Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Older adults with pre-existing noncommunicable conditions and their healthcare access amid COVID-19 pandemic: a cross-sectional study in eastern Nepal.

BACKGROUND: COVID-19 has greatly impacted older adults with pre-existing noncommunicable conditions (hereafter called pre-existing conditions) in terms of their access to essential healthcare services. Based on the theory of vertical health equity, this study investigated access to healthcare by Nepali older adults with pre-existing conditions during the COVID-19 pandemic. METHODS: A cross-sectional study surveyed 847 randomly selected older adults (≥60 years) in three districts of eastern Nepal. Survey questionnaires, administered by trained community health workers, collected information on participants reported difficulty obtaining routine care and medications during the pandemic, in addition to questions on demographics, socioeconomic factors and pre-existing conditions. Cumulative scores for pre-existing conditions were recoded as no pre-existing condition, single condition and multimorbidity for the analyses. χ2 tests and binary logistic regressions determined inferences. RESULTS: Nearly two-thirds of the participants had a pre-existing condition (43.8% single condition and 22.8% multimorbid) and reported experiencing difficulty obtaining routine care (52.8%) and medications (13.5%). Participants with single (OR 3.06, 95% CI 2.17 to 4.32) and multimorbid (OR 5.62, 95% CI 3.63 to 8.71) conditions had threefold and fivefold increased odds of experiencing difficulty accessing routine care. Findings were similar for difficulty obtaining medication (OR single: 3.12, 95% CI 1.71 to 5.69; OR multimorbid: 3.98, 95% CI 2.01 to 7.87) where odds were greater than threefolds. CONCLUSIONS: Older adults with pre-existing conditions in Nepal, who require routine medical care and medication, faced significant difficulties obtaining them during the pandemic, which may lead to deterioration in their pre-existing conditions. Public health emergency preparedness should incorporate plans for both managing the emergency and providing continuing care.