Essential Noncommunicable Disease Interventions Research Articles

Implementation of the Package of Essential Non-Communicable (PEN) Disease Interventions in Low-Resource Settings: A Systematic Review.

To deal with the rising prevalence and death rate of non-communicable diseases, the WHO designed a package of essential interventions for non-communicable diseases for low- and middle-income countries. This review aimed to identify the barriers and facilitators of the implementation of this program. The electronic databases of PubMed, Scopus, Web of Science, Cochrane Library, and Scientific Information Database (SID) were searched for papers without a time limit at the end of Dec 2020. Only English and Persian languages were considered. The PRISMA guideline was consulted. Overall, 15 articles were selected for the final analysis out of 404 initially retrieved ones, based on inclusion/exclusion criteria and quality assessment. Thirteen articles had good quality, while 2 articles were of fair quality. Studies were published during 2014-2020. Thematic analysis was used to make sense of papers so that barriers and facilitators were categorized within 2 main themes and 7 sub-themes. Certain organizational factors including human resources, service delivery, structure, leadership/governance, data and information, resources, and financing were identified as barriers and facilitators. Knowledge and culture, and economic and social factors were identified as contextual factors. By considering the factors identified in this study, policymakers and health system managers can be more successful in implementing this WHO PEN and similar packages.

Evaluating diabetes care in primary healthcare centers in Abuja, Nigeria: a cross-sectional formative assessment

IntroductionNoncommunicable diseases (NCDs) are associated with high and rising burden of morbidity and mortality in sub-Saharan Africa, including Nigeria. Diabetes mellitus (DM) is among the leading causes of NCD-related deaths worldwide and is a foremost public health problem in Nigeria. As part of National policy, Nigeria has committed to implement the World Health Organization (WHO) Package of Essential Non-communicable Disease interventions for primary care. Implementing the intervention requires the availability of essential elements, including guidelines, trained staff, health management information systems (HMIS), equipment, and medications, in primary healthcare centers (PHCs). This study assessed the availability of the DM component of the WHO package, and the readiness of the health workers in these PHCs to implement a DM screening, evaluation, and management program to inform future adoption and implementation.MethodsThis cross-sectional formative assessment adapted the WHO Service Availability and Readiness Assessment (SARA) tool to survey 30 PHCs selected by multistage sampling for readiness to deliver DM diagnosis and care in Abuja, Nigeria, between August and October 2021. The SARA tool was adapted to focus on DM services and the availability and readiness indicator scores were calculated based on the proportion of PHCs with available DM care services, minimum staff requirement, diagnostic tests, equipment, medications, and national guidelines/protocols for DM care within the defined SARA domain.ResultsAll 30 PHCs reported the availability of at least two full-time staff (median [interquartile range] = 5 [4–9]), which were mostly community health extension workers (median [interquartile range]) = 3 [1–4]. At least one staff member was recently trained in DM care in 11 PHCs (36%). The study also reported high availability of paper-based HMIS (100%), and DM screening services using a glucometer (87%), but low availability of DM job aids (27%), treatment (23%), and national guidelines/protocols (0%).ConclusionThis formative assessment of PHCs’ readiness to implement a DM screening, evaluation, and management program in Abuja demonstrated readiness to integrate DM care into PHCs regarding equipment, paper-based HMIS, and nonphysician health workers' availability. However, strategies are needed to promote DM health workforce training, provide DM management guidelines, and supply essential DM medications.

The Association Between Depressive Symptoms, Access to Diabetes Care, and Glycemic Control in Five Middle-Income Countries.

