Noncommunicable Disease Prevention and Control in Mongolia: A Policy Analysis.

BACKGROUND: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCD-related policies introduced in Mongolia align with the World Health Organization (WHO) 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. METHODS: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified. RESULTS: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008-2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards. CONCLUSIONS: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease, physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice

Noncommunicable disease prevention and control in Mongolia: a policy analysis

Background: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCD-related policies introduced in Mongolia align with the World Health Organization (WHO) 2008– 2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs.Methods: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified.Results: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008– 2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008– 2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards.Conclusions: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease,physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice

Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers\u27 perspectives and experiences

BACKGROUND: Hypertension and diabetes, key risk factors for cardiovascular disease, are significant health problems globally. As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000, clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011. This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting. METHODS: A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level, as well as to gain insight into how practitioners view the usability and practicality of the guidelines. Ten family health centres were randomly chosen from a list of all the family health centres (n = 136) located in Ulaanbaatar City. In each centre, a focus group discussion with nurses (n = 20) and individual interviews with practice doctors (n = 10) and practice managers (n = 10) were conducted. Data was analysed using a thematic approach utilising the Theoretical Domains Framework. RESULTS: The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice. They also reported having attended guideline training sessions which were focused on practice skill development. The majority of participants expressed satisfaction with the wide range of resources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines. The resources, supplied from 2011 onwards, included screening devices, equipment for blood tests, medications and educational materials. Other enablers were the participants\u27 commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines. Primary care providers reported a number of challenges in implementing the guidelines, including frustration caused by increased workload and long waiting times, time constraints, difficulties with conflicting tasks and low patient health literacy. CONCLUSIONS: This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low resource primary care settings. It also offers some key lessons that might be carefully considered when other evidence-based clinical guidelines are to be put into effect in low resource settings and elsewhere

The adoption of roles by primary care providers during implementation of the new chronic disease guidelines in urban Mongolia: a qualitative study

(1) BACKGROUND: In 2011, new chronic disease guidelines were introduced across Mongolia. No formal advice was provided regarding role delineation. This study aimed to analyse the roles that different primary care providers adopted, and the variations in these, in the implementation of the guidelines in urban Mongolia; (2) METHODS: Ten group interviews with nurses and ten individual interviews each with practice doctors and practice directors were conducted. Data was analysed using a thematic approach based on the identified themes relevant to role delineation; (3) RESULTS: There was some variability and flexibility in role delineation. Factors involving teamwork, task rotation and practice flexibility facilitated well the guideline implementation. However, factors including expectations and decision making, nursing shortage, and training gaps adversely influenced in the roles and responsibilities. Some role confusion and dissatisfaction was identified, often associated with a lack of training or staff turnover; (4) CONCLUSIONS: Findings suggest that adequate ongoing training is required to maximize the range of roles particular provider types, especially primary care nurses, are competent to perform. Ensuring that role delineation is specified in guidelines could remove confusion and enhance implementation of such guidelines

Primary prevention of cardiovascular disease and diabetes in Mongolia: The role of primary care

