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

Distress and coping mechanisms among people with diabetes: cross-sectional assessment from an NCD screening clinic of a tertiary care hospital in North India

BACKGROUND

Of the numerous complications encountered by people with diabetes (PWD), the effect on mental health is concerning. Within mental health, diabetes distress (DD) occurs when a patient has unfavourable emotional stress while managing their condition, which can be managed by coping strategies but are less studied together in Indian settings. So, the present study aimed to determine the proportion of DD and associated factors and coping skills among the PWD.

METHODS

Cross-sectional study was conducted among 596 clinically stable, ambulatory PWD visiting the NCD clinic of a tertiary care centre in North India between June 2023 and January 2024 and recruited using a systematic random sampling technique. DD was the primary dependent variable assessed using the Hindi version of the Diabetes Distress Scale (DDS). Coping was assessed using a GlucoCoper scale. Independent variables included socio-demographic and clinic history variables. Bivariate analysis described the sample characteristics. Multivariable binary logistic regression analysis explored the factors affecting the DD. The study was ethically approved, and written informed consent was obtained from the patients.

RESULTS

Of the 596 study participants, 17.4% depicted uncontrolled diabetes, while 18.1% PWD experienced moderate to severe DD, with emotional distress depicting the highest prevalence (23.8%). Significantly increased odds of living with DD in professionals compared to Clerical, shop-owners, farmers with less monthly average income (vs. the group with unstable income), tobacco users, and those with uncontrolled disease. Overall, scores for negative coping were higher than positive coping, with significant differences between the two types among the participants with DD.

CONCLUSIONS

The study underscores the complex interplay between diabetes control, distress, and coping mechanisms in patients attending an NCD screening clinic. The findings highlight the need for a holistic approach to diabetes management that addresses not only the physical aspects but also patients' emotional and psychological well-being.

Unhealthy behaviours associated with uncontrolled hypertension among adults in India- Insights from a national survey

BACKGROUND

Non-communicable diseases (NCDs) are governed by a cluster of unhealthy behaviours and their determinants, like tobacco and alcohol, unhealthy diet, lack of physical activity, overweight and obesity, pollution (air, water, and soil), and stress. Regulation of these unhealthy behaviours plays a crucial role in blood pressure control among individuals on hypertensive treatment, especially those suffering from uncontrolled hypertension. Hence, the present study aims at identifying the unhealthy behaviours associated with uncontrolled hypertension.

MATERIALS AND METHODS

We did a secondary data analysis of the National Family Health Survey (NFHS) -5 data (2019-2021). Among those taking prescribed medication to lower blood pressure levels, SBP ≥140 mm Hg or DBP ≥90 mm Hg were considered uncontrolled hypertension. The other socio-demographic variables and unhealthy behaviours were used as independent variables for analysis.

RESULTS

The proportion of uncontrolled hypertension was 49·5% (95% CI: 45·5-53·4) and 36·8% (95% CI: 35.8-37.8) among males and females, respectively. Alcohol consumption, clean fuel usage, and high BMI (≥30kg/m2) were the behavioural characteristics significantly associated with uncontrolled hypertension among males. In contrast, tobacco usage, alcohol consumption, coverage by Health insurance, presence of Diabetes, heart disease, usage of clean fuel, and high BMI (≥30kg/m2) were the behavioural characteristics significantly associated with uncontrolled hypertension among females. Regression results portrayed that higher age groups (45 and above) have found higher odds for men (OR: 7.6, CI: 4.6-12.3) and women (OR: 6.08, CI: 4.0-6.0) compared with 30 years and below age groups. Similarly, higher odds were found among the wealthiest wealth quintile than the poorest wealth quintile among men and women.

CONCLUSION

The current study reported a high proportion of uncontrolled hypertension. Providing opportunistic health education during blood pressure monitoring, regular screening, and targeted interventions will not only help to reduce its prevalence but also reduce the risk of developing related health implications.

Development and evaluation of a training program on non-communicable diseases to empower community health workers in rural India

Objective

We developed and evaluated a training program for Accredited Social Health Activists (ASHAs), female community health workers (CHWs) in India, on non-communicable diseases (NCDs).

Methods

A 5-day training program, developed using government-approved manuals, was tested in a randomised controlled trial in the Tehri-Garhwal district. Quantitative comparisons were undertaken using Student's t-test and two-way ANOVA. ASHAs in the intervention group were asked questions about new skills learnt.

Results

Thirty-six ASHAs (20 intervention, 16 controls) participated (response rate 75.0%). Mean pre-test knowledge score was 43.3/100 points (95% CI 36.7-49.9) for the intervention group and 44.4 (38.9-49.9) for controls. The mean post-test knowledge score increased more in the intervention group (48.5-point increase; P < 0.0001), than in controls (9.8-point increase, P = 0.016; ANOVA interaction term (time*allocation) P < 0.0001). ASHAs in the intervention group reported learning new skills for detecting NCDs.

Conclusion

The training program increased knowledge of ASHAs on NCDs and improved their skills to detect NCDs. Our development and testing process for this training program, coupled with open-source resources, fosters innovation and collaboration in managing NCDs in LMICs.

Innovation

Our novel and adaptable training program incorporates interactive elements, case studies, and real-world scenarios to augment routine communication between ASHAs and community members for preventing NCDs.

Cancer care and outreach in the South Asian Association for Regional Cooperation (SAARC) region: overcoming barriers and addressing challenges

Cancer care in countries in the South Asian Association for Regional Cooperation (SAARC) is hindered by many challenges, including inadequate infrastructure, a shortage of skilled health-care professionals, and economic constraints. These factors contribute to disparities in timely diagnosis and treatment, leading to poorer health outcomes. Health-care systems within the region vary considerably, ranging from free public health care in Sri Lanka to predominantly out-of-pocket expenses in Bangladesh, highlighting inequities in financial access and service delivery for patients within this region. The absence of comprehensive national health insurance systems imposes substantial financial burdens on patients with cancer and their families, often resulting in catastrophic health-care costs. Paediatric oncology services reflect these disparities with greater clarity. Although Bangladesh has developed multiple treatment centres, issues such as delayed diagnoses and financial barriers persist. By contrast, countries such as Afghanistan and the Maldives have few specialised paediatric oncology services, necessitating costly referrals abroad that place large strains on families. Geriatric oncology remains underdeveloped across most SAARC nations, with few dedicated services and guidelines. Despite progress in India and Sri Lanka, gaps in specialised training and holistic care for older patients remain. Addressing these disparities requires coordinated efforts, including improving health-care infrastructure, expanding insurance coverage, and fostering regional collaborations. Implementing comprehensive national cancer control programmes across SAARC nations, leveraging intercountry networks, and ensuring political commitment are essential to achieving equitable cancer care and advancing Sustainable Development Goals in the region.

