Dan Schwarz1,2,3,4,5, Santosh Dhungana6, Anirudh Kumar7, Bibhav Acharya8,9, Pawan Agrawal8, Anu Aryal8,10, Aaron Baum11, Nandini Choudhury8,11, David Citrin8,11,12,13,14, Binod Dangal8, Meghnath Dhimal15, Bikash Gauchan8, Tula Gupta8,16, Scott Halliday8,11,12, Biraj Karmacharya10,17,18, Sandeep Kishore11,19,20, Bhagawan Koirala21, Uday Kshatriya8, Erica Levine11,19, Sheela Maru8,11,19,22,23, Pragya Rimal8, Sabitri Sapkota8,11, Ryan Schwarz8,24,25,23, Archana Shrestha10,26,27, Aradhana Thapa8, Duncan Maru8,9,11,28,29. 1. Nyaya Health Nepal, Kathmandu, Nepal. daschwarz@gmail.com. 2. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA. daschwarz@gmail.com. 3. Department of Medicine, Harvard Medical School, Boston, MA, USA. daschwarz@gmail.com. 4. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA. daschwarz@gmail.com. 5. Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Boston, MA, USA. daschwarz@gmail.com. 6. Department of Internal Medicine, Hurley Medical Center, Flint, MI, USA. 7. Department of Medicine, NYU Langone Health, New York, NY, USA. 8. Nyaya Health Nepal, Kathmandu, Nepal. 9. Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA. 10. School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal. 11. Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 12. Department of Global Health, University of Washington, Seattle, WA, USA. 13. Department of Anthropology, University of Washington, Seattle, WA, USA. 14. Henry M. Jackson School of International Studies, University of Washington, Seattle, WA, USA. 15. Nepal Health Research Council, Ministry of Health and Population, Kathmandu, Nepal. 16. Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA, USA. 17. Nepal Technology Innovation Center, Kathmandu University, Dhulikhel, Nepal. 18. Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China. 19. Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 20. Young Professionals Chronic Disease Network, New York, NY, USA. 21. Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. 22. Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 23. Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. 24. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA. 25. Department of Medicine, Harvard Medical School, Boston, MA, USA. 26. Yale School of Public Health, Center for Methods in Implementation and Prevention Science, New Haven, CT, USA. 27. Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA. 28. Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 29. Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Abstract
BACKGROUND: In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. METHODS: A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. DISCUSSION: This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.
BACKGROUND: In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. METHODS: A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. DISCUSSION: This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.
Entities:
Keywords:
Chronic illness; Community health workers; Decision support systems; Motivational interviewing; Nepal; Noncommunicable diseases; Rural health
Authors: Bhim Prasad Sapkota; Kedar Prasad Baral; Ursula Berger; Klaus G Parhofer; Eva A Rehfuess Journal: PLoS One Date: 2022-09-30 Impact factor: 3.752