Task sharing intervention with nurses is an important strategy to prevent and control common noncommunicable diseases (NCDs). Increasing burden of NCDs in developing countries like India having a low doctor to patient ratio and a high caseload of other diseases had led to increase in the demand for human resource for health (HRH).[1,2] Utilization of nurses to take up the responsibility for primary and secondary prevention of NCDs can contribute toward addressing the scarcity of human resource in health settings for managing NCDs.[3-5] It can be one of the cost-effective solution to use the available human resources efficiently to provide better access to care.[6,7] Evidences on nurse led interventions strongly support the involvement of nurses in NCDs prevention and control. However, not much of the work has been done in this area.[8-10] Thus, the study was conducted to assess the feasibility and effectiveness of nurse led clinic in identification, prevention, and management of common NCDs in a peri-urban community of Chandigarh.
A quasi experimental study was conducted at Public health Dispensary sector-25 Chandigarh, India covering the population of 23,000. Situational analysis and stakeholders interview were done before setting up the clinic by using in-depth topic interview guide. Nurses were trained for the period of 6–8 h by the nurse supervisors. The nurse-led NCD clinic was setup in a separate room and run over a period of 2 months (November – December 2020) by registered nurse and nursing students. Community sensitization was done by involving community leaders, ASHA’s, and Anganwadi workers. The frequency of the clinic was 6 days in a week from 9:00 am to 1:00 pm. Individuals aged ≥30 years were enrolled in clinic. The primary outcome of the study was proportion of population screened, prevalence of common NCDs, risk factors modification, and medication adherence. Interview schedule was used to collect sociodemographic details and clinical profile of patients. Hypertension was assessed (aneroid sphygmomanometer) and interpreted as per (Joint National Committee-VII) criteria. Diabetes mellitus screening was done by assessing random blood glucose level (glucometer). Screening for common cancers included oral cancer and breast cancer. For oral cancer screening oral visual examination was done to assess the presence of any precancerous lesions in the oral cavity. Screening for breast cancer was done by performing clinical breast examination and interpreted as per the NPCDCS guidelines. Cardiovascular diseases risk prediction for individuals aged ≥40 years was done using WHO/ISH risk prediction chart without cholesterol for SEAR D region. Medication adherence (adherence to refill and medication scale) was assessed for already diagnosed cases of hypertension and diabetes mellitus. After screening patients were referred to medical officer for prescription if required. Education and counseling for risk factors modification (government of India IEC material) by using colored pamphlets, flash cards, sharing the video and pdf to study participants having android phone Follow-up for patients was done after 4 weeks to assess the medication adherence and risk factors modification.
Written informed consent was taken from all the participants. Ethical clearance was taken from Institutional Ethics Committee PGIMER, Chandigarh (Reference number NK/6013/MSc/301). Intervention was registered with CTRI (registration number CTRI/2020/06/025907).
Result revealed that it was feasible to run a nurse led clinic in terms of availability of space, equipment to run the clinic, and human resource. A total of 455 patients visited the clinic. Among them, 64.6% were female. At 4 weeks’ follow-up, there was a significant reduction in mean systolic and diastolic blood pressure, random blood sugar, Prevalence of hypertension and Diabetes mellitus was 33.8% and 17.8%,out of which 17.6% and 7.7% cases respectively were newly diagnosed [Table 1] body mass index, and waist circumference [Tables 2 and 3].
Medication adherence score significantly reduced from 20.33 ± 3.44-12.89 ± 1.76 indicates improved medication adherence [Table 3]. Proportion of population in better medication adherence group increased from 7.8% to 76.4%. Significant improvement was also seen in tobacco and alcohol use with quit rate of 21.7% and 16%, respectively. All the study participants were highly satisfied with the nurse led NCD clinic.
Task sharing intervention to optimally utilize existing health care workforce can be one of the best available option in view of the current (HRH) deficit and increasing burden of NCDs.[16,17] Nurse led NCD clinic established in this context at Public health dispensary sector 25 Chandigarh. This center was chosen as it is practice area of PGIMER, Chandigarh.
Screening for common NCDs is an important element for the early detection and initiation of treatment as recommended in NPCDCS program. Involvement of professional nurses in a specialized NCD clinic which was run exclusively for 6 days in a week was helpful in the coverage of large population of the area.
The total prevalence of hypertension and diabetes mellitus in the present study was 33.84% and 17.8%, respectively [Table 1]. The findings of study are consistent with other studies Ramakrishnan S et al. In the present study, 0.4% of females were screened positive for breast cancer and 0.2% for oral cancer which is consistent with the findings of study conducted by Paul D et al., with 0.6% prevalence of breast cancer.
Medication adherence is an important aspect of medical treatment. In the present study, interventions and patient counseling regarding medication adherence were effective in improving the medication adherence has consistent results with a study conducted by Kavita et al.