Barriers and facilitators for strengthening primary health systems for person-centred multimorbid care in low-income and middle-income countries: a scoping review

OBJECTIVE

To understand barriers and facilitators for strengthening health systems for person-centred care of people with multiple long-term conditions-multimorbidity (MLTC-M) at the primary healthcare (PHC) level in low-income and middle-income countries (LMICs).

DESIGN

A scoping review.

METHODS

We adopted a systematic scoping review approach to chart literature guided by Arksey and O'Malley's methodological framework. The review focused on studies conducted in LMICs' PHC settings from January 2010 to December 2023. Papers were extracted from the following databases: PubMed, EBSCOhost and Google Scholar. Framework analysis was undertaken to identify barriers and facilitators for strengthening MLTC-M primary care according to the five health system pillars in the Lancet Global Health Commission on High-Quality Health Systems Framework.

RESULTS

The literature search yielded 4322 citations, evaluated 202 studies and identified 36 for inclusion. Key barriers within the people pillar included poverty, low health education and low health literacy; within the platform pillar, fragmented services and lack of multimorbid care guidelines were mentioned; within the workforce pillar, lack of required skills and insufficient health workers; and in the tools pillar: a shortage of essential medicines and adverse polypharmacy effects were prominent. A lack of political will and the absence of relevant national health policies were identified under the governance pillar. Facilitators within the people pillar included enhancing self-management support; within the platforms, pillar included integration of services; within the tools pillar, included embracing emerging technologies and information and communication technology services; and governance issues included upscaling interventions to respond to multimorbid care needs through enhanced political commitment and financial support.

CONCLUSIONS

Potential solutions to strengthening the healthcare system to be more responsive to people with MLTC-M include empowering service users to self-manage, developing multimorbid care guidelines, incorporating community health workers into multimorbid care efforts and advocating for integrated person-centred care services across sectors. The need for policies and procedures in LMICs to meet the person-centred care needs of people with MLTC-M was highlighted.

Delivering non-communicable disease services through primary health care in selected south Asian countries: are health systems prepared?

In the south Asian region, delivering non-communicable disease (NCD) prevention and control services through existing primary health-care (PHC) facilities is urgently required yet currently challenging. As the first point of contact with the health-care system, PHC offers an ideal window for prevention and continuity of care over the life course, yet the implementation of PHC to address NCDs is insufficient. This review considers evidence from five south Asian countries to derive policy-relevant recommendations for designing integrated PHC systems that include NCD care. Findings reveal high political commitment but poor multisectoral engagement and health systems preparedness for tackling chronic diseases at the PHC level. There is a shortage of skilled human resources, requisite infrastructure, essential NCD medicines and technologies, and dedicated financing. Although innovations supporting integrated interventions exist, such as innovations focusing on community-centric approaches, scaling up remains problematic. To deliver NCD services sustainably, governments must aim for increased financing and a redesign of PHC service.

Health Systems for Rehabilitation - Critical Appraisal of the National Programme for Stroke in India

The organized provision of health services in India has been envisioned since 1946 by the recommendations from the Bhore committee. However, the policy and program strategies for the provision of good quality health care still lack effectiveness. Access to rehabilitation services for persons with disabilities continues to be a significant public health problem in India. This review intended to identify the barriers to integration and implementation of rehabilitation services within the national program for stroke in India. The methods involved the critical review and appraisal of the last five years of the published common review mission reports which report the performance of the entire health system and national program of the country. All relevant policy and program documents related to the national program for the prevention and control of cancer, diabetes, cardiovascular diseases, and stroke, were also reviewed. The World Health Organization, Rehabilitation 2030 recommendations were also cross-compared to summarize the findings from the critical review. The results revealed that rehabilitation was neglected within the conceptualization and implementation of the NPCDCS program. Let alone for the Stroke program, there was not any evidence-based description of the concept of disability management and rehabilitation within the NPCDCS program. The health system in its current form appears to be a non-inclusive system for disability-inclusive development. The priority is mainstreaming disability within the agenda for the health of the nation. If disability could be mainstreamed within the health agenda of India and in LMICs, universal health coverage and disability-inclusive development can certainly, be achieved.

Experiences and challenges of people living with multiple long-term conditions in managing their care in primary care settings in Kerala, India: A qualitative study

BACKGROUND

Multimorbidity or multiple long-term conditions (MLTCs), the coexistence of two or more chronic conditions within an individual, presents a growing concern for healthcare systems and individuals' well-being. However, we know little about the experiences of those living with MLTCs in low- and middle-income countries (LMICs) such as India. We explore how people living with MLTCs describe their illness, their engagements with healthcare services, and challenges they face within primary care settings in Kerala, India.

METHODS

We designed a qualitative descriptive study and conducted in-depth, semi-structured interviews with 31 people (16 males and 15 females) from family health centres (FHCs) in Kerala. Interview data were recorded, transcribed, and thematic analysis using the Framework Method was undertaken.

FINDINGS

Two main themes and three sub-themes each were identified; (1) Illness impacts on life (a)physical issues (b) psychological difficulties (c) challenges of self-management and (2) Care-coordination maze (a)fragmentation and poor continuity of care (b) medication management; an uphill battle and (c) primary care falling short. All participants reported physical and psychological challenges associated with their MLTCs. Younger participants reported difficulties in their professional lives, while older participants found household activities challenging. Emotional struggles encompassed feelings of hopelessness and fear rooted in concerns about chronic illness and physical limitations. Older participants, adhering to Kerala's familial support norms, often found themselves emotionally distressed by the notion of burdening their children. Challenges in self-management, such as dietary restrictions, medication adherence, and physical activity engagement, were common. The study highlighted difficulties in coordinating care, primarily related to traveling to multiple healthcare facilities, and patients' perceptions of FHCs as fit for diabetes and hypertension management rather than their multiple conditions. Additionally, participants struggled to manage the task of remembering and consistently taking multiple medications, which was compounded by confusion and memory-related issues.

CONCLUSION

This study offers an in-depth view of the experiences of individuals living with MLTCs from Kerala, India. It emphasizes the need for tailored and patient-centred approaches that enhance continuity and coordination of care to manage complex MLTCs in India and similar LMICs.

Barriers and enablers to improving integrated primary healthcare for non-communicable diseases and mental health conditions in Ethiopia: a mixed methods study

BACKGROUND

The Ethiopian Primary Healthcare Clinical Guidelines (EPHCG) seek to improve quality of primary health care, while also expanding access to care for people with Non-Communicable Diseases and Mental Health Conditions (NCDs/MHCs). The aim of this study was to identify barriers and enablers to implementation of the EPHCG with a particular focus on NCDs/MHCs.

