Periodic Reporting for period 3 - 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))
Período documentado: 2022-01-01 hasta 2023-06-30
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.
Project Period 1 (January 2019 to June 2020):
During Reporting Period 1, the consortium and MoH redesigned the interventions for the treatment arms in Phase 1. 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).
Project Period 2 (July 2020 – December 2021):
The first year of Reporting Period 2 (July 2020 to June 2021) was heavily affected by the COVID-19 pandemic. To take pressure off tertiary facilities and to protect this vulnerable group, the Ministry of Health opted for an emergency decentralization.For the WHO-PEN@Scale study, this meant that the standard of care has changed substantially, which required the re-design of the two treatment arms. In the first year of Reporting Period 2, two new treatment arms were designed, which are based on the differentiated service delivery models for clients living with HIV (WP2).
The time and motion study has been piloted in two primary care facilities (WP3). The quantitative and qualitative components of the implementation and acceptability studies were carried out (WP4). In 2020, CHAI and UGOE conducted a pilot of the smart device app for the community health workers and used the result to refine and finalized the app (WP6). The protocol fThe systematic review has been published (WP7).
Project Period 3 (January 2022 – June 2023):
The first household took place from October until December 2022. The analysis of the survey data is currently done by UKHD, a report of the main survey results was submitted in April 2023 as D2.9.
The sample included in the analysis consists of 3,655 individuals of which 1,061 had diabetes and 3,350 had hypertension. The results indicate that the WHO-PEN@Scale intervention did not have an effect on population health. As described in the Grant Agreement Annex, we assume that it is not the DSD and CDP models themselves that do not improve population health. Rather, it is likely that there were problems in the implementation that led to these null results (WP2).
The time and motion analysis was completed in Reporting Period 3. By shadowing HCWs in 28 clinics over two days, we calculated the average amount of time spent per patient by each HCW on patient care in the control arm and the intervention arm clinics. We identified two effects of new-patient visits and of the morning peak.
Combining our results from the TMS analysis with the cost data, we are currently working on the model for estimating the total cost of scaling-up these interventions. In addition to the personnel time and salary costs, we also impute the training costs of nurses, medication costs for all estimated diabetes and hypertension patients in the country, and the disease-specific diagnostic equipment costs (WP3).
In terms of the acceptability and implementation of the DSD models, UNESWA conducted 38 interviews with clients across nine health facilities, seven interviews with DSD nurses who were charged with implementing the various models, and 282 questionnaire-based acceptability survey with NCD clients participating in one of the DSD models (WP 4).
The cleaned dataset from the household survey was made available for identifying syndemic complexes in the final months of Reporting Period 3. The qualitative component of data collection has been planned for October 2023, and will be undertaken in the field by AIGHD and UNESWA (WP 5). The evaluation of the smartphone app indicated that the developed mHealth app was well-received by CHWs, guiding them through NCD counseling and improving job satisfaction (WP6).
For the systematic review on lay health workers in primary and community health care for chronic conditions (WP7), the consortium finalised the development of a taxonomy of lay health worker (LHW) interventions, compiled risk of bias asssessments, undertook meta-analyses by comparison, and created an intervention category and prioritised outcomes, among others.
During Reporting Period 1, the consortium and MoH redesigned the interventions for the treatment arms in Phase 1. 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).
Project Period 2 (July 2020 – December 2021):
The first year of Reporting Period 2 (July 2020 to June 2021) was heavily affected by the COVID-19 pandemic. To take pressure off tertiary facilities and to protect this vulnerable group, the Ministry of Health opted for an emergency decentralization.For the WHO-PEN@Scale study, this meant that the standard of care has changed substantially, which required the re-design of the two treatment arms. In the first year of Reporting Period 2, two new treatment arms were designed, which are based on the differentiated service delivery models for clients living with HIV (WP2).
The time and motion study has been piloted in two primary care facilities (WP3). The quantitative and qualitative components of the implementation and acceptability studies were carried out (WP4). In 2020, CHAI and UGOE conducted a pilot of the smart device app for the community health workers and used the result to refine and finalized the app (WP6). The protocol fThe systematic review has been published (WP7).
Project Period 3 (January 2022 – June 2023):
The first household took place from October until December 2022. The analysis of the survey data is currently done by UKHD, a report of the main survey results was submitted in April 2023 as D2.9.
The sample included in the analysis consists of 3,655 individuals of which 1,061 had diabetes and 3,350 had hypertension. The results indicate that the WHO-PEN@Scale intervention did not have an effect on population health. As described in the Grant Agreement Annex, we assume that it is not the DSD and CDP models themselves that do not improve population health. Rather, it is likely that there were problems in the implementation that led to these null results (WP2).
The time and motion analysis was completed in Reporting Period 3. By shadowing HCWs in 28 clinics over two days, we calculated the average amount of time spent per patient by each HCW on patient care in the control arm and the intervention arm clinics. We identified two effects of new-patient visits and of the morning peak.
Combining our results from the TMS analysis with the cost data, we are currently working on the model for estimating the total cost of scaling-up these interventions. In addition to the personnel time and salary costs, we also impute the training costs of nurses, medication costs for all estimated diabetes and hypertension patients in the country, and the disease-specific diagnostic equipment costs (WP3).
In terms of the acceptability and implementation of the DSD models, UNESWA conducted 38 interviews with clients across nine health facilities, seven interviews with DSD nurses who were charged with implementing the various models, and 282 questionnaire-based acceptability survey with NCD clients participating in one of the DSD models (WP 4).
The cleaned dataset from the household survey was made available for identifying syndemic complexes in the final months of Reporting Period 3. The qualitative component of data collection has been planned for October 2023, and will be undertaken in the field by AIGHD and UNESWA (WP 5). The evaluation of the smartphone app indicated that the developed mHealth app was well-received by CHWs, guiding them through NCD counseling and improving job satisfaction (WP6).
For the systematic review on lay health workers in primary and community health care for chronic conditions (WP7), the consortium finalised the development of a taxonomy of lay health worker (LHW) interventions, compiled risk of bias asssessments, undertook meta-analyses by comparison, and created an intervention category and prioritised outcomes, among others.
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.