Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh

OBJECTIVE

The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.

DESIGN AND SETTING

The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh.

PARTICIPANTS

A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female).

OUTCOMES

Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics.

RESULTS

The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.

CONCLUSION

The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.

Poor glycemic control, cardiovascular disease risk factors and their clustering among patients with type 2 diabetes mellitus: A cross-sectional study from Nepal

Background

Cardiovascular disease (CVD) is the most common complication of diabetes mellitus (DM). To prevent morbidity and mortality among patients with type 2 diabetes mellitus (T2DM), optimization of glycemic status and minimizing CVD risk factors is essential. As Nepal has limited data on these CVD risk parameters, we assessed the prevalence of poor glycemic control, CVD risk factors, and their clustering among patients with T2DM.

Methods

Using a cross-sectional study design, we collected data of 366 patients with T2DM. We applied a multistage cluster sampling technique and used the WHO STEPS tools. Binary logistic and Poisson regression was applied to calculate odds and prevalence ratio of clustering of risk factors, considering P< 0.05 statistically significant.

Results

The mean age of participants was 54.5±10.7 years and 208 (57%) were male. The prevalence of poor glycemic control was 66.4% (95% C.I: 61.5–71.2). The prevalence of smoking, alcohol users, inadequate fruit and vegetables intake and physical inactivity were 18% (95% C.I:14 to 21.9), 14.8% (95% C.I:11.1 to 18.4), 98.1% (95% C.I: 96.7–99.4), and 9.8% (95% C.I:6.7–12.8), respectively. Overall, 47.3% (95% C.I: 42.1–52.4) were overweight and obese, 59% (95% C.I: 52.9–63) were hypertensive, and 68% (95% C.I: 63.2–72.7) had dyslipidemia. Clustering of two, three, four, five and more than five risk factors was 12.6%, 30%, 30%,19%, and 8.7%, respectively. Four or more risk factors clustering was significantly associated with gender, age, level of education, T2DM duration, and use of medication. Risk factors clustering was significantly higher among males and users of anti-diabetic medications with prevalence ratio of 1.14 (95% C.I:1.05–1.23) and 1.09 (95% C.I: 1.09–1.18)], respectively.

Conclusions

The majority of the patients with T2DM had poor glycemic control and CVD risk factors. Policies and programs focused on the prevention and better management of T2DM and CVD risk factors should be implemented to reduce mortality in Nepal.

Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review

Background: Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. However, no systematic investigation of factors influencing hypertension treatment and control in Nepal is available. This study aimed to systematically review the published literature and synthesise the findings on barriers, enablers, and strategies for hypertension treatment and control in Nepal.

Methods: Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, and Nepali journals and government websites were searched for qualitative, quantitative, and mixed-methods studies on factors or strategies related to hypertension treatment and control in Nepal. Information from qualitative studies was analysed using template analysis, while results from quantitative studies were narratively synthesised. Summary findings were framed under “health system”, “provider”, and “patient” domains. The protocol was registered in PROSPERO (registration number: CRD42020145823).

Results: We identified 15 studies; ten related to barriers and enablers and five to strategies. The identified barriers associated with the health system were: lack of affordable services and lack of resources. The barriers at the provider's level were: communication gaps, inadequate counselling, long waiting hours for appointments, lack of national guidelines for hypertension treatment, and provider's unsupportive behaviours. Non-adherence to medication, irregular follow-up visits, lack of awareness on blood pressure target, poor help-seeking behaviours, reluctance to change behaviours, perceived side-effects of anti-hypertensive medication, self-medication, lack of family support, financial hardship, lack of awareness on blood pressure complications, and comorbidity were barriers identified at patient level. The following enablers were identified: free essential health care services, family support, positive illness perception, and drug reminders. Strategies implemented at the health system, provider and patient levels were: establishing digital health records at health centres, health worker's capacity development, and health education.

Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, health providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

Building optimal and sustainable kidney care in low resource settings: The role of healthcare systems

Healthcare systems in low-income and lower-middle income countries (LLMICs) face significant challenges in the provision of health services, for example, kidney care to the population. Although this is linked to several high-level factors such as poor infrastructure, socio-demographic and political factors, healthcare funding has often been cited as the major reason for the wide gap in availability, accessibility and quality of care between LLMICs and rich countries. With the steady rising incidence and prevalence of kidney diseases globally, as well as cost of care, LLMICs are likely to suffer more consequences of these increases than rich countries and may be unable to meet targets of universal health coverage (UHC) for kidney diseases. As health systems in LLMICs continue to adapt in finding ways to provide access to affordable kidney care, various empirical and evidence-based strategies can be applied to assist them. This review uses a framework for healthcare strengthening developed by the World Health Organization (WHO) to assess various challenges that health systems in LLMICs confront in providing optimal kidney care to their population. We also suggest ways to overcome these barriers and strengthen health systems to improve kidney care in LLMICs.

Implementation of a non-communicable disease clinic in rural Sierra Leone: early experiences and lessons learned

This study is an evaluation of the first cohort of patients enrolled in an outpatient non-communicable disease clinic in Kono, Sierra Leone. In the first year, the clinic enrolled 916 patients. Eight months after the enrollment of the last patient, 53% were still active in care, 43% had been lost to follow-up (LTFU) and 4% had defaulted. Of the LTFU patients, 47% only came for the initial enrollment visit and never returned. Treatment outcomes of three patient groups [HTN only (n = 720), DM only (n = 51), and HTN/DM (n = 96)] were analyzed through a retrospective chart review. On average, all groups experienced reductions in blood pressure and/or blood glucose of approximately 10% and 20%, respectively. The proportions of patients with their condition controlled also increased. As NCDs remain underfunded and under-prioritized in low-income countries, the integrated program in Kono demonstrates the possibility of improving outpatient NCD care in Sierra Leone and similar settings.

Effectiveness of a community health worker (CHW) training in monitoring and care of patients with chronic obstructive pulmonary disease (COPD) in rural Gujarat, India

Context:

Chronic obstructive pulmonary disease (COPD) is the second leading contributor to the disease burden of India. The current COPD burden cannot be managed effectively just through a physician-based approach. In a primary care setting, community health workers (CHWs) can play an effective role in making COPD care accessible and effective.

Aim:

Findings of an assessment of a training program for CHWs on COPD have been reported here. Methods: 90 CHWs working as a part of a noncommunicable disease prevention and care program in a rural primary care setting were exposed to a series of five training sessions. The sessions were designed and administered jointly by a team of public health experts and physiotherapists in the year 2017–18. Topics covered were basic clinical aspects of COPD, monitoring a patient with COPD, and basic aspects of pulmonary rehabilitation. The assessment comprised 12 MCQs and short questions, 7 video exercises, 2 case vignettes, and 5 skill assessments through objectively structured clinical examination (OSCE).

Statistical Analysis:

Mean percentage scores were calculated for each domain of assessment to make it comparable.

Results:

70 CHWs with a mean age of 42.2 years completed all the training and underwent the assessment. Mean percentage score (SD) for knowledge was 62% (16.3). In OSCE assessment, scores were best in sputum clearance technique demonstration (92.1%) and the least in dyspnea relieving positions (59.2%). The CHWs had difficulties in identifying signs of respiratory distress (score - 55.1%). No statistically significant association was observed between performance scores and their sociodemographic profile.

Conclusion:

The results were encouraging and the program may be pilot tested in a government setting particularly using the health and wellness centers (HWC) platform.