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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)

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