METHODS

A mixed-methods convergent-parallel design was employed after EPHCG implementation in 18 health facilities in southern Ethiopia. Semi-structured interviews were conducted with 10 primary healthcare clinicians and one healthcare administrator. Organisational Readiness for Implementing Change (ORIC) questionnaire was self-completed by 124 health workers and analysed using Kruskal Wallis ranked test to investigate median score differences. Qualitative data were mapped to the Consolidated Framework for Implementation Science (CFIR) and the Theoretical Domains Framework (TDF). Expert Recommendations for Implementing Change (ERIC) were employed to select implementation strategies to address barriers.

RESULTS

Four domains were identified: EPHCG training and implementation, awareness and meeting patient needs (demand side), resource constraints/barriers (supply side) and care pathway bottlenecks. The innovative facility-based training to implement EPHCG had a mixed response, especially in busy facilities where teams reported struggling to find protected time to meet. Key barriers to implementation of EPHCG were non-availability of resources (CFIR inner setting), such as laboratory reagents and medications that undermined efforts to follow guideline-based care, the way care was structured and lack of familiarity with providing care for people with NCDs-MHCs. Substantial barriers arose because of socio-economic problems that were interlinked with health but not addressable within the health system (CFIR outer setting). Other factors influencing effective implementation of EPHCG (TDF) included low population awareness about NCDs/MHCs and unaffordable diagnostic and treatment services (TDF). Implementation strategies were identified. ORIC findings indicated high scores of organisational readiness to implement the desired change with likely social desirability bias.

CONCLUSION

Although perceived as necessary, practical implementation of EPHCG was constrained by challenges across domains of internal/external determinants. This was especially marked in relation to expansion of care responsibilities to include NCDs/MHCs. Attention to social determinants of health outcomes, community engagement and awareness-raising are needed to maximize population impact.

"The burden of lifestyle diseases and their impact on health service in India"-A narrative review

Basically, non-communicable diseases (NCDs) are lifestyle diseases. They cannot be transmitted from one person to another person. Instead, our lifestyle, genetics, and environment influence our susceptibility to various diseases. In India, non-communicable illnesses and injuries are responsible for 52% of fatalities. The burden of non-communicable diseases and the resultant mortality are predicted to increase if the government does not take significant steps to prevent and control NCDs and related risk factors. According to the currently available research, the top causes of illness, disability, and death in India include hypertension, cardiovascular diseases, cancer, diabetes, lung disease, chronic renal disease, trauma, stroke, and chronic obstructive and mental disorders. Since 1980s, the Government of India has assisted the states through several vertical programs to prevent and control NCDs. However, efforts to prevent and control NCDs significantly increased under the 11th plan. New programs were launched on a small scale in a select few districts. The financial burden of NCDs has mostly stayed the same, though based on past experiences, reducing exposure to risk factors requires focusing on health promotion and preventative actions. The public healthcare system must have the tools and talents needed for effective management, early diagnosis, and screening. Effective monitoring systems, integrated management, and public awareness campaigns are required to successfully implement the program and make services available to all national citizens.

Exploring the Interplay of Socioeconomic and Behavioral Factors: Unraveling Gender Disparities in Glycemic Control Among Adult Type 2 Diabetic Patients in Outpatient Care

Background Diabetes mellitus (DM) presents global challenges, with optimal glycemic control being pivotal in managing complications, notably in type 2 diabetes mellitus (T2DM). Yet, achieving sustained control faces barriers stemming from socioeconomic and gender-specific disparities. This study addresses these gaps by examining socioeconomic determinants and gender disparities in diabetes management, particularly in Maharashtra, India. Methodology This cross-sectional study involved 302 T2DM patients aged 20 to 79 years. Data on sociodemographic, behavioral, and clinical factors were collected through interviews, and records were analyzed via logistic regression to identify predictors of glycemic control. Results Significant associations emerged between gender and education, occupation, and religion. Glycemic control, with a mean HbA1c of 8.45%, remained suboptimal. Logistic regression identified gender, average family income, diabetes duration, treatment nature, comorbidities, complications, and medication adherence as glycemic control predictors. Conclusions Addressing socioeconomic and gender-specific factors is paramount in diabetes management, especially in rural areas where sociocultural influences shape health behaviors. Tailored interventions, including gender-sensitive health education, are vital for improving diabetes care and outcomes. This study provides crucial insights into gender-specific influences on glycemic control among T2DM patients in Maharashtra, advocating for personalized interventions to enhance overall diabetes management.

Many hops, many stops: care-seeking "loops" for diabetes and hypertension in three urban informal settlements in the Mumbai Metropolitan Region

Background

The burden of Non-Communicable Diseases (NCDs) in urban informal settlements across Lower and Middle Income Countries is increasing. In recognition, there has been interest in fine-tuning policies on NCDs to meet the unique needs of people living in these settlements. To inform such policy efforts, we studied the care-seeking journeys of people living in urban informal settlements for two NCDs-diabetes and hypertension. The study was done in the Mumbai Metropolitan Region, India.

Methods

This qualitative study was based on interviews with patients having diabetes and hypertension, supplemented by interactions with the general community, private doctors, and public sector staff. We conducted a total of 47 interviews and 6 Focus Group Discussions. We synthesized data thematically and used the qualitative software NVivo Version 10.3 to aid the process. In this paper, we report on themes that we, as a team, interpreted as striking and policy-relevant features of peoples' journeys.

Results

People recounted having long and convoluted care-seeking journeys for the two NCDs we studied. There were several delays in diagnosis and treatment initiation. Most people's first point of contact for medical care were local physicians with a non-allopathic degree, who were not always able to diagnose the two NCDs. People reported seeking care from a multitude of healthcare providers (public and private), and repeatedly switched providers. Their stories often comprised multiple points of diagnosis, re-diagnosis, treatment initiation, and treatment adjustments. Advice from neighbors, friends, and family played an essential role in shaping the care-seeking process. Trade-offs between saving costs and obtaining relief from symptoms were made constantly.

Conclusion

Our paper attempts to bring the voices of people to the forefront of policies on NCDs. People's convoluted journeys with numerous switches between providers indicate the need for trusted "first-contact" points for NCD care. Integrating care across providers-public and private-in urban informal settlements-can go a long way in streamlining the NCD care-seeking process and making care more affordable for people. Educating the community on NCD prevention, screening, and treatment adherence; and establishing local support mechanisms (such as patient groups) may also help optimize people's care-seeking pathways.

