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 Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 3  |  Page : 143-148

Effectiveness of interventions by nurse practitioners for prevention and control of noncommunicable diseases in low- and middle-income countries: A systematic review protocol

1 National Institute of Nursing Education Post Graduate Institute of Medical Education and Research(PGIMER), Chandigarh, India
2 Department of Community Medicine And School of Public Health, PGIMER, Chandigarh, India
3 Department of Dermatology, Venereology and Leprology PGIMER, Chandigarh, India

Date of Submission06-Jun-2020
Date of Decision11-Aug-2020
Date of Acceptance26-Aug-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Kavita Kavita
National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jncd.jncd_24_20

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Introduction: Low- and middle-income countries (LMICs) face numerous challenges in the implementation of noncommunicable disease (NCD) prevention programs due to a shortage of health manpower. Task shifting to nurses is a viable and effective solution to address the health-care human resource crisis. The major advantage of involving nurses is that they are the largest, skilled, and already established workforce in any health-care institution. Despite the effectiveness of NCD interventions by nurse practitioners (NPs), there is a relative lack of evidence from LMICs which prevents the scale-up of the NPs model for better health outcomes. We, therefore, intend to assess the existing evidence on the effectiveness of interventions by NPs for the management of chronic NCDs in LMICs.
Methods and Analysis: Electronic databases, i.e., PubMed, Excerpta Medica Database (EMBASE), CINAHL, Cochrane Central Register of Controlled Trials, and clinical registries of different LMICs in the English language shall be searched between 2004 and 2019 (last 15 years). Research designs to be included are randomized controlled trials, before–after studies, and Quasi-experimental studies. The primary outcome includes the change in behavioral risk factors, physiological risk factors, and clinical parameters. Subgroup and sensitivity analysis will be performed.
Ethics and Dissemination: Ethical approval has been obtained from the institute ethics committee. Results will be disseminated through peer-reviewed scientific journals and presentation at national and international conferences.
Study Design: Systematic review.
PROSPERO registration number CRD42019118430

Keywords: Low- and middle-income countries, noncommunicable diseases, nurse practitioners, systematic review protocol

How to cite this article:
Kavita K, Thakur J S, Ghai S, Narang T. Effectiveness of interventions by nurse practitioners for prevention and control of noncommunicable diseases in low- and middle-income countries: A systematic review protocol. Int J Non-Commun Dis 2020;5:143-8

How to cite this URL:
Kavita K, Thakur J S, Ghai S, Narang T. Effectiveness of interventions by nurse practitioners for prevention and control of noncommunicable diseases in low- and middle-income countries: A systematic review protocol. Int J Non-Commun Dis [serial online] 2020 [cited 2021 Feb 25];5:143-8. Available from: https://www.ijncd.org/text.asp?2020/5/3/143/296791

  Introduction Top

Noncommunicable diseases (NCDs) are the major cause of mortality worldwide. In 2012, there were 56 million total global deaths, out of which nearly two-third, i.e., 68% (38 million) were due to NCDs. Among NCDs deaths, four major diseases were responsible for 82% of these deaths. Cardiovascular diseases (CVDs) contributed nearly half (46.2%), i. e., 17.5 million of all NCD deaths, followed by cancer 21.7% (8.2 million), respiratory diseases 10.7% (4.0 million), and diabetes 4% (1.5 million).[1],[2]

It is further projected that disability-adjusted life years will be three times, whereas mortality will be five times more than of communicable diseases by the year 2030.[3] The burden of NCD is enormous in low- and middle-income countries (LMICs). Age-standardized NCD death rates in 2012 were higher in low-income (625/100,000) and lower-middle-income (673/100,000) countries in comparison to high-income countries (397/100,000) with the global average of 539/100,000 population.[1]

These four NCDs (cardiovascular diseases, cancer, respiratory diseases, and diabetes) share common risk factors which are to a large extent preventable.[4] Many countries have witnessed a decline in NCD risk factors due to major public health interventions/programs.[5],[6],[7],[8],[9],[10] However, implementing a prevention program is challenging in developing countries because of scarce health manpower.[11] Among the various resources required, the availability of human resources is vital for executing the prevention program.

Considering the high burden of NCDs combined with the continued shortage of human resource for health (HRH), task shifting is a priority. Task shifting refers to the “transferring of clinical tasks from physicians to trained nonphysician health workers, e.g., nurses.”[12],[13] Task shifting is feasible in LMICs who are facing a shortage of HRH. Some of the tasks that can be shifted include screening/management, counseling/health education, adherence counseling, follow-ups, and referral.[14]

Although the task shifting can be done with various categories of health workers, nurses are ideal for this task shifting as they are the key health-care providers and one of the largest workforces in any health-care institution.[15] Nurses can be trained as nurse practitioners (NPs) and involved in various tasks for the prevention and management of NCDs ranging from screening, CVD risk assessment, and lifestyle counseling to higher order tasks such as diagnosing, initiating treatment, and follow-ups for medication adjustments.[14],[16]

Internationally, the trend has favored the training of NPs. A framework for the implementation and sustainability of NCD interventions by NPs in both dependent and independent (nurse-led clinics) roles is well documented in the high-income countries.[17],[18],[19],[20],[21],[22],[23],[24],[25],[26]

