PHC. These strategies may include task-shifting and task-sharing approaches, decentralisation of services, integrated clinic models, implementation of clinical guidelines and protocols, workforce strengthening interventions, strengthening of referral pathways, digital health and decision-support tools such as mHealth and telemedicine, and community-based PHC programmes targeting NCDs.

Where data permit, implementation strategies will be described using recommended reporting dimensions, including the actor, action, target, temporality, and dose, to improve interpretability and comparability. The Expert Recommendations for Implementing Change (ERIC) taxonomy may be used as a reference to standardise the classification of strategies where feasible [25].

Outcomes

Studies will be eligible if they report on the implementation, application, or evaluation of at least one strategy for integrating NCD care into PHC settings in SSA. The primary outcome of interest is the implementation strategy. This includes the description, actors, actions, setting, and duration of application. Secondary outcomes include implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, cost, penetration, and sustainability); service delivery outcomes (access, coverage, continuity of care, quality indicators, adherence to guidelines, referral completion, and supply chain performance); and patient-level clinical outcomes (blood pressure control, glycaemic control, retention in care, treatment adherence, complication rates, and patient experience). Studies focused solely on NCD epidemiology or clinical effectiveness without describing an implementation or integration strategy will be excluded.

Types of studies

Our review will include a broad range of empirical study designs to capture the complexity of implementation processes. These will include randomised controlled trials and quasi-experimental studies evaluating integration strategies, observational studies (cross-sectional, cohort, and interrupted time series designs), and qualitative studies exploring implementation experiences, barriers, facilitators, acceptability, and feasibility. The synthesis will also include mixed-methods studies evaluating implementation strategies.

Studies will be excluded if they are conducted exclusively in secondary or tertiary care facilities without a PHC integration component. Studies focusing solely on NCD epidemiology or clinical effectiveness without an implementation or integration strategy will also be excluded. Editorials, commentaries, and opinion pieces will be excluded, except where they are used explicitly for contextual background and clearly identified as non-empirical sources.

Information sources

Studies will be obtained from electronic databases, namely PubMed/MEDLINE, Scopus, Web of Science, African Journals Online (AJOL), and Google Scholar, covering all records from 1 January 1990 to 31 December 2025. To improve the retrieval of Africa-focused evidence and reduce publication bias, supplementary searches will include African Index Medicus, where accessible, as well as targeted searches of organisational and policy repositories such as those of the World Health Organization, ministries of health, and implementing partners. These supplementary searches will be conducted using transparent and reproducible procedures.

Search strategy development

A comprehensive and systematic search strategy will be developed to identify all relevant studies examining implementation strategies for integrating non-communicable disease (NCD) care into primary healthcare (PHC) settings in sub-Saharan Africa (SSA). The search strategy will combine controlled vocabulary (e.g., Medical Subject Headings [MeSH] in PubMed) with free-text keywords to maximise sensitivity and ensure comprehensive retrieval of relevant literature. To enhance transparency and reproducibility, the search strategy will be reviewed by an experienced health sciences librarian to refine the search strings. This will ensure the inclusion of appropriate keywords, synonyms, Boolean operators, truncations, and indexing terms across databases.

The search strategy will be structured around four core concept blocks derived from the PEO framework: (i) non-communicable diseases, (ii) primary healthcare, (iii) integration and implementation strategies, and (iv) sub-Saharan Africa. Within each concept block, synonymous terms and related keywords will be combined using the Boolean operator “OR” to broaden the search, while the four concept blocks will be combined using the Boolean operator “AND” to ensure that retrieved studies address all relevant domains.

For the NCD concept, search terms will include both general and condition-specific terminology. These will include “noncommunicable diseases,” “non-communicable diseases,” “chronic disease,” “chronic diseases,” “chronic illness” and the abbreviation “NCD,” as well as specific conditions such as “hypertension,” “high blood pressure,” “diabetes,” “diabetes mellitus,” “cardiovascular disease,” “stroke,” “cancer,” “neoplasm,” “chronic respiratory disease,” “chronic obstructive pulmonary disease,” “COPD,” “asthma,” “mental health,” “mental disorder,” “depression,” and “anxiety disorder.” These terms will be combined using “OR” to ensure comprehensive coverage of all major NCD categories.

For the PHC concept, keywords will include “primary health care,” “primary healthcare,” “primary care,” “community health services,” “community health service,” “community health center,” “community health centre,” “family practice,” “general practice,” and “PHC.” These terms will also be combined using “OR” to capture variations in terminology across different contexts and study designs.

For the integration and implementation concept, the search will adopt terms related to both service integration and implementation processes. Keywords will include “integrated care,” “service integration,” “integrated service delivery,” “care integration,” “integration,” and “continuity of care,” as well as implementation-focused terms such as “implementation,” “implementation strategy,” “implementation strategies,” “implementation research,” “scale up,” “scale-up,” “sustainability,” “task shifting,” “task sharing,” “decentralisation,” “decentralization,” “guideline implementation,” “quality improvement,” “health system strengthening,” “community-based intervention,” “community-based care,” “digital health,” “mHealth,” “mobile health,” and “telemedicine.” These terms will be combined using “OR” to capture the breadth of implementation approaches relevant to PHC integration.

For the geographic concept, the search will include both controlled vocabulary and free-text terms to capture studies conducted in SSA. Keywords will include “sub-Saharan Africa,” “sub Saharan Africa,” “Africa South of the Sahara,” and the names of individual countries within SSA (Ghana, Nigeria, Kenya, Uganda, Tanzania, Ethiopia, Malawi, Mozambique, South Africa, Rwanda, Zambia, Zimbabwe, Cameroon, Senegal, Sierra Leone, Liberia, Namibia, Botswana, Lesotho, and Eswatini). These terms will be combined using “OR” to maximise the retrieval of region-specific studies.

