PEN Fa’a Samoa



PEN Fa’a SamoaStrengthening NCD prevention, detection and management through community participationExpansion 2016-2017Contents TOC \o "1-3" \h \z \u 1. Background and Introduction PAGEREF _Toc447026055 \h 21.2 From WHO PEN to PEN Fa’a Samoa PAGEREF _Toc447026057 \h 31.3 PEN Fa’a Samoa expansion 2016-2017 PAGEREF _Toc447026058 \h 41.4 Inclusion of Nutrition Screening and Support in PEN Fa’a Samoa expansion 2016-2017 PAGEREF _Toc447026059 \h 52. Methodology for PEN Fa’a Samoa expansion PAGEREF _Toc447026060 \h 62.1 PEN Fa’a Samoa expansion plan: selection of health facilities and villages PAGEREF _Toc447026061 \h 62.2 Timeline and implementation plan for PEN Fa’a Samoa expansion PAGEREF _Toc447026062 \h 82.2.1 Implementation steps of the PEN Fa’a Samoa expansion PAGEREF _Toc447026063 \h 102.2.2 Calculation of number of working days for follow-up of high-risk persons PAGEREF _Toc447026064 \h 112.3 Proposed implementation model at village setting PAGEREF _Toc447026065 \h 132.3.1 General Profile of governance structure at village level in Samoa PAGEREF _Toc447026066 \h 142.3.2 Proposed Terms of Reference for Women Committee in the early NCD detection and control – PEN Fa’a Samoa PAGEREF _Toc447026067 \h 152.4 Logistic and financial resources PAGEREF _Toc447026068 \h 182.5 Monitoring and evaluation – indicators and tools PAGEREF _Toc447026069 \h 202.5.1 Tools for M&E PEN Fa’a Samoa PAGEREF _Toc447026070 \h 202.5.2 Top 18 indicators PAGEREF _Toc447026071 \h 223. Partners PEN Fa’a Samoa expansion PAGEREF _Toc447026072 \h 243.1 Ministry of Women, Community and Social Development PAGEREF _Toc447026073 \h 243.2 Department of Foreign Affairs and Trade Australia(DFAT) PAGEREF _Toc447026074 \h 24[Annex 1] Detailed Nutrition Related Equipment and Training Costs1[Annex 2] Individual NCD Passbook2[Annex 3] Village-level household and individual registration form13[Annex 4] Village-level high-risk people registration form 14[Annex 5] Report form from village level15[Annex 6] NCD Follow up Assessment Form at Health Facility161. Background and Introduction1.1 NCD is a priority for SamoaGlobal health priorities have been transformed in recent decades by an epidemic of non-communicable diseases NCDs, which have escalated in low income and middle income countries. Samoa is undergoing multiple transitions with an increasing burden of non-communicable diseases (NCDs) and double burden of malnutrition.Earlier views that such diseases were conditions of affluence have been challenged by evidence that these chronic conditions can have their origins in under nutrition and poor growth in early life. It appears that the lack of important nutrients at critical stages of growth during the first thousand days (from conception to a child’s second birthday) leads to failure of body organs to develop to their optimal capacity and to a metabolic adaptation that favours the accumulation of excess body fat, and insulin resistance. This then leads to the overweight and obesity and subsequent chronic diseases such as diabetes and heart disease. Therefore, as poor nutrition in early life is a driver of adult chronic disease conditions, improved nutrition and health of adolescent girls, mothers and young children is essential to stem the epidemic of chronic disease. About 5,700 babies are born in Samoa each year with most babies (82%) born in hospital, while about 17% are ‘home births’. Of those with evidence of birth weight, 4.9% are low birth weight with higher rates of low birth weight (6.8%) among babies born in Savai’i and in the Apia Urban area (5.7%).3 The 2014 Samoa Demographic and Health Survey indicates high rates of initiation of breastfeeding with 92% of all children having been breastfed at some time. However breastfeeding practices are compromised with a rapid drop in rates of exclusive breastfeeding. In 2014 it was found that only 60% of babies are exclusively breastfed by age 2 months dropping to only 36% by age 5 months.3 Once obesity is established in a population, maternal obesity and diabetes in pregnancy also drive increasing rates of childhood obesity and subsequent NCDs among those children in later life. This has been recognized in the latest Lancet series on Maternal and Child Nutrition, where the issue of maternal overweight and obesity is flagged as a critical issue for maternal and child health. In effect, there are two routes to adult chronic disease, one being via early life under-nutrition and one via maternal obesity with or without diabetes. Prevention therefore – in both cases – requires a focus on the health and nutrition of adolescent girls, mothers and young children. The ‘First Thousand Days’ movement has been developed to support effective responses to improve nutrition and health of mother and baby, from conception through pregnancy, and up to age of about two years of age.1,,Widespread adult obesity and NCDs can exist concurrently with under-nutrition and micronutrient deficiency diseases. This problem has been termed the ‘Double Burden of Malnutrition‘. It is important to continue to address under-nutrition and nutrient deficiency diseases in early life, while also working to reduce obesity and chronic disease – this has been flagged as an issue in Pacific Island settings.1 1.2 From WHO PEN to PEN Fa’a SamoaThe WHO Package of Essential Non-communicable Disease Interventions (WHO PEN) for primary care in low-resource setting is an innovative and action-oriented response to address the global NCD challenges. The WHO PEN protocol consists of a prioritized set of cost-effective interventions and aims to integrate NCDs into primary health care. It can help to strengthen national capacity and forms a key component to support implementation of a country’s national policy or action plan on NCD prevention and control. The PEN consists of four specific protocols for adaption in primary care at national level: Protocol 1: Prevention of heart attacks, strokes and kidney disease through integrated management of diabetes and hypertension;Protocol 2: Health education and counselling on healthy behaviours; Protocol 3: Management of asthma and chronic obstructive pulmonary disease;Protocol 4: Assessment and referral of women with suspected breast cancer at primary health care. The PEN protocol details that early detection should consist of screening and early diagnosis. Based on global evidence, it offers specific assessment tools for early detection and referral. A key component of the PEN protocol is the assessment and management of cardiovascular risk in people with risk factors who have not yet developed clinically manifested cardiovascular disease (primary prevention). The WHO/ISH risk prediction charts indicate 10-year risk of a fatal or non-fatal major cardiovascular event (myocardial infarction or stroke), according to age, sex, blood pressure, smoking status, total blood cholesterol and presence or absence of diabetes mellitus. The charts provide approximate estimates of CVD risk in people who do not have established coronary heart disease, stroke or other atherosclerotic disease. They are considered as helpful tools to identify those at high risk of cardiovascular diseases and also to motivate patients, particularly to change behaviour in terms of their disease management.Samoa has been one of the first countries to contextualize PEN at country level, here-after referred to as PEN Fa’a Samoa, from November 2014 up to December 2015. Guided