Adapting the WHO package of essential noncommunicable disease interventions, Samoa

Abstract Problem Samoa has been struggling to address the burden of noncommunicable diseases at the health system, community and individual levels. Approach The World Health Organization (WHO) package of essential noncommunicable disease interventions for primary health care in low-resource settings was adopted in seven villages throughout Samoa in 2015. The National Steering Committee Members designed and implemented a screening process, and local facilitators and health-care workers collected health and lifestyle data. The WHO/International Society of Hypertension risk assessment was used on villagers older than 40 years to identify people at high risk of noncommunicable disease. Local setting Samoa is a small island developing state with increasing morbidity and mortality due to noncommunicable diseases. A national representative survey indicated that 50.1% (595/1188) of the Samoan adult population is at high risk of such diseases. High numbers of noncommunicable diseases are undiagnosed or untreated, because of shortage of health-care staff and lack of awareness of risk factors. Relevant changes The teams collected data from 2234 adults. For people older than 40 years, 6.7% (54/804) were identified as being at high-risk and were encouraged to seek treatment or manage risk factors. Community members developed an awareness programme to improve understanding of lifestyle risk factors. Lessons learnt Engaging community members was crucial in conducting a successful screening campaign. By identifying those villagers at high risk of developing noncommunicable diseases, early intervention was possible. Education improved awareness of the symptom-free nature of early-stage noncommunicable diseases.


Introduction
More than 90% of premature and largely preventable deaths from noncommunicable diseases, including cardiovascular disease, cancers, chronic lung diseases and diabetes, occur in low-and middle-income countries. 1 Most premature deaths are linked to the four established risk factors of tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. 1 The social burden associated with noncommunicable diseases includes prolonged disability, diminished resources within families and reduced productivity, in addition to tremendous demands on health systems. 2 The World Health Organization (WHO) designed the package of essential noncommunicable disease interventions for primary health care in low-resource settings as an innovative and action-oriented response to the above challenges. 3 The four protocols of the package, a prioritized set of cost-effective interventions, which aim to integrate noncommunicable disease care into primary health care, 4 are: (i) prevention of heart attack, stroke and kidney disease through management of diabetes and hypertension; (ii) health education; (iii) management of asthma and chronic obstructive pulmonary disease; and (iv) assessment and referral of women with breast and cervical cancer.
We describe how the first two protocols of the WHO package were adapted and implemented to suit the local context in Samoa, engaging the community and training local facilitators in the use of early detection and assessment tools, with the aims of: (i) strengthening links between health services and the community; and (ii) meeting the global target of at least 50% of eligible people receiving treatment and counselling through early detection and management of noncommunicable diseases. 5

Local setting
Human health resources are constrained in Samoa with a chronic shortage of doctors and nurses; there also exists an inequitable distribution of health professionals and services, with the majority being concentrated in the capital city of Apia. The bulk of patients (70-80%) seen by health professionals have noncommunicable diseases. 6 A national representative study of the noncommunicable disease risk factors in 2013, 7 based on the WHO STEPwise approach to surveillance, 8 indicated that 50.1% (595/1188) of the Samoan adult population is at high risk of developing a noncommunicable disease. The survey found a high incidence of previously undiagnosed and untreated noncommunicable diseases in the country: over 70% of the population had never had their blood pressure (1265/1765) or blood glucose (1315/1765) measured, and only 30-40% of those diagnosed were using appropriate medication. 7 Identifying those at risk of developing such diseases could prevent the development of serious, debilitating, fatal and/or costly health conditions later in life. Samoa therefore adopted the WHO intervention package at a country level in 2013. 9 The aims of the Fa'a Samoa (Samoan way of life) version of the package were to address key issues in health system delivery, in particular integrating community participation and village Lessons from the field Noncommunicable disease intervention, Samoa Caroline Bollars et al. outreach services to: (i) ensure early detection of noncommunicable diseases in those at risk; (ii) establish mechanisms for referral to district health facilities for treatment and follow-up; and (iii) increase awareness of risk factors. For the adaptation process, seven villages were selected based on their geographical spread: four from the island of Upolu (Sapulu, Lealalii, Moamoa and Tauo' o) and three from the island of Savaii (Vaisaulu, Lalomalava and Safua).

