The longitudinal effects of Primary Health Care (PHC) interventions on the prevention and control of non-communicable diseases in Kosovo

Background and Context:
Healthy lifestyle behaviours play a crucial role in the prevention and control of non-communicable diseases (NCDs). Limited scientific literature exists on the prevention and control of NDCs such as diabetes and hypertension in Kosovo. The Accessible Quality Healthcare (AQH) project, funded by the Swiss Agency for Development and Cooperation (SDC) and implemented by the Swiss Tropical and Public Health Institute (Swiss TPH), has run in Kosovo since 2016, with a specific focus on improving the primary healthcare (PHC) services through control of NCDs in the public primary health care system. Some interventions of the AQH project, such as the delivery of motivational counseling sessions, tackle behavioural NCD risk factors such as unhealthy diets, tobacco use, physical inactivity and harmful use of alcohol.
These behaviour change interventions of AQH consist of: 1) health information campaigns using mass media, 2) community-based education sessions on diabetes and hypertension delivered by NGOs, targeting specific population groups, 3) health caravans (community awareness raising events), and 4) nurse-guided individual motivational counselling targeting specific sub-groups of public primary health care users.
Specifically, with regard to last point, the AQH project implements the WHO ‘Packages of Essential Non-Communicable Disease (PEN) Protocols’ (1), which were adapted for the Kosovo context by local experts. In this context, Health Resource Centers were embedded into local Main Family Medical Centers (MFMC). If a patient seen in the MFMC fulfils one or more of the following criteria: known hypertension, known diabetes, history of hypertension and/or diabetes in the family (first-degree relatives), age>40, smoker, or is overweight or obese, the family doctor refers the patient to the Health Resource Center for nurse-guided motivational counselling aimed at behaviour changes.
Implementation of the AQH service packages started in 2018 in 5 pilot municipalities with the delivery of individual motivational counselling sessions as one element of this intervention. Before it is rolled out in all municipalities, it is important to evaluate the update and achieved impact of the intervention to further improve and scale it up. The patient preference and needs perspective need to be considered. For example, there is limited understanding of barriers to physical activity among patients with diabetes and hypertension in Kosovo.
In order to evaluate the AQH interventions and to obtain data on lifestyle behaviours and NCDs in Kosovo public primary health care seekers, the Kosovo Non-Communicable Disease Cohort (KOSCO) cohort was set-up (5).
Aims:
This PhD thesis is embedded into the KOSCO cohort and pursuits the following specific aims:
The first aim of this PhD thesis is to assess the effectiveness of motivational counseling sessions delivered in primary healthcare centers and provide evidence for designing tailored behaviour change interventions in the future.
The second aim is to assess individual and structural barriers to physical activity perceived by patients with diabetes and/or hypertension and to inform health care providers and policy-makers in Kosovo on strategies for promoting physical activity.
The third aim is to assess multiple behaviour change interventions delivered by AQH on the following outcome measures: a) physical activity and nutrition behaviours; b) stages of behaviour change for physical activity and nutrition; and c) Body Mass Index (BMI).
Methods and Results:
The PhD dissertation corresponds to a mixed-methods embedded design based on Creswell and Clark’s (2); other studies have also used this study design by embedding qualitative research in a longitudinal quantitative study (3). Likewise, in our study, we used quantitative and qualitative methods to achieve the aims of this dissertation. For quantitative methodology, data were drawn from KOSCO study where participants are being follow-up every 6 months alternating between a telephone interview and face-to-face interview with clinical measurements. The qualitative methodology was achieved through in-depth interviews, which were conducted with twenty-six participants who were KOSCO participants that attended the motivational counselling sessions.
At the first cohort follow-up (October 2019-February 2020), only 22% of the eligible participants in the intervention municipalities obtained motivational counselling. Unhealthy behaviours were common even in persons who underwent motivational counselling (of whom 13% were smokers; 86% physically inactive; 93% with inadequate fruit and vegetable consumption; and 61% were obese); only the rate of smoking was lower in those who obtained counselling. Among smokers, over 80% were still in the precontemplation phase of behaviour change.
Qualitative interviews revealed three main themes relating to such barriers. They were as follows: 1) neighbourhood built environment, 2) health-related problems, and 3) social support.
At the third follow-up in September 2020 and February 2021 after the implementation of AQH interventions in 5 municipalities, there was no effect of residing in an Early Stage Implementation Municipality (ESIM) of the behaviour change interventions on self-reported adherence to WHO physical activity and nutrition guidelines, but adherence to both guidelines was higher in ESIM at the latest follow-up time point. ESIM residence was also associated with a two-fold increase in the probability of reporting a high motivation for a better lifestyle and with a statistically non-significant decrease in BMI of -0.14 kg/m2 (95%-CI: -0.46 to 0.19) at the latest follow-up.