An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study

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.

Implementation Research in Nepal – A Scoping Review, 2015-2022

“…The details and the conclusions of the included studies are presented in Table 2. The objectives of the studies are diverse that includes measuring implementation outcomes; 14,15 reporting implementation challenges; 16 adaptation; 17,18 exploring facilitators and barriers to implementation; 19,20 capacity building; 21 exploring readiness and capacity; [22][23][24][25][26][27][28] identify or test implementation strategy; [29][30][31][32][33] and stakeholder engagement. 9,34 Nine articles evaluated implementation.…”

“…[14][15][16][17]29,30,32,33,35 These articles clearly specified the targeted EBP and the implementation strategies to adoption and/or implementation. Multiple implementation outcomes were reported including: (a) reach, 29,30,33 (b) effectiveness, 30,33 (c) adoption, 15,16,30,33 (d) implementation, 30,36 (e) maintenance; 30 (f) feasibility, [14][15][16][17]28 (g) acceptability, (h) fidelity, 16,17 (i) cost, 16,17 (j) acceptability, 17 (k) appropriateness, 16,17 (l) penetration, 17 and (m) sustainability. 14,16 These implementation outcomes were defined clearly based on the context and study objectives.…”

Theory-based mobile phone text messaging intervention for blood pressure control (TEXT4BP) among hypertensive patients in Nepal: study protocol for a feasibility randomised controlled trial

“…We used a conservative estimate for attrition, based on a recent study. 40 This is a parameter we would ascertain from this feasibility study to power the planned definitive study.…”

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

“…The growing pandemic of NCDs is mainly caused by cardiovascular diseases, cancers, chronic respiratory diseases and diabetes [1,2]. These four major killers contribute to more deaths globally than all other diseases combined [3]. The proportion of global deaths due to NCDs has increased from 68% in 2012 to 71% in 2016 [4].…”