by the data showing high prevalence of NCDs in the STEPS report 2013 (also described in the PEN Fa’a Samoa concept note 2014), Samoa and WHO set up a practical application of the WHO PEN protocol. It was also decided to make a test-case that WHO PEN can effectively intervene in the early phase through NCD early detection and management, as well as increase health literacy at community level. Considering disease prevalence and resources available, It was decided that PEN Fa’a Samoa would initially focus on PEN Protocol 1 and 2, for cardiovascular diseases and diabetes. PEN Fa’a Samoa has adapted WHO PEN into the local Samoan context, building on the existing governance structures of the two demonstration villages. The PEN protocols and guidelines provide a solid basis from which to develop location specific applications. A national steering committee has been set up to guide the implementation, consisting of the Ministry of Health, the National Health Service and WHO.The contextualization from WHO PEN to PEN Fa’a Samoa was initiated through development of a PEN model with three pillars:Pillar One: NCD early detection;Pillar Two: NCD management;Pillar Three: NCD awareness in the community. PEN Fa’a Samoa contextualization model:Goal: To strengthen linkages between health services and the community and adhere to global target of at least 50% of eligible people to receive drug therapy and counselling through NCD early detection and NCD managementPillar One: NCD early detection: Objective 1: Provide comprehensive population screening for NCD Objective 2: Increase the detection rate of people with risk factors for NCD. Pillar Two: NCD management:Objective 3: Increase in the percentage of people with risk factors for NCD who obtain appropriate treatment and/ or management strategies.Objective 4: Increase in compliance with NCD treatment and management protocols.Pillar Three: NCD awareness in the community:Objective 5: Build capacity among district health professionals and community representatives on prevention and treatment of NCDs at community level.Objective 6: Increase health literacy and raise community awareness of NCD-related lifestyle factors.1.3 PEN Fa’a Samoa expansion 2016-2017A consensus has been agreed between MoH and WHO that PEN Fa’a Samoa would be expanded in 2016-2017. Initially launched in two districts, it is now planned to cover all health districts countrywide. The steering committee will continue to function as a key governance mechanism to guide the expansion. Since development partners such as DFAT of Australia have been interested in PEN Fa’a Samoa, a financial support is likely to be provided as the detailed proposal is submitted.The decision to expand PEN Fa’a Samoa is based on the successful implementation for nearly one year. With the main goal of improving connection between health services and the community, women’s committees have been actively engaged in the program, thus revitalizing their traditional role in health in the community. Overall, PEN Fa’a Samoa achieved a high coverage of comprehensive NCD screening for the target population in two demonstration villages. It was found out that around 40% of the screened people had one or more NCD risk factors. Based on the national referral criteria adapted for PEN Fa’a Samoa, people having risk factors were referred to the health facilities and examined for proper management and treatment. Local health staff and community women’s committee members have been trained and strengthened of their capacity for NCD detection and management. Led by women’s committee members, NCD awareness projects have been implemented in the villages. A list of papers is being prepared to include a more elaborate analysis of the effectiveness and impact of PEN Fa’a Samoa.1.4 Inclusion of Nutrition Screening and Support in PEN Fa’a Samoa expansion 2016-2017Non-communicable diseases are silent in their early stages. While overweight and obesity may be visible, the associated metabolic consequences are relatively ‘silent’ and have an insidious, slow onset. By the time people begin to feel un-well, the disease process can already be well advanced. In this respect, the same requirements to screen are common to poor childhood growth and to adult non-communicable disease. A proactive approach, which incorporates routine health checks for adults and children is required to raise awareness and prevent onset of these disease. Nutrition Services in Samoa are limited. There are currently 3 Clinical Dietitians, providing inpatient and outpatient services at the main referral hospital and a limited service to the referral hospital in Savai'i. The public health Nutrition Unit at the Ministry of Health, are able to provide some degree of community nutrition awenesess and promotion activities in addition to their primary role in monitoring and surveillance.In addition to increasing NCDs, Samoa has seen a concurrent increase in child hospital admissions for acute malnutrition, over the last decade. Readmissions for ongoing malnutrition highlight a gap in service between discharge from acute inpatient services to full recovery in the community. Micronutrient deficiency, or “hidden hunger”, is also widespread. Under-nutrition in young children was apparently common up until the 1970s and 1980s, but this declined as Samoa became more prosperous. However, recent years have seen an increase in child hospital admissions for acute malnutrition, with some deaths. These cases are associated with early cessation of breastfeeding, use of inappropriate breast milk substitutes combined with sweetened tea, the use of baby feeding bottles and nutritionally poor solid foods, and appear to occur more frequently in urban areas. While numbers of admissions are relatively small (68 children under 2 years in 2013) these cases indicate that child health outreach services may not be reaching vulnerable population groups.1In response to the increased incidence of young child malnutrition, established links between malnutrition and NCDs and identified gaps in current service the content of the PEN Fa'a Samoa program is to be expanded to include maternal and child growth monitoring and Infant and young child feeding counselling in addition to providing nutrition support for adults with regard to the prevention and management of NCDs.PEN Fa’a Samoa Expansion and Nutrition Integration contextualization model :Goal: To strengthen linkages between health services and the community and adhere to global target of at least 50% of eligible people to receive drug therapy and counselling through NCD early detection and NCD managementPillar One: NCD early detection: Objective 1: Provide comprehensive population screening for NCD Objective 2: Provide comprehensive nutritional status screening for pregnant women and children 0-5 years. Objective 3: Increase the detection rate of people with risk factors for NCD. Pillar Two: NCD management:Objective 4: Increase in the percentage of people with risk factors for NCD who obtain appropriate treatment and/ or management strategies.Objective 5: Increase in compliance with NCD treatment and management protocols.Pillar Three: NCD awareness in the community:Objective 6: Build capacity among district health professionals and community representatives on prevention and treatment of NCDs at community level.Objective 7: Increase health literacy and raise community awareness of NCD-related lifestyle factors.2. Methodology for PEN Fa’a Samoa expansionThe PEN Fa’a Samoa expansion will start with a phased implementation, through Pillar 1: identify high risk cases in need of NCD management and those with risk factors for developing NCDs in the future and at the same time, initiate Pillar 3: NCD awareness. Pillar 2 is a continuous work between village and health centre for the increased management of NCD cases. 