Better health and wellbeing for billion more people: integrating non-communicable diseases in primary care

Voices of care: unveiling patient journeys in primary care for hypertension and diabetes management in Kerala, India

Background

Diabetes and hypertension are leading public health problems, particularly affecting low- and middle-income countries, with considerable variations in the care continuum between different age, socio-economic, and rural and urban groups. In this qualitative study, examining the factors affecting access to healthcare in Kerala, we aim to explore the healthcare-seeking pathways of people living with diabetes and hypertension.

Methods

We conducted 20 semi-structured interviews and one focus group discussion (FGD) on a purposive sample of people living with diabetes and hypertension. Participants were recruited at four primary care facilities in Malappuram district of Kerala. Interviews were transcribed and analyzed deductively and inductively using thematic analysis underpinned by Levesque et al.'s framework.

Results

The patient journey in managing diabetes and hypertension is complex, involving multiple entry and exit points within the healthcare system. Patients did not perceive Primary Health Centres (PHCs) as their initial points of access to healthcare, despite recognizing their value for specific services. Numerous social, cultural, economic, and health system determinants underpinned access to healthcare. These included limited patient knowledge of their condition, self-medication practices, lack of trust/support, high out-of-pocket expenditure, unavailability of medicines, physical distance to health facilities, and attitude of healthcare providers.

Conclusion

The study underscores the need to improve access to timely diagnosis, treatment, and ongoing care for diabetes and hypertension at the lower level of the healthcare system. Currently, primary healthcare services do not align with the "felt needs" of the community. Practical recommendations to address the social, cultural, economic, and health system determinants include enabling and empowering people with diabetes and hypertension and their families to engage in self-management, improving existing health information systems, ensuring the availability of diagnostics and first-line drug therapy for diabetes and hypertension, and encouraging the use of single-pill combination (SPC) medications to reduce pill burden. Ensuring equitable access to drugs may improve hypertension and diabetes control in most disadvantaged groups. Furthermore, a more comprehensive approach to healthcare policy that recognizes the interconnectedness of non-communicable diseases (NCDs) and their social determinants is essential.

The role(s) of community health workers in primary health care reform in Kerala, before and during the COVID 19 pandemic: a qualitative study

Background

Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts.

Methods

We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

Results

Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done.

Conclusion

The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.

Effectiveness of behavioural change interventions on physical activity, diet and body mass index of public primary healthcare users in Kosovo: the KOSCO cohort

BACKGROUND

Prevalent physical inactivity and poor nutrition contribute to high non-communicable disease (NCD) morbidity and mortality in Kosovo. To improve health services for patients with NCD the Accessible Quality Healthcare project developed behaviour change interventions following the principles of the WHO Package of Essential NCD (PEN) protocol. They were implemented into the public primary healthcare (PHC) system of five early-stage implementation municipalities (ESIM, 2018) and seven late-stage implementation municipalities (2020).

OBJECTIVE

To assess the effect of the behaviour change interventions; motivational stages of behaviour change for physical activity and nutrition; and body mass index (BMI).

DESIGN

Prospective cohort study.

DATA COLLECTION AND ANALYSIS

We included 891 public PHC users aged 40 years and above, who were enrolled in the KOSCO (Kosovo Non-Communicable Disease Cohort) cohort in 2019 and followed-up biannually until February 2021. The PHC users who consulted for themselves any health service were approached and recruited for cohort participation. Each participant contributed up to four self-reports of nutrition and physical activity, and up to three reports of motivation to change for a better lifestyle. These outcomes were modelled prospectively with robust mixed-effects Poisson regressions. The association between behaviour change interventions and BMI was quantified using linear regression.

RESULTS

There was a high rate of smokers 20.5% and obesity 53.1%, and high rates of self-reported diagnoses of diabetes: 57.1%; hypertension 62.6%. We found no effect of residing in an ESIM, but adherence to both guidelines was higher in ESIM at the latest follow-up time point. ESIM residence was also associated with a twofold increase in the probability of reporting a high motivation for a better lifestyle and with a statistically non-significant decrease in BMI of -0.14 kg/m2 (95% CI: -0.46 to 0.19) at the latest follow-up.

CONCLUSION

The longitudinal results extend evidence on the effect of WHO PEN protocol in promoting physical activity and nutritional behaviour in the Kosovo context.

Telemedicine in non-communicable chronic diseases care during the COVID-19 pandemic: exploring patients' perspectives

Purpose

This study aimed to explore challenges facing patients using Telemedicine consultations in non-communicable chronic disease clinics in primary care settings and to evaluate their satisfaction and willingness to use this service in the future.

Methods

This is an analytical cross-sectional study enrolling participants who were randomly selected from representative primary care centers in Bahrain and providing Telemedicine consultations. A semi-structured questionnaire permitted data collection using telephone interviews.

Results

A total of 251 individuals participated in the study of whom the majority were Bahraini (90.04%), and the mean age was 54.48 ± 10.78 years. Most of the participants 231 (92.03%) were satisfied with the Telemedicine consultation while only 142 (56.80%) were willing to use this service in the future. The main perceived challenges related to Teleconsultations were the lack of physical examination, inadequate time of TM consultation, fear of medical errors, and lack of privacy. The willingness to use TM consultation in the future was mainly determined by the degree of comfort to tell private information (p < 0.01) and to less extent the ease of the communication tool (p = 0.005) on multivariate analysis.

Conclusion

TM consultations could be a good complement to conventional consultation formats in the future. The sustainability of this innovative healthcare delivery tool requires addressing acceptability by users, ease of use, patient-centeredness, and technological advances to ensure privacy.

