Development of an Electronic-tool for World Health Organization Package of Essential Non-

Communicable Diseases (WHO PEN) Interventions for Cardiovascular Diseases (CVD)

Abstract

Non-communicable diseases (NCDs) particularly cardiovascular diseases (CVD) are

major causes of disabilities and premature deaths throughout the world. Considering
this NCD burden, the Department of Health encourages the implementation of the
World Health Organization Package of Essential Non-communicable diseases (WHO
PEN) Interventions. It is an innovative and action-oriented set of cost-effective
interventions. In support of the WHO PEN implementation, this study was
conceptualized to develop an electronic tool (E-tool) for the assessment and
management of CVD. The E-tool is an organized information system that will help
effectively deliver NCD services. Findings of the study revealed that the E-tool was
well appreciated by the nutrition and health workers. Notably, it was described as very
useful in the implementation of WHO PEN both in the community and health facility
settings. Moreover, it was regarded as simple to use and can lessen the time spent in
writing records, computing for body mass index, and tracking clients for follow-up. The
nutrition messages part of the E-tool was also acknowledged for being colorful and
user-friendly in conducting nutrition education to clients. It is recommended that health
offices in different local government units utilize the WHO PEN E-tool. Moreover, an
evaluation on its application for improving the service delivery of NCD programs
focused on CVD is put forward.

Keywords: application, primary healthcare, software

Introduction

Each year, 15 million people whose age is between 30 and 69 years die from Non-
communicable diseases (NCDs); and over 80% of these premature deaths occur in
low- and middle-income countries like the Philippines (WHO, 2021).

The indigent population are more vulnerable to NCDs because they are more exposed
to its risk factors such as smoking, unhealthy dietary practices, and have limited
access to health care. Health care costs for NCDs are often lengthy and expensive,
including loss of income due to unproductivity drain household resources. In low-
income countries, these concerns impede poverty reduction initiatives. With the
increasing challenges in combating NCDs, there is a pressing need for stronger and
more focused action in the prevention and treatment of NCDs. The World Health
Organization Package of Essential Non-communicable Disease (WHO PEN)
Interventions for primary care in low-resource settings was designed as an innovative
and action-oriented response to these concerns. WHO PEN is a prioritized set of cost-
effective interventions that can be delivered to an acceptable quality of care, even in
resource-poor settings.

Being a successful approach in the management of NCDs and considering the

epidemiological shift happening in the Philippines, the Department of Health (DOH)
implemented the Philippine Package of Essential Non-communicable Disease
Interventions (Phil PEN) through Administrative Order No. 2012-0029. Phil PEN is an
adaption of the World Health Organization (WHO) guidelines in managing NCDs in low
resource settings such as the Philippines. This policy applies to all units and
instrumentalities including attached agencies of the DOH and local government units.
 It also concerns non-government organizations, professional organizations, private
sector, and other relevant partners in the health sector. Phil PEN was piloted in the
Municipality of Pateros in Metro Manila and all regional NCD program managers were
trained about the package.

This research study was undertaken to develop an electronic tool (E-tool) following the
WHO PEN program, particularly in the prevention and management of CVD using total
risk approach, from assessment, estimation of cardiovascular risk,
intervention/treatment, and even referral protocols. It is expected that the research will
create an organized information system easily accessible to clients and health workers
for the effective delivery of NCD services especially in the promotion of healthy diets
and physical activity.

Integrating non-communicable diseases prevention and management into the primary

health care is vital. Despite numerous efforts, NCDs remain to plague the productive
age group. Thus, the need to re-orient health service delivery in order to
systematically identify and manage high-risk individuals has become urgent.

Based on reports from the Department of Health, there are no established NCD
surveillance systems. The current reporting system includes submission of number of
cases seen, assessed, and managed in the health centers to the municipal health
offices, then to the regional DOH.

In view of these, this basic research was conceptualized to develop an electronic tool
for WHO PEN Interventions for CVD. Generally, the study aims to create an organized
information system easily accessible to clients and health workers that will help
effectively deliver NCD services. Specifically, it intends to: (1) create a mobile software
application for WHO PEN Interventions for CVD; and (2) conduct a two-level pretest of
the application among the chronic care team.