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India

BACKGROUND

India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges.

AIM

This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study.

METHODS

A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken.

RESULTS

In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal.

CONCLUSION

This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

The role of the private sector in noncommunicable disease prevention and management in low- and middle-income countries: a series of systematic reviews and thematic syntheses

PURPOSE

Conduct six systematic reviews investigating for-profit private sector roles in NCD prevention and management in low- and middle-income countries (LMICs) through our a priori framework's pillars.

METHODS

Six systematic reviews and thematic syntheses were performed between March-August 2021, Six databases, websites of relevant organizations, and references lists of included studies were comprehensively searched. Studies published in English from 2000 onwards involving the pillar of interest, for-profit private sector, NCD prevention/management, and LMIC context were included. Results were synthesized using an inductive thematic synthesis approach.

RESULTS

Ultimately, 25 articles were included in the PPP review, 33 in Governance and Policy, 22 in Healthcare Provision, 15 in Innovation, 14 in Knowledge Educator, and 42 in Investment and Finance. The following themes emerged: PPPs (coordination; financial resources; provision; health promotion; capacity building; innovation; policy); Governance/Policy (lobbying; industry perception; regulation); Healthcare Provision (diagnosis/treatment; infrastructure; availability/accessibility/affordability); Innovation (product innovation; process innovation; marketing innovation; research; innovation dissemination); Knowledge Educator (training; health promotion; industry framework/guideline formation); Investment and Finance (treatment cost; regulation; private insurance; subsidization; direct investment; collaborative financing; innovative financing; research).

CONCLUSION

These findings will be instrumental for LMICs considering private sector engagement. Potential conflicts of interest must be considered when implementing private sector involvement.

A need to integrate healthcare services for HIV and non-communicable diseases: An Indian perspective

With the decline in HIV mortality, a concomitant increase in morbidity and death not directly related to HIV has been witnessed. Consequently, many countries especially low- and middle-income countries (LMICs) are now facing the dual burden of HIV and non-communicable diseases (NCDs). 2.3 million people living with HIV in India are at a higher risk of developing NCDs due to ageing, which can be attributed to the additional impact of long-standing HIV infection and the side-effects of antiretroviral therapy. This has led to a rise in demand for a combined health system response for managing HIV infection and co-existing NCDs, especially in LMICs such as India. The health and wellness centres (HWCs) envisioned to provide an expanded range of preventive and curative services including that for chronic conditions may act as a window of opportunity for providing egalitarian and accessible primary care services to these individuals. The reasons for integrating HIV and NCD care are epidemiological overlap between these conditions and the similar strategies required for provision of healthcare services.

A Review on Case Burden of Diabetes Mellitus Before and After the Implementation of National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke

This article focuses on the role of the National Health Program called National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke (NPCDCS) in the screening and reduction of the case burden of Diabetes mellitus. The article first discusses the case burden of Diabetes before the implementation of NPCDCS and then the burden of the disease after the implementation of the program by mainly reviewing the cross-sectional studies done in four districts, Jaipur district, Gandhinagar district, Belagavi taluka district, and Udupi district. The studies were conducted at least four years after the program's implementation. The reason for preparing this review article is to assess the efficacy of NPCDCS in controlling the most dreaded chronic disease, which has its highest prevalence in India. Over the past century, there has been a consistent rise in the prevalence of Diabetes.  In all departments of medicine, Diabetes has been a common predisposing factor in several adversities such as blindness, limb amputation, cerebrovascular stroke, diabetic nephropathy, and other microvascular and macrovascular diseases. The studies include field-level cross-checking and on-ground cross-sectional studies, which were done in 2019 in Jaipur, standard cross-sectional studies from the primary data collected from the primary health care center in the Belagavi taluka district, a national-level cross-sectional study conducted by the National NCD Monitoring survey, and cross-sectional studies in Udupi district in Karnataka, which was the first district to be included by NPCDCS in its second phase.

Estimating the Cost of Delivering Tobacco Cessation Intervention Package at Noncommunicable Disease Clinics in Two Districts of North India

INTRODUCTION

Integrated care is likely to improve outcomes in strained healthcare systems while limiting costs. NCD clinics were introduced under the "National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke" (NPCDCS) in India; however, there is limited literature on the costs of delivering tobacco cessation interventions within NPCDCS. One of the study's objectives was to estimate the cost of delivering a culturally specific patient-centric behavioral intervention package in two district-level NCD clinics in Punjab, India.

METHODS

Costing was undertaken using the health systems perspective. A top-down or financial costing approach and a bottom-up or activity-based approach were employed at each step of development and implementation. The opportunity cost was used to include the cost of human resources, infrastructure, and capital resources used. All infrastructure and capital costs were annualized using a 3% annual discount rate. Four additional scenarios were built up concerning three major components to reduce costs further when rolled out on a large scale.

RESULTS

The cost of intervention package development, human resource training, and unit cost of implementation were estimated to be INR 6,47,827 (USD 8,874); INR 134,002 (USD 1810); and INR 272 (USD 3.67), respectively. Based on our sensitivity analysis results, the service delivery cost varied from INR 184 (USD 2.48) to INR 326 (USD 4.40) per patient.

CONCLUSION

The development costs of the intervention package accounted for the majority proportion of the total cost. Of the total unit cost of implementation, the telephonic follow-up, human resources, and capital resources were the major contributory components.

IMPLICATIONS

The current study aims to fill gaps by estimating the unit-level health systems cost of a culturally sensitive, disease-specific, and patient-centric tobacco cessation intervention package delivered at the outpatient settings of NCD clinics at the secondary level hospital, which represents a major link in the health care system of India. Findings from this study could be used to provide supportive evidence to policymakers and program managers for rolling out such interventions in established NCD clinics through the NPCDCS program of the Indian Government.

Integrative approach to lifestyle management: Implications for public health research & practice in the context of SDG-3

In the last 100 years, the communicable diseases have been replaced by non-communicable diseases as the leading cause of deaths across the world. Periodically, the communicable disease outbreaks continue to pose a challenge to the public health systems. Change in human behaviors and lifestyles are recognized as risk factors for the public health challenges we face today, which significantly affect wellbeing and quality of life. Healthy lifestyles are critical to not only controlling diseases, but also to promote good health and wellbeing. Modern Medicine has provided evidence-based approaches to lifestyle management, but there are challenges to implementing them effectively. The traditional disciplines such as Ayurveda, Yoga and Meditation are showing promise as complementary approaches to further community wellbeing. A new perspective and a model is proposed by the author called 'Integrative Lifestyle" which is informed by the evidence in the space of modern and traditional approaches to lifestyle management. The article describes the elements of the model, highlights the emerging evidence and implications for public health practice and research. The efforts by Government of India and its collaborators to promote integrative approaches is worthy of emulation and should be backed by sufficient investments into implementation research and population wide scale up for accelerating SDG-3 outcomes related to health and wellbeing.