The relationship between depression, diabetes, and access to diabetes care is established in high-income countries (HICs) but not in middle-income countries (MICs), where contexts and health systems differ and may impact this relationship. In this study, we investigate access to diabetes care for individuals with and without depressive symptoms in MICs. We analyzed pooled data from nationally representative household surveys across Brazil, Chile, China, Indonesia, and Mexico. Validated survey tools Center for Epidemiologic Studies Depression Scale Revised, Composite International Diagnostic Interview, Short Form, and Patient Health Questionnaire identified participants with depressive symptoms. Diabetes, defined per World Health Organization Package of Essential Noncommunicable Disease Interventions guidelines, included self-reported medication use and biochemical data. The primary focus was on tracking diabetes care progression through the stages of diagnosis, treatment, and glycemic control.Descriptive and multivariable logistic regression analyses, accounting for gender, age, education, and BMI, examined diabetes prevalence and care continuum progression. The pooled sample included 18,301 individuals aged 50 years and above; 3,309 (18.1%) had diabetes, and 3,934 (21.5%) exhibited depressive symptoms. Diabetes prevalence was insignificantly higher among those with depressive symptoms (28.9%) compared with those without (23.8%, P= 0.071). Co-occurrence of diabetes and depression was associated with increased odds of diabetes detection (odds ratio [OR] 1.398, P< 0.001) and treatment (OR 1.344, P< 0.001), but not with higher odds of glycemic control (OR 0.913, P = 0.377). In MICs, individuals aged 50 years and older with diabetes and depression showed heightened diabetes identification and treatment probabilities, unlike patterns seen in HICs. This underscores the unique interplay of these conditions in different income settings.

Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol

IntroductionNon-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted...

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries

IntroductionThe Package of Essential Noncommunicable Disease Interventions—Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to...

Self-reported prevalence of asthma and its associated factors among adult rural population in Bangladesh: a cross-sectional study using WHO PEN protocol

ObjectiveFor over a decade, the prevalence of asthma remained unchanged at around 7% in Bangladesh. Although asthma causes significant morbidity among both children and adults, updates on epidemiological data are...

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

ABSTRACT 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.

Implementing a package of essential non-communicable diseases interventions in low- and middle-income countries: a realist review protocol

IntroductionThe burden of non-communicable diseases (NCDs) is increasing rapidly, particularly in low- and middle-income countries (LMIC), accounting for 85% of premature deaths in the region. LMICs have been facing an...

Baseline prevalence of hyperglycemia and its predictors among community clinic users of a selected rural area of Bangladesh: A cross-sectional study using the WHO PEN Protocol 1.

Our objective was to estimate the prevalence of hyperglycemia at baseline, and identify its predictors among community clinic (CC) users from a selected rural area of Bangladesh. This cross-sectional study partly used the baseline data of implementation research in which a total of 11,244 adults visited the CC, and their blood glucose, blood pressure and anthropometry were evaluated according to 'Action 2' of the World Health Organization (WHO) Package of Essential Noncommunicable Disease Interventions (PEN) protocol 1. Of these, 11,144 had complete information on demography, chronic diseases and their risk factors, which were collected during the implementation of 'Action 1' of WHO PEN protocol 1 at the household level. Hyperglycemia, prediabetes (PreD) and type 2 diabetes were diagnosed using the WHO criteria. Using WHO PEN protocol 1, the estimated baseline prevalence was 12.5% for hyperglycemia, 3.4% for PreD and 9.2% for type 2 diabetes, and was more prevalent among men compared with women. PreD and type 2 diabetes had significantly higher odds ratio (OR >1) of having common risk factors as follows: age ≥40 years (PreD, P < 0.001; type 2 diabetes, P < 0.001), generalized obesity (PreD, P < 0.001; type 2 diabetes, P = 0.005) and hypertension (PreD, P < 0.000; type 2 diabetes, P < 0.001). Furthermore, participants with a family history of diabetes appeared to be a significant predictor of type 2 diabetes (P < 0.001), but not for PreD (P = 0.303). Hyperglycemia, preD and type 2 diabetes showed a comparatively high prevalence among the CC users of the selected rural area. Obesity and hypertension are the key modifiable risk factors that should be reduced using a CC-centered risk reduction strategy.