Some of the reasons for opting NPs models are as follows: they are already an established and sometimes largest category of the workforce in the country so the creation of a new category of health workers is not required, NP-led services are cost-effective and also because of expertise and skills of nurses. Moreover, NPs are flexible multiskilled workforce that provides a wide range of curative and preventive services. They can deliver many of the basic clinical and public health services at a lower cost than trained physicians.[27],[28]

However, evidence related to the involvement of NPs in NCDs management from LMICs is inadequate,[29],[30],[31],[32],[33] although there is the availability of some studies related to the involvement of community health workers in the prevention and management of NCDs, in LMICs.[34],[35],[36],[37] Hence, the systematic review will be undertaken with the aim to assess the existing evidence on the effectiveness of interventions by NPs for the management of chronic NCDs in LMICs.

The review will include studies done in the last 15 years. The time period is chosen to focus on most recent evidence and also because of the fact that more work on task shifting is done in the last 15 years, primarily after the first global conference on task shifting which was convened by the World Health Organization (WHO) in January 2008, where the WHO global recommendations and guidelines for task shifting were formally launched.[38],[39]

NP is a commonly used term in the developed world, and their role and scope is well defined. However, in the developing countries, their role is still evolving, and there is great diversity and variation in the nomenclature. As the job title of nurses varies among country and within country, so for the purpose of this review, NP is defined as “a registered nurse who are carrying out intervention for the prevention and control of common NCDs and holding an academic professional qualification of diploma in “general nursing and midwifery” (GNM) and above (GNM/B. Sc Nursing/M. Sc Nursing/Ph. D)”.

  Methods Top

The protocol of the review is drafted based on the PICO approach (population, intervention, comparison, and outcome) and “Preferred Reporting Items for Systematic Reviews and Meta Analyses Protocols checklist” [Supplementary File S1] has been adhered to while preparing the protocol of the review.


Population in the present review will be individuals >18 years diagnosed with any one or more of the selected chronic diseases (i.e., type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke or chronic obstructive pulmonary disease, and breast, cervical, and oral cancer) and residing in LMICs.

Intervention details

Intervention by nurses ranging from disease prevention and health promotion to diagnosing and managing common NCDs will be considered. It will include nurse-led preventive/promotive/curative/rehabilitative interventions or in combination for prevention and control of common NCDs (type 2 diabetes mellitus, hypertension, cardiovascular disease, stroke or chronic obstructive pulmonary disease, and breast, cervical, and oral cancer).

Studies with NP role in patient diagnosis (disease condition/risk factors), investigations (ordering, conducting, supervising, and interpretation), management (and referral) and prescribing medication (unrestricted and restricted medication), prescription of nonpharmacologic therapies, and counseling individuals, families, and groups for the prevention and management of common NCDs will be included.

NPs working in both independent and dependent roles, i.e., who practice autonomously or in collaboration with health-care professionals and other individuals to assess, diagnose, treat, and manage the patient's health problems/needs will also be within the scope of this review. Interventions carried out at all the health-care settings, i.e., primary, secondary, or tertiary will be included. Interventions with both single and multicomponent will be considered and included. Studies will be excluded in which NP role cannot be distinguished from that of other professionals because it would be difficult to distinguish that the desired effect is the result of the nurse-led intervention.


Routine care. Participants in the routine care (control) group continued on going care from a general practitioner or primary care physician or AYUSH doctor including all face-to-face and telephonic consultations.

Primary outcome

  • Change in behavioral risk factors.

  • Improper diet, physical inactivity, tobacco, and alcohol use

  • Change in physiological risk factors.

  • Body mass index and blood pressure – systolic and diastolic

  • Change in clinical parameters.

  • Blood glucose, total cholesterol, low-density lipoprotein, and high-density lipoprotein cholesterol

    Secondary outcome

  • Change in health service utilization.

Inclusion criteria and exclusion criteria

The studies will have to fulfill a number of criteria in order to be included. First, the study should be randomized controlled trials (RCTs)/cluster RCTs/controlled trials/before–after studies/quasi-experimental studies.

Second, only those interventions will be selected that are carried out by a NP (as defined in the review) in LMICs.

The study will be excluded if any of the above mentioned criteria is not met.

Studies will also be excluded where NP's role cannot be distinguished from that of other professionals or a multidisciplinary team or the studies in which nurses have only distributed the teaching material or have an intervention with a web-based tool. Research publications will be excluded when they are written in a language other than English or where the intervention is done by health worker or auxiliary nurse midwife or lady health visitor or male health worker, or accredited social health activist (ASHA). Qualitative studies will also be excluded.

Search strategy

The multistage search strategy will be used to retrieve maximum relevant evidence related to NPs role in chronic NCDs in LMICs. We will search “PubMed, Excerpta Medica Database (EMBASE), CINAHL (EBSCOhost), The Cochrane Library of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), WHO library by using a well framed search strategy.” The search strategy will include a combination of MeSH terms, Emtree, text terms, synonyms, etc., [Supplementary File S2]. The search period will be limited to the last 15 years (2004–2019).

