Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh
Wubin Xie, Rina Rani Paul, Ian Y Goon, Aysha Anan, Aminur Rahim, Md Mokbul Hossain, Fred Hersch, Brian Oldenburg, John Chambers, Malay Kanti Mridha, Wubin Xie, Rina Rani Paul, Ian Y Goon, Aysha Anan, Aminur Rahim, Md Mokbul Hossain, Fred Hersch, Brian Oldenburg, John Chambers, Malay Kanti Mridha
Abstract
Objective: The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.
Design and setting: The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh.
Participants: A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female).
Outcomes: Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics.
Results: The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.
Conclusion: The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.
Keywords: diabetes & endocrinology; health services accessibility; hypertension.
Conflict of interest statement
Competing interests: None declared.
© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.
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References
- Sun H, Saeedi P, Karuranga S, et al. . IDF diabetes Atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract 2022;183:S0168-8227(21)00478-2. 10.1016/j.diabres.2021.109119
- Roth GA, Mensah GA, Johnson CO, et al. . Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol 2020;76:2982–3021. 10.1016/j.jacc.2020.11.010
- Prabhakaran D, Anand S, Watkins D, et al. . Cardiovascular, respiratory, and related disorders: key messages from disease control priorities. The Lancet 2018;391:1224–36. 10.1016/S0140-6736(17)32471-6
- Zhou B, Carrillo-Larco RM, Danaei G, et al. . Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet 2021;398:957–80. 10.1016/S0140-6736(21)01330-1
- World Health Organization . Global action plan for the prevention and control of NCDs 2013–2020. 2013. Geneva: WHO, 2019.
- Manne-Goehler J, Geldsetzer P, Agoudavi K, et al. . Health system performance for people with diabetes in 28 low-and middle-income countries: a cross-sectional study of nationally representative surveys. PLoS Med 2019;16:e1002751. 10.1371/journal.pmed.1002751
- Geldsetzer P, Manne-Goehler J, Marcus M-E, et al. . The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1· 1 million adults. The Lancet 2019;394:652–62. 10.1016/S0140-6736(19)30955-9
- Kabir A, Karim MN, Islam RM, et al. . Health system readiness for non-communicable diseases at the primary care level: a systematic review. BMJ Open 2022;12:e060387. 10.1136/bmjopen-2021-060387
- Frenk J, Chen L, Bhutta ZA, et al. . Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet 2010;376:1923–58. 10.1016/S0140-6736(10)61854-5
- Chowdhury HA, Paromita P, Mayaboti CA, et al. . Assessing service availability and readiness of Healthcare facilities to manage diabetes mellitus in Bangladesh: findings from a nationwide survey. PLoS One 2022;17:e0263259. 10.1371/journal.pone.0263259
- Islam K, Huque R, Saif-Ur-Rahman KM, et al. . Implementation status of non-communicable disease control program at primary health care level in bangladesh: findings from a qualitative research. Public Health Pract (Oxf) 2022;3:100271. 10.1016/j.puhip.2022.100271
- World Health Organization . Declaration of alma-ata. World Health Organization. Regional Office for Europe, 1978.
- Rawal LB, Kanda K, Biswas T, et al. . Non-communicable disease (NCD) corners in public sector health facilities in Bangladesh: a qualitative study assessing challenges and opportunities for improving NCD services at the primary Healthcare level. BMJ Open 2019;9:e029562. 10.1136/bmjopen-2019-029562
- Rawal L, Jubayer S, Choudhury SR, et al. . Community health workers for non-communicable diseases prevention and control in Bangladesh: a qualitative study. Glob Health Res Policy 2020;6:1. 10.1186/s41256-020-00182-z
- Devi R, Kanitkar K, Narendhar R, et al. . A narrative review of the patient journey through the lens of non-communicable diseases in Low- and middle-income countries. Adv Ther 2020;37:4808–30. 10.1007/s12325-020-01519-3
- Jindal D, Sharma H, Gupta Y, et al. . Improving care for hypertension and diabetes in India by addition of clinical decision support system and task shifting in the National NCD program: I-TREC model of care. BMC Health Serv Res 2022;22:1–12. 10.1186/s12913-022-08025-y
- Brennan AT, Long L, Maskew M, et al. . Outcomes of stable HIV-positive patients down-referred from a doctor-managed antiretroviral therapy clinic to a nurse-managed primary health clinic for monitoring and treatment. AIDS 2011;25:2027–36. 10.1097/QAD.0b013e32834b6480
- Sanne I, Orrell C, Fox MP, et al. . Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. The Lancet 2010;376:33–40. 10.1016/S0140-6736(10)60894-X
- Lehmann U, Van Damme W, Barten F, et al. . Task shifting: the answer to the human resources crisis in Africa? Hum Resour Health 2009;7:49. 10.1186/1478-4491-7-49
- Kruk ME, Nigenda G, Knaul FM. Redesigning primary care to tackle the global epidemic of Noncommunicable disease. Am J Public Health 2015;105:431–7. 10.2105/AJPH.2014.302392
- Kredo T, Ford N, Adeniyi FB, et al. . Decentralising HIV treatment in Lower- and middle-income countries. Cochrane Database Syst Rev 2013;2013:CD009987. 10.1002/14651858.CD009987.pub2
- Labrique AB, Wadhwani C, Williams KA, et al. . Best practices in Scaling Digital health in low and middle income countries. Global Health 2018;14:103. 10.1186/s12992-018-0424-z
- Anchala R, Kaptoge S, Pant H, et al. . Evaluation of effectiveness and Cost‐Effectiveness of a clinical decision support system in managing hypertension in resource constrained primary health care settings: results from a cluster randomized trial. J Am Heart Assoc 2015;4:e001213. 10.1161/JAHA.114.001213 Available:
- Prabhakaran D, Jha D, Prieto-Merino D, et al. . Effectiveness of an mHealth-based electronic decision support system for integrated management of chronic conditions in primary care. Circulation 2019;139:380–91. 10.1161/CIRCULATIONAHA.118.038192
- Kumar A, Schwarz D, Acharya B, et al. . Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal. BMJ Glob Health 2019;4:e001343. 10.1136/bmjgh-2018-001343 Available:
- Vos T. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. Lancet 2020;396:1204–22. 10.1016/S0140-6736(20)30925-9
- Sathi NJ, Islam MA, Ahmed MS, et al. . Prevalence, trends and associated factors of hypertension and diabetes mellitus in Bangladesh: evidence from BHDS 2011 and 2017–18. PLoS One 2022;17:e0267243. 10.1371/journal.pone.0267243
- Khan N, Oldroyd JC, Hossain MB, et al. . Awareness, treatment, and control of diabetes in Bangladesh: evidence from the Bangladesh demographic and health survey 2017/18. Int J Clin Pract 2021;2022.