2.1 PEN Fa’a Samoa expansion plan: selection of health facilities and villages Two villages were chosen to implement PEN Fa’a Samoa 2014-2015, one village in Upolu called Faleasiu and the other village in Savaii called Lalomalava. Village 1, Faleasiu, is within the of Aana Alofi IDistrict located in the Statistical Region of North West Upolo and has 3,745 people . Village 2, Lalomalava, is based in Faasaleleage District in the Statistical Region of Savaii and counts 387 people. For the expansion in 2016, the Samoa Ministry of Health and the National Health Service has aimed to involve all the health facilities in the public-sector, covering the total four statistical regions in Samoa. Region I (Apia Urban Area) is covered by one health facility which is the main referral hospital for Samoa (TTM). Region II (North West Upolu) has two health facilities: Leulumoega District Hospital and Faleolo Health Centre, among which Leulumoega has already been part of the PEN Fa’a Samoa demonstration. Region III (Rest of Upolu) is mainly located on the south of the Island and is covered through four district health facilities (Saapanu District Hospital, Poutasi District Hospital, Lalomanu District Hospital and Lufilufi Health Centre). Finally, Region IV covers Savaii Island and has a total of five health facilities. Since MTII Referral Hospital has already been implementing PEN Fa’a Samoa 2014-2015, the other four district hospitals in Savaii will be included (Vaipouli, Safotu, Satuau and Foailalo). This will give the total coverage of 12 district health facilities for the whole of Samoa. Each health facility will add one implementation site or village. As two villages are already implementing and will continue with PEN Fa’a Samoa, the total villages will be up to 14 villages for PEN Fa’a Samoa expansion 2016-2017. Table 1 shows the region/district and their responsible health facilities and the additional population for PEN Fa’a Samoa expansion which was estimated based on 2011 Census.Table 1: PEN Fa’a Samoa expansion - health facilities and estimated populationSamoa Region/DistrictHealth Facility Estimated population per demonstration villageRegion I - Apia Urban AreaVaimauga WestTupua Tamasese Meaole (TTM) Hospital?473 Faleata East1,053 Region II - North West UpoluAana Alofi I (PEN Fa’a Samoa 2015)Leulumoega District Hospital1,988Aana Alofi II1,622Aana Alofi IIIFaleolo Health Center553Region III - Rest of UpoluSafataSaanapu District Hospital 554 FalealiliPoutasi District Hospital284 Aleipata itupa i LugaLalomanu District Hospital441 Anoamaa EastLufilufi Health Center534 Region IV - SavaiiFaasaleleaga I (PEN Fa’a Samoa 2015)Malietoa Tanumafili II(MTII) Hospital421 Gagaemauga IIIVaipouli District Hospital270 Gagaifomauga ISafotu District Hospital702 Vaisigano WestSataua District Hospital539 Palauli WestFoailalo District Hospital563 TOTAL 1210,0032.2 Timeline and implementation plan for PEN Fa’a Samoa expansionThe timeline for expansion will start from February 2016.TimeActivity plannedMarch 2016National Health Sector Consultation for PEN Fa’a Samoa expansion: Develop operational plans with all stakeholders involved: Ministry of Health, National Health Service, Ministry of Women Community and Social Development, women’s committee representatives, civil society representatives such as Samoa Cancer Society, Samoa Medical Association, development partners, and WHO April – June 2016:PEN Fa’a Samoa implementation in 5 sites?Region I - Apia Urban Area?:Site 1: Vaimauga West (covered by TTM)Site 2: Faleata East (covered by TTM)Training organized at TTM for both sites involved in April 2016Implementation PEN Fa’a Samoa at involved sites (two villages in each site April 2016)Region II – North West of Upolu?:Site 3: Aana Alofi I (covered by Leulumoega)Site 4: Aana Alofi II (covered by Leulumoega)Training organized at Leulumoega for both sites involved in May 2016Implementation PEN Fa’a Samoa at involved sites (two villages in each site May 2016)Site 5: Aana Aloif II (covered by Faleolo)Training organized at Faleolo Health Clinic for their site involved in June 2016Implementation PEN Fa’a Samoa at involved sites (two villages in June 2016)July – November 2016:PEN Fa’a Samoa implementation in 9 sites?Region III – Rest of Upolu:Site 6: Safata (covered by Saanapu)Training organized at Saanapu for their site involved in July 2016Implementation PEN Fa’a Samoa at involved sites (two villages in July 2016)Site 7: Falealili (covered by Poutasi)Training organized at Poutasi for their site involved in July 2016Implementation PEN Fa’a Samoa at involved sites (two villages in July 2016)Site 8: Aleipata itupa I Luga (covered by Lalomanu)Training organized at Lalomanu for their site involved in August 2016Implementation PEN Fa’a Samoa at involved sites (two villages in August 2016)Site 9: Anoamaa East (covered by Lufilufi)Training organized at Lufilufi for their site involved in August 2016Implementation PEN Fa’a Samoa at involved sites (two villages in August 2016)Region IV – Savaii?:Site 10: Faasaleleaga I (covered by MTII)Training organized at MTII for their site involved in September 2016Implementation PEN Fa’a Samoa at involved sites (two villages in September 2016)Site 11: Gagaemauga III (covered by Vaipouli)Training organized at Vaipouli for their site involved in October 2016Implementation PEN Fa’a Samoa at involved sites (two villages in October 2016)Site 12: Gagaemauga I (covered by Safotu)Training organized at Safotu for their site involved in October 2016Implementation PEN Fa’a Samoa at involved sites (two villages in October 2016)Site 13: Vaisigano West (covered by Sataua)Training organized at Sataua for their site involved in November 2016Implementation PEN Fa’a Samoa at involved sites (two villages in November 2016)Site 14: Palauli Est (covered by Foailalo)Training organized at Foailalo for their site involved in November 2016Implementation PEN Fa’a Samoa at involved sites (two villages in November 2016)December 2016 – January 2017Evaluation and scale up, involve more villages per district2.2.1 Implementation steps of the PEN Fa’a Samoa expansionTraining planned per district with the timeline is suggested above. Training will be held at each district health facility. Expected participants include the health district staff, the women committee representatives of the village selected in the district, the civil society organisation such as the Samoa Cancer Society if involved in outreach activities in that district, and team members of the PEN Fa’a Samoa steering committee. The training will consist of an introduction of the PEN Fa’a Samoa model with its pillars, the roles and responsibilities of partners involved, and the planned timeline of feedback mechanism. The different tools used in each pillar will be also introduced as described below:Pillar 1: NCD early detection:NCD community registration form, page 1 by women’s committee members: Women’s committee member per village will initially identify the people at risk of NCDs through the NCD community registration form. Their role