The Experiences of Community Health Workers in Preventing Noncommunicable Diseases in an Urban Area, the Philippines: A Qualitative Study

(1) Background: Barangay health workers (BHWs) play important roles as community health workers in preventing noncommunicable diseases (NCDs), where the shortage of health professionals is felt more acutely in the Philippines. However, there is little research on the experiences of BHWs as community health workers in preventing NCDs. This study aimed to clarify the roles and difficulties of BHWs in conducting activities for the prevention of NCDs. (2) Methods: Qualitative data were collected from 25 BHWs. (3) Results: The mean age of the participants was 50.4 ± 9.5 years, 23 were women, and the mean length of time as a BHW was 9.1 ± 7.7 years. Three major themes about the role of BHWs in preventing NCDs-"screening for NCDs", "assisting patients with management of their conditions", and "promoting healthy behaviors"-and four major themes about the difficulties-"insufficient awareness of preventative behaviors", "economic burdens", "lack of resources for managing NCDs", and "difficulty of access to medical care facilities"-were identified. (4) Conclusions: Through the findings of this study, focusing interventions aimed at addressing the difficulties for the prevention of NCDs among BHWs may help reduce health inequities.

R. L, S. S, Panniyammakal J, Lavis A. Patients', carers' and healthcare providers' views of patient-held health records in Kerala, India: A qualitative exploratory study

INTRODUCTION

Poor medical information transfer across healthcare visits and providers poses a potential threat to patient safety. Patient-held health records (PHRs) may be used to facilitate informational continuity, handover communication and patient self-management. However, there are conflicting opinions on the effectiveness of PHRs, other than in maternal and child care. Moreover, the experiences of users of PHRs in low- and middle-income countries are critical in policy decisions but have rarely been researched.

AIM

This study aimed to explore similarities and differences in the perspectives of patients, carers and healthcare providers (HCPs) on the current PHRs for diabetes and hypertension in Kerala.

METHODS

A qualitative design was used comprising semistructured interviews with patients with diabetes/hypertension (n = 20), carers (n = 15) and HCPs (n = 17) in Kerala, India. Data were analysed using thematic analysis.

RESULTS

Themes generated regarding the experiences with PHRs from each user group were compared and contrasted. The themes that arose were organized under three headings: use of PHRs in everyday practice; the perceived value of PHR and where practice and value conflict. We found that in the use of PHRs in everyday practice, multiple PHRs posed challenges for patients carrying records and for HCPs locating relevant information. Most carers carried all patients' past PHRs, while patients made decisions on which PHR to take along based on the purpose of the healthcare visit. HCPs appreciated having PHRs but documented limited details in them. The perceived value of PHRs by each group for themselves was different. While HCPs placed value on PHRs for enabling better clinical decision-making, preventing errors and patient safety, patients perceived them as transactional tools for diabetes and hypertension medications; carers highlighted their value during emergencies.

CONCLUSION

Our findings suggest that users find a variety of values for PHRs. However, these perceived values are different for each user group, suggesting minimal functioning of PHRs for informational continuity, handover communication and self-management.

PATIENT AND PUBLIC INVOLVEMENT

Patients and carers were involved during the pilot testing of topic guides, consent and study information sheets. Patients and carers gave their feedback on the materials to ensure clarity and appropriateness within the context.

Availability and readiness of primary healthcare facilities for the management of non-communicable diseases in different districts of Punjab, Pakistan

Introduction

Non-communicable diseases (NCDs) and their effects are rising quickly. NCDs such as cardiovascular illnesses, diabetes, cancer, and chronic lung diseases cause 60% of global deaths; of which, 80% occur in developing countries. In established health systems, primary healthcare handles most of the NCD care.

Methodology

This is a mixed-method study conducted to analyze the health service availability and readiness toward NCDs using the SARA tool. It included 25 basic health units (BHUs) of Punjab, which were selected through random sampling. Quantitative data were collected using the SARA tools, while qualitative data were collected through in-depth interviews with healthcare providers working at the BHUs.

Results

There was a problem of load shedding of both electricity and water in 52% of the BHUs, which leads to the poor availability of healthcare services. Only eight (32%) out of 25 BHUs provide the diagnosis or management of NCDs. The service availability was the highest for diabetes mellitus (72%), followed by cardiovascular disease (52%) and then chronic respiratory disease (40%). No services were available for cancer at the BHU level.

Conclusion

This study raises issues and questions about the primary healthcare system in Punjab in two areas: first, the overall performance system, and second, the readiness of basic healthcare institutions to treat NCDs. The data show that there are many persisting primary healthcare (PHC) deficiencies. The study found a major training and resource deficit (guidelines and promotional materials). Therefore, it is important to include NCD prevention and control training in district training activities. NCDs are underrecognized in primary healthcare (PHC).

Primary health care system responses to non-communicable disease prevention and control: a scoping review of national policies in Mainland China since the 2009 health reform

This study aims to review China's national policies related to non-communicable disease (NCD) prevention and control at the primary health care (PHC) level since China's 2009 health system reform. Policy documents from official websites of China's State Council and 20 affiliated ministries were screened, where 151 out of 1,799 were included. Thematic content analysis was performed, and fourteen 'major policy initiatives' were identified, including the basic health insurance schemes and essential public health services. Several areas showed to have strong policy support, including service delivery, health financing, and leadership/governance. Compared with WHO recommendations, several gaps remain, including lack of emphasis on multi-sectoral collaboration, underuse of non-health-professionals, and lack of quality-oriented PHC services evaluations. Over the past decade, China continues to demonstrate its policy commitment to strengthen the PHC system for NCD prevention and control. We recommend future policies to facilitate multi-sectoral collaboration, enhance community engagement, and improve performance evaluation mechanisms.

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.

