Nurse-led interventions for prevention and control of noncommunicable diseases in low- and middle-income countries: A systematic review and meta-analysis : International Journal of Noncommunicable Diseases

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Systematic Review Article

Nurse-led interventions for prevention and control of noncommunicable diseases in low- and middle-income countries

A systematic review and meta-analysis

Kavita, Kavita; Thakur, Jarnail Singh1; Ghai, Sandhya; Narang, Tarun2; Kaur, Rajbir1

Author Information

National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India

1Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India

2Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Address for correspondence: Dr. Kavita Kavita, National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]

Received October 31, 2022

Received in revised form November 29, 2022

Accepted February 21, 2023

International Journal of Noncommunicable Diseases 8(1):p 4-13, Jan–Mar 2023. | DOI: 10.4103/jncd.jncd_74_22
  • Open

Abstract

Introduction

Noncommunicable diseases (NCDs) are the major cause of mortality worldwide. Nearly 41 million people die each year due to NCDs which is equivalent to 71% of all deaths globally. Cardiovascular diseases (CVDs) contribute to most of the NCD deaths (17.9 million) annually followed by cancer (9.3 million), respiratory diseases (4.1 million), and diabetes 4% (1.5 million).[1] More than 15 million NCD deaths are premature, i.e., between the ages of 30 and 69 years. These four groups of diseases account for 80% of all premature NCD deaths. The burden of NCD is enormous in low- and middle-income countries (LMICs) as 77% of all deaths and 85% of premature deaths are in these countries.[2] These four NCDs (CVDs, cancer, respiratory diseases, and diabetes) share common risk factors which are to a large extent preventable.[3] Evidence suggests that NCDs can be prevented with appropriate primary and secondary prevention strategies. Many countries have witnessed a decline in NCD risk factors due to major public health interventions/programs.[4,5,6,7,8,9] However, implementing prevention program is challenging in developing countries due to the scarce health workforce.[10] Among various resources required, the availability of human resources is vital for executing prevention program.

In response to the human resource for health (HRH) deficit, many countries have adopted task shifting which refers to the “transferring of clinical tasks from physicians to trained nonphysician health workers, for example, nurses.”[11] Although task shifting can be done with various categories of health workers, nurses are ideal for this task shifting as they are the key health-care providers and one of the largest workforce in any health-care institution.[12] Being professionals, nurses can be trained to take up some of the higher-order tasks such as diagnosing, initiating treatment, and medication adjustment based on the prespecified algorithms for different NCDs in addition to other tasks such as screening, CVD risk assessment, and lifestyle counseling.[13,14] Evidence from the high-income countries suggests that nurse-led NCD interventions are effective and sustainable where they work in both dependent and independent (nurse led clinics) roles.[14,15,16,17,18,19,20,21,22,23]

Although there is availability of some studies related to the involvement of community health workers in the prevention and management of NCDs in LMICs,[24,25,26,27] evidence related to the involvement of nurses in NCDs management from LMICs is inadequate.[28,29,30] Hence, the systematic review was undertaken with the aim to assess the existing evidence on the effectiveness of interventions by nurses for the management of chronic NCDs in LMICs.

Methods

For this systematic review and meta-analysis, we used a multistage search strategy to retrieve maximum relevant evidence related to nurse practitioners' role in chronic NCDs in LMICs. [Appendix p 1-2] We developed a search strategy in PubMed and modified for use in other databases (EMBASE, CINAHL, and CENTRAL) for locating articles for the past 15 years to focus on the most recent evidence and also due to the fact that more work on task shifting is done in the past 15 years, primarily after the first global conference on task shifting which was convened by the World Health Organization (WHO) in January 2008, where the WHO Global recommendations and guidelines for task shifting were formally launched.[31,32] Additional searches were done in Scopus, Web of Science, and WHO International Clinical Trials Registry Platform portal, ClinicalTrials.gov, and Clinical registries of different LMICs were also explored. Manual searching was done using citations and reference list of included studies. Bibliographies of the systematic and nonsystematic reviews were also examined. LMICs were defined using the World Bank classification.[33]

We included randomized controlled trials (RCTs)/cluster RCTs/controlled trials/before[FIGURE DASH]after studies/quasi-experimental studies that were done in LMICs. To be included the intervention must have been carried out by a registered nurse on patients aged 18 years and above with NCDs (type 2 diabetes mellitus, hypertension (HTN), CVD, stroke or chronic obstructive pulmonary disease (COPD), and breast, cervical, and oral cancer). We excluded studies where the interventions were led by health workers/Accredited Social Health Activist/Anganwadi workers. Studies, where nurses' role cannot be distinguished from that of other professionals or a multidisciplinary team, were also excluded.

