INTRODUCTION:

Community nurses are increasingly being recognized as a crucial part of the health workforce. Their roles are better understood in the areas of maternal and child health and parallel to management of non-communicable diseases (NCDs). Community nurse’s task over the years has evolved from mainly focusing on prevention and promotion to more supportive roles that are associated with the increased burden of chronic life-long diseases like NCDs.

Studies showed that the modifiable risk factors are usually seen during adolescence and are then carried to adulthood^1,2. The WHO identified four main NCD as a leading cause of mortality: cardiovascular diseases, diabetes mellitus, chronic respiratory diseases, and cancers. These four diseases share the four potential modifiable risk factors of NCDs: physical inactivity, unhealthy diet, harmful alcohol use, and tobacco use. The four modifiable risk factors contribute to over 80% of NCD premature mortality³.

Community nurses provide crucial follow up to behavioral interventions that aim to modify the key risk factors for NCDs and give health education regarding promotion of health. Nurses provided services on reduction of risk factors associated with NCDs by implementing WHO’s recommended ‘best buys” (that is cost effective, feasible and with a low implementation cost)⁴. The Political Declaration highlights important measures to promote and support breastfeeding, prevent obesity and NCDs later in life, improve access to immunization and cancer screening and scale up health education⁵.

A qualitative study was conducted by Tsolekile L et al⁶ on the role of community health workers in management of non-communicable diseases. This article discussed principally the community health workers had multiple roles and these could be summarized into six broad themes: advisor, provision of direct services, monitoring of clients, linking clients with the health system, capacity building and administration. There is a need to develop the capacity of community health workers in a sustained manner and to create on-going education that is organized and relevant to the context in which they work.

An observational study was conducted by Lall D et al⁷ on challenges in primary care for diabetes and hypertension at Kolar district in rural India. The articles discussed that several challenges were identified in the current organization of services that impede the delivery of care responsive to the needs of chronic conditions such as doctor-centered care processes that impede adequate counseling and result in poor communication, lack of decision support to enable evidence-based treatment decisions, a broken information system that did not facilitate follow up and revisits, a fragmented delivery of services that requires multiple visits and poor support for self-management that went beyond just managing the disease condition.

With this background, researchers have following questions:

· Do community nurses do the screening for NCDs?

· Do community nurses educate the client and their family members regarding the risk factors of NCDs?

· Are there any referral criteria for clients with NCDs?

· Do community nurses faced any challenge?

Therefore, the study is undertaken to assess the role of community nurses towards NCDs services and to find out challenges faced by community nurses towards providing NCDs services.

METHODS AND SUBJECTS:

Study design and Population: This community based cross-sectional study was conducted with community nurses who were posted in selected blocks in the selected district of West Bengal during 02/01/2021 to 31/01/2021 period. In this study Community nurses denote all nurses who provide the above services regarding NCD services in the sub-centre and health wellness centre i.e., Auxiliary nurse midwife (ANM) and Community Health Officer (CHO) respectively. Role towards NCDs services refers to the following practices i.e. screening, health education, clinical management, referral services, distribution and management of essential drug to patients having NCDs and follow-up. Challenges refer to obstruction or barriers during providing NCD in terms of infrastructure, manpower, equipment/logistics, training status, patients’ compliance to NCD services, awareness for accessing NCDs among the community people, availability of drugs and treatment related factors etc.

Sample and sampling technique: Sampling done at different stages. At first stage district was selected conveniently, then three blocks were selected randomly but subjects were selected through total enumeration sampling technique. 100 community nurses (n_ANM=76, n_CHO=24) were recruited.

Ethical Clearance: Permission to carry out the study was obtained from the Institutional Ethical Committee of the Government Medical College and Hospital, West Bengal. Informed consent was obtained from parents/guardians after explaining them about the purpose of the study.

