Abstract
BackgroundSierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention.MethodsA mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate.ResultsA Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients.ConclusionOur study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed.
Highlights
Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs)
The local Technical working groups (TWG) worked on the initial adaptation of the desktop guidelines for clinical management and lifestyle interventions, and associated training curriculum and modules, which had been pilot tested and shown to be acceptable and feasible in rural settings in China [16], Pakistan [17,18,19], Swaziland and other low- and middle-income countries (LMICs) countries
The local TWG included two Royal College of General Practice (RCGP) doctors and 5 community health officer (CHO) who scored highly in the first module and were most keen to teach on NCDs and these CHOs became the trainers in the following training activities and mentors during the pilot implementation of the intervention
Summary
Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). 15 million people die prematurely from an NCD, and 85% of these deaths occur in LMICs. The World Health Organisation (WHO) has proposed a framework for integrating NCD prevention into primary health care through a Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-resource Settings with a set of cost-effective priority interventions for poor-resource settings [2]. In sub-Saharan Africa, taskshifting, to overcome the shortage of trained physicians and other issues relating to access to primary care, is an increasingly widespread delivery approach for PHC interventions for hypertension, diabetes and other NCDs [4,5,6,7], along with other simple interventions [8, 9]
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