The literature search was done by one author (KK) in consultation with other authors. All the titles and abstracts identified in the search were imported into reference manager software (EndNote). After removing the duplicates remaining citations were reviewed based on titles to obtain relevant abstracts by using Rayyan software. All selected abstracts were independently reviewed by two reviewers (KK and RK) to retrieve full-text articles for review. Two authors independently reviewed full texts of selected studies for final inclusion in the review. Any disagreement was resolved by consultation with the third author (JST). Multiple reports of the same study were considered as one trial. Our study protocol was registered in the PROSPERO database (CRD42019118430).

The Cochrane risk of bias tool was used to assess the quality of included studies.[34] [Appendix p 2] Data extraction form was developed and piloted to extract data in duplicate by two authors (KK/TN). Any disagreement was resolved by discussion but if the disagreement persists third reviewer (JST) made the final decision. We extracted data for study detail (author, country, publication date and time, etc.), study methods (inclusion and exclusion criteria, randomization, allocation concealment, blinding, etc.), details of the intervention (type of intervention, content, delivery, duration of intervention, and follow-up period), and outcome (observer-reported outcomes and patient-reported outcome). In addition, detail about funding source and declaration of interest for the primary investigators was also collected. We extracted the outcome measurements for systolic blood pressure (SBP), diastolic blood pressure (DBP), glycated hemoglobin (HbA1c), fasting blood sugar (FBS), low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC), and triglycerides (TG).

Statistical analysis

A narrative synthesis of all the included articles was done. For meta-analysis, eligible studies were included for each outcome. In meta-analysis, only RCTs and cluster RCTs were included. For cluster RCTs, average cluster size, intracluster correlation coefficient, and design effect were used to calculate the effective sample size for the study. We used a random effect model with an inverse variance approach to assign appropriate weights for each study.

Results

We identified 2097 references from all databases, 62 of which were duplicates. We screened 2035 titles and 582 abstracts for eligibility and promoted 74 articles for full-text review. Of the 74 articles selected for full-text review, 35 were excluded. A total of 39 articles were included in the narrative synthesis with 15,672 participants [Figure 1].

F1-2
Figure 1:
Literature search and article inclusion

General characteristics of included studies

Of the 39 studies included in the review, there were 24 RCTs, five cluster RCTs, two quasi-experimental, seven before-after studies, and one controlled before-after study. Studies were done in India (4),[35,36,37,38] Bangladesh (1),[39] Brazil (3),[40,41,42] Nigeria (2),[43,44] Iran (3),[45,46,47] Turkey (3),[48,49,50] China (8),[51,52,53,54,55,56,57] Sri Lanka (1),[58] Ghana (4),[59,60,61,62] Malaysia (2),[63,64] Cameroon (4),[65,66,67,68] Ethiopia (1),[69] Thailand (2),[70,71] and South Africa.[72] Sixteen of the studies were with patients with diabetes mellitus, 10 with HTN, four with both diabetes and HTN, two with stroke, six with coronary artery disease, and one with dyslipidemia. The sample size ranged from 35 to 3977 participants [Appendix p 3-12]. The role of nurses in the majority of the studies was nonpharmacological education and counseling. Only three studies involved drug treatment protocols and adjustments in medications. Subgroup analysis for all the outcomes was performed by study population and sample size.

Effect of nurse-led interventions on outcomes

Systolic blood pressure

Regarding the effect of nurse-led interventions on SBP we included 18 studies (15 RCTs and three cluster RCTs) in the analysis. A total of 2916 study participants (intervention group [n = 1459] and control group [n = 1457]) were included in the meta-analysis for SBP. Overall the average pooled mean difference in SBP was −4.30 (95% confidence interval [CI] −7.07–−1.54) [Figure 2]. The Chi-square test showed significant heterogeneity (χ2 = 163.6, P < 0.01, I2 = 90%) Sensitivity analysis was done to assess heterogeneity by excluding each study. The exclusion of one study[46] decreased the overall heterogeneity from 90% to 66% without much affecting the pooled estimate. The funnel plot for publication bias did not show any asymmetry [Appendix p 13]. The overall quality of evidence based on Grading of Recommendations Assessment, Development, and Evaluations (GRADE) was low [Appendix p 14].

