A critical review of addressing cardiovascular and other non-communicable diseases through a primary health care approach in the South-East Asia Region

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.

Exploring Therapeutic Potential of Pleurotus ostreatus and Agaricus bisporus Mushrooms against Hyperlipidemia and Oxidative Stress Using Animal Model

The mushrooms oyster (Pleurotus ostreatus) and white button (Agaricus bisporus) contain bioactive compounds that have potential beneficial effects on hypercholesterolemia and cardiovascular diseases. In this study, hypolipidemic and antioxidative potential of these mushrooms' extract were explored using hypercholesterolemic (HC) rats as animal model. For the study, 56 adult rats were divided into seven groups, i.e., G1 (negative control), G2 (positive control group), G3 (HC rats with statin drug orally), G4 and G5 (HC rats @ 100 and 200 mg/kg body weight (BW) dose of oyster mushroom extracts), and G6 and G7 (HC rats @ 100 and 200 mg/kg BW dose of white button mushroom extracts). The hypercholesterolemia was induced experimentally in fasted rats through a high-fat diet along with injection of triton WR-1339. After 48 h, the treatment groups were given extract for 28 days along with standard diet. At the trial termination, we analyzed the blood sugar levels, antioxidant parameters, lipid profile, and renal function, as well as conducting liver function tests of the rats. The results indicated that positive control group rats exhibited increased levels of total cholesterol (TC), triglycerides (TG), low-density level (LDL), and very-low-density level (vLDL) by 19%, 37%, 52%, and 32%, respectively, and 53% decrease in HDL, whereas treatment groups that received 200 mg oyster and white button mushroom extracts reported 15%, 34%, 22% reduction in TC, TG, vLDL, respectively, and 22% improvement in HDL level. The enzyme profiles of different groups showed non-significant differences, although both mushroom extracts provision reduced glutamic oxaloacetic transaminase (GOT) and glutamic pyruvic transaminase (GPT) levels. Overall, the results indicated that mushroom extracts were helpful in maintaining oxidative stress and have the potential to improve dyslipidemia in the tested rat animal model.

Cascade of diabetes care in Bangladesh, Bhutan and Nepal: identifying gaps in the screening, diagnosis, treatment and control continuum

Diabetes has become a major cause of morbidity and mortality in South Asia. Using the data from the three STEPwise approach to Surveillance (STEPS) surveys conducted in Bangladesh, Bhutan, and Nepal during 2018-2019, this study tried to quantify the gaps in diabetes screening, awareness, treatment, and control in these three South Asian countries. Diabetes care cascade was constructed by decomposing the population with diabetes (diabetes prevalence) in each country into five mutually exclusive and exhaustive categories: (1) unscreened and undiagnosed, (2) screened but undiagnosed, (3) diagnosed but untreated, (4) treated but uncontrolled, (5) treated and controlled. In Bangladesh, Bhutan, and Nepal, among the participants with diabetes, 14.7%, 35.7%, and 4.9% of the participants were treated and controlled, suggesting that 85.3%, 64.3%, and 95.1% of the diabetic population had unmet need for care, respectively. Multivariable logistic regression models were used to explore factors associated with awareness of the diabetes diagnosis. Common influencing factors for awareness of the diabetes diagnosis for Bangladesh and Nepal were living in urban areas [Bangladesh-adjusted odd ratio (AOR):2.1; confidence interval (CI):1.2, 3.6, Nepal-AOR:6.2; CI:1.9, 19.9].

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.