Prevalence, awareness, treatment, and control of hypertension in China, 2004-18: findings from six rounds of a national survey

OBJECTIVE

To assess the recent trends in prevalence and management of hypertension in China, nationally and by population subgroups.

DESIGN

Six rounds of a national survey, China.

SETTING

China Chronic Disease and Risk Factors Surveillance, 2004-18.

PARTICIPANTS

642 523 community dwelling adults aged 18-69 years (30 501 in 2004, 47 353 in 2007, 90 491 in 2010, 156 836 in 2013, 162 293 in 2015, and 155 049 in 2018).

MAIN OUTCOME MEASURES

Hypertension was defined as a blood pressure of ≥140/90 mm Hg or taking antihypertensive drugs. The main outcome measures were hypertension prevalence and proportion of people with hypertension who were aware of their hypertension, who were treated for hypertension, and whose blood pressure was controlled below 140/90 mm Hg.

RESULTS

The standardised prevalence of hypertension in adults aged 18-69 years in China increased from 20.8% (95% confidence interval 19.0% to 22.5%) in 2004 to 29.6% (27.8% to 31.3%) in 2010, then decreased to 24.7% (23.2% to 26.1%) in 2018. During 2010-18, the absolute annual decline in prevalence of hypertension among women was more than twice that among men (-0.83 percentage points (95% confidence interval -1.13 to -0.52) v -0.40 percentage points (-0.73 to -0.07)). Despite modest improvements in the awareness, treatment, and control of hypertension since 2004, rates remained low in 2018, at 38.3% (36.3% to 40.4%), 34.6% (32.6% to 36.7%), and 12.0% (10.6% to 13.4%). Of 274 million (95% confidence interval 238 to 311 million) adults aged 18-69 years with hypertension in 2018, control was inadequate in an estimated 240 million (215 to 264 million). Across all surveys, women with low educational attainment had higher prevalence of hypertension than those with higher education, but the finding was mixed for men. The gap in hypertension control between urban and rural areas persisted, despite larger improvements in diagnosis and control in rural than in urban areas.

CONCLUSIONS

The prevalence of hypertension in China has slightly declined since 2010, but treatment and control remain low. The findings highlight the need for improving detection and treatment of hypertension through the strengthening of primary care in China, especially in rural areas.

Outcomes and Challenges in Noncommunicable Disease Care Provision in Health Facilities Supported by Primary Health Care System Strengthening Project in Sri Lanka: A Mixed-Methods Study

The Primary Healthcare System Strengthening Project in Sri Lanka focuses on improving noncommunicable disease (NCD) care provision at primary medical care institutions (PMCIs). We conducted an explanatory mixed-methods study to assess completeness of screening for NCD risk, linkage to care, and outcomes of diabetes/hypertension care at nine selected PMCIs, as well as to understand reasons for gaps. Against a screening coverage target of 50% among individuals aged ≥ 35 years, PMCIs achieved 23.3% (95% CI: 23.0-23.6%) because of a lack of perceived need for screening among the public and COVID-19-related service disruptions. Results of investigations and details of further referral were not documented in almost half of those screened. Post screening, 45% of those eligible for follow-up NCD care were registered at medical clinics. Lack of robust recording/tracking mechanisms and preference for private providers contributed to post-screening attrition. Follow-up biochemical investigations for monitoring complications were not conducted in more than 50% of diabetes/hypertension patients due to nonprescription of investigations by healthcare providers and poor uptake among patients because of nonavailability of investigations at PMCI, requiring them to avail services from the private sector, incurring out-of-pocket expenditure. Primary care strengthening needs to address these challenges to ensure successful integration of NCD care within PMCIs.

Primary Health Care System Strengthening Project in Sri Lanka: Status and Challenges with Human Resources, Information Systems, Drugs and Laboratory Services

A Primary Healthcare-System-Strengthening Project (PSSP) is implemented by the Ministry of Health, Sri Lanka, with funding support from the World Bank for providing quality care through primary medical care institutions (PMCIs). We used an explanatory mixed-methods study to assess progress and challenges in human resources, drug availability, laboratory services and the health management information system (HMIS) at PMCIs. We conducted a checklist-based assessment followed by in-depth interviews of healthcare workers in one PMCI each in all nine provinces. All PMCIs had medical/nursing officers, but data entry operators (44%) and laboratory technicians (33%) were mostly not available. Existing staff were assigned additional responsibilities in PSSP, decreasing their motivation and efficiency. While 11/18 (61%) essential drugs were available in all PMCIs, buffer stocks were not maintained in >50% due to poor supply chain management and storage infrastructure. Only 6/14 (43%) essential laboratory investigations were available in >50% of PMCIs, non-availability was due to shortages of reagents/consumables and lack of sample collection−transportation system. The HMIS was installed in PMCIs but its usage was sub-optimal due to perceived lack of utility, few trained operators and poor internet connectivity. The PSSP needs to address these bottlenecks as a priority to ensure sustainability and successful scale-up.

Assessment of competencies in the prevention and control of chronic diseases and their influencing factors among health assistants in Bhutan: a cross-sectional study

Background

The morbidity and mortality of chronic diseases are increasing worldwide. The literature confirms that the prevention and control of chronic disease necessitates a robust primary health care system with a competent health care workforce. Studies on competencies in the prevention and control of chronic diseases and their determinants among health assistants (HAs) in Bhutan are scarce. This cross-sectional survey aimed to examine the level of competencies and investigate the factors influencing competencies in the prevention and control of chronic diseases among HAs.

Methods

The sample consisted of 330 HAs who were recruited through simple random sampling. A validated and reliable self-administered questionnaire was used to collect data through a web-based Google Form. Data were analysed using descriptive statistics and multiple regression analysis.

