Building linkages between private pharmacies and public facilities to improve diabetes and hypertension care in urban areas of Nepal: a protocol for implementation research.

Abstract

Background: Rapid urbanization is accelerating in low- and middle-income countries (LMICs), which impacts health behaviors and contributes to noncommunicable diseases (NCDs), such as diabetes and hypertension. As primary care services are overstretched, urban residents rely on pharmacies, creating an urgent need to implement evidence-based approaches such as the World Health Organization's Package of Essential Non-communicable Diseases (PEN) to reach low-income households at risk of hypertension and diabetes. This study aims to identify the facilitators and barriers to the adoption, implementation, and long-term delivery of strategies to link pharmacies with public facilities in Pokhara Metropolitan City Nepal, to improve diabetes and hypertension prevention and management among poor urban populations.

Methods and analysis: This study uses a sequential mixed-method design within the RE-AIM framework. Data from client surveys will assess the costs and effectiveness of system linkages and interventions in improving diabetes and hypertension screening, management, and referral. Data will be collected at four time points from at least 20 clients per pharmacy and public health facility at baseline, midline, and endline and, to assess maintenance of delivery, post endline. During each time point, repeat questionnaires will be used to assess clients' adherence to lifestyle and referral advice. The quantitative data will be analyzed via descriptive statistics and logistic regression models to identify factors associated with change in major outcomes. Qualitative data from semi-structured interviews with health workers at pharmacies, clients, and public health facility staff will be analyzed via thematic analysis to identify barriers to and facilitators of intervention adoption, implementation, and sustainability. Endline and post-endline surveys will replicate baseline methods to evaluate intervention impact.

Discussion: This study will provide insights into how private pharmacies can be linked to the public health system to provide appropriate, quality services for diabetes and hypertension within the context of a pluralistic urban health system. Using the RE-AIM framework will enable assessment across implementation domains, providing valuable insights for local governments and health systems within Nepal. Given the rapid urbanization and increasing prevalence of NCDs, which characterize the majority of LMICs, our study contributes to the understanding of how to implement such strategies to meet the needs of the urban poor in other similar contexts.