Approach
We adapted the intervention to the Samoan context through the development of a three-step package. The conceptual development of the three-step package took place from September to December 2014, and screening at the pilot sites occurred from February to March 2015.
Step 1 included consultations with stakeholders to introduce the concept of a Fa'a Samoa intervention package. A national steering committee, comprising the health ministry, National Health Service representatives and local WHO Country Office staff, determined the overall direction of the Fa' a Samoa package and established national referral criteria for noncommunicable diseases: 10 symptoms of stroke, hypertension and diabetes; risk factors including smoking, alcohol and inactivity; blood pressure; body mass index; random glucose; cholesterol (total and high-density lipoprotein for those older than 40 years); and WHO/International Society of Hypertension risk prediction. 11 Specific tools for non-health professionals were developed, including: an assessment community registry form on which to record data; a flowchart for referral of patients demonstrating risks; a followup form to record subsequent visits to a health facility; and an awareness project template. All these tools are available from the corresponding author.
Village chiefs nominated one to three representatives of their local Women's Committee (funded by the Ministry of Women, Community and Social Development) as voluntary local facilitators; their role was to brief other committee members, inform all villagers of planned events and assist with the screening. Village members received information at monthly coordination events and church meetings; the screening itself took place in community halls. Primary health-care staff helped to design the screening algorithm, with a focus on the clinical measurements required at each primary health-care facility. 12 Step 2 involved training of local facilitators and health-care workers to form cross-disciplinary outreach teams, each comprising four health professionals and six to 10 local facilitators, and the screening process itself. Training sessions took place at local health facilities during January 2015, costing approximately 500 United States dollars per session for refreshments and disposable testing strips for measuring blood sugar and cholesterol. Local facilitators received training in conducting the basic part of the assessment, recording information such as village, name, age, gender, date of birth, contact number, weight (scales), height (stadiometer), known symptoms and details of any risk factors. Health-care workers were educated on the use of WHO/International Society of Hypertension risk prediction charts.
Between February and March 2015, each outreach team screened all village members older than 18 years for indications of elevated risk. Local facilitators recorded the identities of villagers who attended initial screening, inviting those who did not initially attend to a second screening held in May 2015. Health-care workers performed the clinical measurements of blood pressure (an average of two measurements) and random blood glucose and cholesterol levels (using a CardioChek analyser). Health-care workers did not enforce fasting before clinical measurements. For those older than 40 years, the WHO/International Society of Hypertension risk prediction charts were used to estimate the 10-year risk of a major cardiovascular event by using information on age, sex, smoking status, blood pressure, total cholesterol and random blood glucose level (> 11.1 mmol/L indicating diabetes). Risks are provided in the form of scores, with a score of > 30% interpreted as a high risk of noncommunicable disease development.
In Step 3, screening results in terms of numbers (not identities) were delivered to the community at a public meeting and local facilitators were informed of the identities of villagers at high risk. Those villagers were provided with a personalized management plan, including initiation of a treatment regime and/ or a risk factor consultation. Members of the Women's Committees reported to the village chiefs on those villagers and their attendance at follow-up appointments on a quarterly basis, and the steering committee made visits to the community to assess progress.

Screening results
The teams collected data from 2234 adults between February 2015 and May 2015 (Table 1). Health-care workers measured blood pressure in 1536 adults (70%), of whom 511 (32.7%) had an elevated blood pressure. Of the 1528 adults (68.4%) for whom body mass index (BMI) was measured, 820 (53.7%) had a BMI over 30. For the 1550 villagers (69.4%) for whom random blood glucose data were collected, 108 (7.1%) had elevated levels. Of the screened population older than 40 years, 6.7% (54/806) were classified as being at high risk.
Since the 2011 Population and Housing Census Report from Samoa 13 only provides stratified age group data by statistical region and not by village, we extrapolated the population data to calculate the proportion of the population per village aged over 18 years. Differences in the total numbers of participants are due to missing clinical assessment data, a result of the limited number of health-care workers at the primary level.