Perceived Loneliness, Peer, and Parental Relationship With Smoking: A Cross-Sectional Analysis of Adolescents Across South-East Asia

Tobacco use among youth in the South-East Asian region is quite prevalent. This study aims to examine if psychosocial factors (perceived loneliness, peer, and parental relationships) were associated with adolescent smoking, and whether the effects were different according to sex and age. Data came from the Global School-based Student Health Surveys collected between 2012 and 2015 in Brunei, Cambodia, Indonesia, Laos, Malaysia, Philippines, Thailand, Timor-Leste, and Vietnam. 64 578 (males = 48.5%) adolescents aged 13-18 completed the survey. Prevalence of past-month cigarette use was 10.6%. Adolescent smoking was associated with loneliness (OR = 1.75), lack of close friends (OR = 1.43), and lack of parental understanding (OR = 1.35). There was significant interactions between sex with loneliness, close friends, and parental understanding (p < .001). Interactions indicated having no close friends is associated with smoking and is stronger for females than males. Conversely, loneliness was associated with smoking more strongly in males than females. Results indicate that psychosocial factors are linked to adolescent smoking in South-East Asia, suggesting a further need for research on the relation of psychosocial factors with smoking, and their underlying factors.

Health sector readiness for the prevention and control of non-communicable diseases: A multi-method qualitative assessment in Nepal

In Nepal, deaths attributable to NCDs have increased in recent years. Although NCDs constitute a major public health problem, how best to address this has not received much attention. The objective of this study was to assess the readiness of the Nepalese health sector for the prevention and control of NCDs and their risk factors. The study followed a multi-method qualitative approach, using a review of policy documents, focus group discussions (FGDs), and in-depth interviews (IDIs) conducted between August and December 2020. The policy review was performed across four policy categories. FGDs were undertaken with different cadres of health workers and IDIs with policy makers, program managers and service providers. We performed content analysis using the WHO health system building blocks framework as the main categories. Policy documents were concerned with the growing NCD burden, but neglect the control of risk factors. FGDs and IDIs reveal significant perceived weaknesses in each of the six building blocks. According to study participants, existing services were focused on curative rather than preventive interventions. Poor retention of all health workers in rural locations, and of skilled health workers in urban locations led to the health workers across all levels being overburdened. Inadequate quantity and quality of health commodities for NCDs emerged as an important logistics issue. Monitoring and reporting for NCDs and their risk factors was found to be largely absent. Program decisions regarding NCDs did not use the available evidence. The limited budget dedicated to NCDs is being allocated to curative services. The engagement of non-health sectors with the prevention and control of NCDs remained largely neglected. There is a need to redirect health sector priorities towards NCD risk factors, notably to promote healthy diets and physical activity and to limit tobacco and alcohol consumption, at policy as well as community levels.

The readiness of public primary health care (PUSKESMAS) for cardiovascular services in Makasar city, Indonesia

BACKGROUNDS

The increasing burden of cardiovascular disease (CVD) has become a major challenge globally, including in Indonesia. Understanding the readiness of primary health care facilities is necessary to confront the challenge of providing access to quality CVD health care services. Our study aimed to provide information regarding readiness to deliver CVD health services in public primary health care namely Puskesmas.

METHODS

The study questionnaire was adapted from the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA), modified based on the package of essentials for non-communicable disease (PEN) and the Indonesian Ministry of health regulation. Data were collected from all Puskesmas facilities (N = 47) located in Makassar city. We analysed relevant data following the WHO-SARA manual to assess the readiness of Puskesmas to deliver CVD services. Human resources, diagnostic capacity, supporting equipment, essential medication, infrastructure and guidelines, and ambulatory services domain were assessed based on the availability of each tracer item in a particular domain. The mean domain score was calculated based on the availability of tracer items within each domain. Furthermore, the means of all domains' scores are expressed as an overall readiness index. Higher scores indicate greater readiness of Puskesmas to deliver CVD-related health care.

RESULTS

Puskesmas delivers health promotion, disease prevention, and prompt diagnosis for cardiovascular-related diseases, including hypertension, diabetes, coronary heart disease (CHD), and stroke. Meanwhile, basic treatments were observed in the majority of the Puskesmas. Long-term care for hypertension and diabetes patients and rehabilitation for CHD and stroke were only observed in a few Puskesmas. The readiness score of Puskesmas to deliver CVD health care ranged from 60 to 86 for. Furthermore, there were 11 Puskesmas (23.4%) with a score below 75, indicating a sub-optimal readiness for delivering CVD health services. A shortage of essential medicines and a low capacity for diagnostic testing were the most noticeable shortcomings leading to suboptimal readiness for high-quality CVD health services.