Diagnostic testing for hypertension, diabetes, and hypercholesterolaemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveys

Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemographic inequalities. We aimed to address this knowledge gap. In this cross-sectional analysis, we pooled individual-level data for non-pregnant adults aged 18 years or older from nationally representative surveys done between Jan 1, 2010, and Dec 31, 2019 in LMICs that included a question about whether respondents had ever had their blood pressure, glucose, or cholesterol measured. We analysed diagnostic testing performance by quantifying the overall proportion of people who had ever been tested for these cardiovascular risk factors and the proportion of individuals who met the diagnostic testing criteria in the WHO package of essential noncommunicable disease interventions for primary care (PEN) guidelines (ie, a BMI >30 kg/m2 or a BMI >25 kg/m2 among people aged 40 years or older). We disaggregated and compared diagnostic testing performance by sex, wealth quintile, and education using two-sided t tests and multivariable logistic regression models. Our sample included data for 994 185 people from 57 surveys. 19·1% (95% CI 18·5-19·8) of the 943 259 people in the hypertension sample met the WHO PEN criteria for diagnostic testing, of whom 78·6% (77·8-79·2) were tested. 23·8% (23·4-24·3) of the 225 707 people in the diabetes sample met the WHO PEN criteria for diagnostic testing, of whom 44·9% (43·7-46·2) were tested. Finally, 27·4% (26·3-28·6) of the 250 573 people in the hypercholesterolaemia sample met the WHO PEN criteria for diagnostic testing, of whom 39·7% (37·1-2·4) were tested. Women were more likely than men to be tested for hypertension and diabetes, and people in higher wealth quintiles compared with those in the lowest wealth quintile were more likely to be tested for all three risk factors, as were people with at least secondary education compared with those with less than primary education. Our study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested. Harvard McLennan Family Fund, the Alexander von Humboldt Foundation, and the National Heart, Lung, and Blood Institute of the US National Institutes of Health.

Perceptions of women enrolled in a cardiovascular disease screening and prevention in HIV study.

The ISCHeMiA (integration of cardiovascular disease screening and prevention in the human immunodeficiency virus [HIV] management plan for women of reproductive age) study is an ongoing, 3-year, prospective, quasi-experimental study comparing usual care to a primary health care intervention plan guided by the World Health Organization Package of Essential Non-Communicable (WHO-PEN) disease interventions. Sixty eight percent of women were overweight or obese at baseline in the ISCHeMiA study, many of whom reported nonadherence to interventions at 6 months post enrolment. This study explores the perceptions of women living with HIV (WHIV) towards their participation in the ISCHeMiA study to understand the barriers and facilitators to lifestyle modification interventions for cardiovascular disease (CVD) risk prevention. A qualitative enquiry using semistructured interviews was conducted with 30 overweight WHIV at one year post-enrolment in the WHO-PEN intervention arm of the ISCHeMiA study. Data were transcribed verbatim following the interviews and analysed using conventional content analysis. Four major themes emerged from the data, namely perceived body image, benefits barriers and recommendations to improve adherence to WHO-PEN lifestyle modification management. Women in the ISCHeMiA study believed that HIV associated stigma hindered access to care. Financial limitations and the lack of social support posed barriers to adherence to programme participation. They were further challenged by poor body image perception. Participants believed that such interventions offered them hope and feelings of improved well-being. Women recommended that lifestyle modification interventions such as those studied in the ISCHeMiA study should include partners and family to improve adherence through social support.

A cost-effectiveness analysis of risk-based intervention for prevention of cardiovascular diseases in IraPEN program: A modeling study.

