Protocol for the evaluation of a pilot implementation of essential interventions for the prevention of cardiovascular diseases in primary healthcare in the Republic of Moldova

Does training on the WHO package of essential noncommunicable (PEN) disease interventions enhance consultation quality? A real-world assessment of adherence to PEN protocol in primary health centres in the Republic of Moldova

BACKGROUND

Noncommunicable diseases (NCDs) pose a significant global health challenge. Primary health centres are pivotal in addressing this challenge by providing essential care to NCD patients. The WHO Package of Essential Noncommunicable (PEN) disease interventions has been designed to enhance the quality of NCD consultations and ensure adherence to the protocol. This study investigates the effects of PEN training in Moldova.

OBJECTIVES

The primary objective of this study is to assess the effects of training on WHO PEN on the quality of NCD consultations and adherence to the PEN protocol in a real -world setting in primary health centres in Moldova.

METHODS

An observational, cross-sectional study was conducted, comparing primary health centres where health personnel received PEN training, provided by the Healthy Life project, to those where such training was not provided. In total, 24 family doctors and 24 medical assistants were observed for 233 workdays and covering 2,166 NCD consultations.

RESULTS

Intervention primary health centres (PHCs) showed longer NCD consultation durations, with family doctors and medical assistants spending an added 1 minute 43 seconds and 3 minutes 10 seconds, respectively. These PHCs also reported a higher proportion of primary NCD consultations, indicating better screening for new NCD patients. Medical assistants in the intervention group took on a more pronounced role in NCD care. However, the findings also highlight the necessity to refine aspects of the PEN training, especially concerning follow-up consultations, risk assessments, and task delegation.

CONCLUSIONS

The findings suggest that the PEN training contributed to improvement of both the quality of NCD consultations and adherence to the PEN protocol. Yet, there is a need for enhancing the identified aspects of the PEN training. The findings highlight the potential of PEN training in primary healthcare settings for improved NCD management.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

Strategies to address non-communicable diseases in the Commonwealth of Independent States countries: a scoping review

Aim:

The aim of this study is to review the literature in Commonwealth of Independent States (CIS) countries with regard to their response to non-communicable diseases (NCDs) and the implementation of the World Health Organization (WHO) Package of Essential Non-communicable (PEN) disease interventions for primary health care.

Background:

NCDs are estimated to account from 62% to 92% of total deaths in CIS countries. Current management of NCDs in CIS countries is focused on specialists and hospital care versus primary health care (PHC) as recommended by the WHO.

Methods:

This paper uses a scoping review of published and grey literature focusing on diabetes and hypertension in CIS countries. These two conditions are chosen as they represent a large burden in CIS countries and are included in the responses proposed by the WHO PEN.

Findings:

A total of 96 documents were identified and analysed with the results presented using the WHO Health System Building Blocks. Most of the publications identified focused on the service delivery (41) and human resources (20) components, while few addressed information and research (17), and only one publication was related to medical products. As for their disease of focus, most studies focused on hypertension (14) and much less on diabetes (3). The most studies came from Russia (18), followed by Ukraine (21) and then Kazakhstan (12). Only two countries Moldova and Kyrgyzstan have piloted the WHO PEN. Overall, the studies identified highlight the importance of the PHC system to better control and manage NCDs in CIS countries. However, these present only strategies versus concrete interventions. One of the main challenges is that NCD care at PHC in CIS countries continues to be predominantly provided by specialists in addition to focusing on treatment versus preventative services.

How effective was implementation of the package of essential non-communicable disease (PEN) interventions: A review of evidence?

AIMS

This paper reviewed the outcomes, cost-effectiveness and challenges of implementation of WHO PEN protocol in LMICs.

METHODS

MEDLINE databases, the Cochrane Central Register of Controlled Trials and Google Scholar were searched and content analysis of the included studies was done.

RESULTS

A total of 14 articles were included. Lack of essential medicines and manpower, poor recording and mis-calculation of CVD risk score, suboptimal recording of patient information and loss-to-follow-up were the key challenges reported in various PEN implementation settings.

CONCLUSION

The study has highlighted concerns and recommendations which need to be addressed before scale up.

Implementing Package of Essential Non-communicable Disease Interventions in the Republic of Moldova-a feasibility study

BACKGROUND

The aim of this study is to determine the feasibility of implementing and evaluating the World Health Organization Package of Essential Non-communicable Disease Interventions (WHO PEN) approach in primary healthcare in the Republic of Moldova.