F2-2
Figure 2:
Changes in the SBP comparing nurse-led intervention group to usual care. SBP - Systolic blood pressure

Diastolic blood pressure

A total of 17 studies with 2856 participants were included in the metanalysis for DBP [Figure 3]. Overall, the average pooled mean difference in DBP was −3.04 (95% CI −4.82–−1.26) [Figure 1]. The Chi-square test showed significant heterogeneity (χ2 = 336.37, P < 0.01, I2 = 95%) Sensitivity analysis was done to assess heterogeneity by excluding each study. The exclusion of two studies[45,46] decreased the overall heterogeneity from 95% to 53% without much affecting the pooled estimate. The funnel plot for publication bias did not show any asymmetry [Appendix p 13]. The overall quality of evidence based on GRADE was low.

F3-2
Figure 3:
Changes in the DBP comparing nurse-led intervention group to usual care. DBP [FIGURE DASH] Diastolic blood pressure

Glycated hemoglobin

A total of 14 studies with 2400 participants were included in the metanalysis for HbA1c [Figure 4]. Overall, the average pooled mean difference in HbA1c was −0.73 (95% CI −1.08–−0.38). The Chi-square test showed significant heterogeneity (χ2 = 78.45, P < 0.01, I2 = 83%) sensitivity analysis was done to assess heterogeneity by excluding each study. There was not much variation in the heterogeneity. The funnel plot for publication bias did not show any asymmetry. The overall quality of evidence based on GRADE was low.

F4-2
Figure 4:
Changes in the HbA1c comparing nurse-led intervention group to usual care. HbA1c [FIGURE DASH] Glycated hemoglobin

A total of eight studies with 1496 participants were included in the metanalysis for FBS [Figure 5]. Overall, the average pooled mean difference in FBS was − 8 (95% CI −13.42–−2.58). The Chi-square test showed moderate heterogeneity (χ2 = 15.59, P < 0.03, I2 = 55%) Sensitivity analysis revealed not much variation in the heterogeneity by excluding each study. The funnel plot for publication bias did not show any asymmetry. The overall quality of evidence based on GRADE was moderate.

F5-2
Figure 5:
Changes in the FBG comparing nurse-led intervention group to usual care. FBG [FIGURE DASH] Fasting blood glucose

A total of 11 studies with 1344 participants were included in the metanalysis for LDL [Figure 6]. Overall, the average pooled mean difference in LDL was −5.33 (95% CI −11.58–−0.92). The Chi-square test showed significant heterogeneity (χ2 = 43.56, P < 0.01, I2 = 77%) sensitivity analysis was done to assess heterogeneity by excluding each study. The removal of one study[48] decreased the heterogeneity from 77% to 52%. The funnel plot for publication bias did not show any asymmetry. The overall quality of evidence based on GRADE was very low.

F6-2
Figure 6:
Changes in the LDL comparing nurse-led intervention group to usual care. LDL [FIGURE DASH] Low-density lipoprotein

A total of 12 studies with 1448 participants were included in the meta-analysis for HDL [Figure 7]. Overall, the average pooled mean difference in HDL-c was −0.03 (95% CI −1.50–1.45). The Chi-square test showed significant heterogeneity (χ2 = 37.84, P < 0.01, I2 = 71%) sensitivity analysis was done to assess heterogeneity by excluding each study. The removal of one study significantly reduced the heterogeneity from 71% to 30%. The funnel plot for publication bias did not show any asymmetry. The overall quality of evidence based on GRADE was low.

F7-2
Figure 7:
Changes in the HDL comparing nurse-led intervention group to usual care. HDL [FIGURE DASH] High-density lipoprotein

A total of 11 studies with 1306 participants were included in the meta-analysis for TC [Figure 8]. Overall, the average pooled mean difference in TC was −11.18 (95% CI − 20.06–−3.57). The Chi-square test showed significant heterogeneity (χ2 = 49.9, P < 0.01, I2 = 80%) Sensitivity analysis was done to assess heterogeneity by excluding each study. The exclusion of two studies[48,63] reduced the heterogeneity from 80% to 54%. The funnel plot for publication bias did not show any asymmetry. The overall quality of evidence based on GRADE was low.

F8-2
Figure 8:
Changes in the TC comparing nurse-led intervention group to usual care. TC [FIGURE DASH] Total cholesterol

A total of 11 studies with 1395 participants were included in the meta-analysis for TG [Figure 9]. Overall, the average pooled mean difference in TG was −12.20 (95% CI − 23.52–−0.87). The Chi-square test showed significant heterogeneity (χ2 = 35.3, P < 0.01, I2 = 72%) Sensitivity analysis was done to assess heterogeneity by excluding each study. The funnel plot for publication bias did not show any asymmetry. The overall quality of evidence based on GRADE was low.

