Scaling Up Community-based Noncommunicable Disease Research into Practice in Pokhara Metropolitan City of Nepal (SCALE-NCD) - Modified Project Summary/Abstract Rapid globalization and urbanization continue to escalate the burden of non-communicable diseases (NCD) across the world. 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 physicians 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 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 urban Nepal, where there is a well-established CHW programs with robust governance and operational system, making it an ideal place to test. 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 from the study area that significantly reduced BP and fasting BG, and improved smoking cessation rate in semi-urban areas 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 order to institutionalize and sustain the intervention, 2) Understand reach, 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 over time, including policy makers, implementors, advocates, health professionals, CHWs, and patients with NCDs. Our study in Nepal provides a valuable model for the U.S. by demonstrating how task-sharing with CHWs can effectively manage hypertension, diabetes, and tobacco use in resource-constrained settings. Leveraging Nepal’s long-standing and well-functioning CHW systems, the study offers practical implementation insights that are relevant to underserved communities in the U.S., where access to care remains uneven. Our team has already initiated pilot work in the Washington, DC–Maryland–Virginia (DMV) area to assess current care delivery and identify opportunities and models for CHW integration, enabling concrete next steps toward adopting integrated comorbidity management in the U.S. The findings also contribute to advancing implementation science methodologies and developing scalable frameworks for managing multiple chronic conditions through team-based care; an area of growing priority in U.S. Results will be widely disseminated through domestic conferences, further contributing to implementation scientists. Finally, given the disproportionate cardiovascular disease burden among South Asian populations in the U.S., this research offers culturally and epidemiologically relevant strategies that could be adapted to improve outcomes in these high-risk population.