Factors influencing the decision to use state-funded healthy lifestyle centres in a low-income setting: a qualitative study from Sri Lanka

OBJECTIVE

Healthy lifestyle centres (HLCs) in Sri Lanka provide screening and lifestyle modification services targeting major non-communicable diseases (NCDs). Even though the service is highly accessible and affordable, HLCs are underused by its target population (adults >35 years). We aimed to explore the factors that influence the decision-making process of utilisation of HLCs in Sri Lanka.

SETTING

Two districts (Gampaha and Kalutara) from the highest populous province (Western) located adjacent to the capital district of Sri Lanka.

PARTICIPANTS

Nine service providers, 37 HLC clients and 52 community participants were selected using judgemental, convenient and purposive sampling methods. Theoretical sampling method was used to decide the sample size for each category.

METHOD

A qualitative study design based on constructivist grounded theory was used. Data collected using in-depth interviews and focus group discussions during January to July 2019 and were analysed using the constant comparison method.

RESULTS

The decision-making process of utilisation of HLCs was found to be a chain of outcomes with three main steps, such as: intention, readiness and utilisation. Awareness of HLCs, positive attitudes on health, intrinsic or extrinsic motivators, positive attitudes on NCDs and screening were internal factors with a positive influence on intention. Readiness was positively influenced by positive characteristics of the HLCs. It was negatively influenced by negative attitudes on staff and services of HLCs and negative past experiences related to services in state healthcare institutions and HLCs, service provider-related barriers and employment-related barriers. Family-related factors, social support and norms influenced both intention and readiness, either positively or negatively.

CONCLUSION

The decision-making process of utilisation of HLCs links with factors originating from internal, family, service provider and societal levels. Thus, a multifactorial approach that addresses all these levels is needed to improve the utilisation of HLCs in Sri Lanka.

A commentary on cancer prevention and control in India: Priorities for realizing SDGs

In India, cancers along with cardiovascular diseases contribute to significant mortality and morbidity. With less than 10 years remaining towards achieving Sustainable development Goals (SDGs), public health systems in India need to be critically assessed and strengthened, for addressing non-communicable diseases (NCDs) in general and cancers in particular. Our Commentary address the public health response to cancer prevention and control, with specific pointers based on emerging evidence. The relevant issues are stratified as: emphasis on the critical appraisal of national programs, strengthening primary health care (PHC) systems, enhancing focus on client and community centricity, exploring integrative approaches to cancer management and stepping up implementation and multidisciplinary research. Ongoing surveillance is essential to assess the current and future trends of cancer as well as the outcomes of prevention and treatment measures. For revitalizing comprehensive PHC, much depends on our epidemiological capacity and surveillance systems which impart information for local planning. It is imperative to address the cultural barriers and societal norms, which limit the acceptability and participation in screening programs. SDG 3 has ushered the wellbeing agenda at an opportune time. There is a compelling need to conduct research on an integrated approach (ayurveda complimenting allopathic medication) for the treatment of cancer. The unique challenges posed by the rise in NCD morbidity in LMIC, requires horizontal integration of the health systems with new services focused on cancer control.

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.

COVID-19 effect on patients with noncommunicable diseases: A narrative review

Background and Aims

On March 11, 2020, the WHO has declared COVID-19 a global pandemic, affecting our day-to-day lives. Physical distancing and lockdown made significant obstacles to populations, particularly healthcare systems. Most healthcare workers were reallocated to COVID-19 facilities. Noncommunicable disease patients were given low priority and are at a higher risk of severe COVID-19 infection, which disrupted the treatment and disease management of these patients. This review aimed to assess the effect of COVID-19 on different types of noncommunicable diseases and the severity it may cause to patients.

Methods

We have conducted a review of the literature on COVID-19 and noncommunicable diseases from December 2019 until January 2022. The search was done in PubMed and Cochrane for relevant articles using variety of searching terms. Data for study variables were extracted. At the end of the selection process, 46 papers were selected for inclusion in the literature review.

Result

The result from this review found that the COVID-19 pandemic has affected the efficiency of the patient's treatment indirectly by either delaying or canceling sessions, which solidified the need to rely more on telemedicine, virtual visits, and in-home visits to improve patient education and minimize the risk of exposure to the patients. The major and most common types of noncommunicable diseases are known to be related to the severe outcomes of COVID-19 infection. It is strongly recommended to prioritize these patients for vaccinations against COVID-19 to provide them with the protection that will neutralize the risk imposed by their comorbidities.

Conclusion

We recommend conducting more studies with larger population samples to further understand the role of noncommunicable diseases (NCDs) in this pandemic. However, this pandemic has also affected the efficiency of NCDs treatment indirectly by delaying or canceling sessions and others.

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke: A Scoping Review in the Context of Hypertension Prevention and Control in India

SUMMARY

A scoping review was carried out to identify gaps in the performance of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) towards the preparedness of the public health system especially at primary level in dealing with hypertension (HTN). The World Health Organization Innovative Care for Chronic Conditions (WHO ICCC) framework was adapted for the current review under three levels namely micro, meso, and macro. PubMed Central was accessed to retrieve eligible articles published since 2010. Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews checklist was followed for reporting. A final selection of 27 articles that fulfilled the eligibility criteria of the current review was drawn from a long list of 542 articles. Cross-sectional studies contributed to 51.8% of the included studies. We observed that NPCDCS had gaps across all levels of health care, especially at the primary level. At the micro-level noncommunicable diseases (NCDs), awareness among patients was suboptimal and treatment adherence was poor. At the meso-level, there was a vacancy in all cadres of workers and lack of regular training of workforce, laboratory services, and inconsistent availability of essential drugs, equipment, and related supplies to be ensured. At the macro-level, public spending on NCD care needs to be increased along with strategies to reduce out-of-pocket expenditure and improve universal health coverage. In conclusion, there is a need to improve components related to all three levels of the WHO ICCC framework to amplify the impact of HTN care through NPCDCS, particularly at the primary level.