F9-2
Figure 9:
Changes in the TG comparing nurse-led intervention group to usual care. TG [FIGURE DASH] Triglycerides

Discussion

We did a systematic review of available literature on nurse-led intervention and quantitatively synthesized the population average pooled mean difference for SBP, DBP, HbA1c, FBS, LDL, HDL, TC, and TG. Our findings support the use of nurse-led interventions for the management of HTN, diabetes mellitus, and dyslipidemias.

Task shifting and task-sharing interventions can be useful to address the HRH deficit in LMICs. Although tasks related to the management of NCDs can be shifted or shared with different categories of nonphysician health workers, nurses are the ideal choice to manage these tasks. Nurses are professionally trained so are better equipped to take up higher-order tasks. Our review favored the nurse-led intervention for the prevention of NCDs. Findings are consistent with another review where dose-response relationship was observed based on health-care worker cadre, i.e., workers with better training and experience of autonomy may be more effective in treating NCDs.[73] However, economic evaluations are also required to justify the involvement of nursing professionals in NCD prevention.

For blood pressure, the overall pooled estimate showed a reduction of −4.8 mmHg and −3.31 mmHg in systolic and DBP, respectively, which might have a significant public health significance. Hardy et al. have also demonstrated that modest population-wide shifts in SBP could have a substantial impact on CVD incidence.[74] Framingham Heart Study investigators observed 6% reduction in coronary heart disease risk and 17% decrease in HTN prevalence with 2 mmHg population-wide reduction in DBP.[75] The findings of our review are consistent with the review done by Anand et al.[76]

A significant reduction of −0.73 (95% CI −1.08–−0.38) and −0.8 (95% CI − 13.42–−2.58) was observed in our pooled estimate for HbA1c and FBS, respectively. Khaw et al. reported that a reduction of population means by 0.1% and 0.2% in HbA1c was associated with a reduction in mortality by 12% and 25%, respectively.[77] Thus, population distribution and reduction of HbA1c can have significant public health impact. In STENO 2 study, Vaag reported the role of glycemic control in the prevention of microvascular and macrovascular disease.[78] Our findings are consistent with the review done by Maria et al. where authors found a significant reduction in averaged pooled mean difference for HbA1c.[79]

High cholesterol levels are a predictor of cardiovascular events. Jeong et al.[80] in their study demonstrated that increased cholesterol levels were associated with high CVD risk in young adults. The result of our meta-analysis showed a statistically significant reduction in TC and TG. The findings of our review are consistent with the systematic review done by Anand et al. where a statistically significant reduction was observed in TC and LDL with task-sharing interventions.[81]

Nurses' role in most of the included studies was nonpharmacological, i.e., mainly focusing on lifestyle modification. Lack of prescription authority for nurses in LMICs may be the contributing factor. Whereas in high-income countries, nurses are successfully working as nurse practitioners in the independent role and also as a part of the health team.

Our study results imply that nurse-led interventions for the management of NCDs need to be scaled up. However, expanding the role of nurses in LMICs for the management of NCDs will also require policy considerations and legal protection for the tasks the nurses undertake. Health system support in terms of training, guidance, and logistics will play a key role in the successful scaling up of nurse-led interventions.[82] The role of nurses also needs to be well defined. It is also recommended that task shifting should occur at all levels, i.e., some of the tasks can be shifted from nurses to lower cadre health workers so that they are not overburdened and can provide quality care.

Strengths and limitations

The strengths of the present review are that our review is registered in PROSPERO and we searched multiple databases to retrieve relevant literature. The inclusion of quasi-experimental/pre-post studies in addition to RCTs and cluster RCTs also provided more insight into the nurses' role in NCDs.

The review also has limitations. First is that we included studies only in the English language. Hence, we might have missed certain relevant articles in other languages. We could not get studies related to nurse-led interventions for COPD and cancers.

Conclusion

Policymakers must consider the role of nurses in NCD prevention and strengthening the National NCD program. Strengthening and optimal utilization of nurses can contribute significantly for achieving sustainable developmental goals.

Ethical approval

Ethical approval was obtained from the Institute Ethics Committee of the Post Graduate Institute of Medical Education and Research, Chandigarh.

Financial support and sponsorship

The authors received a grant under World NCD Federation – IAPSMCON2021 strategic partnership.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

The authors acknowledge the contribution of the center of excellence for evidence-based research on NCDs in LMICs.

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Keywords:

Low- and middle-income countries; noncommunicable diseases; nurse-led interventions; nurse practitioners; systematic review

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