Diabetes - national program for prevention and control of cancer - diabetes - cardio-vascular
diseases and stroke - screening
Introduction
India is in the grip of an epidemic of non-communicable diseases (NCD). They are responsible
for sizeable mortality and morbidity.[1]
[2] Sensing this growing concern, Ministry of Health and Family Welfare, Government
of India, launched the National Program for Prevention and Control of Cancer, Diabetes,
Cardio-vascular Diseases and Stroke (NPCDCS). This program envisages provision of
preventive, promotive, curative and supportive services to people with NCDs at various
levels of health-care starting from the sub-center level to tertiary hospitals. At
the sub-center level, three types of the package of services are planned viz. health
promotion for behavior change, “opportunistic" screening using blood pressure and
blood glucose measurement. Suspected cases are referred to the next level of health-care
for conformation and further management.[3]
Program evaluation enables program improvement. Information gathered from such an
evaluation process can help school administrators make decisions about maintaining
or modifying programs and allocating resources wisely. Both qualitative and quantitative
research are designed to gain knowledge on program functioning. Both methods have
different strengths, weakness. While, quantitative data explains the why and how of
your program, qualitative data explains the what, who and when.[4]
This qualitative study was planned with the objective of assessing the current status
of the implementation of NPCDCS piloted at sub-center level in one district of Haryana
and to assess the views of the community regarding this newly launched program.
Materials and Methods
Personal interviews were conducted by trained personnel using a guide of items grouped
in two heading viz. views of health-care workers about the implementation of the program
and views of people who availed screening services under the program. Meetings were
held with patients who attended the out-patient diabetes clinic in General Hospital
Naraingarh, Ambala. The following topics were incorporated in the individual interviews:
How was your experience of being screened under this program? Would you like to elaborate
on the problems faced by you (if any) in this process of screening? This group consisted
of twelve suspected diabetes screened patients.
Furthermore, a team of filed investigators visited villages and interviewed eight
patients in their houses. A focus group discussion was planned with the community
leaders (two from every village). They were asked to relate the weakness of this newly
launched program. Finally, health-care workers of the selected villages were interviewed
to gain insight into their point of view regarding implementation of the program.
Interviews were tape recorded and later transcribed by the principal investigator.
During their field visit, the investigators observed some screening sessions. Data
collected was typed and later theoretical categories were defined.
Discussion
It has often been highlighted in public health debates that some health programs do
succeed, but many fail to meet their objective in some way or the other. There have
been dramatic successes of health programs such as the eradication of smallpox, guinea
worm and goiter and the near eradication of polio, though a bit delayed. Contrary
to this, there has been the failure in reducing the prevalence of anemia by launching
the national program for control of anemia. Unfortunately, anemia control efforts
in population groups have suffered from stressing on single interventions, i.e., iron
supplementation. A behavioral change communications strategy to promote a balanced
diet and compliance with iron supplements has been the ignored component of this program.
With an aim of doing operational research aimed at improving program effectiveness
of the newly launched NPCDCS we tried to analyze the results of the present study
in the context of the design reality gap. Design is what our government wants its
people to get from the health program. Reality is current field situation. The larger
is this design reality gap, the greater risk of failure and equally the smaller the
gap, the greater the chance of success. Some of the pitfalls and redressal mechanisms
in the implementation of this program are enlisted in the subsequent paragraphs.
Inadequate priming
The first identified gap is that between the desired and actual preparation of community
for a new program component. People were ill-informed, a reason why there was poor
response to the screening component of this program. Screening is not a simple activity,
because individuals who participate in screening consider themselves to be healthy
and do not have any symptoms. Further screening is not just a test and labeling strategy
condition. It should be linked with interventions and treatment. Program planners
and implementers have a special duty of care when conducting investigations on apparently
healthy asymptomatic person in screening programs. It is desired to make a person
aware of the limitations of screening and the uncertainties, in particular the chance
of false positive and false negative results. They need to be explained any follow
up plans, including the availability of referral, counseling and support services.
Referral continuity gap
The second identified gap was referral continuity gap. There was no required referral
arrangement for screened patients. As a minimum a carefully designed standard operating
procedures should be included in the screening process. This should include interpreting
test results and the assistance of referral health-care institution in case of positive
screening.
Training gap
The third identified gap was training gap. No training modules were given to health-care
workers. Training should be extensive and using the latest teaching techniques. The
use of audio-visual aids and interactive lecture sessions increase the transfer of
knowledge. Furthermore, refresher course sessions need to be planned for them.
Faulty and invalidated hard component
The continuing screening activity with these fault kits raises doubts on the seriousness
of health planners in the successful implementation of this health program. Questions
arise when it comes to making such diagnostic kits available for large scale screening.
Before rolling out the program establishing validity (sensitivity and specificity)
should have been established. Invalidated faulty kits create considerable confusion
and generate ethical concerns. It is morally necessary to discuss screening in terms
of human rights. Labeling a person as diseased with faulty kit is a serious error.
Such mass screening program should be regulated and labeled as research until it the
diagnostic kits validity is established.
Health promotion gap
Our observations point out to aggressive stressing on diagnostic screening. It is
in this context that sound understanding of the NCD management is necessary. Screening
kits will not serve to influence a choice of healthy life-style. There is need of
a comprehensive, systematic, coordinated approach to affecting long-term health behavior
change by influencing the norms of people through health education. Long-term behavior
change is very difficult for most people. Strategies must provide people with health
information and develop opportunities for people to practice healthful choices and
encouraging them.
Manpower gap
Persistent gaps in manpower exist at the primary health-care level. The existing health
manpower is overburdened by the manual tasks is collecting and transmitting data.
Already there is established integrated diseases surveillance project (IDSP) system
in place for transmission of information related to NCD (regular periodic surveillance).
The IDSP is so designed that it has a dedicated team of experts for undertaking the
scheduled activities of surveillance, data transfer and maintenance of records. Further,
in this era of mobile-health improving operational efficiency through health services
research can be a viable option. Mobile devices with smart application will enable
health workers to record the data and send it electronically to concerned health centers.
Conclusion
In conclusion, this newly launched program needs some modifications in its implementation.
Priming work by means of informing and educating people before and after launching
a health program should be done. Referral support for screened patients should be
in place. Induction training and thereafter refresher training at regular intervals
should be given to health-care professionals. Mobile health and using existing mechanism
of transmission of information can ease the manpower gap.