A Scoping Review of Interventions for Prevention and Control of Hypertension in India

SUMMARY

In India, hypertension (HTN) is a raging public health problem and demands contextualized strategies to combat it. However, there is a gap in indigenous research output on interventions related to HTN that work in the Indian context. We aimed to identify, describe, and systematically compile context-derived evidence for the prevention and control of HTN in adults in India across the community, health-care organization, and health policy domains by reviewing papers published over the past 10 years (January 2013-December 2022). Our goal was to prepare a ready-reckoner document that could serve as a baseline critique for HTN researchers, policymakers, and program managers for planning their respective courses of action. We searched for relevant literature published between January 2013 and December 2022, indexed in PubMed and Web-of-Science. We extracted information using the Template for Intervention Description and Replication checklist and used the Innovative Care for Chronic Conditions Framework for analysis and reporting. Only 33 articles emerged as "eligible." The papers focused on community (39.4%), health-care organization (36.4%), and multi-domain (24.2%) strategies. Majority (69.7%) reported HTN control as an indicator to assess intervention effectiveness. Original research from India on HTN interventions is sparse. Thus, there is a need to promote research activities and publications that generate evidence for action in alignment with provisions and priorities of existing programs and policies, and with a focus on scalability and sustainability. Consequently, we call for increased attention to implementation science and research for HTN combat in India.

Associations between e-health literacy and chronic disease self-management in older Chinese patients with chronic non-communicable diseases: a mediation analysis

BACKGROUND

Chronic non-communicable diseases (CNCDs) are an urgent public health issue in China, especially among older adults. Hence, self-management is crucial for disease progression and treatment. Electronic health (e-health) literacy and self-efficacy positively correlate with self-management. However, we know little about their underlying mechanisms in older adults with CNCDs.

OBJECTIVE

To explore the factors that influence chronic disease self-management (CDSM) and verify self-efficacy as the mediator between e-health literacy and self-management behavior in older patients with CNCDs.

METHODS

This cross-sectional study included 289 older patients with CNCDs from Hunan province, China, between July and November 2021. E-health literacy, self-efficacy, social support, and CDSM data were collected through questionnaires. The influence of each factor on CDSM was explored with multiple linear regression analysis. Intermediary effects were computed via a structural equation model.

RESULTS

The total CDSM score in the patients was 29.39 ± 9.60 and only 46 (15.92%) patients used smart healthcare devices. The regression analysis showed e-health literacy, self-efficacy, and social support were the factors that affected CDSM. Furthermore, the structural equation model revealed that self-efficacy directly affected CDSM (β = 0.45, P < 0.01), whereas e-health literacy affected it directly (β = 0.42, P < 0.01) and indirectly (β = 0.429, P < 0.01) through self-efficacy.

CONCLUSIONS

This study revealed that self-management among older patients with CNCDs is at a low level, and few of them use smart healthcare devices. Self-efficacy plays a partial intermediary role between e-health literacy and self-management in older patients with CNCDs. Thus, efforts to improve their CDSM by targeting e-health literacy may be more effective when considering self-efficacy.

Systematic Development of the ReWin Application: A Digital Therapeutic Rehabilitation Innovation for People With Stroke-related Disabilities in India

This is a viewpoint paper that aims to describe the systematic approach to the development of a technology-driven stroke rehabilitation innovation to manage disabilities following a stroke at home in India. This paper intends to sensitize public health innovators and intervention development experts about the important aspects that need to be considered to develop a culturally sensitive, patient-centered, scalable solution for stroke care using technology. Stroke has been the second-leading cause of death and the third-leading cause of disability globally for the past 3 decades. The emerging technological innovations for stroke care were predominantly designed and developed by digital technology experts as stand-alone products with very minimal efforts to explore their feasibility, acceptability, and, more importantly, scalability. Hence, a digital therapeutic rehabilitation innovation for people with stroke-related disabilities in India was systematically developed and is being evaluated. ReWin is an innovation that is technologically driven and envisions digital therapeutics as a medium for the provision of rehabilitation to persons with disabilities. It is conceptualized and developed based on the International Classification of Functioning, Disability and Health. ReWin encompasses specific technological aspects to enable its scientific framework and conceptualization to suit the context and needs of stroke care providers and consumers. The framework is built with 2 separate applications, one for the providers and one for the patients and caregivers. Each of these applications has a specific inbuilt design to add data about the demographic details of the user, stroke severity using the National Institute of Health Stroke Scale, and self-assessment of disability measured by the modified Barthel Index. Users can communicate with each other and decide on their therapeutic goals, therapy training information, and progress remotely from where they are. The ultimate outcome expected from the ReWin innovation is a continuum of care for stroke survivors that is effective, safe, and of good quality. Systematic development cannot make the intervention scalable. The intervention needs to be evaluated for its feasibility, acceptability, and effectiveness. Currently, ReWin is being evaluated for its feasibility and acceptability. The evaluation of ReWin will provide an opportunity to develop a scalable solution for empowering therapists and persons with disabilities, in general, to objectively self-manage their treatment. Findings from this study will also provide valuable information about the resources required to deliver such interventions in resource-constrained settings like India.

Socio-demographic, behavioural and clinical factors influencing control of diabetes and hypertension in urban Mysore, South India: a mixed-method study conducted in 2018

BACKGROUND

Inadequate control of diabetes and hypertension is a major concern in India because of rising mortality and morbidity. Few studies in India have explored factors that influence control of diabetes and hypertension. The current study aimed to improve the understanding of multifactorial influence on the control of diabetes and hypertension among patients in Primary Health Care Settings(PHC) of urban Karnataka.

METHODS

We used a mixed-method study design, within a project aiming to improve non-communicable disease (NCD) continuum of care across PHC in Mysore city, India, conducted in 2018. The quantitative study was conducted among 399 patients with diabetes and/or hypertension and a logistic regression model was used to assess the factors responsible for biological control levels of diabetes and hypertension measured through Glycated Haemoglobin(HbA1c) and blood pressure. Further, in-depth interviews(IDI) were conducted among these patients and the counsellors at PHCs to understand the barriers and enablers for better control.

RESULT

The quantitative assessment found odds of poor control amongst diabetics' increased with older age, longer duration of disease, additional chronic conditions, and tobacco consumption. For hypertensives, odds of poor control increased with higher body mass index(BMI), alcohol consumption, and belongingness to lower social groups. These findings were elaborated through qualitative assessment which found that the control status was affected by stress as a result of family or financial worries. Stress, poor lifestyle, and poor health-seeking behaviour interplay with other factors like diet and exercise leading to poor control of diabetes and hypertension.

CONCLUSION

A better understanding of determinants associated with disease control can assist in designing focused patient outreach plans, customized communication strategies, need-based care delivery plans, and specific competency-based capacity-building models for health care workers. Patient-centric care focusing on biological, social and behavioural determinants is pivotal for appropriate management of NCDs at community level in low-middle income countries.