Results

The findings showed that the mean summed competency score was 191 (SD = 25.7). Approximately 96% of the participants perceived that they were competent in the prevention and control of chronic diseases. The multiple regression analysis indicated that work environment (β = 0.473), sex (β = 0.126), location of the health facility (β = − 0.114), and organizational support (β = 0.117) affected competencies in the prevention and control of chronic diseases by 31.4% with statistical significance (R² = 0.314) (p < 0.05).

Conclusions

This study suggested that improving the number of staff and availability of learning resources, considering training for both sexes, especially female primary health care workers, enhancing mentorship and supervision in rural areas, and establishing the recognition and encouragement of primary health care workers are needed.

Management of type 1 diabetes in low- and middle-income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania

AIMS

To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania.

METHODS

The Rapid Assessment Protocol for Insulin Access, a multi-level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin.

RESULTS

Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes-related supplies, this has not necessarily translated into access to insulin or diabetes care for all. Insulin and related supplies were often unavailable and unaffordable. Across the four countries test strips and insulin, when paid for by the individual, represented respectively 48-82% and 25-36% of total costs. Care was mainly delivered at tertiary-level hospitals by specialists. Only Kyrgyzstan had data collection systems integrated into the Ministry of Health structure. In addition, issues with healthcare worker training and education and empowerment of people with diabetes were present in these health systems.

CONCLUSIONS

People with type 1 diabetes in these countries face different barriers, including the cost of insulin and care. Given the renewed attention to diabetes on the global health agenda tailored health system responses for type 1 diabetes are needed. Insulin should be prioritized as it is the foundation of type 1 diabetes care, but other elements of care and support need to be fostered by different actors.

Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia's Family Health Teams

BACKGROUND

Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia's family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and system-level factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains.

RESULTS

Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally-driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators.

CONCLUSION

Lessons from Ethiopia's challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.

Strengthening urban primary healthcare service delivery using electronic health technologies: A qualitative study in urban Nepal

Background

Nepal is a South Asian country with a high burden of non-communicable diseases. Electronic health technologies are a promising strategy to mitigate the rising burden of non-communicable diseases by strengthening primary healthcare center service delivery. However, electronic health implementation in Nepal is limited. Furthermore, electronic health use at the primary healthcare center level is chronically understudied. This qualitative study seeks to understand the perceived awareness, benefits, and determinants of electronic health uptake in Nepal, focusing on primary healthcare center-level non-communicable disease management.

Methods

We conducted in-depth interviews with 27 participants including policymakers, health experts, facility administrators, providers, and non-communicable diseases patients in 2019. We selected six urban primary healthcare center facilities via cluster convenience sampling for recruiting facility administrators, providers, and patients, and used convenience sampling to recruit policymakers and experts. We conducted thematic data analysis inductively and deductively using the electronic health readiness assessment framework to understand perceived barriers and facilitators of electronic health implementation.

Results

While there was general awareness and acceptance of electronic health, multiple barriers impede readiness for implementation. These include policy making gaps, language barriers, low user technical literacy, concerns of overreliance on technology, and inadequate training for administrators and providers. Stakeholder suggestions include creating electronic health interfaces that meet the needs of end users (providers and patients), providing training to enable end users to effectively use electronic health technologies, and strong policy support at the national level.

Conclusion

We identify several determinants for effectively promoting the use of electronic health for non-communicable diseases service delivery at the primary healthcare center level in Nepal.

Health Service Readiness, Availability, and Utilization of Primary Health Care Facilities for Non-Communicable Diseases in Shan State, Myanmar

BACKGROUND

Non-communicable diseases (NCDs) are increasing in Myanmar. There have been limited studies to assess the health service system for NCDs patients at the primary health care (PHC) level. We aimed to assess and compare the health service readiness, availability, and utilization of PHC facilities for NCDs in districts in Myanmar.

METHODS

This cross-sectional study collected data by questionnaires from 242 health care providers working at PHC facilities in three districts in Shan State, Myanmar from January 2020 to January 2021. Differences were calculated with the ANOVA test for NCD capacity readiness and NCD service availability and the Kruskal-Wallis test for NCD service utilization.

RESULTS

PHC facilities had a mean score of greater than 70% for NCD capacity readiness of health workforces, health information systems, and essential medicines and equipment domains, but there were large gaps for improvement in financing and governance of health. Almost all PHC facilities had NCD services available, and the differences were not significant among the three districts. However, the mean scores of NCD services availability for chronic respiratory diseases and cancers were lower in all districts. Regarding NCD service utilization, the screening and new patient rates had significant differences among districts (P-value < 0.05).

CONCLUSION

We revealed the situation and gaps in managing NCDs in Myanmar's PHC facilities. These findings can inform policymakers at the state and district levels to implement programs for improving health services for NCDs, particularly in rural areas.

Non-communicable disease prevention in Kosovo: quantitative and qualitative assessment of uptake and barriers of an intervention for healthier lifestyles in primary healthcare

BACKGROUND

Smoking, physical inactivity, low fruit and vegetable consumption, and obesity are common in Kosovo. Their prevention is a priority to relieve the health system of from costly non-communicable disease treatments. The Accessible Quality Healthcare project is implementing a primary healthcare intervention that entails nurse-guided motivational counselling to facilitate change in the domains of smoking, diet, alcohol consumption and physical inactivity for at-risk patients. This study quantitatively assesses the uptake of motivational counselling and the distribution of health behaviours and stages of health behaviour change of the participants according to the intervention, as well as qualitatively describes experiences and perceived benefits of motivational counselling.