IraPEN, a program developed in Iran based on the World Health Organization (WHO) package of essential noncommunicable (PEN) disease interventions for primary healthcare, was launched in 2015. Preventive interventions for cardiovascular diseases (CVDs) are based on the level of risk calculated using the WHO CVD risk chart. The main objective of this study was to measure the potential cost-effectiveness (CE) of IraPEN preventive actions for CVD in comparison with the status quo. A CE analysis from a healthcare perspective was conducted. Markov models were employed for individuals with and without diabetes separately. Based on the WHO CVD risk chart, four index cohorts were constructed as low (<10%), moderate (10%-19%), high (20%-29%), and very high risk (≥30%). Life years (LY) gained and quality-adjusted life years (QALY) were used as the outcome measures. The intervention yields an incremental cost-effectiveness ratio (ICER) of $804, $551, and -$44 per QALY for moderate, high, and very high CVD risk in groups without diabetes, respectively. These groups gained 0.69, 0.96, and 1.45 LY, respectively, from the intervention. The results demonstrated an ICER of $711, $630, -$42, and -$71 for low, moderate, high, and very high-risk groups with diabetes, respectively, while they gained 0.46, 1.2, 2.04, and 2.29 years from the intervention. The IraPEN program was highly cost-effective for all CVD risk groups in the individuals without diabetes except the low-risk group. The intervention was cost-effective for all patients with diabetes regardless of their CVD risk. The results demonstrated that the IraPEN program can likely provide substantial health benefits to Iranian individuals and cost savings to the national healthcare provider.

Preparedness of primary health care facilities on implementation of essential non-communicable disease interventions in Osun State South-West Nigeria: a rural–urban comparative study

BackgroundGlobal response to the growing burden of non-communicable diseases (NCDs) in developing countries includes the development of WHO Package of Essential Non-communicable Disease Interventions (WHO PEN) for Primary Health Care (PHC). The study assessed the level of preparedness of PHC facilities on implementation of essential NCD interventions in rural and urban Local Government Areas (LGAs) of Osun State, Nigeria.MethodsThe study was a comparative cross-sectional survey. Information was collected from heads of 33 rural and 33 urban PHC facilities and through direct observation on the domains of staff training, basic equipment, diagnostics and essential medicines for cardiovascular diseases, diabetes and chronic respiratory diseases (CRDs) using a semi-structured interviewer administered questionnaire.ResultsManual sphygmomanometer was found in similar proportions (84.8%) of PHC facilities in rural and urban LGAs. Glucometer was available in 45.5% of the PHC facilities in urban and 33.3% of the PHC facilities in the rural LGAs, the difference was not statistically significant (χ2 = 1.015; p = 0.314). Basic equipment for CRDs were not available in majority of PHC facilities in both locations. Moduretic tablets were the most reported essential NCD medicines, available in 15% of PHC facilities in rural LGAs and none in urban LGAs. The anti-diabetic medicines were not available in any of the PHC facilities in both locations. More than 90% (≥ 30) of the PHC facilities in both locations were not prepared to implement essential interventions for each NCD across domains of staff training and essential medicines. Overall, 97.0% of the PHC facilities in the rural LGAs and all the PHC facilities in urban LGAs were not prepared on implementation of essential interventions for the three NCDs.ConclusionThe level of preparedness of the PHC facilities on implementation of essential NCD interventions in the rural and urban LGAs of Osun State is very low. Government needs to strengthen the PHC system by providing needed essential medicines, basic diagnostics, equipment, and training of clinical health care workers for implementation of essential NCD interventions in the state.

The incremental cost of implementing the world health organization Package of essential non-communicable (PEN) diseases interventions in Iran.

World-Health-Organization's PEN package proposes a minimum set of cost-effective interventions for early diagnosis and management of Non-Communicable-Disease (NCD). IraPEN (the PEN package implemented in Iran), adopted from PEN and Iran National Action Plans for NCDs, addresses challenges regarding NCD prevention and control. IraPEN was piloted in four districts of Iran. In this research, we estimate incremental per-capita cost of IraPEN program implementation in two of the pilot districts. We utilized a bottom-up, ingredient-based costing approach. Institutional expenditure data was collected via information forms. Information pertaining to personnel costs was gathered by performing task time measurements using Direct Observation Method. An individual-level survey was conducted in under-study districts to determine program coverage and its users' demographic information via systematic random cluster sampling. Sampling of districts was based on systematic random cluster sampling. In each district, 250 families in 25 clusters proportional to urban or rural populations were randomly selected by postal codes. All family members eligible for the program were interviewed. Interviews were organized and conducted in each district by NCD experts in provincial Universities of Medical Sciences. Costs were re-categorized into fixed and variable costs based on their dependency on the program's coverage. Fixed and variable costs were, respectively, divided by total eligible populations and covered populations in each district to calculate cost per-capita for each protocol. Total per-capita cost per-service was then calculated for each protocol and whole program by adding these figures. All costs are reported in US$ 2015-2016. The incremental costs of IraPEN implementation per user, with and without introduction cost, were US$24.90 and US$25.32, respectively. Total incremental cost per-capita for each protocol ranged between US$1.05 to US$7.45. The human resources and supplies had the highest contribution in total program cost (74.97% and 15.76%, respectively). The present study shows that IraPEN program implementation to be a high-cost package within Iranian context, that necessitates cautions in other similar contexts for implementation. It is, however, difficult to make decisions on implementation of NCD prevention and control programs purely based on their cost. Informed decision making requires assessment of a programs' effectiveness and justifications and alterations to the current package could reduce the costs, leading to increased efficiency of the program.

