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Scaling up the WHO-PEN package for diabetes and hypertension in Swaziland: a nation-wide cluster-randomised evaluation of three strategies in Swaziland (WHO-PEN@Scale)

Periodic Reporting for period 1 - WHO-PENatScale (Scaling up the WHO-PEN package for diabetes and hypertension in Swaziland: a nation-wide cluster-randomised evaluation of three strategies in Swaziland (WHO-PEN@Scale))

Reporting period: 2019-01-01 to 2020-06-30

Diabetes and hypertension are a rapidly growing, public health threat in Eswatini. A quarter of Emaswati aged 15-69 have hypertension and almost one fifth live with diabetes or pre-diabetes. Diabetes and hypertension and their most deadly complications – cardiovascular diseases, such as stroke and heart attacks – are responsible for one in five deaths in the country. Of particular concern is that the rate of premature death from these diseases is exceedingly high. The risk of a Liswati individual living with hypertension or diabetes dying from their disease before the age of 70 is nearly double that of their counterparts in high-income settings. Moreover, diabetes and hypertension are among the leading drivers of disability in the country, being responsible for the majority of strokes, kidney failure, blindness and lower limb amputation.

Out of a study of 48 countries in sub-Saharan Africa, Eswatini was found to be the country with the fifth lowest proportion of the population (6.1%) residing within two hours of travel time to the nearest public hospital. Care for diabetes and hypertension is, therefore, in practice inaccessible to most of the population. In the standard of care, there is no proactive screening for diabetes and hypertension at the primary care or community level. Similarly, patients with diabetes or hypertension are initiated on medications and followed up almost exclusively at tertiary care facilities.

Our overall objective is to reduce the burden of diabetes and hypertension in eSwatini and the wider sub-Saharan African region. In pursuit of this overall objective, the WHO-PEN@Scale will develop and test three novel community-based programmes for diabetes and hypertension care in Eswatini over the project period.
Due to the shift to the government-led Community Health Worker (CHW) cadre and the government’s constrained capacity to manage this cadre, the Eswatini Ministry of Health (MoH) will only provide resources to implement two novel community-based programmes in Phase 1. In Phase 2, the MoH will implement the intervention outlined in the grant agreement under “ePEN+ICT” and we are currently working on the design of a second treatment arm for Phase 2. A Grant Agreement amendment request is ongoing.

During Reporting Period 1, the consortium and MoH redesigned the interventions for the treatment arms in Phase 1. With scientific guidance by the consortium, the MoH developed the standardized treatment guidelines and training materials for nurses and CHWs.

The University of Göttingen developed the smart-device app that will be used by the CHWs in Phase II. The app has been reviewed by the beneficiaries and MoH. A special focus was put on its intuitiveness, adequacy for the CHWs’ level of literacy, and its potential to support the CHWs in their daily activities. The app has been piloted and a feasibility study on equipping CHWs with battery-powered blood pressure machines were conducted. In addition, a Service Availability and Readiness Assessment was conducted.

Survey instruments have been developed and tested for all quantitative and qualitative studies (household survey, acceptability surveys, time-and-motion study, policy maker and health worker in-depth interviews). To date, telephone interviews have been done with 25 health care workers (nurses) across three regions namely Shiselweni, Manzini and Hhohho. Lubombo region and patient interviews are to follow shortly in August 2020.

The protocol for the Cochrane review “Lay health workers in primary and community health care for chronic conditions” has been developed.
In Eswatini, before the start of WHO-PEN@Scale health care for diabetes and hypertension was available only at tertiary health care facilities and provided exclusively by physicians at these facilities. The limited access to these services resulted in low rates of detection and treatment initiation and adherence. In addition, there were no standardized guidelines on the prevention, screening, and treatment of diabetes and hypertension that health care personnel could follow. Together with the Eswatini Ministry of Health, the WHO-PEN@Scale consortium aims to address these issues by (i) decentralizing health care service provision to nurses in primary care clinics (ii) involving community health workers that engage in activities at the community and household level by standardizing guidelines (iii) developing standardized treatment guidelines for physicians, nurses, and community health workers.

The research results will not only inform the Swazi government but be of value to other governments in sub-Saharan Africa that plan to decentralize health care services for non-communicable diseases. We will estimate the health impact of the WHO-PEN intervention at the population level through household surveys. During these surveys, we will also collect data to assess the socio-economic impact of the health care service decentralization on the clients. First, we will look at changes in household income and wealth. Second, we will estimate changes in out of pocket health care expenditure. Third, we will also estimate whether there is a reduction in travel time – and thus absence from productive activities – related to accessing health care. Fourth, we will disaggregate the analyses by socio-economic status to verify that WHO-PEN enhances health equity. involving Community Health Workers that engage in activities at the community and household level. All these components will result in a comprehensive analysis.