The final search string will combine the four concept blocks using the Boolean operator “AND,” ensuring that all retrieved studies address NCDs, PHC, implementation/integration strategies, and the SSA context. Truncation symbols (e.g., “*”) will be used where appropriate to capture variations in word endings, and phrase searching (using quotation marks) will be employed to improve precision S1 Text.

Study records and management

All identified records will be imported into the reference management software Zotero for de-duplication. The de-duplicated records will then be uploaded into Covidence to facilitate screening and data extraction processes. All decisions made during the full-text screening stage will be documented, including reasons for exclusion, to ensure transparency and to support the development of a PRISMA flow diagram S1 Fig.

Selection process

Our study selection will be conducted in two stages. First, TYB and JO will independently screen titles and abstracts of all retrieved records for potential eligibility. Second, the full texts of all potentially eligible studies will be retrieved and independently assessed against the inclusion criteria. Any disagreements at either stage will be resolved through discussion and consensus. Where consensus cannot be reached, HA will be consulted to adjudicate. These screening approaches are intended to minimise selection bias and enhance the reliability of the review process.

Data extraction

We will use a standardised data extraction form based on JBI [24]. TYB and JO will pilot the form on a subset of included studies before full extraction. The form will be refined iteratively to ensure clarity and completeness. We will extract bibliographic details such as author, year, country, and publication type, and study characteristics (aims, design, sampling, and PHC setting). Information on the NCD conditions addressed will be collected, along with detailed descriptions of the integration model and implementation strategies, including who implemented the strategy, what actions were undertaken, where they were implemented, and over what period.

We will also extract data on barriers and facilitators to implementation, which may be coded inductively or mapped to common categories during synthesis. Outcomes reported in the studies, including implementation, service delivery, and patient outcomes, will also be extracted, along with measurement tools and timepoints.

Quality appraisal

We will assess the methodological quality of the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018 [26]. This is suitable for appraising qualitative, quantitative, and mixed-methods studies within a single framework S2 Table. The two reviewers will independently assess each study, and disagreements will be resolved through discussion. Each included study will be evaluated using the five criteria relevant to its design category. We will summarise the quality appraisal findings and present them transparently to contextualise the interpretation of results. No overall numerical score will be calculated unless explicitly required by the publication outlet.

Data synthesis

Our study will adopt a narrative synthesis approach [27] due to the anticipated heterogeneity in interventions, contexts, and outcome reporting. The synthesis will follow established guidance for narrative synthesis, including developing a preliminary synthesis, exploring relationships within and between studies, and assessing the robustness of findings.

The findings will be organised thematically around types of implementation strategies and integration models, barriers and facilitators across contexts, reported effects on implementation and service delivery outcomes, patient outcomes where available, and implications for scale-up, sustainability, and health system strengthening. Where a subset of studies demonstrates sufficient homogeneity in intervention type, outcome definition, and measurement, a meta-analysis may be conducted using a random-effects model. Statistical heterogeneity will be assessed using the I² statistic. Where pooling is not appropriate, results will be synthesised narratively using clearly defined grouping and comparison strategies.

Meta-bias and publication bias

Because meta-analysis is not anticipated as the primary synthesis approach, we will assess publication bias qualitatively by examining patterns such as selective outcome reporting, differences between peer-reviewed and grey literature, and gaps in reporting across outcomes and settings. Where meta-analysis is feasible, small-study effects will be explored using appropriate methods such as funnel plot assessment [28].

Confidence in cumulative evidence

Where quantitative synthesis is conducted, the certainty of evidence will be assessed using the GRADE approach [29]. For qualitative findings, confidence may be assessed using the GRADE-CERQual framework, considering methodological limitations, coherence, adequacy, and relevance [30]. Where formal grading is not feasible, confidence in the cumulative evidence will be assessed narratively based on study quality, consistency, and contextual relevance.

Ethics and dissemination

Our review does not require ethical approval because it involves the use of published and publicly available data and does not involve primary data collection. As part of the data extraction process, we will document whether each included primary study reported ethical approval or exemption. The findings of this review will be disseminated through peer-reviewed journal publications, presentations at conferences relevant to primary healthcare and health systems, and policy-oriented outputs. These will include policy briefs and stakeholder engagement activities aimed at supporting implementation decision-making for integrated NCD care within PHC systems in sub-Saharan Africa.

Patient and public involvement

Patients and members of the public will not be involved in the design of this protocol. However, the findings of the review are intended to inform policymakers, health system managers, and primary healthcare implementers, with the ultimate goal of improving access to and quality of integrated NCD care in sub-Saharan Africa.

Limitations

Our protocol has several limitations. The review will be restricted to English-language publications due to resource and feasibility constraints related to the translation and interpretation of non-English full-text articles. This restriction may result in the exclusion of relevant studies from Francophone and Lusophone countries, potentially limiting the geographic representativeness of the findings. Additionally, variability in how integration and implementation strategies are defined and reported across studies may pose challenges for synthesis and comparison. Differences in outcome measurement and reporting may further limit the ability to draw definitive conclusions about effectiveness. The reliance on narrative synthesis, while appropriate for heterogeneous data, may introduce a degree of interpretive subjectivity. These limitations will be addressed through transparent reporting, rigorous methodological procedures, and careful interpretation of findings. Despite these challenges, the review is expected to make a meaningful contribution to the evidence base on health system strengthening in SSA.