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.
   A combination of quantitative and qualitative research methods to address the aims of this PhD was used. The studies estimating the PREVALENCE 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.
   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.
   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.
   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 POLICY 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.
   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 PRACTICE 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.
   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.