Management of diabetes patients with comorbidity in primary care: a mixed-method study in Odisha, India.

Diabetes patients with comorbidities need regular and comprehensive care for their disease management. Hence, it is essential to assess the primary care preparedness for managing diabetes patients and the perspectives of the diabetes patients on the care received at the primary care facilities. All 21 Urban Primary Health Centres (UPHCs) in Bhubaneswar city of Odisha, India, were assessed using the modified Primary Care Evaluation Tool and WHO Package of Essential Non-communicable disease interventions questionnaire. Additionally, 21 diabetes patients with comorbidities were interviewed in-depth to explore their perception of the care received at the primary care facilities. All the UPHCs had provisions to meet the basic requirements for the management of diabetes and common comorbidities like hypertension. There were few provisions for chronic kidney illness, cardiovascular disease, mental health, and cancer. Diabetes patients felt that frequent change in primary care physicians at the primary care facilities affected their continuity of care. Easy accessibility, availability of free medicines, and provisions of basic laboratory tests at the facilities were felt to be necessary by the diabetes patients. Our study highlights the existing gaps in India's healthcare system preparedness and the needs of diabetes patients with comorbidity. The government of India's Health and Wellness (HWC) scheme aims to deliver comprehensive healthcare to the population and provide holistic care at the primary care level for NCD patients. It is imperative that there is an early implementation of the various components of the HWC scheme to provide optimal care to diabetes patients.

PS-P13-7: O.N.E. (ONWARD NONCOMMUNICABLE DISEASE EDUCATION) CAVITE INITIATIVE: A COLLABORATIVE PROJECT TO IMPLEMENT PHILPEN AMONG PRIVATE PRACTITIONERS

Objective: Cardiovascular diseases account for most noncommunicable disease (NCD) deaths about 17.9 million people annually. The Philippine Department of Health (DOH) began implementing the PhilPEN (Philippine Package of Essential Noncommunicable Disease interventions) nationwide in 2014. The protocol screens adult Filipinos seen in the public health facilities for major cardiovascular disease risk factors and includes interventions such as lifestyle advice and medications to achieve target goals. ONE Cavite Project is a collaboration between DOH, the Philippine Society of Hypertension (PSH), and private practitioners in Cavite- a densely populated semi-urbanized province in the Philippines. The primary objective of the One Cavite Project is to engage private medical practitioners in Cavite in screening, diagnosing, and managing adult patients (20 years old and above) for the following significant cardiovascular risk (CV) factors: hypertension, type 2 diabetes mellitus, dyslipidemia, smoking and to complement the PhilPEN implementation by the DOH in all its public health facilities in Cavite by private general physicians. Design and Methods: The first phase of the project is to organize a series of seminars to gather, enroll, and engage private doctors to ensure proper screening, monitoring, and follow up of patients with hypertension, diabetes, dyslipidemia, and other CV risk factors. The second phase is to enroll the patients of these private doctors, where patient data was collected, collated, and submitted to PSH for descriptive analysis by a third party. Results: A total of 680 doctors were engaged with a total of 41,477 patients screened. Preliminary data showed that out of the 41,477 patients, 61% have hypertension, 17% have diabetes, 22% have dyslipidemia, and 16% are smokers. Moreover, 21% have both hypertension and diabetes, 19% have hypertension and dyslipidemia, while 7% have hypertension, diabetes, and dyslipidemia. On follow-up after six months, out of 18,348 patients with hypertension, 88% of patients with hypertension had their blood pressure under control. For the 5,024 patients with diabetes, 15% had a fasting blood sugar &lt; 110 mg/dL, and 32% had an HBA1c&lt; 6.5 mg/dl. Out of 7,146 patients with dyslipidemia, 14% had an LDL &lt; 130 mg/dl, while for the 3,510 smokers, 56% quit smoking on follow-up. Conclusion: The One Cavite Project has shown that engagement of private medical practitioners in screening, diagnosing, and managing adult patients for significant cardiovascular risk (CV) factors have complemented the implementation of PhilPEN by the DOH and this led to active prevention and control of these risk factors.

