Periodic Reporting for period 4 - 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: 2023-07-01 to 2023-12-31
Diabetes and hypertension are a rapidly growing public health threat in Eswatini. A quarter of Swazis aged 15-69 have hypertension and almost one fifth live with diabetes or pre-diabetes. Before COVID-19, care for diabetes and hypertension was, therefore, in practice inaccessible to most of the population. There was no proactive screening for diabetes and hypertension at the primary care or community level. Similarly, clients with diabetes or hypertension were initiated on medications and followed up almost exclusively at tertiary care facilities. In the course of the emergency decentralization, care was shifted from physicians in tertiary facilities to nurses in in primary care clinics. The two new treatment arms involve additional efforts in bringing NCD services closer to the people. Differentiated Service Delivery models at the facility and community levels will tailor NCD services to the needs of clients living with diabetes and hypertension. Furthermore, Community Distribution Points, which are set up temporarily every month will provide health services in the communities. WHO-PEN@Scale’s 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 project will develop and test four novel community-based programmes for diabetes and hypertension care in Eswatini over the project period.
During the four-year (2019-2023) implementation of WHO-Pen@Scale, the project has conducted a comprehensive evaluation of the two diabetes and hypertension health service provision models at the community and household levels in Eswatini.
The main findings from the study are:
• The trial findings from household survey 1 and 2 indicate that the WHO-PEN@Scale intervention did not have an effect on population health. It did not seem to reduce HbA1c, systolic blood pressure, and diastolic blood pressure. Further analysis is needed to assess possible explanations for this lack of positive effects.
• WHO-PEN@Scale interventions were found to be cheaper to implement with a more efficient delivery of care. At the same time, they did not exacerbate any existing health inequities in Eswatini and were found to slightly reduce the overall health expenditures incurred by the intervention arm study participants. It also found to be more efficient for delivering care in terms of seeing more patients while spending less time per patient, even as the reported workday duration of HCWs increased.
• The findings from syndemic analysis point to a clear need for health care delivery models to take comorbidities for NCDs into account. A health care provider at the primary care level in Eswatini can expect to encounter comorbidities in most NCD clients above 40 years of age. A client suffering from HIV and Diabetes, who lives alone is at particular risk of exacerbated burdens of disease, in particular depression, especially in Shiselweni.
• The evaluation of the developed app indicated that the developed mobile app was well-received by RHMs, guiding them through NCD counselling and improving job satisfaction.
• From the systematic review, using lay health workers in primary and community care may lead to small improvements in outcomes among people living with diabetes, compared to usual care.
• From the acceptability studies, decentralisation of diabetes and hypertension care to primary health care facilities was welcomed by clients, while nurses had mixed reactions. Differentiated Service Delivery (DSD) Models have the potential to improve retention in care and reduce defaulting among clients.
The comprehensive summary and the decision pathway are explained in the Evidence to Decisions framework (Deliverable 8.1) to inform the decision making in Eswatini.
Results of the project will be used to inform the decision of scaling up WHO-PEN implementation in Eswatini and the Southern African region in general.
The main findings from the study are:
• The trial findings from household survey 1 and 2 indicate that the WHO-PEN@Scale intervention did not have an effect on population health. It did not seem to reduce HbA1c, systolic blood pressure, and diastolic blood pressure. Further analysis is needed to assess possible explanations for this lack of positive effects.
• WHO-PEN@Scale interventions were found to be cheaper to implement with a more efficient delivery of care. At the same time, they did not exacerbate any existing health inequities in Eswatini and were found to slightly reduce the overall health expenditures incurred by the intervention arm study participants. It also found to be more efficient for delivering care in terms of seeing more patients while spending less time per patient, even as the reported workday duration of HCWs increased.
• The findings from syndemic analysis point to a clear need for health care delivery models to take comorbidities for NCDs into account. A health care provider at the primary care level in Eswatini can expect to encounter comorbidities in most NCD clients above 40 years of age. A client suffering from HIV and Diabetes, who lives alone is at particular risk of exacerbated burdens of disease, in particular depression, especially in Shiselweni.
• The evaluation of the developed app indicated that the developed mobile app was well-received by RHMs, guiding them through NCD counselling and improving job satisfaction.
• From the systematic review, using lay health workers in primary and community care may lead to small improvements in outcomes among people living with diabetes, compared to usual care.
• From the acceptability studies, decentralisation of diabetes and hypertension care to primary health care facilities was welcomed by clients, while nurses had mixed reactions. Differentiated Service Delivery (DSD) Models have the potential to improve retention in care and reduce defaulting among clients.
The comprehensive summary and the decision pathway are explained in the Evidence to Decisions framework (Deliverable 8.1) to inform the decision making in Eswatini.
Results of the project will be used to inform the decision of scaling up WHO-PEN implementation in Eswatini and the Southern African region in general.
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, 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.
First of all, because of the nationwide emergency decentralization, we will be able to evaluate how NCD health service uptake evolved over time in primary care clinics. The implementation and acceptability studies provide more granular qualitative and quantitative evidence on how the health service decentralization was perceived on the ground by healthcare workers and clients. Second, because of the preparations undertaken before COVID-19 and the systematic and standardized emergency decentralization, WHO-PEN@Scale will be able to formally evaluate a push that has happened in other countries in Sub-Saharan Africa over the past two years. These results can be used to refine the already implemented decentralization strategies in other countries.
First of all, because of the nationwide emergency decentralization, we will be able to evaluate how NCD health service uptake evolved over time in primary care clinics. The implementation and acceptability studies provide more granular qualitative and quantitative evidence on how the health service decentralization was perceived on the ground by healthcare workers and clients. Second, because of the preparations undertaken before COVID-19 and the systematic and standardized emergency decentralization, WHO-PEN@Scale will be able to formally evaluate a push that has happened in other countries in Sub-Saharan Africa over the past two years. These results can be used to refine the already implemented decentralization strategies in other countries.