Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh


Background: Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD
deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10
million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation
of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and
acceptability in two NCD clinics within two primary-care centres in Bangladesh.

Methods: We used a convergent mixed methods design. We first assessed the level of appropriate hypertension
and cardiovascular disease patient management, based on a composite outcome indicator using data from
patients’ treatment cards. Appropriate management was primarily informed by International Diabetes Federation
(IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with
doctors and patients to explain these quantitative findings and to understand the challenges to achieving
appropriate patient management in the NCD clinics.

Results: Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of
patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis
alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level
of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a
shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined
patients’ willingness to attend clinics and doctors’ willingness to offer follow-ups. Hands-on skill-building training
was valuable in increasing doctors’ competence for appropriate management, but was seen as a novel training
method and faced constraints to implementation.

Conclusions: A clinical guide, skill-based training and recording package can be implemented in routine primary
care and can lead to appropriate management of around half of diabetic and hypertensive patients in a lowincome country. However, considerable health systems challenges must be addressed before more patients can be
managed appropriately.

Keywords: Non-communicable disease, Diabetes, Hypertension, Primary health care, Bangladesh

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