Intervention design
The following 6 themes emerged during intervention design based on community conversation: (1) Willingness, (2) Importance of family support; (3) incentives for CHWs (4) trainings health workers (5) Basic Equipment (6) Medical supplies
Willingness to have FCM implemented
During the process of intervention development, we received positive feedback about the FCM in relation to willingness for stakeholders to have the FCM implemented to support service delivery in the Zambian context.
“ Yes it will be nice to have people coming to our homes to test us at least once a month for checking our BP’s, and sugar levels…….sometimes this side you find old people sometimes they can’t even manage to come to the clinic because of distance and so coming to our homes will be a good thing”. NCD_indexpatient004
“We are yet to implement screening of NCDs in the communities ….we are in the process like right now….ummm we’ve identified those people with such problems (NCDs) and all we need is to provide services right in the communities. If we form groups and identified people that have those conditions and also if we have like door to door visitations we can be able to identify people with NCD’s and link them to care?. Healthworker_001
Importance of Family support.
It was acknowledged that chronic care was a big problem in the community and that families played a central role in providing care for sick family members. Therefore, training of family members was seen as a crucial ingredient of FCM.
If only they …….(family member) can receive sensitization of these NCDs and how we can prevent them, it can be good for our family because they are the ones who cook and put salt and cooking oil to our food and so they need to be educated also. NCD_indexpatient009.
Family empowerment was seen as an effective way to address shortages in human resources and supporting health system. Talking about this issue, one of the hypertensive patient said:
They are a lot of people suffering from hypertension, it even leads to stroke but they have no one to come and talk to them, even at church or within the communities…I think what you are proposing will work better than at the hospital because some of these old people fear going to the hospital but home they will be that confidentiality. NCD_indexpatient006.
Incentives for CHWs.
Incentives for the CHWs was seen as a crucial part of FCM. This was closely linked to the need to provide training of CHWs as a form of incentive.
“Indeed the use of mobile phones made our work even easier because we were able to contact family members and coordinate the screening process and delivery of essential drugs for hypertensive patients….we had challenges with health facilities in terms of drug stock out, but if this can be addressed, we can reach a lot of people” Healthworker_005
Re-training of health workers.
The importance of having trained health worker in NCDs was emphasized, noting that most of them needed refresher training as NCDs were not seen as a priority from donors. It was also reported that most in-service training provided by government or partners was tailored towards HIV.
“Training in new methods of managing NCDs at facility level and refresher courses for facility staff would be good for us. Currently we have no training opportunities for NCDs, we usually participates in infectious diseases training like HIV, TB and in some cases cervical cancer screening but we equally need refresher training for NCDs” Healthworker_007.
Need for basic Equipment
The majority of participants indicated that most health facilities had limited basic equipment to manage NCDs at health facility level. Most of the equipment’s were either not available or mal-functional
….like diabetes, we don’t have any equipment for that and hypertension we only have the high blood pressure machines…equipment’s are inadequate and in cases where a diabetes patient comes, we just examine them clinically in the lab and send them to Chongwe to have their blood sample checked. Healthworker_001
Medical supplies
From both providers and patients, medical supplies were seen as a bridge between the community and health facilities. The lack of medical supplies especially drugs undermined trust in the health system. One participant had this to say…
We usually experience drug stock out especially essential drugs to manage NCDs has been a challenge for our facility, most often we write prescriptions for the patients to buy on their own. …. Our facility is about 40 plus kilometers from the district pharmacy so if we have a shortage we have to go that far. Healthworker_006
Intervention Feasibility:
Recruitment and group formation
Recruitment of patients was easy and several were happy to act as point of contact persons for others to test for blood pressure in the community. The number of people ranged from 5–8 people per household in the study areas. We approached 9 families. One family declined to take part. So 8 families were screened with a total of 32 family members. Hypertension prevalence was 43.8% (14/32) among all those who were screened.
Communication by WhatsApp in the groups
The groups were coordinated by the WhatsApp whose administrator was a CHWs. The major issues raised related to information about hypertension and new people wanting to join the group from the community. Mobile network coverage was good with internet connectivity working as long as bundles were bought for the groups.
Use of automated blood pressure machines at community level.
The use of automated BP measurements was acceptable, with few encounters of finished batteries and technical problems with cuff placement. With support from CHW, these errors were not reported by the third month in all the four groups.
Refresher training of health workers
From the health system side, we conducted a short refresher course for the Health workers at each health center using national guidelines for hypertension management in Zambia. Most clinicians were aware about the management and just needed few reminders especially consistence in management of patients.
Refresher training in hypertension was very refreshing… currently we have no training opportunities for NCDs, we usually participates in infectious diseases training like HIV, TB and in some cases cervical cancer screening but we equally need refresher training for NCDs