METHODS

Study participants (n = 907) were recruited consecutively in 2019 from patients visiting the Main Family Medical Centres in 12 municipalities participating in the Kosovo Non-Communicable Disease Cohort study as part of the Accessible Quality Healthcare project. For the quantitative study, we used baseline and first follow-up data on smoking status, physical inactivity, obesity, fruit and vegetable as well as alcohol consumption, uptake of counselling, and stages for behavioural change. For the qualitative study, in-depth interviews were conducted with a subset of 26 cohort participants who had undergone motivational counselling.

RESULTS

Motivational counselling was obtained by only 22% of the eligible participants in the intervention municipalities. Unhealthy behaviours are high even in persons who underwent counselling (of whom 13% are smokers; 86% physically inactive; 93% with inadequate fruit and vegetable consumption; and 61% are obese); only the rate of smoking was lower in those who obtained counselling. Among smokers, over 80% were still in the pre-contemplation phase of behaviour change. More advanced stages of behaviour change were observed among the highly prevalent group of inactive persons and participants with poor dietary habits, among the 5 intervention municipalities. According to the qualitative study results, the participants who obtained motivational counselling were very satisfied with the services but requested additional services such as group physical activity sessions and specialized services for smoking cessation.

CONCLUSIONS

More tailored and additional primary health care approaches in accordance with patients' views need to be considered for the motivational counselling intervention to reach patients and efficiently facilitate lifestyle behaviour change.

Updates in hypertension: new trials, targets and ways of measuring blood pressure

PURPOSE OF REVIEW

Several recent trials and observational studies have identified critical areas that can help to improve the management and measurement of blood pressure in patients with hypertension.

RECENT FINDINGS

High-quality trial evidence supports intensive SBP lowering to 110-130 mmHg in older patients, potassium- based salt substitution in patients without chronic kidney disease, and chlorthalidone for the management of hypertension in patients with chronic kidney disease. In addition, population-based studies indicate enormous underdiagnosis of primary aldosteronism as well as greater sustained intensification of antihypertensive therapy in older patients by maximizing medication dosage rather than adding new agents. The prevalence of hypertension is stable worldwide, though is generally improving in high-income countries and worsening in low-income countries. Furthermore, although cuffless blood pressure devices have the potential to improve access to blood pressure measurement, they have not yet demonstrated sufficient accuracy for clinical use.

SUMMARY

Growing evidence supports intensive blood pressure lowering, sodium reduction, targeted antihypertensive treatment and appropriate screening for secondary hypertension to optimize blood pressure control and reduce the risk of target organ damage from hypertension. Future studies are needed to identify ways to improve our ability to implement these findings in routine clinical practice.

Barriers to effective hypertension management in rural Bihar, India: A cross-sectional, linked supply- and demand-side study

Effective management of hypertension in low- and middle-income settings is a persistent public health challenge. This study examined supply- and demand-side barriers to receiving quality care and achieving effective hypertension management in rural Bihar, India. A state-representative household survey collected information from adults over 30 years of age on characteristics of the hypertension screening, diagnosis, and management services they received. A linked provider assessment determined the percent of providers who provided quality hypertension care (i.e., had a functioning BP measurement device, measured a patient's BP, could correctly diagnose hypertension, had at least one first-line antihypertension medication, and could prescribe correctly based on standard guidelines). Patients were linked with their provider to determine the quality-adjusted coverage of hypertension management and logistic regression analysis was conducted to determine characteristics associated with receiving quality care. A total of 14,386 patients and 390 providers were studied. Nearly a quarter (22.5%) of adults had never had their BP measured before and 8.1% of adults reported a previous hypertension diagnosis. Less than one third (31.0%) of all interviewed providers demonstrated ability to provide quality hypertension care, and quality varied between provider types (14.8% of private homeopathic, 25.2% of informal, 40.0% of private modern medicine, and 60.0% of public providers gave quality care). While 95.8% of diagnosed individuals received some treatment, only 10.9% of patients received care from quality local providers. Nearly 45% of individuals with hypertension received care from non-local providers. Individuals from the general caste with comorbidities living in villages with more high-quality providers were most likely to receive quality care from a local provider. Whereas the coverage of services for individuals diagnosed with hypertension is high, the quality of these services is suboptimal for economically and socially vulnerable populations, which limits effective management and control of hypertension in rural Bihar. Efforts should be targeted towards providers to initiate quality treatment upon diagnosis, including correct prescription of antihypertensives.

Ischemic Heart Disease in Nigeria: Exploring the Challenges, Current Status, and Impact of Lifestyle Interventions on Its Primary Healthcare System

The burden of ischemic heart disease in Nigeria calls for an evidence-based, innovative, and interdisciplinary approach towards decreasing health inequalities resulting from individual lifestyle and poor socioeconomic status in order to uphold the holistic health of individuals to achieve global sustainability and health equity. The poor diagnosis and management of ischemic heart disease in Nigeria contributes to the inadequate knowledge of its prognosis among individuals, which often results in a decreased ability to seek help and self-care. Hence, current policies aimed at altering lifestyle behaviour to minimize exposure to cardiovascular risk factors may be less suitable for Nigeria's diverse culture. Mitigating the burden of ischemic heart disease through the equitable access to health services and respect for the autonomy and beliefs of individuals in view of achieving Universal Health Coverage (UHC) requires comprehensive measures to accommodate, as much as possible, every individual, notwithstanding their values and socioeconomic status.