There is significant reduction in the mean values of various risk factors. The findings were consistent with a study conducted by Sharma etal. on nurse-led intervention for risk factors modifications which also suggested the significant reduction in behavioral risk factors in intervention group.
The study concludes that task sharing for managing NCDs in nurse led NCD clinic is feasible and effective in increasing the screening rates, risk factors modification, and improved medication adherence. The study recommends the involvement of nurses in NCDs prevention and control. The study also had limitation that due to COVID-19 pandemic. Cervical cancer screening was not feasible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Abbafati C, Abbas KM, Abbasi-Kangevari M, Abd-Allah F, Abdelalim A, Abdollahi M, et al. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396:1223–49.
2. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, 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.
3. Joshi R, Peiris D. Task-sharing for the prevention and control of non-communicable diseases. Lancet Glob Health 2019;7:e686–7.
4. Joshi R, Thrift AG, Smith C, Praveen D, Vedanthan R, Gyamfi J, et al. Task-shifting for cardiovascular risk factor management:Lessons from the global alliance for chronic diseases. BMJ Glob Health 2018;3:e001092.
5. Joshi R, Pakhare A, Kumar S, Khadanga S, Joshi A. Improving the capacity of nurses for non-communicable disease service delivery in India:How do they fare in comparison to doctors?. Educ Prim Care 2019;30:230–6.
6. The Top 10 Causes of Death. Available from: https://www.who.int/newsroom/fact-sheets/detail/the-top-10-causes-of-death
. Last accessed on 2021 Jun 18.
7. Mendis S, Al Bashir I, Dissanayake L, Varghese C, Fadhil I, Marhe E, et al. Gaps in capacity in primary care in low-resource settings for implementation of essential noncommunicable disease interventions. Int J Hypertens 2012;2012:584041.
8. Randall S, Crawford T, Currie J, River J, Betihavas V. Impact of community based nurse-led clinics on patient outcomes, patient satisfaction, patient access and cost effectiveness:A systematic review. Int J Nurs Stud 2017;73:24–33.
9. Kavita K, Thakur JS. Epidemic of non-connunicable diseases:Role of nurse practitioners. Nurs J India 2015;106:274–7.
10. Sharp A, Riches N, Mims A, Ntshalintshali S, McConalogue D, Southworth P, et al. Decentralising NCD management in rural southern Africa:Evaluation of a pilot implementation study. BMC Public Health 2020;20:44.
11. Joint National Committee (JNC) Guidelines For Hypertension. Available from: https://medicoapps.org/m-joint-national-committeecommitteejnc-guidelines-for-hypertension/
. Last accessed on 2021 Jul 14.
12. Directorate General of Health Services, Ministry of Health & Family welfare, Government Of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS); Operational Guidelines (revised: 2013–17); 2013. Available from: http://www.karnataka.gov.in/hfw/nhm/Documents/NPCDCS%20Final%20Operational%20Guidelines.pdf
. Last accessed on 2021 Jun 30.
13. World Health Organization. Prevention of Cardiovascular Disease: Guidelines for assessment and management of cardiovascular risk 2007.
14. Kripalani S, Risser J, Gatti ME, Jacobson TA. Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease. Value Health 2009;12:118–23.
15. Ministry of Health and Family Welfare Government of India. Available from: https://www.mohfw.gov.in/
. Last accessed on 2021 Jun 30.
16. Kar SS, Thakur JS, Jain S, Kumar R. Cardiovascular disease risk management in a primary health care setting of north India. Indian Heart J 2008;60:19–25.
17. Kavita K, Thakur JS, Ghai S, Narang T. Effectiveness of interventions by nurse practitioners for prevention and control of noncommunicable diseases in low-and middle-income countries:A systematic review protocol. IJNCD 2020;5:143.
18. Ramakrishnan S, Zachariah G, Gupta K, Rao JS, Mohanan PP, Venugopal K, et al. Prevalence of hypertension among Indian adults:Results from the great India blood pressure survey. Indian Heart J 2019;71:309–13.
19. Paul D, Kavita K, Thakur JS, Sikka P. Effectiveness of nurse led screening and intervention for common non communicable diseases in a peri urban community of Chandigarh. Int J Community Med Public Health 2020;7:4485–92.
20. Jeffery RA, To MJ, Hayduk-Costa G, Cameron A, Taylor C, Zoost CV, et al. Interventions to improve adherence to cardiovascular disease guidelines:A systematic review. BMC Fam Pract 2015;16:147.
21. Kavita K, Thakur JS, Vijayvergiya R, Ghai S. Task shifting
of cardiovascular risk assessment and communication by nurses for primary and secondary prevention of cardiovascular diseases in a tertiary health care setting of Northern India. BMC Health Serv Res 2020;20:10.
22. Sharma M, Banerjee B, Ingle GK, Garg S. Effect of mHealth on modifying behavioural risk-factors of non-communicable diseases in an adult, rural population in Delhi, India. Mhealth 2017;3:42.