Early impact of the PEN HEARTS package to manage noncommunicable diseases in Bhutan: a mixed-methods evaluation

Introduction: Non-communicable diseases (NCDs) pose significant public health challenges in Bhutan. In 2019, Bhutan’s Ministry of Health introduced a set of interventions associated with the World Health Organization’s Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Income Settings called PEN HEARTS. This initiative encompassed six components: healthy lifestyle intervention, evidence-based protocols, access to medicines and technology, risk-based management, team-based care, and systems monitoring. Evaluations of PEN interventions in other countries documented barriers to implementation. The present report provides the result of a 2019–2020 evaluation assessing implementation of PEN HEARTS in Bhutan and initial impacts on provision of care for NCDs and patient outcomes. Methods: A cross-sectional, mixed-methods evaluation was conducted in six districts, two where the interventions were first initiated, two where they were implemented subsequently, and two where no implementation had begun. In each district, data were collected at the district hospital and three basic health units. Quantitative data collection encompassed facility checklists, health worker surveys, and patient record abstraction. For the survey, health workers were selected using random or convenience sampling depending on facility size. For patient record abstraction, enumerators created a sampling frame at each facility to include eligible patients who were then selected randomly for record review. Qualitative data collection included in-depth interviews (IDIs) with health workers, and IDIs with NCD patients. A convenience sample of health worker IDI participants was selected randomly at hospitals; all health workers at BHUs were invited to participate. A convenience sample of NCD patients was recruited from facility waiting rooms on the day(s) of data collection. Lastly, a convenience sample of homebound patients was recruited to participate in IDIs. Quantitative analysis methods included bivariate analysis of categorical and continuous variables, and pairwise comparisons among groups. Qualitative data were analyzed using thematic content analysis with inductive coding. Results: A total of 153 health workers participated in the knowledge survey and 121 patient records were reviewed. IDIs were conducted with 13 health workers, 18 hospital or BHU patients, and four homebound patients. Most elements of the PEN HEARTS program were implemented as planned, including monitoring and supervision. PEN HEARTS had a positive impact on disease control: group A districts had a significantly lower proportion of patients with a treatment gap (p<0.001) and a significantly higher proportion of patients retained in care (p<0.001). Health workers experienced implementation challenges in four main areas: human resources, medicine shortages, equipment failure, and record-keeping. They also described benefits from increased supervision and peer support. Patients described experiencing more patient-centered care and overall positive experiences with the program. Conclusion: The evaluation identified areas of PEN HEARTS implementation that should be strengthened and improved, particularly training, record-keeping, and the use of AUDIT and cardiovascular disease risk assessments. The evaluation also showed evidence of improved disease control across achievement of treatment goals, reduction of treatment gaps, and improved patient retention in care. PEN HEARTS has potential to make a difference for NCD patients, and focusing on improving future implementation may further yield benefits in Bhutan.