Relevant changes
As a result of the Fa'a Samoa intervention package, those high-risk members of the population were made aware of their risk status and were motivated to seek treatment or manage risk factors. Village members learned about the risk of noncommunicable diseases at organized sessions, which brought villagers together and translated findings into their language and understanding. By being made aware that such diseases have no symptoms in their early stages, the cultural belief that illness is only present when a person feels ill was overcome.
After initiation by the steering committee and discussions with the local facilitators, village members chose to develop a noncommunicable disease awareness project. Data from the screening focused the village members on prevention of noncommunicable diseases by, for example, reducing intake of salt, sugar, tobacco and/or alcohol.
Lessons from the field Noncommunicable disease intervention, Samoa Caroline Bollars et al.

Lessons learnt
The Fa'a Samoa intervention package used a community-focused, participatory approach and strengthened links between health services and those they serve: their communities (Box 1). Suc-cessful application of the package was demonstrated in less than a year and results are consistent with the national survey conducted in 2013. 7 The health screening conducted in the villages enabled the detection of people at high risk of developing noncommunicable diseases and raised awareness of disease risk factors through the local facilitators. Critical to this result was the clearly defined three-step Fa'a Samoa package process, including thresholds for assessing risk as defined by national referral criteria, and training both health-care Lessons from the field Noncommunicable disease intervention, Samoa Caroline Bollars et al.
workers and local facilitators in the use of data recording and patient monitoring tools. To scale up to a nation level, including the community, would ensure compliance and help to address the challenges within the health-care system. Although the lack of a digitalized health system in Samoa hindered the collection of data, improvements in data management and the follow-up of those referred could improve adherence to recommended treatment.
Design of the Fa'a Samoa package was based upon existing systems without the need to mobilize additional resources. Replicating the Fa' a Samoa package in other Samoan villages should be feasible without any drain on resources. Village members at high risk of developing noncommunicable diseases can then be identified by their local health facility and receive effective interventions to prevent their condition from progressing to a more serious illness. 14 The Fa'a Samoa package provides an example of the transformation of the health system structure by incorporating communities. We have also highlighted the relevance of training primary healthcare workers and using local community stakeholders in the early detection of noncommunicable diseases. Future community-based interventions could accelerate progress towards the goal of universal health coverage, as detailed in the Tokyo Declaration on Universal Health Coverage. 15

Box 1. Summary of main lessons learnt
• The Fa'a Samoa package strengthened links between health services and their communities through application of a community-focused, participatory approach. • Data management and follow-up of people referred to the health-care facility could be improved to monitor progress of the intervention over time. • Providing the screening results to the community improved understanding of the risks of such diseases, increasing awareness of the symptom-free nature of their early stages.

Adaptación del Conjunto de intervenciones esenciales de la OMS para las enfermedades no contagiosas, Samoa
Problema Samoa se esfuerza por hacer frente a la carga de las enfermedades no contagiosas a nivel del sistema de salud, la comunidad y los individuos. Enfoque En 2015 se aprobó en siete aldeas de Samoa el Conjunto de intervenciones esenciales de la Organización Mundial de la Salud (OMS) para las enfermedades no contagiosas para la atención primaria en entornos de bajos recursos. Los miembros del Comité Directivo Nacional diseñaron e implementaron un proceso de evaluación, mientras que los coordinadores locales y los trabajadores de la salud recopilaron datos sobre la salud y el estilo de vida. La evaluación del riesgo de hipertensión Lessons from the field Noncommunicable disease intervention, Samoa Caroline Bollars et al.