CONCLUSION

Close cooperation with the government and other related stakeholders is required to tackle the identified shortcomings, especially the continuous monitoring of adequate supplies of medicines and diagnostic tools to achieve better CVD care for patients in Indonesia.

Strengthening urban primary healthcare service delivery using electronic health technologies: A qualitative study in urban Nepal

Background

Nepal is a South Asian country with a high burden of non-communicable diseases. Electronic health technologies are a promising strategy to mitigate the rising burden of non-communicable diseases by strengthening primary healthcare center service delivery. However, electronic health implementation in Nepal is limited. Furthermore, electronic health use at the primary healthcare center level is chronically understudied. This qualitative study seeks to understand the perceived awareness, benefits, and determinants of electronic health uptake in Nepal, focusing on primary healthcare center-level non-communicable disease management.

Methods

We conducted in-depth interviews with 27 participants including policymakers, health experts, facility administrators, providers, and non-communicable diseases patients in 2019. We selected six urban primary healthcare center facilities via cluster convenience sampling for recruiting facility administrators, providers, and patients, and used convenience sampling to recruit policymakers and experts. We conducted thematic data analysis inductively and deductively using the electronic health readiness assessment framework to understand perceived barriers and facilitators of electronic health implementation.

Results

While there was general awareness and acceptance of electronic health, multiple barriers impede readiness for implementation. These include policy making gaps, language barriers, low user technical literacy, concerns of overreliance on technology, and inadequate training for administrators and providers. Stakeholder suggestions include creating electronic health interfaces that meet the needs of end users (providers and patients), providing training to enable end users to effectively use electronic health technologies, and strong policy support at the national level.

Conclusion

We identify several determinants for effectively promoting the use of electronic health for non-communicable diseases service delivery at the primary healthcare center level in Nepal.

The organisation of primary health care service delivery for non-communicable diseases in Nigeria: A case-study analysis

As chronic diseases, non-communicable diseases (NCDs) require sustained person-centred and community-based care. Given its direct link to communities and households, Primary Health Care (PHC) is well positioned to achieve such care. In Nigeria, the national government has prioritized PHC system strengthening as a means of achieving national NCD targets. However, strengthening PHC systems for NCDs require re-organization of PHC service delivery, based on contextual understanding of existing facilitators and barriers to PHC service delivery for NCDs. We conducted a mixed method case study to explore NCD service delivery with 13 PHC facilities serving as the cases of interest. The study was conducted in two northern and two southern states in Nigeria-and included qualitative interviews with 25 participants, 13 focus group discussion among 107 participants and direct observation at the 13 PHCs. We found that interprofessional role conflict among healthcare workers, perverse incentives to sustain the functioning of PHC facilities in the face of government under-investment, and the perception of PHC as an inferior health system were major barriers to improved organisation of NCD management. Conversely, the presence of physicians at PHC facilities and involvement of civil society organizations in aiding community linkage were key enablers. These marked differences in performance and capacity between PHC facilities in northern compared to southern states, with those in the south better organised to deliver NCD services. PHC reforms that are tailored to the socio-political and economic variations across Nigeria are needed to improve capacity to address NCDs.

Healthcare providers' perspectives on integrating NCDs into primary healthcare in Thailand: a mixed method study

BACKGROUND

In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand's PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement.

METHODS

This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews.

RESULTS

Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs.

CONCLUSION

PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.