Familial hypercholesterolemia in community-based KHDC Nepal program-baseline data

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): HUG and Republic and Canton of Geneva – Service de solidarité internationaleBP Koirala Institute of Health Sciences Familial hypercholesterolemia (FH) is either underdiagnosed or diagnosed after primary coronary events. Although homozygous variant of FH is considered rare, heterozygous FH is estimated to occur in about 1 in 200 to 300 individuals. There is no study pertaining to prevalence of FH in Nepal which could be a factor influencing cardiovascular morbidity and mortality. We present a baseline data of FH in an ongoing in participants of community-based cardiovascular and kidney diseases preventive (KHDC Nepal) program in Mechinagar municipality in Eastern Nepal. KHDC is a program to collaborate among health post, primary health center or equivalent, and local government along with community representatives created to educate, screen, and intervene for selective NCDs. This program is in alignment with the World Health Organization’s Package of Essential Noncommunicable (WHO PEN) disease interventions for primary health care in low-resource settings. General health status and lifestyle habits, physical examination, and blood pressure were assessed. Blood tests done included fasting lipid profile, serum creatinine, FBS, and HbA1c. A mechanism was developed to follow-up screened positive persons in the primary health centers. Referrals were made to the tertiary care center as needed. We analyzed initial 7289 participants, 20 years or above, who were enrolled in KHDC program in the year 2020. We assessed for FH using Dutch Lipid Clinic Network(DLCN), Simon Broome and AHA criteria. Participants were categorized as definite, probable, possible, or no FH based on the scores of DLCN criteria; as definite and probable based on Simon Broome criteria and as clinically diagnosed FH based on AHA criteria. The median age of the patient was 54 years, the majority being females (62.7%). A total of 70(0.96%) of the participants had elevated LDL-C levels of more than 190mg/dl detected during the screening and had no secondary cause for hyperlipidemia. According to DLCN criteria, 65(0.89%) participants were grouped under possible FH, 5(0.06%) were grouped under probable FH while none of them could be delineated as definite FH. According to Simon Broome criteria, 14(0.2%) participants were grouped under probable and none of them could be delineated as definite. According to AHA criteria, 10 (0.13%) participants were categorized as clinically diagnosed FH. DNA analysis was not available in our setup. Clinically manifested atherosclerotic disease was recorded in 5 participants. None of the participants were aware of the FH. This community-based program of the adult population help create baseline data of FH in Nepal. Larger study with genetic analysis is likely to reveal true prevalence of FH in Nepal.

Effect of brief interventions to promote behavior change on clinical outcomes of selected non-communicable diseases: The World Health Organization (WHO) Package of Essential Non-communicable disease (PEN) Interventions for primary health care settings – study protocol of a quasi-experimental study

BackgroundThe World Health Organization designed a minimum set of interventions, the World Health Organization Package of Essential Noncommunicable disease interventions (WHO PEN), for detection, prevention, treatment, and care of Non-communicable diseases (NCDs) in resource constraint settings. This intervention study examines the effectiveness of the integration of components of WHO PEN protocols on improved clinical outcomes among patients of cardiovascular disease and diabetes mellitus in urban and rural primary health care settings. MethodsIn this quasi-experimental study (pre-test post-test control group design), trained non-physician health workers will provide behavior change interventions regarding four major NCD risk factors, i.e., tobacco use, excessive alcohol intake, physical inactivity, an unhealthy diet; using ‘Brief Advice’ to the NCD patients enrolled in the experimental arm. The health centers in the control arm will provide the usual care to all the NCD patients. The intervention will last for six months, and the two groups will be followed up at two months, four months, and six months since enrolment in the study. ResultsThe primary outcome is improved mean blood pressure levels and the proportion of patients with controlled blood pressure levels. The secondary outcomes assess medication adherence, self-reported reductions in tobacco and alcohol intake, consumption of a heart-healthy diet, and regular physical activity. DiscussionThis intervention trial will provide evidence for the utility of individual-level behavioral interventions for adequate management of NCDs.Trial registration: Clinical Trial Registry of India: CTRI/2018/12/016707.

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

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. 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. 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. 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.