Integrating maternal, newborn, child health and non-communicable disease care in the sustainable development goal era.

Noncommunicable diseases (NCDs) and maternal newborn and child health (MNCH) are two deeply intertwined health areas that have been artificially separated by global health policies, resource allocations and programming. Optimal MNCH care can provide a unique opportunity to screen for, prevent and manage early signs of NCDs developing in both the woman and the neonate. This paper considers how NCDs, NCD modifiable risk factors, and NCD metabolic risk factors impact MNCH. We argue that integrated management is essential, but this faces challenges that manifest across all levels of domestic health systems. Progress toward Sustainable Development targets requires joined-up action.

National electronic primary health care database in monitoring performance of primary care in Kyrgyzstan.

AIM: The aim of this study was to assess the feasibility of the national electronic primary health care (PHC) database in Kyrgyzstan in producing information on the disease burden of the patient population and on the processes and quality of care of noncommunicable diseases (NCDs) in PHC. BACKGROUND: Strengthening of the PHC is essential for low- and middle-income countries (LMICs) to tackle the increasing burden of NCDs. Capacity building and quality improvement require timely data on processes and quality of care. METHODS: A data extraction was carried out covering four PHC clinics in Bishkek in 2019 to pilot the use of the national data for quality assessment purposes. The data included patient-level information on all appointments in the clinics during the year 2018 and consisted of data of altogether 48 564 patients. Evaluation indicators of the WHO Package of Essential NCD Interventions framework were used to assess the process and outcome indicators of patients with hypertension or diabetes. FINDINGS: The extracted data enabled the identification of different patient populations and analyses of various process and outcome indicators. The legibility of data was good and the structured database enabled easy data extraction and variable formation on patient level. As an example of process and outcome indicators of those with hypertension, the blood pressure was measured at least on two occasions of 90% of women and 89% of men, and blood pressure control was achieved among 61% of women and 53% of men with hypertension. This study showed that a rather basic system gathering nationally patient-level data to an electronic database can serve as an excellent information source for national authorities. Investments should be made to develop electronic health records and national databases also in LMICs.

Evaluation and pilot implementation of essential interventions for the management of hypertension and prevention of cardiovascular diseases in primary health care in the Republic of Tajikistan.

BACKGROUND: The aim of this study was to determine the feasibility of implementing and evaluating essential interventions for the management of hypertension and prevention of cardiovascular disease in primary healthcare in Tajikistan. METHODS: The study protocol was published a priori. A pragmatic, sequential, mixed methods explanatory design was piloted. The quantitative strand is reported here. All primary health care facilities that met inclusion criteria in Shahrinav district were included and computer randomized to either usual care or intervention. The intervention consisted of: adaptation of WHO PEN/HEARTS clinical algorithms for hypertension and diabetes, a two-day training of doctors and nurses, supportive supervision visits, clinical decision support tools, and quality improvement support. Data were collected from paper-based clinical records at baseline and 12 months follow-up. The primary outcome was blood pressure control among patients with hypertension, in addition to several secondary process indicators along the care pathway. Age and sex adjusted logistic regression models were used for intervention and control clinics to determine changes between baseline and follow-up and to assess interactions between allocation group and time. For continuous variables, multivariate linear regression models were used. RESULTS: 19 primary health care centres were included of which ten were randomized to intervention and nine to control. 120 clinicians received training. The records of all registered hypertensive patients were reviewed at baseline and follow-up for a total of 1,085 patient records. Blood pressure control significantly improved in the intervention clinics (OR 3.556, 95 % CI 2.219, 5.696) but not the control clinics (OR 0.644, 95 % CI 0.370, 1.121) (p < 0.001 for interaction). Smoking assessment, statin prescribing, triple therapy prescribing, and blood pressure measurement significantly improved in intervention clinics relative to control, whereas cholesterol and glucose testing, and aspirin prescribing did not. CONCLUSIONS: It is feasible to use routine, paper-based, clinical records to evaluate essential CVD interventions in primary health care in Tajikistan. Adapted WHO PEN/HEARTS guidelines in the context of a complex intervention significantly improved blood pressure control after 12 months.

Capacity building of health care professionals to perform interprofessional management of non-communicable diseases in primary care - experiences from Ukraine.