METHODS

According to our published a priori methods, 20 primary care clinics were randomized to 10 intervention and 10 control clinics. The intervention consisted of implementation of adapted WHO PEN guidelines and structured training for health workers; the control clinics continued with usual care. Data were gathered from paper-based patient records in July 2017 and August 2018 resulting in a total of 1174 and 995 patients in intervention and control clinics at baseline and 1329 and 1256 at follow-up. Pre-defined indicators describing assessment of risk factors and total cardiovascular risk, prescribing medications and treatment outcomes were calculated. Differences between baseline and follow-up as well as between intervention and control clinics were calculated using logistic and linear regression models and by assessing interaction effects.

RESULTS

Improvements were seen in recording smoking status, activity to measure HbA1c among diabetes patients and achieving control in hypertension treatment. Improvement was also seen in identification of patients with hypertension or diabetes. Less improvement or even deterioration was seen in assessing total risk or prescribing statins for high-risk patients.

CONCLUSIONS

It is feasible to evaluate the quality and management of patients with non-communicable diseases in low-resource settings from routine data. Modest improvements in risk factor identification and management can be achieved in a relatively short period of time.

Capacity building of health care professionals to perform interprofessional management of non-communicable diseases in primary care - experiences from Ukraine

BACKGROUND

Non-communicable diseases are leading causes of death and disability across the world. Countries with the highest non-communicable disease (NCD) burden in the WHO European Region are often those that have some of the greatest health system challenges for achieving good outcomes in prevention and care. The aim of this study was to evaluate the effect of an interprofessional capacity building intervention carried out in Ukraine to improve the management non-communicable diseases in primary health care.

METHODS

A mixed-methods evaluation study was performed in 2018 to analyse the effect of a capacity building intervention carried out for over 10,000 primary care professionals in Ukraine in 2018. Quantitative data were collected from primary health care records of intervention and control areas preceding the intervention and 1.5 to 2 years after the intervention. Altogether 2798 patient records before and 2795 after the intervention were reviewed. In control areas, 1202 patient records were reviewed. Qualitative data were collected carrying out focus group interviews for health professionals, clinic managers and patients. Also, observations of clinical practice and patient pathways were performed.

RESULTS

The capacity building intervention improved the capacity of professionals in detection and management of non-communicable disease risk factors. Significant improvement was seen in detection rates of both behavioural and biological risk factors and in medication prescription rates in the intervention areas. However, almost similar improvement in prescription rates was also observed in control clinics. Improvements in control of blood pressure, blood glucose and cholesterol were not seen during the evaluated implementation period. Qualitative analyses highlighted the improved knowledge and skills but challenges in changing the current practice.

CONCLUSIONS

A large scale capacity building intervention improved primary health care professionals' knowledge, skills and clinical practice on NCD risk detection and reduction. We were not able to detect improvements in treatment outcomes - at least within 1.5 to 2 years follow-up. Improvement of treatment outcomes would most likely need more comprehensive systems change.

Implementing a package of noncommunicable disease interventions in the Republic of Moldova: two-year follow-up data

Noncommunicable diseases (NCDs) are a growing challenge in the Republic of Moldova. A previously reported pilot cluster randomized controlled trial aimed to determine the feasibility of implementing and evaluating essential interventions for NCDs (e.g. cardiovascular risk scoring, hypertension management, statin treatment, etc.) in primary health care in the Republic of Moldova, with a view toward national scale up. One-year follow-up data (previously published) demonstrated modest improvements in NCD risk factor identification and management could be achieved. Herein, we report the second-year follow-up data and conclude that sustainable improvements in NCD risk factor control (e.g. hypertension control) can be achieved in primary health care in low resource settings by adapting existing resources (e.g. WHO PEN) and conducting focused clinical training and support. If scaled to a national level, these improvements in risk factor control could significantly translate to reductions in premature mortality from NCDs.

Implementing essential interventions for cardiovascular disease risk management in primary healthcare: lessons from Eastern Europe and Central Asia

