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

Abstract

Background In Nepal, the burden of non-communicable, 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 twelve-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated non-communicable 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 Non-communicable 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 include three evidence-based components: 1) non-communicable disease care provision using mid-level practitioners and community health workers; 2) digital clinical decision support tools to ensure delivery of evidence-based care; and 3) 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. Discussion This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low- and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for non-communicable disease care management in the future.