Defining comprehensive models of care for NAFLD

Non-alcoholic fatty liver disease (NAFLD) is now the leading cause of chronic liver disease globally. Despite the increased demand placed on health-care systems, little attention has been given to the design and implementation of efficient and effective models of care for patients with NAFLD. In many health-care settings, no formal pathways exist and, where pathways are in place, they are often not standardized according to good practices. We systematically searched the peer-reviewed literature with the aim of identifying published examples of comprehensive models of care that answered four key questions: what services are provided? Where are they provided? Who is offering them? How are they coordinated and integrated within health-care systems? We identified seven models of care and synthesized the findings into eight recommendations nested within the 'what, where, who and how' of care models. These recommendations, aimed at policy-makers and practitioners designing and implementing models of care, can help to address the increasing need for the provision of good practice care for patients with NAFLD.

Perception and Use of Primary Healthcare Services Among People With Cardiometabolic Diseases in Two Resource-Limited Areas in Nepal: A Mixed Methods Study

Nepal is a country in south Asia with a high burden of cardiometabolic diseases (CMDs). Strengthening primary healthcare (PHC) is a key strategy to mitigate this increasing burden and achieve universal health coverage. While previous studies in Nepal have assessed PHC use among the elderly, none have specifically explored PHC use among people with CMDs. Therefore, this mixed-methods study aimed to assess the use and perception of PHC services in Nepal among people living with CMDs for primary and secondary prevention of cardiovascular disease. We used a quantitative survey followed-up by semi-structured qualitative interviews. The sampling frame comprised five PHC facilities in Sindhuli district (rural; eastern Nepal) and five in Kailali district (urban; western Nepal), with participants selected from each facility via convenience sampling. 114 people (mean age: 54.5 ± 14.7, sex ratio 1.04) with CMDs participated in the survey. Survey data showed general dissatisfaction with PHC services. Medicine cost was rated "too expensive" by 52 and 63% of rural and urban participants, respectively. Interview data showed that perceived poor bedside manner was tied to negative perceptions of PHC quality, and vice versa. Lack of resources and excessive barriers to care was mentioned by every interviewee. In conclusion, PHC use was high but overall satisfaction relatively low. Our results suggest that bedside manner is a practical target for future research. Additionally, we identified several barriers to care, and, based on existing literature, we suggest electronic-health interventions may have potential to mitigate these challenges.

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

BACKGROUND

Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories.

METHODS

We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age.

FINDINGS

The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran.

INTERPRETATION

Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings.

FUNDING

WHO.

An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries

BACKGROUND

Noncommunicable diseases (NCDs), including mental health, have become a major concern in low- and middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied.

METHODS

This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool.

RESULTS

In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was just 20%. Through a range of channels, bilateral donors were the other major source of NCD funding (contributing 41% of NCD funding). The UK and the US were the largest bilateral investors in NCDs, each contributing 8%. However, NCDs are still under-prioritised within bilateral portfolios - receiving just 0.48% of US funding and 1.66% of the UK. NGOs were the key channels of funding for NCDs, spending 48% of the funds from donors in 2019. The reviewed literature generally focused on NCD policies of WHO, with policies of multilateral and bilateral donors given limited attention. The analysis of policies indicated a limited prioritisation of NCDs in policy documents. NCDs are framed in the policies as a barrier to economic growth, poverty reduction, and health system sustainability. Bilateral donors prioritise prevention, while multilateral actors offer policy options for NCD prevention and care. Even where stated as a priority, however, funding allocations are not aligned.

CONCLUSION

The growing threat of NCDs and their drivers are increasingly recognised. However, global actors' policy priorities and funding allocations need to align better to address these NCD threats. Given the level of their investment and engagement, more research is needed into the role of private philanthropies and NGOs in this area.

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Despite positive NCD policies in recent years, majority of Sub-Saharan African (SSA) health systems are inadequately prepared to deliver comprehensive first-line care for NCDs. Primary health care (PHC) settings in countries like Malawi and Zambia could be a doorway to effectively manage NCDs by moving away from delivering only episodic care to providing an integrated approach over time. As part of a collaborative health system strengthening project, we assessed and compared the preparedness and operational capacity of two target networks of public PHC settings in Lilongwe (Malawi) and Lusaka (Zambia) to integrate NCD services within routine service delivery. Data was collected and analyzed using validated health facility survey tools. These baseline assessments conducted between August 2018 and March 2019, also included interviews with 20 on-site health personnel and focal persons, who described existing barriers in delivering NCD services. In both countries, policy directives to decentralize disease-specific NCD services to the primary care level were initiated to meet increased demand but lacked operational guidance. In general, the assessed PHC sites were inadequately prepared to integrate NCDs into various service delivery domains, thus requiring further support. In spite of existing multi-faceted limitations, there was motivation among healthcare staff to provide NCD services.

Early detection and management of major non-communicable diseases in urban primary healthcare facilities in Ethiopia: a study protocol for a type-3 hybrid implementation-effectiveness design

INTRODUCTION

Integrating early detection and management of non-communicable diseases in primary healthcare has an unprecedented role in making healthcare more accessible particularly in low- and middle-income countries such as Ethiopia. This study aims to design, implement and evaluate an evidence-based intervention guided by the HEARTS technical package and implementation guide to address barriers and facilitators of integrating early detection and management of hypertension, diabetes mellitus and cardiovascular diseases in primary healthcare settings of Addis Ababa.

METHODOLOGY

We will employ a type-3 hybrid implementation-effectiveness study from November 2020 to May 2022. This study will target patients ≥40 years of age. Ten health centres will be randomly selected from each subcity of Addis Ababa. The study will have four phases: (1) Baseline situational analysis (PEN facility-capacity assessment, 150 observations of patient healthcare provider interactions and 697 patient medical record reviews), (2) Consolidated Framework for Implementation Research (CFIR) inspired qualitative assessment of barriers and facilitators (20 in-depth interviews of key stakeholders), (3) Design of intervention protocol. The intervention will have capacity enhancement components including training of non-communicabledisease (NCDservice providers, provision of essential equipment/supporting materials and monthly monitoring and feedback and (4) Implementation monitoring and evaluation phase using the RE-AIM (reach, efficacy, adoption, implementation and maintenance) framework. Outcomes on early detection and management of NCDs will be assessed to examine the effectiveness of the study.