This thesis examines three domains to address the noncommunicable disease (NCD) burden in Mongolia – Prevalence, Policy and Practice. In Mongolia, since 2000 cardiovascular disease (CVD) has been the leading cause of population mortality. The aim of this PhD study is to strengthen the NCD prevention and control policy and practice by exploring the prevalence trends of overweight and obesity in Mongolian adults, the government responses to the burden of NCDs and implementing the clinical guidelines in the primary care setting to reduce commonly occurring NCDs. <br>    A combination of quantitative and qualitative research methods to address the aims of this PhD was used. The studies estimating the <b>PREVALENCE</b> of obesity among Mongolian adults provided trends and dynamics in the obesity prevalence over time using international and Asian-specific BMI cut-off points. Under the prevalence, two studies were conducted: the first focused on analysing trends in the prevalence of overweight and obesity among Mongolian adults during the past decade; and the second examined whether increases in waist circumference (WC) were greater than expected from changes in weight in Mongolian adults. In this study we also estimated changes in the age-standardised prevalence of four categories of obesity (not obese; obese by WC only; obese by body mass index (BMI) only; obese by both BMI and WC) in order to assess the potential for underestimating the increasing burden of obesity in Mongolian adults when only considering weight or BMI. <br>    The findings of the first study indicate that the age standardised prevalence of overweight and obese individuals increased from 36.9% to 53.3% for men and from 52.3% to 63.3% for women between 2005 and 2013. The impact of using different obesity measures and cut-off points reflected in substantial differences in the prevalence of obesity, defined by the international and Asian-specific BMI cut-off points. The age-standardised prevalence of obesity in men and women across all time points defined by the Asian-specific BMI cut-off points was approximately 1.5-2 times that of the international BMI cut-off points. <br>    International evidence suggests that WC is increasing at a faster rate than weight and abdominal obesity because WC may be a more accurate predictor of the metabolic risks of obesity compared to BMI. The findings of the second study show that increase in WC rose more than 1.3 cm in 2009 and by 1.9 cm in 2013 than expected from increases in weight. Almost one in six persons in 2013 were classified as ‘obese by WC only’ and these individuals would not be detected as obese if they were screened by BMI alone. Therefore, the studies demonstrated evidence of significant increases in the prevalence of overweight and obesity for Mongolian adults between 2005 and 2013. Additionally, they provided evidence of the importance of measuring obesity using WC and not only BMI. <br>    The analysis of POLICY involved reviewing NCD-related policy documents (n=45) in Mongolia. The policies were analysed against the objectives and recommended actions of the WHO 2008-2013 NCD Action Plan. The findings of the <b>POLICY</b> review demonstrate that the importance of a timely and coordinated response to the emerging burden of NCDs appears to be well recognised by Mongolia’s government. The main characteristics of government responses were a top-down and population health-based approach paralleled with health systems strengthening and emphasis on primary health care. However, the study revealed some areas for further improvement such as developing strategies to address chronic respiratory disease, promoting physical activity, educating the public with diet guidelines, introducing better regulation of food and beverage marketing especially to children and enhancing targeted NCD research funding. <br>    Under the practice, two studies were conducted: first focused on analysing enablers and barriers in the implementation of the clinical guidelines on hypertension and diabetes in urban Mongolia; and the second examined the roles of different primary care providers in implementing the guideline. The studies on implementation <b>PRACTICE</b> involved semi-structured interviews (n=30). The interviews were conducted across ten family health centres (FHCs) chosen from a list of all the FHCs (n = 136) located in urban Mongolia with primary care nurses (n = 20), practice doctors (n = 10) and practice managers (n = 10). In the first study, data was analysed using a thematic approach utilising the Theoretical Domains Framework (TDF). This exploration of the implementation of the clinical guidelines on hypertension and diabetes identified several core drivers for the successful implementation, in particular, continuing medical education, face-to-face instruction, monitoring and feedback, supply and resource and ongoing support. In contrast, the study also identified the following problems, such as time constraints, demands from other competing tasks and increased workload that prevent the primary care providers from adhering to the guidelines’ recommendation. Findings of the second study suggest that adequate ongoing training is required to maximise the range of roles particular provider types, especially primary care nurses. Therefore, we conclude that comprehensive investment in distribution and implementation strategies is essential for successful implementation of the guidelines. <br>    This PhD project creates a valuable contribution to addressing the three P’s holistically, namely prevalence or problem, policy and practice in the concerted efforts of NCD prevention and control in Mongolia and advancing the evidence base in the field of NCDs that has been increasing dramatically in the world

Noncommunicable Disease Prevention and Control in Mongolia: A Policy Analysis / Prevención y Control de Enfermedades no Transmisibles en Mongolia: Un Análisis de las Políticas

BACKGROUND: Noncommunicable diseases (NCDs) are the major global cause of morbidity and mortality. In Mongolia, a number of health policies have been developed targeting the prevention and control of noncommunicable diseases. This paper aimed to evaluate the extent to which NCD-related policies introduced in Mongolia align with the World Health Organization (WHO) 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. METHODS: We conducted a review of policy documents introduced by the Government of Mongolia from 2000 to 2013. A literature review, internet-based search, and expert consultation identified the policy documents. Information was extracted from the documents using a matrix, mapping each document against the six objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs and five dimensions: data source, aim and objectives of document, coverage of conditions, coverage of risk factors and implementation plan. 45 NCD-related policies were identified. RESULTS: Prevention and control of the common NCDs and their major risk factors as described by WHO were widely addressed, and policies aligned well with the objectives of the WHO 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of NCDs. Many documents included explicit implementation or monitoring frameworks. It appears that each objective of the WHO 2008-2013 NCD Action Plan was well addressed. Specific areas less well and/or not addressed were chronic respiratory disease, physical activity guidelines and dietary standards. CONCLUSIONS: The Mongolian Government response to the emerging burden of NCDs is a population-based public health approach that includes a national multisectoral framework and integration of NCD prevention and control policies into national health policies. Our findings suggest gaps in addressing chronic respiratory disease, physical activity guidelines, specific food policy actions restricting sales advertising of food products, and a lack of funding specifically supporting NCD research. The neglect of these areas may hamper addressing the NCD burden, and needs immediate action. Future research should explore the effectiveness of national NCD policies and the extent to which the policies are implemented in practice