is to ensure participation of the target population above 18 years of age, complete demographic data and NCD risk factor questions. Nutritional status data will be collated for pregnant women and young children. Women's committee members with the support of a Nutrition assistant will identify pregnant women and children 0-5 years of age and measure height and weight and complete a short nutritional intake form. NCD community registration form, page 2-3, NHS outreach team from the involved district health facility: The NHS outreach team will clinically assess each villager and complete page 2-3 at the fixed site in the village arranged by the women’s committee. If applicable, villagers will be referred to the district health facility of their WHO/ISH risk >30% and/or by the use of the national referral criteria for NCDs. If the electronic registration system is already available through the NCD tablets, the team will electronically store the clinical data and assess the WHO/ISH risk. The Nutritional assistants will calculate Z-scores from growth monitoring information and enter data collected into a data base. Pillar 2: NCD managementNCD referral form: Referred villagers will be seen at a district health facility. A medical doctor will assess their NCD cases, confirm diagnosis and treatment if applicable, and decide the detail of the case management in the NCD referral form. NCD referral form overview per village: high-risk NCD cases needed for intense follow up and management will be shared with the women committee members for their support to the family (with regards to medication adherence, NCD prevention and control activities at village level)Pillar 3: NCD awareness in the communityPrior to the start, the Health Literacy tool adapted to Samoan context will be completed for the women committee members in the participating villages. The PEN Fa’a Samoa committee will assess the results and provide feedbacks to the women committee members. This will guide the NCD awareness activities towards improvement of specific components of their health literacy.An NCD awareness project will be set up by the women committee members per village. Their project can focus on either salt reduction, sugar reduction, tobacco control and/or tobacco cessation activities or alcohol. The PEN Fa’a Samoa Steering Committee will support the project through site visits and learning seminars on their topics.The Nutrition assistants will work with Women's committee members to deliver nutrition education sessions, promote breastfeeding, and promote the use of micronutrient supplements, as required, to pregnant women.The Nutrition assistants will work with Women's committee members to deliver Infant and Young Child Feeding counselling sessions to parents or carers of young children.Children identified with moderate Acute Malnutrition (MAM) or Severe Acute Malnutrition (SAM) will be entered into a log, referred to the paediatric outpatient clinic for confirmation of diagnoses and then, if without complications, managed under a community based malnutrition protocol. Management will include the provision of nutritional supplements, regular growth monitoring and IYCF Education.After one year of implementation, the health literacy will be assessed again to measure progress of their literacy and see if changes are made within each core component of health literacy. 2.2.2 Calculation of number of working days for follow-up of high-risk personsSince women’s committee members play a key role in PEN Fa’a Samoa and are expected to be involved in more activities in the expansion plan, there is a worry that they may take high burden. In this regard, the number of working days has been calculated for women committee members to follow up the high-risk population. This estimation is based on the data from the first year implementation of PEN Fa’a Samoa. It provides a series of scenarios per different proportion of high-risk group and per available number of women committee representatives. As most assumptions are based on the most populous village, Faleasiu, it is possible that the actual workload could be lesser than these estimates below.Basic assumptions:Village A has 3000 of total population, of which 1600 are adults.Village A has total 400 households, which means that each household has average 4 adults.Village A has 4 subvillages, each subvillage has 100 households, 750 people and 400 adults.3 women committee members can visit 4 households and interview 16 adults per day.Women committees visit normal population annually and high-risk population quarterly.3 months are used for annual screening and 9 months for follow-ups. (3 months/1 follow-up)Scenario 1 (high-risk = 20%)There are 6 women committee member for PEN Fa’a Samoa in a subvillage.About 20% of population is classified as high-risk group.In a subvillage, there are 400 adults, 80 of whom are high-risk persons.For 3 months, it takes 2.5 days for 6 women members to perform one follow-up session for 80 high-risks persons in a subvillage.Scenario 2 (high-risk = 40%) – most likely scenario based on PEN Fa’a Samoa implementation 2014-2015There are 6 women committee member for PEN Fa’a Samoa in a subvillage.About 40% of population is classified as high-risk group.In a subvillage, there are 400 adults, 160 of whom are high-risk persons.For 3 months, it takes 5 days for 6 women members to perform one follow-up session for 160 high-risks persons in a subvillage.Scenario 3 (high-risk = 80%)There are 6 women committee member for PEN Fa’a Samoa in a subvillage.About 80% of population is classified as high-risk group.In a subvillage, there are 400 adults, 320 of whom are high-risk persons.For 3 months, it takes 10 days for 6 women members to perform one follow-up session for 320 high-risks persons in a subvillage.No. of days for one follow-up session?(3 months)??No. of women's committee members??369% of High-risk10% 2.50 1.25 0.83 20% 5.00 2.50 1.67 40% 10.00 5.00 3.33 80% 20.00 10.00 6.67 * 400 adults per one subvillage2.3 Proposed implementation model at village settingProposed Implementation Model for PEN Faa Samoa at Village levelVillage Matai committeeParamount Chiefs/ Village Mayor/Chiefs and untitled men/womenNHS (including Nutrition Assistants) MOHVillage MayorVillage Women’s CommitteePresident (wife of the paramount chief) & Committee members MWCSDVillage Women RepresentativeSelected Women Community health promoters Youth Representative Head of householdsSchools committee/ principal Head Churches/Religious2.3.1 General Profile of governance structure at village level in SamoaVillage Matai CommitteeGovernance and leadership body at village levelDirectly linked under the Ministry of Women, Community and Social Development – through the Division for Internal Affairs. Consists of paramount chiefs & chiefs (both men and women) Average group size range from 30 – 100 (depending on population size of village or pitonuu ‘subvillage’)Age of members range from 16 – 60+Governance specific groups such as Women’s Committee & Untitled men’s group to name a few.Selects Village and village women rep – this post is mainstreamed in the government structure. Sui o le Malo/Village representativeSelected by village Responsible to the village Matai Committee and Ministry of Women community and social development specifically to the division for women and the division of internal affairs.Women village representative can change from time to time depending