ETHICS AND DISSEMINATION PLAN

Ethical clearance was obtained from the Addis Ababa University, College of Health Sciences Institutional Review Board and Addis Ababa Health Bureau. We plan to present the findings from this research in conferences and publish them in peer-reviewed journals.

Improving primary care for diabetes and hypertension: findings from implementation research in rural South India

BACKGROUND

Chronic conditions are a leading cause of death and disability worldwide. Low-income and middle-income countries such as India bear a significant proportion of this global burden. Redesigning primary care from an acute-care model to a model that facilitates chronic care is a challenge and requires interventions at multiple levels.

OBJECTIVES

In this intervention study, we aimed to strengthen primary care for diabetes and hypertension at publicly funded primary healthcare centres (PHCs) in rural South India.

DESIGN AND METHODS

The complexities of transforming the delivery of primary care motivated us to use a 'theory of change' approach to design, implement and evaluate the interventions. We used both quantitative and qualitative data collection methods. Data from patient records regarding processes of care, glycaemic and blood pressure control, interviews with patients, observations and field notes were used to analyse what changes occurred and why.

INTERVENTIONS

We implemented the interventions for 9 months at three PHCs: (1) rationalise workflow to include essential tasks like counselling and measurement of blood pressure/blood glucose at each visit; (2) distribute clinical tasks among staff; (3) retain clinical records at the health facility and (4) capacity building of staff.

RESULTS

We found that interventions were implemented at all three PHCs for the first 4 months but did not continue at two of the PHCs. This fadeout was most likely the result of staff transfers and a doctor's reluctance to share tasks. The availability of an additional staff member in the role of a coordinator most likely influenced the relative success of implementation at one PHC.

CONCLUSION

These findings draw attention to the need for building teams in primary care for managing chronic conditions. The role of a coordinator emerged as an important consideration, as did the need for a stable core of staff to provide continuity of care.

Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions

Globally, cardiovascular diseases are the leading cause of disease burden and death. Timely and appropriate provision of primary care may lead to sizeable reductions in hospitalizations for a range of chronic and acute health conditions. In this paper, we study the impact of Brazil's More Doctors Program (MDP) on hospitalizations due to cerebrovascular disease and hypertension. We exploit the geographic variation in the uptake of the MPD and combine coarsened exact matching and difference-in-difference methods to construct valid counterfactual estimates. We use data from the Hospital Information System in Unified Health System, the MDP administrative records, the Brazilian Regulatory Agency, the Ministry of Health, and the Brazilian Institute of Geography and Statistics, covering the years from 2009 to 2017. Our analysis resulted in estimated coefficients of -1.47 (95%CI: -4.04,1.10) for hospitalizations for cerebrovascular disease and -1.20 (95%CI: -5.50,3.11) for hypertension, suggesting an inverse relationship between the MDP and hospitalizations. For cerebrovascular disease, the estimated MDP coefficient was -0.50 (95%CI: -2.94,1.95) in the year of program introduction, -5.21 (95%CI: -9.43,-0.99) and -8.21 (95%CI: -13.68,-2.75) in its third and fourth year of implementation, respectively. Our results further suggest that the beneficial impact of MDP on hospitalizations due to cerebrovascular disease became discernable in urban municipalities starting from the fourth year of implementation. We found no evidence that the MDP led to reductions in hospitalizations due to hypertension. Our results highlight that increased investment in resources devoted to primary care led to improvements in hospitalizations for selected cardiovascular conditions. However, it took time for the beneficial effects of the MDP to become discernable and the Program did not guarantee declines in hospitalizations for all cardiovascular conditions, suggesting that further improvements may be needed to enhance the beneficial impact of the MDP on the level and distribution of population health in Brazil.

Patient experiences in managing non-communicable diseases in Namibia

INTRODUCTION

The prevalence of non-communicable diseases (NCDs) is rising in Namibia, and with it, the need for pharmacists to empower patients. This research aims to 1) identify patient-reported barriers and facilitators to managing chronic NCDs for Namibians, and 2) characterize common patient-reported medication and health-related needs of Namibians with chronic NCDs.

METHODS

This qualitative study used semi-structured interviews to elicit participant perspectives regarding NCDs. The study used the conceptual frameworks of the Health Belief Model, the Theory of Planned Behavior, and the Explanatory Models of Illness to identify and understand key factors necessary to develop relevant patient-centered interventions. Participants were recruited from pharmacies throughout Namibia. Data were analyzed using thematic analysis from the transcribed interviews.

RESULTS

A total of 23 interviews were conducted, with 20 being included in the final analysis. Themes identified included: 1) participants were motivated to seek care when they were symptomatic; 2) participants felt motivated to care for their condition to improve their own lives and their families for their family's sake; 3) participants integrated information from a variety of sources into their disease knowledge; 4) participants describe wanting to be more engaged in managing their health and wanting support to help manage their condition; 5) participants describe awareness of lifestyle changes necessary to improve health, but face many barriers to achieving them.

CONCLUSION

This study identified key factors that are essential for pharmacists and other health care professionals to be aware of in order to support patients who are diagnosed with an NCD. Health care providers should consider strategies to engage patients to harness their motivations, enhance health education, and create systems to reduce barriers to addressing lifestyle.

