Development and Pilot Testing of a Non-Physician
Healthcare Worker Training Curriculum for the
Assessment and Management of Cardiovascular
Maheer Khan M.Sc.
• Global Burden of Cardiovascular Disease
• Evidence for Task Shifting in Cardiovascular disease
• HOPE-4 Program
• Package of Interventions
• Training Curriculum
• Phases of Development
• Pilot Process
• Contextual Adaptability
• Our Experience
• Next Steps - Policy Implications
Global Burden of NCDs
• Non-communicable diseases (NCDs) caused an
estimated 35 million deaths in 2005
• Four major NCDs – CVD, cancer, chronic
respiratory disease and diabetes – together are
responsible for 28 million deaths a year and
make the largest contribution to the NCD burden
in low and middle income countries (LMIC)
• 60% of all deaths globally are NCDs
• 80% of NCD deaths occur in low and middle
income countries
(WHO 2010)
CVD Mortality
NCD Global Monitoring
• In 2011, WHO developed a global monitoring
framework to enable global tracking of NCDs
• The mortality target – a 25% reduction in premature
mortality from NCDs by 2025
• Mortality target cannot be achieved without
reducing the global burden of CVD in LMIC
• Currently, most LMIC do not have systematic
approaches for screening
• Task-shifting to non-physician healthcare workers is
one potential solution
Evidence for Task Shifting
• Task shifting: the rational re-distribution of tasks
between health care workers
• Basic management of chronic diseases can be shifted
to Non-Physician Healthcare Worker (with physician
oversight), with improved outcomes.
– Callaghan et al., 2010
– Lekoubou et al., 2010
• Supported by WHO Task Shifting-Global
Recommendations and Guidelines
• Joint development of a WHO/PHRI curriculum for
training NPHW in the assessment and management of
Heart Outcomes Prevention and
Evaluation (HOPE-4) Program
• Objective: Implement a programme for CVD risk assessment and
management in select low and middle income countries
• 190 rural and urban communities (10 000 participants) in Asia
(India, Malaysia, Philippines), South America (Colombia,
Argentina), and Sub-Saharan Africa (South Africa, Tanzania,
• Package of Interventions:
– Task shifting to teams of NPHWs using the HOPE-4 Training
– The Polycap (low cost, fixed dose, combination CV
medications (4-5 pills in one) ($5/month)
– Mobile phone technology-text messages*
– Non-Professional Treatment Supporters*
*To improve adherence to medication and lifestyle
HOPE-4 Training Curriculum
• Developed in response to limitations in other CVD
training curriculum
– WHO’s CVD Risk Management Package
– WHO’s Package of Essential NCD interventions
• Interdisciplinary team
• Participation of Stakeholders
- Ministry of Health (Malaysia)
- Ministry of Public Health (Columbia)
Curriculum Development
• Phase 1: Defining the Need
– Standardization
– Defining the ‘fixed’ and ‘adaptable’ elements
• Phase 2: Improving Guidelines
– Multiple Blood Pressure Readings
– Empowering NPHWs
– Cultural Adaptability
• Phase 3: Understanding Task Shifting in a Global Context
– Legal and Ethical Implications
– Experience from HIV/AIDS programs
Phase 4: Defining NPHW Roles
and Responsibilities
NPHW Roles and Responsibilities
1. Understanding risk factors to CVD such as hypertension, diabetes and high blood
2. Expressing competency in assessing risk and potential consequences of high risk
of CVD
3. Showing proficiency with skills relevant to managing and preventing CVD such
as measuring blood pressure and the waist/hip ratio
4. Providing culturally relevant and appropriate counseling
5. Serving as a link between academic researchers and the communities
6. Developing the ability to appropriately conduct patient interviews and counsel
them on lifestyle modifications such as smoking cessation, diet and physical
7. Prescribing treatment regimens with physician oversight
8. Developing the ability to accurately record and organize patient data
Phase 5: Curriculum
• Curriculum Content
• Trainer Manual
• Workbooks for NPHW
• 9 Modules delivered over 1 week
• Pre-post module tests
Module Descriptions
1. Health and Disease
Define the concepts of health & disease
2. Organization and Communication Skills Understand importance of these skills
3. The Cardiovascular System
Understand the basics of the CV system
4. Risk Factors for Cardiovascular Disease Understand the common CVD risk factors
5. Cardiovascular Risk Assessment
Assess overall CVD risk
6. Cardiovascular Risk Prevention and
Learn counseling techniques for
behavioural modification
7. Pharmacological Management of
Cardiovascular Disease
8. HOPE-4 Program Specific Training
Understand the basics of how different
drugs are used to manage CVD
Understand the role of an NPHW
9. Observed Standardized Clinical Exam
of NPHWs
Successfully complete all scenarios
Phase 6: Developing the
• Preferred method of evaluation in clinical exams*
• Advantages of this approach
• Challenges we faced in developing the OSCE
• Evaluation
Sample OSCE Scenario
Information for NPHW:
For this practice scenario, you will need to counsel a
participant on alcohol consumption. The participant is a 56 year old
and admits to drinking 10 beers per day.
Standardized Participant Instructions:
You are a 56 year old participant who consumes over 10 beers
per day. You want to cut back and you realize that your drinking is
negatively impacting your health.
Marking Scheme
NPHW evaluated using a checklist and marked out of seven
Pilot Sessions
• Recruitment of local ‘NPHWs’ and instructor
• Curriculum was delivered in its entirety over 5 sessions, 3.5 hours
• Objective of the sessions
– Determine areas of confusion, inconsistency and misinterpretation
• Evaluation
– NPHWs required to pass all pre/post module tests and OSCE
– Successful completion means NPHWs are trained to go out in the
Contextual Adaptability
• Adaptable elements of the curriculum
– Legal roles of NPHW
– Cultural differences (Columbia and Malaysia
– Teaching styles
• Patient centered approach
– Role playing and discussion activities
– Use of standardized patients
Our Experience
• Lessons Learned:
Interdisciplinary team was an advantage
Difficulties in gauging cultural sensitivities
Re-testing of NPHWs
NPHW and instructor recruitment bias
• What we would do differently:
More active involvement of local stakeholders
Summarize and re-iterate NPHW roles
Better documentation of development process
More objective evaluations
Next Steps – Policy
• Feedback from pilot sessions used to further refine the
• Curriculum has been translated to Spanish and Malay
(April 2014)
• HOPE-4 in Canada
– Aboriginal populations
– Low SES groups
• Success of HOPE-4 could be used to tackle regulatory
barriers preventing re-distribution of tasks in existing
health systems