Original Research

Early impact of the PEN HEARTS package to manage noncommunicable diseases in Bhutan: a mixed-methods evaluation


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Karma Tenzin1
MBBS, MD, Assistant Professor

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Lora L Sabin2
MA, PhD, Associate Professor *

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Wangchuk Wangchuk3
BSc, MPH, Assistant Professor

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Karma Choden4
BSc, MSc, Senior Lecturer

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Frank Feeley5
JD, Associate Professor

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Sangay Zam6
BPH, MPH, Senior Lecturer

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Nafisa Halim7
MA, PhD, Research Assistant Professor

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Bolanle Banigbe8
MD, MPH, Doctor of Public Health Program

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Zimba Letho9
BSc, MSc, Senior Program Manager

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Emily R George10
DrPH, RN, Doctor of Public Health Program

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Kinzang Yangden11
BPH, Associate Lecturer

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Jennifer Beard12
MPH, PhD, Clinical Associate Professor

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Rebecca West13
MPH, Doctor of Public Health Program

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Gampo Dorji14
MPH, DrPH, Technical Officer


1, 3, 4, 6, 11 Khesar Gyalpo University of Medical Sciences, Menkhang Lamg, Thimphu, Bhutan

2, 5, 7, 8, 10, 12, 13 Department of Global Health, School of Public Health, Boston University, 801 Massachusetts Avenue, Crosstown, 3rd Floor, Boston, MA 02118, USA

9 Jigme Dorji Wangchuck National Referral Hospital, Menkhang Lamg, Thimphu, Bhutan

14 World Health Organization South-East Asia Regional Office, Parsvnath Capital Tower, Bhai Vir Singh Marg Gole Market, New Delhi, 110001, India

ACCEPTED: 11 May 2022

early abstract:

Introduction: Noncommunicable diseases (NCDs) pose significant public health challenges in Bhutan. In 2019, Bhutan’s Ministry of Health (MoH) introduced a set of interventions associated with the World Health Organization’s Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Income Settings called PEN HEARTS. This initiative encompassed six components: healthy lifestyle intervention, evidence-based protocols, access to medicines and technology, risk-based management, team-based care, and systems monitoring. Evaluations of PEN interventions in other countries documented barriers to implementation. The present report provides the result of a 2019-2020 evaluation assessing implementation of PEN HEARTS in Bhutan and initial impacts on provision of care for NCDs and patient outcomes.
Methods: A cross-sectional, mixed methods evaluation was conducted in six districts, two where the interventions were first initiated, two where they were implemented subsequently, and two where no implementation had begun. In each district, data were collected at the district hospital and three basic health units (BHUs). Quantitative data collection encompassed facility checklists, health worker surveys, and patient record abstraction. For the survey, health workers were selected using random or convenience sampling depending on facility size. For patient record abstraction, enumerators created a sampling frame at each facility to include eligible patients who were then selected randomly for record review. Qualitative data collection included in-depth interviews (IDIs) with health workers, and IDIs with NCD patients. A convenience sample of health worker IDI participants was selected randomly at hospitals; all health workers at BHUs were invited to participate. A convenience sample of NCD patients was recruited from facility waiting rooms on the day(s) of data collection. Lastly, a convenience sample of homebound patients was recruited to participate in IDIs. Quantitative analysis methods included bivariate analysis of categorical and continuous variables, and pairwise comparisons among groups. Qualitative data were analyzed using thematic content analysis with inductive coding.
Results: N=153 health workers participated in the knowledge survey and n=121 patient records were reviewed. IDIs were conducted with 13 health workers, 18 hospital or BHU patients, and four homebound patients. Most elements of the PEN HEARTS program were implemented as planned, including monitoring and supervision. PEN HEARTS had a positive impact on disease control: Group A districts had a significantly lower proportion of patients with a treatment gap (p<.001) and a significantly higher proportion of patients retained in care (p<.001). Health workers experienced implementation challenges in four main areas: human resources, medicine shortages, equipment failure, and record-keeping. They also described benefits from increased supervision and peer support. Patients described experiencing more patient-centered care and overall positive experiences with the program.
Conclusion: The evaluation identified areas of PEN HEARTS implementation that should be strengthened and improved, particularly training, record-keeping, and the use of AUDIT and cardiovascular disease risk assessments. However, the evaluation also showed evidence of improved disease control across achievement of treatment goals, reduction of treatment gaps, and improved patient retention in care. PEN HEARTS has potential to make a difference for NCD patients and focusing on improving future implementation may further yield benefits in Bhutan.