Pilot implementation of rural rehabilitation services, India

Objective

To implement rehabilitation services in a rural area of Raigad district, Maharashtra, India.

Methods

We piloted a rehabilitation service delivery model through the Mahatma Gandhi Mission Institute of Health Sciences, in five villages. The institute performed participatory rural appraisal and focus group discussions with stakeholders to identify general issues in village life that could affect delivery. To integrate rehabilitation service delivery into the existing primary care system, a team from the institute developed a strategic plan through multidisciplinary clinical meetings. A rehabilitation team conducted a door-to-door survey and referred people needing rehabilitation services to the outreach visits the team was making to the primary health centre twice a week. If needed, patients could be referred to a university teaching hospital for tertiary-level care.

Findings

The rural appraisal identified lack of awareness, inadequate workforce and infrastructure as key issues for rehabilitation services delivery. In response, we conducted awareness campaigns and formed a rehabilitation team consisting of personnel and students from the institute. Between 2018 and 2021, the team provided care to 1800 patients, of which half (900 patients) had musculoskeletal disorders. After rehabilitation, 360 (40%) of these 900 patients performed daily-living activities and continued to work with reduced pain within 2-3 days after rehabilitation. The team provided antenatal care to 1629 pregnant women with musculoskeletal pain or stress urinary incontinence.

Conclusion

Provision of rehabilitation services built awareness about physiotherapy, developed a rehabilitation care pathway and established a need for regular services. Using existing resources of the institute and involving students rendered the model sustainable.

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

BACKGROUND

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO's Thirteenth General Programme of Work for 2019-2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

METHODS

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

RESULTS

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States' health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO's guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

CONCLUSIONS

The challenges identified reflect the national health systems' (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

Exploring Challenges of Access to Non-Communicable Disease (NCD) Prevention, Treatment and Care: A Qualitative Study on People Living with NCDs (PLWNCDs) in West Bengal, India

BACKGROUND

People living with noncommunicable diseases (PLWNCDs) are often disproportionately affected due to adverse interaction with socioecological and biological factors. Hence, it is imperative to learn from their lived experience to gain a greater understanding of interactions as well as explore their priorities and needs in accessing care and identify areas of priority action through multistakeholder engagement.

MATERIALS AND METHODS

The qualitative study with grounded theory approach was conducted between October and December 2020. An online key-informant interview with the health policymaker, virtual group discussion with eight PLWNCDs, and in-depth telephonic interviews with five PLWNCDs were conducted, after obtaining informed consent using interview guide, developed, and validated by the experts. Data collection continued till data saturation was achieved. Transcripts generated from the interview recordings were coded using hand-code technique and analyzed thematically.

RESULTS

Challenges faced by PLWNCDs in accessing care were lack of empathy and support from health-care professionals, stigma, financial hardship, and hospital overcrowding. Caregivers emphasized on the felt need to involve civil society organizations (CSOs) in raising awareness toward noncommunicable diseases (NCDs) at family, community, and policymaking levels. The need for home-based NCD care and rehabilitation centers was voiced by the PLWNCDs. Impediments toward effective implementation of NCD policies were adoption of a "top-down" approach, poor awareness about government health insurance schemes, skewed distribution of empanelled hospitals in and around cities, nonavailability of qualified health-care professionals in underserved areas, aggravated allocation-utilization disparity during COVID-19 pandemic, and lack of robust information technology infrastructure to support access to telemedicine services.

CONCLUSION

The collective role of governments, CSOs, and health-care providers, along with meaningful involvement of PLWNCDs, would help to create an enabling environment for overcoming the challenges of access to care and thus achieve universal health coverage.

Preparedness of healthcare facilities of manipur in the management of noncommunicable diseases: A cross-sectional study

Background

India is experiencing a rapid health transition with a rising burden of noncommunicable diseases (NCDs), causing significant morbidity and mortality. Cost-effective interventions for comprehensive NCD management can only be designed after assessing the readiness of various health facilities.

Objectives

This study aimed to assess the preparedness of healthcare facilities of Manipur in the management of NCDs and to assess the knowledge of doctors regarding NCDs.

Methods

A cross-sectional study was conducted in 21 public healthcare facilities in seven districts of Manipur during October 2021. Readiness of these facilities was assessed through observation and interview of doctors and nurses using a checklist adapted from the WHO Package of Essential NCDs. Knowledge of 153 doctors was also assessed using a self-administered, structured questionnaire. Data were entered in SPSS-26 and expressed using descriptive statistics.

Results

General readiness index of primary health centers (PHCs), community health centers (CHCs), district hospitals (DHs), and tertiary care centers (TCCs) was 47%, 66.3%, 73.2%, and 70%, respectively. CHCs were ready in the domains of patient care services (80%), human resources (75%), and advocacy (91.7%). DHs and TCCs were ready in terms of patient care services, human resources, record maintenance, referral system, and advocacy. PHCs were not ready in any of the nine domains. Majority of the doctors (88%) had inadequate knowledge regarding NCDs.

Conclusion

PHCs and CHCs were not adequately prepared, but DHs and TCCs were ready to manage NCDs. More than four-fifth of the doctors had inadequate knowledge. Strengthening PHCs and CHCs and training of healthcare workers are needed for integrated NCD management.

Risk Factors Analysis and Management of Cardiometabolic-Based Chronic Disease in Low- and Middle-Income Countries

The epidemic of obesity or adiposity-based chronic diseases presents a significant challenge with the rising prevalence of morbidities and mortality due to atherosclerotic cardiovascular diseases (ASCVD), especially in low- and middle-income countries (LMIC). The underlying pathophysiology of metabolic inflexibility is a common thread linking insulin resistance to cardiometabolic-based chronic disease (CMBCD), including dysglycemia, hypertension, and dyslipidemia progressing to downstream ASCVD events. The complex CMBCD paradigm in the LMIC population within the socio-economic and cultural context highlights considerable heterogeneity of disease predisposition, clinical patterns, and socio-medical needs. This review intends to summarize the current knowledge of CMBCD. We describe recently established or emerging trends for managing risk factors, assessment tools for evaluating ASCVD risk, and various pharmacological and non-pharmacological measures particularly relevant for LMICs. A CMBCD model positions insulin resistance and β-cell dysfunction at the summit of the disease spectrum may improve outcomes at a lower cost in LMICs. Despite identifying multiple pathophysiologic disturbances constituting CMBCD, a large percentage of the patient at risk for ASCVD remains undefined. Targeting dysglycemia, dyslipidemia, and hypertension using antihypertensive, statins, anti-glycemic, and antiplatelet agents has reduced the incidence of ASCVD. Thus, primordial prevention targeting pathophysiological changes that cause abnormalities in adiposity and primary prevention by detecting and managing risk factors remains the foundation for CMBCD management. Therefore, targeting pathways that address mitochondrial dysfunction would exert a beneficial effect on metabolic inflexibility that may potentially correct insulin resistance, β cell dysfunction and, consequently, would be therapeutically effective across the entire continuum of CMBCD.