Methods

This study is a qualitative action research conducted in four phases – preparatory,

development of E-tool, pre-testing and finalization.

In the preparatory phase several management meetings was done between the
researcher and the software developer. Coordination with the Municipal Health Office
of Pateros as the test site was also done in this phase. Along with this, secondary data
on the primary health care unit, nutrition and health staff, and clients were collected.

This was followed by a series of brainstorming activities in drafting and developing the
E-tool, including the writing of nutrition and health messages. Once the E-tool was
developed, the researchers conducted the first-level pretest using secondary data
collected from the test site. Before Level 2 pretest, training among the primary health
care staff of the Municipal Health Office of Pateros on the use of the E-tool was carried
out; this includes all primary health care service providers from the barangay nutrition
scholars, barangay health workers, midwives, nurses, and rural health physicians.

The training was done at the College of Human Ecology Research and Extension
Center, University of the Philippines Los Baños on December 2, 2016. Pretesting from
actual clients was done January to March 2017. The evaluation of the pretest activities
and observations of the researchers were the bases in revising and the finalization of
the E-tool.
Results and Discussion

Data on health care facilities and equipment, nutrition and health staff, and clients of
the Municipality of Pateros revealed that there are five (5) health centers in the
municipality, namely, Juan R. Sanchez Health Center (JRSHC), Moises R. Flores
Health Center (MRFHC), Masikap Health Center (MHC), Quintin De Borja Health
Center (QDBHC), and Delfin Salonga Health Center (DSHC). all these health centers
operate from Monday to Friday 8:00 am to 5:00 pm. In addition, there are two
specialty clinics (cardiac and diabetes clinics) and one rehabilitation clinic (physical
therapy clinic) that operates in Pateros. The municipality is already implementing
WHO PEN in the health centers but only JRSHC, the main health center uses an
electronic recording system.

All health centers have blood pressure measuring device and glucometer but only
JRSHC and MRFHC have ECG machines. Generally, all health centers have the basic
equipment for managing major NCDs. It was also noted that all the health centers
have limited information, education and communication materials on healthy lifestyle.

There are four physicians available to manage NCD clients at the health center. All
physicians, nurses, midwives, and barangay nutrition scholars are regularly trained on
NCD. They are all designated as health educators, providing health counseling to
clients at risk of NCD. The municipality also has two specialist physicians, a
cardiologist based in MRFHC and a diabetologist at JRSHC.

During the field visit there were already more than a thousand clients for NCD in the
municipality who were assessed and managed using the WHO PEN. The health
centers usually keep the client’s record through a patient’s file or registry system.
When the client goes back to the health center for a check-up, brown envelopes were
pulled from a cabinet holding their health check history.

The initial data collected in the preparatory phase were used in the development of the
E-tool. Regular consultation meetings with the software designer were carried out to
draft the E-tool. Key points discussed during the meetings were:

- The E-tool should be designed as an application (app) which can be downloaded on

mobile phones or tablets as well as laptops and desktops;
- The community part of the E-tool (for community/field use) should include information
of the client, questions on healthy lifestyle, and nutrition and health assessment.
- Data in the community part can be synced in the health facility part (for health facility
use)

In writing the nutrition messages was focused on healthy weight, balanced diets,
physical activity, and healthy lifestyle.

The training and second level of pretesting was done among the Barangay Nutrition
Scholars of Pateros. The program started with a review of the guidelines on how to
implement WHO PEN. This was followed by the actual demonstration and use of the
E-tool. Role-playing was also done to check how long would it take to encode a client’s
information in the field. After the training, the participants were asked to pretest the E-
tool in their respective health care facilities and to actual clients.
 Findings of the study revealed that the E-tool was well appreciated by the nutrition and
health workers. Notably, it was described as very useful in the implementation of WHO
PEN both in the community and health facility settings. Moreover, it was regarded as
simple to use and can lessen the time spent in writing records, computing for body
mass index, and tracking clients for follow-up. The nutrition messages part of the E-
tool was also acknowledged for being colorful and user-friendly in conducting nutrition
education to clients. Detailed comments during the pretesting of the E-tool can be seen
in Appendix A.