BACKGROUND: Non-communicable diseases are leading causes of death and disability across the world. Countries with the highest non-communicable disease (NCD) burden in the WHO European Region are often those that have some of the greatest health system challenges for achieving good outcomes in prevention and care. The aim of this study was to evaluate the effect of an interprofessional capacity building intervention carried out in Ukraine to improve the management non-communicable diseases in primary health care. METHODS: A mixed-methods evaluation study was performed in 2018 to analyse the effect of a capacity building intervention carried out for over 10,000 primary care professionals in Ukraine in 2018. Quantitative data were collected from primary health care records of intervention and control areas preceding the intervention and 1.5 to 2 years after the intervention. Altogether 2798 patient records before and 2795 after the intervention were reviewed. In control areas, 1202 patient records were reviewed. Qualitative data were collected carrying out focus group interviews for health professionals, clinic managers and patients. Also, observations of clinical practice and patient pathways were performed. RESULTS: The capacity building intervention improved the capacity of professionals in detection and management of non-communicable disease risk factors. Significant improvement was seen in detection rates of both behavioural and biological risk factors and in medication prescription rates in the intervention areas. However, almost similar improvement in prescription rates was also observed in control clinics. Improvements in control of blood pressure, blood glucose and cholesterol were not seen during the evaluated implementation period. Qualitative analyses highlighted the improved knowledge and skills but challenges in changing the current practice. CONCLUSIONS: A large scale capacity building intervention improved primary health care professionals' knowledge, skills and clinical practice on NCD risk detection and reduction. We were not able to detect improvements in treatment outcomes - at least within 1.5 to 2 years follow-up. Improvement of treatment outcomes would most likely need more comprehensive systems change.

Implementing a package of noncommunicable disease interventions in the Republic of Moldova: two-year follow-up data.

Noncommunicable diseases (NCDs) are a growing challenge in the Republic of Moldova. A previously reported pilot cluster randomized controlled trial aimed to determine the feasibility of implementing and evaluating essential interventions for NCDs (e.g. cardiovascular risk scoring, hypertension management, statin treatment, etc.) in primary health care in the Republic of Moldova, with a view toward national scale up. One-year follow-up data (previously published) demonstrated modest improvements in NCD risk factor identification and management could be achieved. Herein, we report the second-year follow-up data and conclude that sustainable improvements in NCD risk factor control (e.g. hypertension control) can be achieved in primary health care in low resource settings by adapting existing resources (e.g. WHO PEN) and conducting focused clinical training and support. If scaled to a national level, these improvements in risk factor control could significantly translate to reductions in premature mortality from NCDs.

Implementing Package of Essential Non-communicable Disease Interventions in the Republic of Moldova-a feasibility study.

BACKGROUND: The aim of this study is to determine the feasibility of implementing and evaluating the World Health Organization Package of Essential Non-communicable Disease Interventions (WHO PEN) approach in primary healthcare in the Republic of Moldova. METHODS: According to our published a priori methods, 20 primary care clinics were randomized to 10 intervention and 10 control clinics. The intervention consisted of implementation of adapted WHO PEN guidelines and structured training for health workers; the control clinics continued with usual care. Data were gathered from paper-based patient records in July 2017 and August 2018 resulting in a total of 1174 and 995 patients in intervention and control clinics at baseline and 1329 and 1256 at follow-up. Pre-defined indicators describing assessment of risk factors and total cardiovascular risk, prescribing medications and treatment outcomes were calculated. Differences between baseline and follow-up as well as between intervention and control clinics were calculated using logistic and linear regression models and by assessing interaction effects. RESULTS: Improvements were seen in recording smoking status, activity to measure HbA1c among diabetes patients and achieving control in hypertension treatment. Improvement was also seen in identification of patients with hypertension or diabetes. Less improvement or even deterioration was seen in assessing total risk or prescribing statins for high-risk patients. CONCLUSIONS: It is feasible to evaluate the quality and management of patients with non-communicable diseases in low-resource settings from routine data. Modest improvements in risk factor identification and management can be achieved in a relatively short period of time.

Implementing essential interventions for cardiovascular disease risk management in primary healthcare: lessons from Eastern Europe and Central Asia.

Globally, non-communicable diseases (NCDs) are the leading cause of morbidity and mortality, including in the WHO European region. Within this region, the Member States with the greatest cardiovascular disease (CVD) burden are also some of the lowest resourced. As the need for technical support for the implementation of essential CVD/NCD interventions in primary healthcare (PHC) in these regions grew urgent, the WHO Regional Office for Europe has been directly supporting national governments in the development, assessment, scale-up and quality improvement of large scale PHC interventions for CVD. Herein, we synthesise the key learnings from providing technical support to national governments under the auspices of the WHO across the European region and share these learnings as a resource for public health professionals to consider when increasing coverage of quality essential health services. Based on our experience providing technical support to a diversity of Member States in the European Region (eg, Tajikistan, Republic of Moldova, Ukraine and Uzbekistan), we have identified six key lessons: prioritising NCDs for public health intervention, identifying and mapping existing resources, engaging key stakeholders, tailoring interventions to the local health system, generating local evidence and ensuring quality improvement while mainstreaming. Common challenges across all phases of implementation include multiple and inconsistent international toolkits and guidance, lack of national capacity for evidence-based healthcare, limited access to essential medicines and technologies, inconsistent national guidelines and limited experience in evaluation methodology, clinical epidemiology and guideline implementation. We map the lessons to the Consolidated Framework for Implementation Research and highlight key learnings and challenges specific to the region. Member States in the region are at various stages of implementation; however, several are currently conducting pragmatic clinical trials to generate local evidence for health policy. As this work expands, greater engagement with peer-to-peer sharing of contextual wisdom, sharing of resources, publishing methodology and results and development of region-specific resources is planned.