- Khan MdN, Oldroyd JC, Chowdhury EK, et al. . Prevalence, awareness, treatment, and control of hypertension in Bangladesh: findings from national demographic and health survey, 2017–2018. J of Clinical Hypertension 2021;23:1830–42. 10.1111/jch.14363 Available:
- Khan MN, Oldroyd JC, Hossain MB, et al. . Awareness, treatment, and control of diabetes in Bangladesh: evidence from the Bangladesh demographic and health survey 2017/18. Public and Global Health 2021. 10.1101/2021.07.09.21260274
- Riaz BK, Islam MZ, Islam ANMS, et al. . Risk factors for non-communicable diseases in Bangladesh: findings of the population-based cross-sectional national survey 2018. BMJ Open 2020;10:e041334. 10.1136/bmjopen-2020-041334
- D. G. o. H. S . Non-communicable disease control programme, "multi-Sectoral action plan for prevention and control of non-communicable diseases 2018-2025. 2018.
- Bank W. Hypertension and Type-2 Diabetes in Bangladesh: Continuum of Care Assessment and Opportunities for Action. World Bank, 2018. 10.1596/30041
- M. o. H. a. F. W . Government of people’s Republic of Bangladesh, facility Registry. 2022.
- World Health Organization . WHO package of essential Noncommunicable (PEN) disease interventions for primary health care. 2020.
- Zou GY, Donner A. Extension of the modified Poisson regression model to prospective studies with correlated binary data. Stat Methods Med Res 2013;22:661–70. 10.1177/0962280211427759
- Yelland LN, Salter AB, Ryan P. Performance of the modified Poisson regression approach for estimating relative risks from clustered prospective data. Am J Epidemiol 2011;174:984–92. 10.1093/aje/kwr183
- BRAC Health Nutrition and Population Program . Accessible and affordable primary health care for all: annual report progress of social enterprises April 2018 - April 2019. 2020. Available:
- Alam BB, Koziel A, Fraser-Hurt N, et al. . Hypertension and Type-2 diabetes in Bangladesh: continuum of care assessment and opportunities for action. 2020.
- Srinivasapura Venkateshmurthy N, Ajay VS, Mohan S, et al. . M-power heart project-a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial. Trials 2018;19:1–9. 10.1186/s13063-018-2813-2
- Peiris D, Praveen D, Mogulluru K, et al. . Smarthealth India: a stepped-wedge, cluster randomised controlled trial of a community health worker managed mobile health intervention for people assessed at high cardiovascular disease risk in rural India. PLoS ONE 2019;14:e0213708. 10.1371/journal.pone.0213708
- Labhardt ND, Balo J-R, Ndam M, et al. . Task shifting to non-physician Clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res 2010;10:339. 10.1186/1472-6963-10-339
- Kachimanga C, Dibba Y, Patiño M, et al. . Implementation of a non-communicable disease clinic in rural Sierra Leone: early experiences and lessons learned. J Public Health Policy 2021;42:422–38. 10.1057/s41271-021-00304-y
- Deo S, Singh P. Community health worker-led, technology-enabled private sector intervention for diabetes and hypertension management among urban poor: a retrospective cohort study from large Indian metropolitan city. BMJ Open 2021;11:e045246. 10.1136/bmjopen-2020-045246
- He J, Irazola V, Mills KT, et al. . Effect of a community health worker–led Multicomponent intervention on blood pressure control in low-income patients in Argentina: A randomized clinical trial. JAMA 2017;318:1016–25. 10.1001/jama.2017.11358
- Jafar TH. A community-based intervention for hypertension in rural South Asia. reply. N Engl J Med 2020;382:10.1056/NEJMc2006112#sa2. 10.1056/NEJMc2006112
- Schwalm J-D, McCready T, Lopez-Jaramillo P, et al. . A community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster-randomised controlled trial. Lancet 2019;394:1231–42. 10.1016/S0140-6736(19)31949-X
- Chow CK, Teo KK, Rangarajan S, et al. . Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013;310:959–68. 10.1001/jama.2013.184182
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