Perception and Use of Primary Healthcare Services Among People With Cardiometabolic Diseases in Two Resource-Limited Areas in Nepal: A Mixed Methods Study

Nepal is a country in south Asia with a high burden of cardiometabolic diseases (CMDs). Strengthening primary healthcare (PHC) is a key strategy to mitigate this increasing burden and achieve universal health coverage. While previous studies in Nepal have assessed PHC use among the elderly, none have specifically explored PHC use among people with CMDs. Therefore, this mixed-methods study aimed to assess the use and perception of PHC services in Nepal among people living with CMDs for primary and secondary prevention of cardiovascular disease. We used a quantitative survey followed-up by semi-structured qualitative interviews. The sampling frame comprised five PHC facilities in Sindhuli district (rural; eastern Nepal) and five in Kailali district (urban; western Nepal), with participants selected from each facility via convenience sampling. 114 people (mean age: 54.5 ± 14.7, sex ratio 1.04) with CMDs participated in the survey. Survey data showed general dissatisfaction with PHC services. Medicine cost was rated "too expensive" by 52 and 63% of rural and urban participants, respectively. Interview data showed that perceived poor bedside manner was tied to negative perceptions of PHC quality, and vice versa. Lack of resources and excessive barriers to care was mentioned by every interviewee. In conclusion, PHC use was high but overall satisfaction relatively low. Our results suggest that bedside manner is a practical target for future research. Additionally, we identified several barriers to care, and, based on existing literature, we suggest electronic-health interventions may have potential to mitigate these challenges.

Access to Non-Communicable Disease (NCD) Services Among Urban Refugees and Asylum Seekers, Relative to the Thai Population, 2019: A Case Study in Bangkok, Thailand

Background

The health of urban refugees and asylum seekers (URAS) in Thailand has been under-researched compared with other groups of non-Thai populations, especially in the area of chronic non-communicable diseases (NCD). The objectives of this study were to i) examine NCD prevalence; ii) access to NCD services; and iii) factors associated with access to NCD services among urban refugees and asylum seekers (URAS) in comparison with the Thai population.

Methods

A cross-sectional study, using a self-administrative questionnaire adapted from the Thai Health and Welfare Survey (HWS), was conducted in 2019. URAS were randomly selected from the register of the Bangkok Refugee Center. One hundred and eighty-one URAS participated in the survey. The data were combined with 2941 Thai records from the HWS. The population scope was confined to Bangkok. Bivariate analysis by Chi-square, Fisher's exact, and Mann-Whitney U-tests was conducted to examine difference in demographic and access to NCD services between URAS and Thais. Multivariable logistic regression was performed to identify factors associated with access to NCD services.

Results

Overall, URAS were young, less educated, and poorer than Thais. The trend of NCDs was similar to the Thai population, except mental health disorders appeared to be more prevalent in URAS. Almost half of the URAS did not receive any formal treatment. Being insured, abiding with Buddhism, and living in more affluent households were factors associated with better access to NCD services. URAS from Asian countries had greater access to NCD care than those from non-Asian countries.

Conclusion

Policymakers should consider expanding the insurance coverage to URAS, similar to coverage for Thai populations. Additional studies on refugees' health status and service utilization in other settings outside Bangkok are strongly recommended.

Moving Towards Optimized Noncommunicable Disease Management in the ASEAN Region: Recommendations from a Review and Multidisciplinary Expert Panel

Introduction

Noncommunicable diseases (NCDs) are the leading cause of morbidity and mortality in the Association of Southeast Asian Nations (ASEAN) member states. Progress has been slow despite the World Health Organization action plan for the prevention and control of NCDs in the region. This paper presents recommendations focused on practical strategies for optimizing NCD management in the ASEAN region.

Methods

A multidisciplinary group of experts from six ASEAN member states convened for two face-to-face meetings to discuss barriers and possible recommendations for optimizing NCD management, focused on cardiovascular diseases and mental disorders, in the region. Multiple approaches, ie, analysis of insights from the meetings and a review of existing literature on NCD programs in the ASEAN region were followed. The proposed recommendations were also based on selected successful interventions in ASEAN member states, thus providing actionable strategies.