on village selection.Youth Representative Selected by village Responsible to the village Matai Committee and Ministry of Women community and social development specifically to the division for women.Village Women’s Committee Consists of women only. Married and unmarried ladiesDirectly linked under the Ministry of Women, Community and Social Development – specifically division for women.Age group ranges from 16 – 60+Has its’ own governance structure and processes to be respected. Headed and led by President with her core groups consisting/ secretary/ finance person.Average group size of committee members 15 – 50+Implements and supports any programs Women’s Community health promoters Selected community health volunteers/promoters by the women’s committee Lives within the village Active and mobile and is able to have basic skills to read and write This mandate is now been given through the Ministry of Women, Community and Social Development and her role in health is mainly related to sanitation 2.3.2 Proposed Terms of Reference for Women Committee in the early NCD detection and control – PEN Fa’a SamoaObjective: Improving community response to NCDs and other health issuesVillage Matai committeeLeadership and commitment to supporting PEN Fa’a Samoa and other health programs.Promotes smooth facilitation of access to households for PEN Fa’a Samoa women representatives and health workers. Enforces the active participation of men to not only for PEN Fa’a Samoa but all health programs.Promotes and support the enforcement of other health and social programs such as the Aiga ma nuu manuia program and Smoke free homes, to name a few.Enforce regular updates from women’s committee on PEN Fa’a Samoa on a quarterly basis. Responsible to:National Level: ACEO – Division For Internal Affairs of the MWCSDVillage Levels: Their own respective village by laws Village Mayor/ PulenuuRefer to Performance measures for Pulenuu Responsible to:National Level: ACEO – Division For Internal Affairs of the MWCSDVillage Level: Village Women’s CommitteeVillage Women Représentative/ Sui o le NuuRefer to performance measures for women representativeResponsible to:National Level: ACEO – Division For Women of the MWCSDVillage Level: Village Women’s Committee.Village youth representativeRefer to performance measures for youth representativeResponsible to:National Level: ACEO – Division For Women of the MWCSDVillage Level: Village Women’s Committee.Village Women’s CommitteeLeadership and commitment to supporting PEN Fa’a Samoa from women’s committee level.Coordinate and facilitates health activities under the PEN Fa’a Samoa. Develops a overall work plan on the implementation of PEN Fa’a Samoa.Engages Sui o Nuu and Sui o le Malo on a monthly basis to provide report Monitors the implementation of selected community health promoters.Enforces monthly reporting on the PEN Fa’a Samoa.Promotes and support the enforcement of other health related programs directly linked to such as Smoke free homes and villages/Aiga ma nuu manuia. Reports to the Village Matai for updates on a quarterly basis.Provide basic report to NHS,MOH, MWCS, Village Matai on their progress.Responsible to:Village Level: Village Women’s Committee.Ministry of Women Community and Social Development Ministry of Health and National Health Service (District Hospital)Selected Community health promoters (women representatives and/or youth representative)Record, collect basic data of 1) population 2) at risk people 3) people on medication in village for PEN Fa’a Samoa (pillar 1 and pillar 2)Record collect information on their selected village projects for PEN Fa’a Samoa (pillar 3) and coordinate the utilization of information from other related programs that will be useful for their programs.Visit villagers' home at a quarterly basis to follow up people whom are high risk and medications, with assistance from Nutrition Assistants if required. (pillar 2)Assist and support the Health outreach team (including Nutrition Assistants) and organize the target people to receive medical services required. (pillar 1 and pillar 2)Assist and support Identified people whom at risk and on medications to;Go to district hospital for regular follow upUse NCD passbook General Healthy behavioural practises.Work with the Nutrition Assistants to assist and support carers of children identified with MAM or SAM to;Go to district hospital or paediatric clinic for regular follow upGive nutrition supplements as prescribedUndertake regular growth monitoring while on management protocolEncourage families to learn and understand more about IYCF and GM to manage malnutrition in their familyEncourage families of those identified; on the importance of learning and understanding NCDs to better support their family members at risk or already suffering from NCD for prevention and better management. Educate community members to recognize the danger signs of high blood pressure and diabetes. Understand when to refer based on the local standard referral guideline for communityFacilitate and mobilize health sector and partners to carry out health education and other activities based on the needs of each community or specific groups.Work with the (Sui o Nuu and Sui o le Malo) to promote the implementation of the PEN Fa’a Samoa.Responsible to: Women’s Committee President and group as a whole.Ministry of Women Community and Social Development Ministry of Health and National Health Service (District Hospital)Additional tasks (to consider)Identify pregnant women and children under Antenatal/ImmunizationEngagement of Communities What - Capacity building on PEN Fa’a Samoa pillars Who can support this capacity building How Village Matai committee Village mayorVillage women representativeVillage presidentSession on good governance and leadership specific to health.Ministry of Health (MOH)National Health Service (NHS) NGO such as Samoa Cancer SocietyPillar 3 – developed communication materials such as the information leaflets, posters for in the village Session on men’s health specific to NCD NHS and MOHSession led by the village mayor Pillar 3 – developed communication materials such as the information leaflets, posters for in the villageAnnual health screening 1st meeting Ministry of Health (MOH)National Health Service (NHS) Women representative and youth representation Pillar 1 – NCD early detection Monthly update on PEN Fa’a Samoa Women representative and youth representation Pillar 2 – NCD management in the community 2.4 Logistic and financial resourcesThe PEN Fa’a Samoa built upon existing linkages where these were already quite strong by providing further opportunities for health professionals to serve their community. Where linkages were not so strong the demonstration project provided an opportunity for health professionals to provide services and work with one of the communities in their catchment area. This process began with the orientation workshop conducted at the district health facility for both health professionals and women’s committee representatives. By having defined and complimentary roles in working toward project objectives and making and honouring commitments to each other, a stronger relationship and link has developed between the community and the local health service.The additional cost for one year implementation was approximately 40,000 USD/site (health facility and village). Below is the breakdown of the additional cost.Additional costs for the PEN Faa