Maheer Khan M.Sc.

1. Population Health Research Institute Development and Pilot Testing of a Non-Physician Healthcare Worker Training Curriculum for the Assessment and Management of Cardiovascular Disease Maheer Khan M.Sc. 2014-05-28

2. Outline • Global Burden of Cardiovascular Disease • Evidence for Task Shifting in Cardiovascular disease management • HOPE-4 Program • Package of Interventions • Training Curriculum • Phases of Development • Pilot Process • Contextual Adaptability • Our Experience • Next Steps - Policy Implications

3. Global Burden of NCDs • Non-communicable diseases (NCDs) causedan estimated 35 million deaths in 2005 • Four major NCDs – CVD, cancer, chronic respiratory disease and diabetes – together are responsible for 28 million deaths a year and make the largest contribution to the NCD burden in low and middle income countries (LMIC) • 60% of all deaths globally are NCDs • 80% of NCD deaths occur in low and middle income countries (WHO 2010)

4. CVD Mortality

5. NCD Global Monitoring Framework • In 2011, WHO developed a global monitoring framework to enable global tracking of NCDs • The mortality target – a 25% reduction in premature mortality from NCDs by 2025 • Mortality target cannot be achieved without reducing the global burden of CVD in LMIC • Currently, most LMIC do not have systematic approaches for screening • Task-shifting to non-physician healthcare workers is one potential solution

6. Evidence for Task Shifting • Task shifting: the rational re-distribution of tasks between health care workers • Basic management of chronic diseases can be shifted to Non-Physician Healthcare Worker(with physician oversight), with improved outcomes. • Callaghan et al., 2010 • Lekoubou et al., 2010 • Supported by WHO Task Shifting-Global Recommendations and Guidelines • Joint development of a WHO/PHRI curriculum for training NPHW in the assessment and management of CVD

7. Heart Outcomes Prevention and Evaluation (HOPE-4) Program • Objective: Implement a programme for CVD risk assessment and management in select low and middle income countries • 190 rural and urban communities (10 000 participants) in Asia (India, Malaysia, Philippines), South America (Colombia, Argentina), and Sub-Saharan Africa (South Africa, Tanzania, Rwanda). • Package of Interventions: • Task shifting to teams of NPHWs using the HOPE-4 Training Curriculum • The Polycap (low cost, fixed dose, combination CV medications (4-5 pills in one) ($5/month) • Mobile phone technology-text messages* • Non-Professional Treatment Supporters* • *To improve adherence to medication and lifestyle modifications

8. HOPE-4 Training Curriculum • Developed in response to limitations in other CVD training curriculum • WHO’s CVD Risk Management Package • WHO’s Package of Essential NCD interventions • Interdisciplinary team • Participation of Stakeholders • Ministry of Health (Malaysia) • Ministry of Public Health (Columbia)

9. Curriculum Development • Phase 1: Defining the Need • Standardization • Defining the ‘fixed’ and ‘adaptable’ elements • Phase 2: Improving Guidelines • Multiple Blood Pressure Readings • Empowering NPHWs • Cultural Adaptability • Phase 3: Understanding Task Shifting in a Global Context • Legal and Ethical Implications • Experience from HIV/AIDS programs

10. Phase 4: Defining NPHW Roles and Responsibilities

11. Phase 5: Curriculum Design • Curriculum Content • Trainer Manual • Workbooks for NPHW • 9 Modules delivered over 1 week • Pre-post module tests

12. Module Descriptions

13. Phase 6: Developing the OSCE • Preferred method of evaluation in clinical exams* • Advantages of this approach • Challenges we faced in developing the OSCE • Evaluation *(Zayyan,2011)

14. Sample OSCE Scenario • Information for NPHW: • For this practice scenario, you will need to counsel a participant on alcohol consumption. The participant is a 56 year old and admits to drinking 10 beers per day. • Standardized Participant Instructions: • You are a 56 year old participant who consumes over 10 beers per day. You want to cut back and you realize that your drinking is negatively impacting your health. • Marking Scheme • NPHW evaluated using a checklist and marked out of seven

15. Pilot Sessions • Recruitment of local ‘NPHWs’ and instructor • Curriculum was delivered in its entirety over 5 sessions, 3.5 hours each • Objective of the sessions • Determine areas of confusion, inconsistency and misinterpretation • Evaluation • NPHWs required to pass all pre/post module tests and OSCE scenarios • Successful completion means NPHWs are trained to go out in the field

16. Contextual Adaptability • Adaptable elements of the curriculum • Legal roles of NPHW • Cultural differences (Columbia and Malaysia experience) • Teaching styles • Patient centered approach • Role playing and discussion activities • Use of standardized patients

17. Our Experience • Lessons Learned: • Interdisciplinary team was an advantage • Difficulties in gauging cultural sensitivities • Re-testing of NPHWs • NPHW and instructor recruitment bias • What we would do differently: • More active involvement of local stakeholders • Summarize and re-iterate NPHW roles • Better documentation of development process • More objective evaluations

18. Next Steps – Policy Implications • Feedback from pilot sessions used to further refine the curriculum • Curriculum has been translated to Spanish and Malay (April 2014) • HOPE-4 in Canada • Aboriginal populations • Low SES groups • Success of HOPE-4 could be used to tackle regulatory barriers preventing re-distribution of tasks in existing health systems