Additional searches to identify relevant literature will include Scopus, Web of science, WHO International Clinical Trials Registry Platform (ICTRP) portal and ClinicalTrials.gov. In addition, clinical registries of different LMICs will also be explored.

A manual search of reference lists of articles identified through above mentioned search will also be done. Bibliographies of the systematic and nonsystematic review will be examined. Conference proceedings, unpublished reports, and other gray literature will be searched on appropriate databases (e.g., www.asco.org/ASCO/meeting, www.greylit.orgetc). Relevant individuals/authors of the trials/organization will also be contacted through telephone/email for any clarity in methodology, analysis, or outcome if required. LMICs will be defined using the World Bank classification 2019.[40]

Selection of trials

All the titles and abstracts identified in the search will be imported in reference manager software (EndNote). Two reviewers will independently review the abstracts. In case of disagreement, the full text will be reviewed for better assessment, and if disagreement persists, then the third reviewer will be involved. Full text of all the articles meeting the inclusion criteria will be retrieved. Multiple reports of the same study will be considered as one trial.

Extraction and management of data

Data abstraction form will be developed after discussion with all the reviewers in Microsoft Excel 2010. The data abstraction form will be piloted and modified as per the suggestions of the review team. Data will be extracted using this form in duplicate. Two independent reviewers (KK and TN) will extract the data. Any disagreement among reviewers will be resolved by discussion, but if the disagreement persists, it will be resolved by the final decision of the third reviewer (JST). Data will be extracted for study detail (author, publication date and time, etc.), study methods (inclusion and exclusion criteria, randomization, allocation concealment, blinding, etc.), details of the intervention (type of intervention, content, delivery, duration of intervention, and follow-up period), and outcome (observer-reported outcomes and patient-reported outcome). In addition, detail about funding source and declaration of interests for the primary investigators will also be collected.

Risk of bias assessment

The Cochrane EPOC risk of bias guidelines will be used for assessing the risk of bias for included studies.[41] Two reviewers will independently undertake assessment of risk of bias (KK/TN/SG) and the third reviewer (JST) will be involved in case of disagreement. Each study will be categorized in either of the three levels, i.e., low risk, high risk, and unclear risk after the assessment of sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data for short-term and long-term outcomes, and selective reporting.[42] In addition to the Cochrane risk of bias tool, we will also use the EPHPP quality assessment tool.[43] Outcome level assessment of risk of reporting bias will be performed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Assessment of heterogeneity

Heterogeneity and variability in relation to the participant, intervention, comparison, and outcome among the studies will be assessed.

Similarities and dissimilarities among studies will be looked at to assess clinical and methodological heterogeneity. Where meta-analysis is undertaken, heterogeneity will be assessed using visual inspection of overlap of CIs and statistical heterogeneity. Statistical heterogeneity will be measured by visual inspection of forest plots and will be quantified using by X2 and I2 statistics. I2 value between 50% and 100% shall represent substantial heterogeneity, whereas value between 0% and 50% shall indicate that heterogeneity is not important or within reasonable limits. Subgroup analysis will also be done to investigate heterogeneity. Subgroups analysis will be based on patient characteristics, trial characteristics, qualification of NPs, and also on the area of work, e.g., prevention, surveillance, or management. In case of statistical heterogeneity is high, then the data will not be pooled statistically and only narrative synthesis of the data will be done.

Data analysis

The meta-analysis will be done if two or more studies are homogenous in terms of population, methods, intervention, and outcome. We propose to use a random effect model due to anticipated heterogeneity between studies.

Continuous data will be summarized by pooled mean differences and 95% CI. For dichotomous outcomes, relative risk and 95% CI will be reported.

Assessment of reporting biases

Funnel plots will be used if there are more than 10 trials for the outcome. Asymmetry in the plots will indicate publication bias.

Data synthesis

Data synthesis will be done using RevMan for windows. A separate meta-analysis will be done for each outcome. A Forest plot will be formulated for each outcome. The quality of evidence for each outcome will be assessed using GRADE.

Patient and public involvement statement

No patients or members of the public were involved in the design of the systematic review.

Ethics and dissemination

Ethical approval of the institute ethics committee of the Post Graduate Institute of Medical Education and research, Chandigarh, has been obtained. Dissemination will be done through peer-reviewed journals and presenting the results at relevant conferences and meetings.

Strengths and limitations

  1. The review will generate evidence on the effectiveness of interventions done by NPs for the prevention and control of NCDs in LMICs
  2. This review will be first of its kind to generate an evidence from LMICs
  3. The evidence generated may guide and draw the attention of the policymakers for optimum utilization of the existing nursing workforce in NCD prevention
  4. This review will focus only on LMICs.

  Discussion Top

Achieving sustainable developmental goals requires significant strengthening and optimal utilization of HRH. There is extensive evidence in the literature to suggest that some forms of task shifting to NPs have been adopted formally and informally in response to the human resource needs. Through this review, we aim to explore their success in NCD prevention. This will help to conclude on NP's role in NCD prevention and promote a formal framework that can support task shifting as a national strategy for organizing the nursing health workforce in LMICs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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