Samoa Expansion ActivitiesCost (March-December 2016)Cost of operation for district and village activities(includes launch events in the villages, training (including costs for travel and food to the training for the participants, tools)15,000 USDProcurementVillage level?: Blood pressure device/ (145 USD), Stadiometer (130 USD), weight scale (80 USD). Health facility level: cardio-check: 800 USD (government will procure strips through their national procurement system)1155 USDNational cost Ministry of Health and National Health Service (support outreach visit + monitoring visits, including transport costs)12,0000 USDAllowance to village women’s committees1000 USDVillage projects500 USD Information, Education and Communication materials (total cost for full national roll out as materials already developed)70000 USDTraining materials 500 USDOther operational cost (boat tickets to Savaii, rental venues for training,…)As the integration of the maternal and child nutrition activities and nutrition support for the prevention and management of NCDs is in line with the Australian DFAT Health Investment Plan 2015-2018, it is anticipated that the additional cost of these activities could be funded by this donor agency. A separate table of nutritional related activities and estimated costs has been prepared below. The cost to integrate the maternal and child nutrition project with the PEN Faa Samoa Expansion framework will be up to $480,000 AUD. The largest expense will be the initial workforce support. There are long term liabilities for the GoS, if the new cadre of Nutrition Assistants is mainstreamed after the conclusion of the Samoa Health Investment Plan. These liabilities include salaries, leave allowances and other entitlements e.g. training and superannuation.Additional Costs for the PEN Faa Samoa Expansion - Nutrition IntegrationBudget Items2016WST2017WST2018WSTTotal budgetWSTTotal budgetAUDSenior Project Officer wage ($39,500 WST PA)$26,3008 months$39,50012 months$19,7506 months$85,550$48,000Nutrition Assistant wage(14 positions at $12,500 WST PA)$116,7008 months$175,00012 months$87,5006 months$379,200$211,000Nutrition Assistant allowances e.g. overnight accommodation/transport$33,000$50,000$25,000$108,000$60,000Equipment, resources and nutritional products$95,000$40,000$25,000$160,000$89,000Transport, accommodation, consumables and catering for training workshops$ 60,0006 w/shops$30,0003 w/shops$90,000$50,000Transport, Consumables, VWC allowances and catering for meetings or community events$14,000$14,000$14,000$42,000$23,000TOTAL$345,000$348,500$171,250$864,750$480,000Costing notes:MOH have set the Senior Project Officer position wage on par with a Senior Nutritionist position and the Nutrition Assistant wage on par with a Community Nutrition Worker position. The costing has been based on a maximum of fourteen Nutrition Assistant positions, however the final number employed will depend on available applicants and the number of Village sites that wish to integrate the nutrition objectives, in which case the cost would be lower. The nursing division pays approximately AUD 10 per night for allowances for food where a nurse stays out of his/her home location. PEN Expansion will cover at least 10 sites outside of the Apia urban area, so it is likely that at least 10 staff will be living away from home. It is anticipated that the Nutrition Assistants will be able to access Nurses Accommodation at these sites, at no cost to the project. Away from home allowances have also been included for the project office position while undertaking supervision or support visits to the Nutrition Assistant staff.Equipment, resources and nutritional products will be provided to each Nutrition Assistant or Health Service site. Some less frequently used resources will be shared between sites. A detailed breakdown of this budget item is provided in Annex 1.2.5 Monitoring and evaluation – indicators and tools Monitoring and evaluation (M&E) are essential components of a program. M&E is needed to check the progress in the middle of the ongoing process and also the outcome and impact after a program ends. The objectives of M&E for PEN Fa’a Samoa are to assess (1) whether the community-based screening and early detection is going well; (2) how the screened population with risk factors are managed at either communities or health facilities; (3) how good is adherence among the referred people to follow-up and medication; (4) whether the complications are checked and managed; and (5) how much the overall health status has been improved. Since PEN Fa’a Samoa targets entire adult population and children 0-5 years of age, in the villages, it is likely to accumulate a population-based cohort data for the next years. As PEN Fa’a Samoa will be expanded to countrywide and more villages, appropriate data collection , management, and analysis is significantly needed.For the first year, it is apparent that significant progress has been made, while it is not possible at this early stage to provide accurate qualitative data for all of the PEN Fa’a Samoa objectives. Overall, more than 90% of the target population has been screened for NCD. Close to half of the population screened in villages were found to have NCD risk factors and were referred to their local health facility for follow-up and treatment initiation. Those who have been referred urgently, visited the health facility more than once since the implementation of the PEN Fa’a Samoa. The demonstration increased the detection rate for NCD risk factors since the majority of those found to have risk factors were previously unaware of their risk factor status. Once more data are available, a more rigorous cost-effectiveness analysis will be done. 2.5.1 Tools for M&E PEN Fa’a SamoaA number of tools are in development for M&E of PEN Fa’a Samoa for the year 2016. An individual-level information booklet will be distributed to a screened person. As there is currently no available individual identification number nationwide, a PEN Fa’a Samoa-specific individual ID will be allocated with the booklet (see Annex 2). There are two options for distribution of the booklet. First is to give booklets to all the registered and screened persons. Advantages include that all the screened persons can be included in the cohort data, that it will be easy to manage data as the program continues, and that community members would feel they are equally respected. However, it might cost a lot to give the papers to all the people and would be hard to manage for healthy people. Second option is to distribute booklets to only high-risk people. It would be practical to focus on the follow-ups and NCD management of high-risk population for the early phase. It also would save costs and be easier to manage the record since the number would be small.Women’s committee representatives will continue to register, screen, and manage people at village level for both Pillar 1 and 2 of PEN Fa’a Samoa. As the people identified having risk factors may not have been properly checked for the management and follow-up for adherence to health advice and treatment, the registration form is to be revised (see Annex 3 and 4). Women’s committee representatives will also have responsibility to report the progress and intermediate outputs to the health facilities and the national committee either quarterly or annually, as it could help to improve the process and solve unexpected problems in the