Moving Towards Optimized Noncommunicable Disease Management in the ASEAN Region: Recommendations from a Review and Multidisciplinary Expert Panel

Introduction

Noncommunicable diseases (NCDs) are the leading cause of morbidity and mortality in the Association of Southeast Asian Nations (ASEAN) member states. Progress has been slow despite the World Health Organization action plan for the prevention and control of NCDs in the region. This paper presents recommendations focused on practical strategies for optimizing NCD management in the ASEAN region.

Methods

A multidisciplinary group of experts from six ASEAN member states convened for two face-to-face meetings to discuss barriers and possible recommendations for optimizing NCD management, focused on cardiovascular diseases and mental disorders, in the region. Multiple approaches, ie, analysis of insights from the meetings and a review of existing literature on NCD programs in the ASEAN region were followed. The proposed recommendations were also based on selected successful interventions in ASEAN member states, thus providing actionable strategies.

Results

The gaps identified in NCD management for cardiovascular diseases and mental disorders in the ASEAN region were classified into gaps relating to policies and to clinical and public health practice. The proposed solutions addressing policy gaps include fostering multisectoral public–private partnerships, employing “whole-of-government” and “whole-of-society” approaches and promoting “health-in-all policies approach” to manage issues with financing, accessibility, efficiency and quality of health services. Whereas proposed solutions to bridge clinical and public health practice gaps entail strengthening primary care services, building the capacity of trained healthcare workers and employing collaborative care for holistic management of patients.

Conclusion

The scale of premature and preventable deaths from NCDs in the ASEAN region remains a serious public health concern and requires a “whole-of-system approach”. The interventions proposed in this paper build on regional collaborations and knowledge sharing to help develop a concerted and targeted response to NCDs.

A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India

BACKGROUND

Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist.

METHOD

The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC).

RESULT

The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level.

CONCLUSION

This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings.

A qualitative study of facilitators and barriers to cardiovascular risk factor control in a semiurban population in India

Cardiovascular (CV) risk factors like diabetes and hypertension are poorly controlled in both rural and urban India. This study was designed to identify the reasons for suboptimal control in a semiurban population in India. A total of 70 participants from the Study to Expand Heart Associated Treatments (SEHAT) trial, conducted in West Bengal, India. We qualitatively examined perspectives regarding CV risk factor control using focus group discussions based on the theory of reasoned action. Qualitative content analysis was used to analyze prevailing themes. Participants demonstrated a generalized knowledge of healthy lifestyle practices but lacked insight into disease-specific prevention methods. We further noticed significant gaps in the translation of existing knowledge into behavior. While personal and systemic barriers exist, factors like high patient motivation and a deep sense of trust in providers can potentially be harnessed to improve risk factor control in the community. We identified key facilitators and barriers to CV risk factor control in the community using a knowledge attitude behavior approach. Our findings provide direction for the development of community-based CV risk reduction models.

Feasibility assessment of invigorating grassrooTs primary healthcare for prevention and management of cardiometabolic diseases in resource-limited settings in China, Kenya, Nepal, Vietnam (the FAITH study): rationale and design

Background

Cardiometabolic diseases are the leading cause of death and disability in many low- and middle-income countries. As the already severe burden from these conditions continues to increase in low- and middle-income countries, cardiometabolic diseases introduce new and salient public health challenges to primary health care systems. In this mixed-method study, we aim to assess the capacity of grassroots primary health care facilities to deliver essential services for the prevention and control of cardiometabolic diseases. Built on this information, our goal is to propose evidence-based recommendations to promote a stronger primary health care system in resource-limited settings.

Methods

The study will be conducted in resource-limited settings in China, Kenya, Nepal, and Vietnam using a mixed-method approach that incorporates a literature review, surveys, and in-depth interviews. The literature, statistics, and document review will extract secondary data on the burden of cardiometabolic diseases in each country, the existing policies and interventions related to strengthening primary health care services, and improving care related to non-communicable disease prevention and control. We will also conduct primary data collection. In each country, ten grassroots primary health care facilities across representative urban-rural regions will be selected. Health care professionals and patients recruited from these facilities will be invited to participate in the facility assessment questionnaire and patients’ survey. Stakeholders – including patients, health care professionals, policymakers at the local, regional, and national levels, and local authorities – will be invited to participate in in-depth interviews. A standard protocol will be designed to allow for adaption and localization in data collection instruments and procedures within each country.

Discussion

With a special focus on the capacity of primary health care facilities in resource-limited settings in low- and middle-income countries, this study has the potential to add new evidence for policymakers and academia by identifying the most common and significant barriers primary health care services face in managing and preventing cardiometabolic diseases. With these findings, we will generate evidence-based recommendations on potential strategies that are feasible for resource-limited settings in combating the increasing challenges of cardiometabolic diseases.

Scaling up effective treatment of hypertension-A pathfinder for universal health coverage

High blood pressure is the world's leading cause of death, but despite treatment for hypertension being safe, effective, and low cost, most people with hypertension worldwide do not have it controlled. This article summarizes lessons learned in the first 2 years of the Resolve to Save Lives (RTSL) hypertension management program, operated in coordination with the World Health Organization (WHO) and other partners. Better diagnosis, treatment, and continuity of care are all needed to improve control rates, and five necessary components have been recommended by RTSL, WHO and other partners as being essential for a successful hypertension control program. Several hurdles to hypertension control have been identified, with most related to limitations in the health care system rather than to patient behavior. Treatment according to standardized protocols should be started as soon as hypertension is diagnosed, and medical practices and health systems must closely monitor patient progress and system performance. Improvement in hypertension management and control, along with elimination of artificial trans fat and reduction of dietary sodium consumption, will improve many aspects of primary care, contribute to goals for universal health coverage, and could save 100 million lives worldwide over the next 30 years.