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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. Outline. Global Burden of Cardiovascular Disease

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Maheer khan m sc

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.



  • 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

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)

CVD Mortality

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

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

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

  • 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)

    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

    Phase 5: Curriculum Design

    • Curriculum Content

      • Trainer Manual

      • Workbooks for NPHW

      • 9 Modules delivered over 1 week

      • Pre-post module tests

    Phase 6: Developing the OSCE

    • Preferred method of evaluation in clinical exams*

    • Advantages of this approach

    • Challenges we faced in developing the OSCE

    • Evaluation


    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

    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

    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

    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

    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