Project Summary
Rapid globalization and urbanization continue to escalate the burden of non-communicable diseases (NCDs)
across the world, disproportionally affecting low- and middle-income countries (LMICs). Nepal is one of the
fastest urbanizing LMICs where the NCD burden has skyrocketed. In Nepal, control of the major three NCD
risk factors – high blood pressure (BP), high blood glucose (BG) and smoking—are dismally low, particularly
in urban areas, due to multiple levels of adverse health determinants. One reason for poor control is a
dearth of physician and nurses. Community health workers (CHWs) can fill this void. To date, trials have
documented that task-sharing with CHWs reduces systolic BP and fasting BG and achieves smoking
cessation. However, most trials have been done in rural areas, and most trials of CHWs tested management
of a single condition, e.g. just hypertension. Furthermore, despite demonstrated impact in systematic
reviews, task-sharing with CHWs is far from being fully implemented in health care delivery systems in
LMICs, including Nepal.
In this context, we propose to conduct the first implementation research study on task-sharing with CHWs for
concurrent management of hypertension, diabetes, and smoking in an urban, LMIC setting. Our
overarching goal is to scale up our demonstrated evidence-based task-sharing interventions to
address three NCD risk factors in which we engage key stakeholders and partners, and use
contemporary mobile health (m-health) tools. This study, a type 2 hybrid effectiveness-implementation
research study, will be conducted in 33 study sites in Pokhara, the second largest city in Nepal. Building
upon our teams’ three CHW-led, home- based interventions that significantly reduced BP and fasting BG,
and improved smoking cessation rate in semi-urban areas in Nepal as well as an m-health intervention that
lowered systolic BP in an urban area in Nepal, we will develop the intervention package named SCALE-
NCD. Our specific aims are 1) Establish a partnership with stakeholders in Pokhara in order to
institutionalize and sustain the intervention, 2) Understand equity, determinants, and structured barriers for
scale-up of the intervention, and 3) Determine the effectiveness of the SCALE-NCD intervention, and its
impact on reach, adoption, fidelity, sustainability, and cost. This study will be led by exceptionally strong
team of implementation scientists, epidemiologists, clinicians, and anthropologists in the field of NCDs who
have built trusted relationship with stakeholders in Nepal over time, including policy makers, implementors,
advocates, health professionals, CHWs, and patients with NCDs. Greater understanding of “how” the
intervention can be scaled up will inform key steps for implementation of task-sharing with CHWs in health
care delivery systems in LMICs.