Results

The gaps identified in NCD management for cardiovascular diseases and mental disorders in the ASEAN region were classified into gaps relating to policies and to clinical and public health practice. The proposed solutions addressing policy gaps include fostering multisectoral public–private partnerships, employing “whole-of-government” and “whole-of-society” approaches and promoting “health-in-all policies approach” to manage issues with financing, accessibility, efficiency and quality of health services. Whereas proposed solutions to bridge clinical and public health practice gaps entail strengthening primary care services, building the capacity of trained healthcare workers and employing collaborative care for holistic management of patients.

Conclusion

The scale of premature and preventable deaths from NCDs in the ASEAN region remains a serious public health concern and requires a “whole-of-system approach”. The interventions proposed in this paper build on regional collaborations and knowledge sharing to help develop a concerted and targeted response to NCDs.

Fixed dose drug combinations - are they pharmacoeconomically sound? Findings and implications especially for lower- and middle-income countries

Introduction: There are positive aspects regarding the prescribing of fixed dose combinations (FDCs) versus prescribing the medicines separately. However, these have to be balanced against concerns including increased costs and their irrationality in some cases. Consequently, there is a need to review their value among lower- and middle-income countries (LMICs) which have the greatest prevalence of both infectious and noninfectious diseases and issues of affordability.Areas covered: Review of potential advantages, disadvantages, cost-effectiveness, and availability of FDCs in high priority disease areas in LMICs and possible initiatives to enhance the prescribing of valued FDCs and limit their use where there are concerns with their value.Expert commentary: FDCs are valued across LMICs. Advantages include potentially improved response rates, reduced adverse reactions, increased adherence rates, and reduced costs. Concerns include increased chances of drug:drug interactions, reduced effectiveness, potential for imprecise diagnoses and higher unjustified prices. Overall certain FDCs including those for malaria, tuberculosis, and hypertension are valued and listed in the country's essential medicine lists, with initiatives needed to enhance their prescribing where currently low prescribing rates. Proposed initiatives include robust clinical and economic data to address the current paucity of pharmacoeconomic data. Irrational FDCs persists in some countries which are being addressed.

Feasibility assessment of invigorating grassrooTs primary healthcare for prevention and management of cardiometabolic diseases in resource-limited settings in China, Kenya, Nepal, Vietnam (the FAITH study): rationale and design

Background

Cardiometabolic diseases are the leading cause of death and disability in many low- and middle-income countries. As the already severe burden from these conditions continues to increase in low- and middle-income countries, cardiometabolic diseases introduce new and salient public health challenges to primary health care systems. In this mixed-method study, we aim to assess the capacity of grassroots primary health care facilities to deliver essential services for the prevention and control of cardiometabolic diseases. Built on this information, our goal is to propose evidence-based recommendations to promote a stronger primary health care system in resource-limited settings.

Methods

The study will be conducted in resource-limited settings in China, Kenya, Nepal, and Vietnam using a mixed-method approach that incorporates a literature review, surveys, and in-depth interviews. The literature, statistics, and document review will extract secondary data on the burden of cardiometabolic diseases in each country, the existing policies and interventions related to strengthening primary health care services, and improving care related to non-communicable disease prevention and control. We will also conduct primary data collection. In each country, ten grassroots primary health care facilities across representative urban-rural regions will be selected. Health care professionals and patients recruited from these facilities will be invited to participate in the facility assessment questionnaire and patients’ survey. Stakeholders – including patients, health care professionals, policymakers at the local, regional, and national levels, and local authorities – will be invited to participate in in-depth interviews. A standard protocol will be designed to allow for adaption and localization in data collection instruments and procedures within each country.

Discussion

With a special focus on the capacity of primary health care facilities in resource-limited settings in low- and middle-income countries, this study has the potential to add new evidence for policymakers and academia by identifying the most common and significant barriers primary health care services face in managing and preventing cardiometabolic diseases. With these findings, we will generate evidence-based recommendations on potential strategies that are feasible for resource-limited settings in combating the increasing challenges of cardiometabolic diseases.