A semi-systematic review on hypertension and dyslipidemia care in Egypt-highlighting evidence gaps and recommendations for better patient outcomes

BACKGROUND

Both hypertension and dyslipidemia are considered as major modifiable risk factors of cardiovascular diseases (CVDs), and their prevalence in Egypt has increased in recent years. Evidence-based systematic evaluation of data on hypertension and dyslipidemia is critical for effective patient-centric management to reduce the overall risk of CVDs in Egypt. This semi-systematic review aimed to quantify and identify data gaps in the prevalence and distribution of patient journey touchpoints including awareness, screening, diagnosis, treatment, adherence, and control of hypertension and dyslipidemia to provide the basis for research prioritization, practice guidance, and health care reforms in Egypt.

MAIN BODY

Structured search was conducted on MEDLINE and Embase to identify articles published in English between January 2010 and December 2019 that reported key patient journey touchpoints in hypertension and dyslipidemia management. Unstructured search was conducted on public or government websites with no date restriction. Data from all sources were extracted and presented descriptively. In total, 22 studies published between 1995 and 2020 on hypertension and dyslipidemia were included in the final analyses. The prevalence of hypertension in Egypt ranged from 12.1 to 59%. Studies reported awareness (37.5% and 43.9%), diagnosis (42% and 64.7%), treatment (24% and 54.1%), and adherence to antihypertensive medication (51.9%) to be low. Furthermore, the percentage of patients who had their blood pressure controlled ranged from 8 to 53.2%. The prevalence of dyslipidemia varied in the general population (range 19.2-36.8%) but was higher in patients with acute coronary syndrome (ACS) (50.9% and 52.5%) and coronary artery disease (58.7%). A national report indicated that 8.6% of the general population was screened for dyslipidemia; however, no data was available on the diagnosis and treatment rates. Among ACS patients, 73.9% were treated for dyslipidemia. Data indicated low levels of medication adherence (59%) among dyslipidemia patients, with overall low control rates ranging from 5.1 to 34.4% depending on CVD risk in populations including ACS patients.

CONCLUSION

Data on patient journey touchpoints of hypertension and dyslipidemia are limited in Egypt, indicating the need for more systematic and high-quality evidence-based studies covering different aspects of patient-centric management for better management of CVD and its risk factors.

Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: results of a National Noncommunicable Disease Monitoring Survey (NNMS)

BACKGROUND

The monitoring framework for evaluating health system response to noncommunicable diseases (NCDs) include indicators to assess availability of affordable basic technologies and essential medicines to treat them in both public and private primary care facilities. The Government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in 2010 to strengthen health systems. We assessed availability of trained human resources, essential medicines and technologies for diabetes, cardiovascular and chronic respiratory diseases as one of the components of the National Noncommunicable Disease Monitoring Survey (NNMS - 2017-18).

METHODS

NNMS was a cross-sectional survey. Health facility survey component covered three public [Primary health centre (PHC), Community health centre (CHC) and District hospital (DH)] and one private primary in each of the 600 primary sampling units (PSUs) selected by stratified multistage random sampling to be nationally representative. Survey teams interviewed medical officers, laboratory technicians, and pharmacists using an adapted World Health Organization (WHO) - Service Availability and Readiness Assessment (SARA) tool on handhelds with Open Data Kit (ODK) technology. List of essential medicines and technology was according to WHO - Package of Essential Medicines and Technologies for NCDs (PEN) and NPCDCS guidelines for primary and secondary facilities, respectively. Availability was defined as reported to be generally available within facility premises.

RESULTS

Total of 537 public and 512 private primary facilities, 386 CHCs and 334 DHs across India were covered. NPCDCS was being implemented in 72.8% of CHCs and 86.8% of DHs. All essential technologies and medicines available to manage three NCDs in primary care varied between 1.1% (95% CI; 0.3-3.3) in rural public to 9.0% (95% CI; 6.2-13.0) in urban private facilities. In NPCDCS implementing districts, 0.4% of CHCs and 14.5% of the DHs were fully equipped. DHs were well staffed, CHCs had deficits in physiotherapist and specialist positions, whereas PHCs reported shortage of nurse-midwives and health assistants. Training under NPCDCS was uniformly poor across all facilities.

CONCLUSION

Both private and public primary care facilities and public secondary facilities are currently not adequately prepared to comprehensively address the burden of NCDs in India.

Progress and challenges in achieving noncommunicable diseases targets for the sustainable development goals

The 2030 Agenda for Sustainable Development adopted by the United Nations in 2015 recognizes noncommunicable diseases (NCDs) as a major public health challenge. Sustainable Development Goal (SDG) 3 includes target 3.4 to reduce premature NCD mortality by one‐third by 2030. This review article analyzes the progress towards the attainment of targets within 3.4, the gaps in meeting the targets, and implementation challenges correlated with those gaps. A literature review was performed in September 2020 to identify the published literature and data discussing the SDGs and NCDs, its progress since 2015, and the associated challenges. The analysis reveals SDG target 3.4 is interrelated to at least nine SDGs. There have been many positive SDG initiatives, but the progress has been slow. Data from various countries show that only two out of the ten NCD progress indicators are being met by at least half of the 176 countries who signed the SDGs. The ongoing COVID‐19 pandemic is expected to further aggravate the prevalence and hinder the progress towards the achievement of goals and the targets of the SDGs. The next decade is critical to advance progress on reducing NCDs across countries. The article concludes with a commentary and recommended actions. A combination of prevention, early detection, and treatment are the key to achieve the SDG 3.4 targets. Increased funding and commitments at international and national levels are required to bring about the transformative changes.

Non-communicable diseases' risk factors in Iran; a review of the present status and action plans

Non-communicable Diseases (NCDs) are the leading causes of death globally, imposing a heavy burden on the healthcare systems, especially in low- and middle-income countries. Iran is a country in the Middle-East region with an aging population and changing disease risk factors, and now is facing NCDs as the major health problem of the country. Investigating NCDs' risk factors and tackling preventable ones is the main intervention to control their heavy burden. In this review, we discussed the most critical risk factors in Iran and the implemented programs and action plans to control them. A better knowledge on current status of risk factors and plans to tackle them, could help policymakers effectively rule policies and allocate resources to curb heavy burden of NCDs in Iran.