middle of implementation (see Annex 5).Staff at health facilities responsible for the demonstration villages will carefully reassess and manage risk factors and diagnosed NCDs for the referred people for Pillar 2 of PEN Fa’a Samoa. Since the follow-up management has been one of the identified challenges from the first year of implementation, an NCD follow-up assessment form will be provided to health facilities (see Annex 5). As it is practically hard for local health facility staff to give special attention and work to manage data for PEN Fa’a Samoa cohort, the national-level PEN Fa’a Samoa team will continue to support data collection, management, and analysis, with possible cooperation with research institutions such as National University of Samoa (NUS). Note: Those tools, forms and templates are currently being developed and will be further revised through the consultations with national stakeholders, health staff, and women’s committee members.2.5.2 Top 18 indicatorsBelow is the proposed list of selected top 18 indicators to monitor the progress and evaluate the effectiveness of the interventions.NoIndicatorsPillarFrequencySource of data1Proportion of persons with NCD screening aged above 18 years(Number of persons with NCD screening aged above 18 years / Number of total population in the catchment area aged above 18 years)1AnnuallyVillage registration 2 Proportion of children aged 0-5 years, screened for nutritional status (Number of children aged 0-5years screened/ total number of children aged 0/5 years in the catchment area)1AnnuallyVillage registration and Nutrition Assistant's records3Proportion of persons with regular follow-up among high risk group(Number of persons with quarterly follow-up / Number of high risk population)2QuarterlyVillage registration 4Proportion of children identified with MAM or SAM with regular follow up as per the malnutrition management protocol(Number of children with weekly-monthly follow -up / Number of children diagnosed with MAM-SAM) 2Weekly (SAM), Monthly (MAM)Village registration and Nutrition Assistant's records5Proportion of good compliance among those who need NCD medication(Number of persons who take medicine regularly / Number of those who need NCD medication)2QuarterlyVillage registration 6Proportion of compliance among pregnant women and children who need nutritional supplements(Number of pregnant women and children requiring nutritional supplements)2QuarterlyNutrition Assistant's records7Proportion of children aged 0-5 with MAM or SAM(Number of children aged 0-5 years with a -2zscore (MAMA) or a -3 Z score (SAM)/ Number of children screened)3AnnuallyVillage registration and Nutrition Assistant's records8Proportion of overweight population(Number of persons with BMI more than25 /Number of persons with NCD screening)3AnnuallyAnnual NCD screening9Proportion of overweight children aged 0-5 years(Number of children aged 0-5 years with >+2 Z score / Number of children aged 0-5 years screened)3AnnuallyVillage registration and Nutrition Assistant's records10Proportion of smoker(Number of current smokers /Number of persons with NCD screening)3AnnuallyAnnual NCD screening11Proportion of persons with uncontrolled blood pressure(Number of persons with systolic blood pressure more than 140 /Number of persons with NCD screening)2AnnuallyAnnual NCD screening12Proportion of persons with uncontrolled blood sugar level (Number of persons with random blood sugar is more than 11.1mmol/l /Number of persons with NCD screening)2AnnuallyAnnual NCD screening13Proportion of pregnant women with anaemia(Number of pregnant women with Hb < 10.9g/dl (DHS level for any anaemia) / Number of pregnant women screened)2QuarterlyVillage registration and Nutrition Assistant's records14Proportion of children aged 0-5 years with anaemia(Number of children aged 0-5 years with Hb < 10.9g/dl (DHS level for any anaemia) / Number of children screened)2QuarterlyVillage registration and Nutrition Assistant's records15Number of foot amputation due to diabetes in the catchment area2AnnuallyAnnual report from district hospital16Number of stroke events in the catchment area2AnnuallyAnnual report from district hospital17Number of notification of stock-outs and/or equipment failures at the district hospital2AnnuallyAnnual report from district hospital18Number of notifications of stock-outs of nutritional supplements 2QuarterlyNutrition Assistant's records3. Partners PEN Fa’a Samoa expansionThe partners involved are the following:National PartnersMinistry of HealthNational Health Service Ministry of Women, Community and Social DevelopmentNational Association of Women Committee’s National University of Samoa, Centre for Samoan Studies (TBC)Samoa Cancer Society World Health Organization (Technical and Financial Support)DFAT, Australia (Financial support, TBC)3.1 Ministry of Women, Community and Social DevelopmentThe Ministry of Women, Community and Social Development (MWCSD) is the principal government organization that is responsible for the women’s committees in the villages. MWCSD has not been officially involved in PEN Fa’a Samoa for the first year. Since the role of women’s committee representatives has been crucial in the program, a series of consultations and official agreement between MWCSD is planned. It is expected through this official communication between the government entities that women’s committee can have strengthened roles and support, thus have more ownership and capacity for their own villages. 3.2 Department of Foreign Affairs and Trade Australia(DFAT)Among the development partners, notably, the Department of Foreign Affairs and Trade Australia(DFAT) has committed to support PEN Fa’a Samoa expansion, and the linkage of another MoH project, focused on maternal and child nutrition. The concept of the maternal and child nutrition project is to strengthen and enhance existing community based primary health care activities such as child growth monitoring and promotion and Infant and young child feeding education and counselling. The project also aims to improve health sector access to and assessment of child growth data currently collected by District Hospitals and Health Services, and to enhance the knowledge and capacity of local primary health care staff and village based volunteers. The overall goal, being to demonstrate that a village focused capacity building service delivery model can improve the nutritional status and growth in pregnant women and children aged 0-5 years. As the village based delivery and capacity building components of the two initiatives are very similar and there is strong evidence of links between nutritional status and growth in early life and NCD development in adults, the MoH have proposed that, as part of the 2016 expansion, the nutrition project is integrated into the existing community-based health program structure of PEN Fa’a Samoa. [Annex 1] Detailed Nutrition Related Equipment and Training Costs Description of Item 2016$WST2017$WST2018$WSTPortable tablets, for mobile data entry, camera for documentation, and use in education sessions in the field, for the Project Officer and each pilot site.$22,500(15)Mobile phones, SIM card and $5WST weekly credit during implementation phase. One for each nutrition Assistant, project officer and nutrition advisor to assist with organisation of site visits, clinical supervision and referrals.