These comments and suggestions were presented to the software designer for the
finalization of the E-tool. The study was limited to the evaluation of the use of the E-tool
in the primary health care setting it does not measure the outcome of its use.

Conclusion and Recommendation

The developed E-tool is straightforward and useful in the implementation of WHO PEN
in the primary health care. It is recommended that health offices in different local
government units utilize the WHO PEN E-tool. Moreover, an evaluation on its
application for improving the service delivery of NCD programs focused on CVD is put
forward.

The study only covered up to the output level. It is recommended to evaluate the
outcome, if there will be an improvement of health service delivery for CVD. To ensure
application of utilization of the material in the field or in the community is by creating a
memorandum of agreement with partner local government unit, link the output with
existing policy guidelines of the Department of Health to ensure continuous utilization.

References

Bagabaldo, P.A., et al. (2014). Preparedness of Health Care Units in Adapting the Phil
PEN Interventions in Los Baños, Laguna. (unpublished)

Cuevas, F.R., et al. (2011). Creating a Health Service Delivery Model for NCDs
(particularly CVDs) at the Primary Health Care Level, Pateros, Metro Manila.
(unpublished)

Municipality of Pateros. (2011). Manual on the PEN Protocol on the Integrated

Management of Hypertension and Diabetes. Retrieved from
http://www.who.int/ncds/management/Manual_of_Procedures_on_WHO_PEN_PHL.pd
f?ua=1.

Nsubuga, P. et al. (n.d.). Chapter 53 Public Health Surveillance: A Tool for Targeting
and Monitoring Interventions. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK11770/.

Parco, J.P., et al. (2015). Assessment of the capacity to prevent and manage major
non-communicable diseases in primary health care centers in Pateros, Metro Manila,
Philippines. Manila: Philippine Journal on Health Research and Development Vol. 19,
No 3.
Philippine Health Insurance Corporation. (2013). Adoption of the Philippine Package of
Essential Non-Communicable (NCD) Interventions (PHIL PEN) in the Implementation
of PhilHealth’s Primary Care Benefit Package. Retrieved from
https://www.philhealth.gov.ph/circulars/2013/circ20_2013.pdf.

World Health Organization. (2007). Prevention of Cardiovascular Disease Pocket

Guidelines for Assessment and Management of Cardiovascular Risk. Geneva 27,
Switzerland: WHO Press.

World Health Organization. (2010). Global status report on non-communicable

diseases 2010. Geneva 27, Switzerland: WHO Press.

World Health Organization. (2010). Package of Essential Non-communicable (PEN)

Disease Interventions for Primary Health Care in Low-Resource Settings. Geneva 27,
Switzerland: WHO Press.

World Health Organization. (2013). Implementation tools: package of essential non-

communicable (PEN) disease interventions for primary health care in low-resource
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https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
Appendix A

PRETESTING OF THE WHO-PEN E-TOOL

Part of the e-tool Comments Actions to be taken

Full name - what should be written first will include instructions in the
- is middle name included manual
Age should be automatically
computed
Civil status how about solo parent classification single also
includes solo parent
Barangay and Municipality suggested to make a drop
down list
Occupation suggested to make a drop
down list
Nutritional status classification should be
indicated beside the result/data
Smoker include never smoked and
passive smoker

General comments

 The e-tool is very helpful especially during caravans since client information can directly be
inputted; “maganda siya”;
 No need to translate in Filipino the Client Information
 Messages are very informative; will be better if pictures are added
 All 4 set of messages are alright; Can also be printed as flyers; Ok with Filipino translation
 Increase font size – “dapat naizo-zoom or nalalakihan”
 Check on the pictures and colors (sometimes they are different in the cover and inside)
 The e-tool though intended for field use can also be used as center-based tool