Globally, non-communicable diseases (NCDs) are the leading cause of morbidity and mortality, including in the WHO European region. Within this region, the Member States with the greatest cardiovascular disease (CVD) burden are also some of the lowest resourced. As the need for technical support for the implementation of essential CVD/NCD interventions in primary healthcare (PHC) in these regions grew urgent, the WHO Regional Office for Europe has been directly supporting national governments in the development, assessment, scale-up and quality improvement of large scale PHC interventions for CVD. Herein, we synthesise the key learnings from providing technical support to national governments under the auspices of the WHO across the European region and share these learnings as a resource for public health professionals to consider when increasing coverage of quality essential health services. Based on our experience providing technical support to a diversity of Member States in the European Region (eg, Tajikistan, Republic of Moldova, Ukraine and Uzbekistan), we have identified six key lessons: prioritising NCDs for public health intervention, identifying and mapping existing resources, engaging key stakeholders, tailoring interventions to the local health system, generating local evidence and ensuring quality improvement while mainstreaming. Common challenges across all phases of implementation include multiple and inconsistent international toolkits and guidance, lack of national capacity for evidence-based healthcare, limited access to essential medicines and technologies, inconsistent national guidelines and limited experience in evaluation methodology, clinical epidemiology and guideline implementation. We map the lessons to the Consolidated Framework for Implementation Research and highlight key learnings and challenges specific to the region. Member States in the region are at various stages of implementation; however, several are currently conducting pragmatic clinical trials to generate local evidence for health policy. As this work expands, greater engagement with peer-to-peer sharing of contextual wisdom, sharing of resources, publishing methodology and results and development of region-specific resources is planned.

Sodium, Potassium and Iodine Intake, in A National Adult Population Sample of the Republic of Moldova

In the Republic of Moldova, more than half of all deaths due to noncommunicable diseases (NCDs) are caused by cardiovascular disease (CVD). Excess salt (sodium) and inadequate potassium intakes are associated with high CVD. Moreover, salt iodisation is the preferred policy to prevent iodine deficiency and associated disorders. However, there is no survey that has directly measured sodium, potassium and iodine consumption in adults in the Republic of Moldova. A national random sample of adults attended a screening including demographic, anthropometric and physical measurements. Sodium, potassium and iodine intakes were assessed by 24 h urinary sodium (UNa), potassium (UK) and iodine (UI) excretions. Knowledge, attidues and behaviours were collected by questionnaire. Eight-hundred and fifty-eight participants (326 men and 532 women, 18-69 years) were included in the analysis (response rate 66%). Mean age was 48.5 years (SD 13.8). Mean UNa was 172.7 (79.3) mmoL/day, equivalent to 10.8 g of salt/day and potassium excretion 72.7 (31.5) mmoL/day, equivalent to 3.26 g/day. Only 11.3% met the World Health Organization (WHO) recommended salt targets of 5 g/day and 39% met potassium targets (>90 mmoL/day). Whilst 81.7% declared limiting their consumption of processed food and over 70% not adding salt at the table, only 8.8% looked at sodium content of food, 31% still added salt when cooking and less than 1% took other measures to control salt consumption. Measures of awareness were significantly more common in urban compared to rural areas. Mean urinary iodine was 225 (SD: 152; median 196) mcg/24 h, with no difference between sexes. According to WHO criteria, 41.0% had adequate iodine intake. Iodine content of salt table was 21.0 (SD: 18.6) mg/kg, lower in rural than urban areas (16.7, SD = 18.6 vs. 28.1, SD = 16.5 mg/kg, p < 0.001). In most cases participants were not using iodised salt as their main source of salt, more so in rural areas. In the Republic of Moldova, salt consumption is unequivocally high, potassium consumption is lower than recommended, both in men and in women, whilst iodine intake is still inadequate in one in three people, although severe iodine deficiency is rare. Salt consumed is often not iodised.

Evaluation and pilot implementation of essential interventions for the management of hypertension and prevention of cardiovascular diseases in primary health care in the Republic of Tajikistan

Background: Non-communicable diseases (NCDs) are the leading cause of death worldwide and are a major burden in Tajikistan. The health system of Tajikistan is still shaped by the country's Soviet legacy and the pace of reform has been slow, with high patient out-of-pocket expenditure. The aim of this study is to determine the feasibility of implementing and evaluating essential interventions for the management of hypertension and prevention of cardiovascular disease in primary health care in Tajikistan. Methods and analysis: A pragmatic, sequential mixed methods explanatory design, composed of quantitative and qualitative strands will be used with greater weighting of the quantitative strand. A single geographic district was nominated by the Ministry of Health and chosen for implementation. All primary health care centres in the district that meet inclusion criteria will be included; half will be randomly assigned to the intervention arm and half to the control arm. The overall process is organized into seven steps: (1) refresh clinical decision-making tools including open source WHO PEN and HEARTS resources; (2) update training package for primary health care workers; (3) collection of baseline data; (4) training staff in intervention clinics; (5) implementation of protocols and implementation coaching; (6) collection of follow-up data after 12 months; (7) evaluation of results and sharing experience. Ethics and dissemination: Ethical review and approval have been obtained. Findings will be disseminated at the participant level, national level through a national conference of key stakeholders, and internationally through publication in an open-access peer review journal.