Protocol for the evaluation of a pilot implementation of essential interventions for the prevention of cardiovascular diseases in primary healthcare in the Republic of Moldova.

INTRODUCTION: Nearly 90% of all deaths in the Republic of Moldova are caused by non-communicable diseases, the majority of which (55%) are caused by cardiovascular diseases (CVD). In addition to reducing premature mortality from CVD, it is estimated that strengthening primary healthcare could cut the number of hypertension-related hospital admissions and diabetes-related hospitalisations in half. The aim of this evaluation is to determine the feasibility of implementing and evaluating essential interventions for the prevention of CVD in primary healthcare in the Republic of Moldova, with a view towards national scale-up. METHODS AND ANALYSIS: A national steering group including international experts will be convened to adapt WHO Package of Essential NCD Intervention from Primary Healthcare in Low Resource Settings protocols 1 and 2 to the health system of the Republic of Moldova, develop and conduct training of primary healthcare workers and test a core set of indicators to monitor the quality of care and change in clinical practice. To evaluate the impact of this pilot implementation, a pragmatic, sequential mixed methods explanatory design, composed of quantitative and qualitative strands of equal weight, will be used. Twenty primary healthcare centres will be selected and randomised to the training and implementation arm (n=10) and the usual care arm (n=10). At baseline and 12 months follow-up, a standardised data collection form will be piloted to extract data directly from patient paper records in order to estimate the change in clinical practice. Semi-structured interviews and interclinic peer workshops will be conducted at 12 months follow-up, and qualitative data collected from these formats will be analysed thematically for explanatory themes that relate to the quantitative findings. ETHICS AND DISSEMINATION: Ethical review and approval has been obtained. Findings of the evaluation will be shared in a project report to key stakeholders, presented back to participants and written into a manuscript for an open access peer-reviewed scientific journal.

Evaluation and pilot implementation of essential interventions for the management of hypertension and prevention of cardiovascular diseases in primary health care in the Republic of Tajikistan.

Background: Non-communicable diseases (NCDs) are the leading cause of death worldwide and are a major burden in Tajikistan. The health system of Tajikistan is still shaped by the country's Soviet legacy and the pace of reform has been slow, with high patient out-of-pocket expenditure. The aim of this study is to determine the feasibility of implementing and evaluating essential interventions for the management of hypertension and prevention of cardiovascular disease in primary health care in Tajikistan. Methods and analysis: A pragmatic, sequential mixed methods explanatory design, composed of quantitative and qualitative strands will be used with greater weighting of the quantitative strand. A single geographic district was nominated by the Ministry of Health and chosen for implementation. All primary health care centres in the district that meet inclusion criteria will be included; half will be randomly assigned to the intervention arm and half to the control arm. The overall process is organized into seven steps: (1) refresh clinical decision-making tools including open source WHO PEN and HEARTS resources; (2) update training package for primary health care workers; (3) collection of baseline data; (4) training staff in intervention clinics; (5) implementation of protocols and implementation coaching; (6) collection of follow-up data after 12 months; (7) evaluation of results and sharing experience. Ethics and dissemination: Ethical review and approval have been obtained. Findings will be disseminated at the participant level, national level through a national conference of key stakeholders, and internationally through publication in an open-access peer review journal.

Healthy Cities Phase V evaluation: further synthesizing realism.

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phases.

Evaluation of risk factor reduction in a European City Network.

There is a substantial and growing burden of premature mortality caused by non-communicable diseases (NCDs) globally. This paper evaluates the preventive efforts of the WHO European Healthy Cities Network during its fifth phase (2009-13), specifically for four behavioural risk factors (tobacco use, alcohol abuse, unhealthy diet and physical inactivity). Drawing on case studies, questionnaire responses and other materials, it notes which cities were involved, what worked and did not, the triggers for action, challenges met and lessons learnt. Few cities appeared to have taken comprehensive approaches to NCD prevention across multiple risk factors, or have combined population- and individual-level interventions. Work on healthy food and diet predominantly focused on children in educational or care settings, and few cities appeared to take a comprehensive approach to tackling obesity. Partnerships were a strong feature for all the NCD risk factor work, and were frequently extensive, being most diverse for the Healthy Diet and Food work. There were strong examples of engagement with communities, also involved in co-designing and shaping projects. Equity also featured strongly and there were multiple examples of how attention had been paid to the social determinants of health. There was evidence that cities continue to be significant innovative forces within their countries and drivers of change, and the mutual dependency of the national and local levels was highlighted. Interventions to promote physical activity have shifted focus from specific events and projects to being more integrated with other policy areas and based on intersectoral collaboration.