$5,000(16)$4000(weekly credit)$2000(weekly credit)Mother and Baby Scales Seca 874 and carry bag. One for each Nutrition Assistant for use in growth monitoringFunded under PEN Faa SamoaMeasuring mat Seca 210, light weight and portable. One for each Nutrition Assistant for use in growth monitoring$4,000Hb point of contact test machine and strips to monitor anaemia levels. One for each of the 8 health sites$15,000(8)$10,000(strips)$10,000(strips)PC viewer, portable projector, 3000 lumens. One shared between teams on Upolu and on Savaii$3,600(2)1 x laminator A3/A4, for laminating educational tools and resources. One shared between teams on Upolu and on Savaii$1,000(2)White board (portable) to be used for educational sessions in the field. One for each village site $2,500(14)Food models and educational tools. One for each of the 8 health facility sites.$10,000(5)Cooking demonstration kit. One kit for each of the 8 health facility sites.$4,800(8)Nutritional Supplements for community managed MAM and SAM cases (non-acute or post-hospital discharge). (Est. cost for 4 MAM/SAM cases per site and ~40% anaemia rates in children 0-5 years in village sitesE.g. Ready to Use Therapeutic Feeds (RUTF), Multi-Micronutrient Powder sachets, vitamin A capsules, worming medication and Resomal rehydration solution.The technology to produce RUTF is simple and can be transferred to any country with minimal industrial infrastructure. RUTF cost about US$3 per kilogram when locally produced. A child being treated for severe acute malnutrition will need 10–15 kg of RUTF, given over a period of six to eight weeks.$25,000$25,000$12,500Total$93,400$39,000$24,500[Annex 2] Individual NCD Passbook-44452673353917950267335????????NCD Passbook for Samoa(Ma’i Tumau)????Name: ___________________ID: ________________???Personal Record and Information Booklet??????????????????Patient Information?Name:_____________________________________________________________Village:_____________________________________________________________Telephone:__________Blood Group:________Type of NCD:HypertensionDiabetes Type IICVDOther?Health facility:_______________________________________________________Doctor’s name:__________Nurse name:____________Date diagnosed:__/__/____Review visits recommended: 1x/year2x/year3x/year1x/month?Calendar of visits: __/__/______/__/______/__/______/__/______/__/______/__/____????Medication Register?DATENAME OF MEDICATIONDOSAGETimes per day1__/__/____??2__/__/____??3__/__/____??4__/__/____??5__/__/____??6__/__/____??7__/__/____??8__/__/____??9__/__/____??10__/__/____??11__/__/____??12__/__/____??13__/__/____??14__/__/____??15__/__/____??16__/__/____??17__/__/____??18__/__/____??19__/__/____??20__/__/____??21__/__/____??22__/__/____??23__/__/____??RECORD OF VISITSDATEBlood SugarBMIBlood PressureComments?__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____????__/__/____?????Every 6 monthsEvery 12 monthsDATEFoot sensationHbA1cTGLCholUrinary ProteinEye exam__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????__/__/____??????DIABETES and HYPERTENSIONWhat is diabetes?Everyone has some sugar in their blood. If you have too much sugar in your blood, you have diabetes. Too much sugar in your blood can damage your body. ?What are the symptoms of diabetes?Some people with diabetes do not have any signs, so it is important to have your blood sugar level mon symptoms are:Feeling tired or lacking energyFeeling more thirsty than usualPassing urine more frequently than usualBlurred visionSkin infections or ulcers that heal slowlyWeight loss?Healthy Targets for Diabetes/Hypertension control?Good controlFair ControlCould be betterFBS (mmol/L)4.0-6.0 6.1-7.07.1 or MORERBS (mmol/L) 4.0-8.0 8.1-11.011.1 or MOREHBA1c (%)<66.0-7.0≥7.0Total Cholesterol (mmol/L)<4.04.1-4.9≥5.0HDL-Cholesterol (mmol/L)>1.0<1.0-0.9<0.9LDL-Cholesterol (mmol/L)<3.03.0-4.0>4.0Triglycerides (mmol/L)<1.51.6-2.0>2Body Mass Index (kg/m2)20-2525-30>30Blood pressure (mm Hg)120/80130/85140/90Medication DiabetesName of drugsCounsellingReasonsMetformin (Glucophage)Do not forget to take the medicationTo avoid hypoglycemia (low blood sugar symptoms induced by drugs)Glibenclamide (Daonil)Tolbutamide (Rastinon)Gliclazide (Diamicron)INSULINDescriptionRegularAre clear in colour and usually given 20-30 minutes before mealIsophaneGiven in the morning or the night. This lasts for 16-24 hoursMedication HypertensionName of drugsCounsellingReasonsxxDo not forget to take the medicationxxWhat is hypertension/high blood pressure?Normal blood pressure is 120/80 mmHg.If your blood pressure is always 140/90 mmHg or higher, you have high blood pressure.Most people with high blood pressure do not know it.The only way to find out if your blood pressure is high is to have it measured.?Are diabetes and hypertension serious?Yes, having diabetes and high blood pressure increases your risk of: Heart attackStroke Kidney failureAmputations (in people with diabetes)Blindness (in people with diabetes)?What kind of lifestyle do you recommend?Quit smokingReduce alcohol drinkTake care with diet (less sugar, salt, and fat)Be physically active1322705539877027698705398770??????????????????????????????[Annex 3] Village-level household and individual registration formNoNameDate of BirthSexPhoneHistory(DM/HTN/Heart/Stroke)DateSmoking (Y/N)Alcohol(Y/N)HeightWeightSBP/DBPRBSHigh risk (Y/N)Medication (Already/Need/No need)[Annex 4] Village-level high-risk people registration formNoIDNameDate of BirthSexHeightDateWeightSmoking (y/n)SBP/DBPComplianceReferral (elective/emergent/no need)Next checkup[Annex 5] Report form from village level[Note]Reporter: A member of the village women’s groupCollector (consolidator): A representative of the village women’s groupSource of data: PEN Fa’a Samoa village registration form 1 and 2Date _____________DescriptionNumberNumber of population age > 30 (or 40) in the catchment areaNumber of NCD risk group identified during annual screeningNumber of those who need NCD medication identified during annual screeningNumber of persons whose quarterly follow-up information was collectedNumber of current smoker among those followed upNumber of persons with systolic blood pressure more than 140 among those followed upNumber of persons who take medicine regularly among those followed up[Annex 6] NCD Follow up Assessment Form at Health FacilityNCD Registry No:(YYMMDD-VV-NN)*Name:(Igoa)Male: Female: (Ali'i) (Tamaitai)Date of Birth: (Aso Fanau)......... / ......... / ........Village/Matai:……………. / …………….Contact:(Telefoni)Home: Mobile:(Fale) (Selula)Date of first assessment: ......... / ......... / .........Height (cm):Known: Hypertension , Diabetes , Cardiac , Other: Newly Diagnosed: Hypertension , Diabetes , Other:Risk(s) Identified: Smoking , Overweight , Alcohol , Inactivity , High Cholesterol , Other:Follow up - AssessmentDateWtBPBSL (mmo/l)**Cholesterol (mmol/l)***WHO/ISH RiskSmokingPrescription(Name, dose, times)(Kg)Sys.Dia.FastRand.T CHDLTC/HDLNotes (Date and Sign):* YY: Birth year (2 digit), MM: Birth month, DD: Birth day, VV: Village code (2 digit), NN: Sequence number** Glucose conversion factor - mg/dl X 0.0555 = mmol/l ; *** Cholesterol conversion factor - mg/dl X 0.0259 = mmol/l Patient Management/Counselling Check List:Date:MedicationsUsesImportanceComplianceOver dose / under doseMediation RefillsFree Drug SupplyPhysical ActivityExerciseNutrition/DietSugarSaltHigh fat foodsDangerous HabitsSmokingAlcoholDrugsNotes (Date and Sign): ................
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