Study tool: To assess the community nurses role towards NCDs services, Rating Scale was developed from the guidelines of job responsibilities of CHO, released by Department of Health and Family Welfare, Govt. of West Bengal dated 19.06.2019, memo no: 578⁸and guidelines of job responsibilities of ANM, released by Department of Health and Family Welfare, Govt. of West Bengal dated 11.06.13, memo no: No/HNG/6M-7-2013/783^8.The rating scale consists of 22 items with different role components like educator role, administrator role, collaborator role, supervisor role and rehabilitator role. Score was for always =2, sometimes =1 and never =0. To cross check the response in rating scale record analysis Performa also prepared which mainly check: community based assessment checklist, medicine stock register and referral register. To identify the challenges faced by the community nurses, 16 items checklist was prepared consisting of two options that is yes or no and scoring was one (1) for yes and zero (0) for no. The validity and reliability was established before final data collection. Reliability of rating scale of Community nurses role was 0.86 through Cronbach’s alpha. Inter rater reliability of record analysis Performa was 1. Reliability of check list for challenges was computed through Kuder-richerdson formula 20 methods and it was 0.87.

Data collection: Investigator made contact with all the Block Medical Officer of Health and Senior Public Health nurse of selected blocks to fix an appointment for visiting the sub-centre. Name list of community nurses was obtained from Senior Public Health Nurse of selected blocks. On the fixed date investigator reached the selected sub-centers, self-introduction was given to the subject. Purpose of the study was mentioned to the subject before data collection.. Sub-centers and Health Wellness Centers were visited from Monday to Friday from 10 am- 4 pm. Investigator collected data from 4-5 community nurses per day. 30-40 minutes time was taken to collect data from each subject.

Statistical analysis: Data have been summarized by routine descriptive statistics. For assessment of the role of community nurses towards NCDs services- mean, standard deviation, mean% and‘t’ value is calculated. Chi square test is calculated to find out the association between role of community nurses (ANM) towards NCDs services and selected demographic characteristics. Chi-square with Yates’ correction is done where expected frequency <5 is present for less than 20% cells to determine the association between role of community nurses (CHO) towards NCDs services and selected demographic characteristics. Statistical analysis data were entered into SPSS software version 22.

RESULTS:

Table-1: Frequency and percentage distribution of demographic characteristics of community nurses. n=100 (n_ANM=76, n_CHO=24)

Demographic characteristics	Frequency	%
Age
21 – 30 years	7	7%
31 – 40 years	42	42%
41 – 50 years	29	29%
51 – 60 years	22	22%
Professional qualification
ANM	76	76%
GNM	24	24%
Distance of work place from residence
< 5 km	49	49%
5 – 10 km	18	18%
>10 km	33	33%
Population served
< 6000	12	12%
6000 – 8000	62	62%
>8000	26	26%
Professional experience of working
< 10 years	34	34%
10 – 20 years	39	39%
>20 years	27	27%
Special training received on NCDs Yes	65	65
No	35	35

Figure 1: Bar diagram showing community nurses’ role in different sub scale in terms of mean percentage.

Table 2: Assessment of different community nurses’ role towards NCD services in terms of mean, SD and ‘t’ value. n= 100 (n_ANM=76, n_CHO=24)

Sl. No.	Subscale of community nurses’ role	ANM		CHO		‘t’ value	‘p’value
Sl. No.	Subscale of community nurses’ role	Range of score	Mean + SD	Range of score	Mean + SD	‘t’ value	‘p’value
1.	Care provider role	0-6	5.71+ 0.457	0-10	10+ 0	45.876	0.000*
2.	Educator role	0-10	9.87 + 0.340	0-10	10+ 0	1.888	0.062
3.	Administrator role	0-14	12.82 + 0.82	0-14	13.13 + 0.68	1.660	0.100
4.	Collaborator role	0-4	2.55 + 0.70	0-4	3.00 + 0.72	2.708	0.008*
5.	Supervisor role	0-6	5.63 + 0.48	0-6	6+ 0	3.704	0.000*
6.	Rehabilitator role	0-4	4.00 + 0	0-6	5.83 + 0.38	42.455	0.000*

*p< 0.05 significance

Table 3: Reasons for not performing the particular role towards NCDs services as stated by the respondents. n_ANM= 58, n_CHO= 9

Sl. No.	Reasons stated by community nurses (CHO)	F (%)	Reasons stated by community nurses (ANM)	F (%)
1.	100% role performed		Care Provider role · Inadequate training regarding NCDs	22 (37.93%)
2.	100% role performed		Administrator role · Shortage of staff	18 (31.03%)
3.	Collaborator role · Inadequate support from Panchayat members	9 (100%)	Collaborator role · Inadequate support from Panchayat members for Village Health Nutrition Day Session (VHND)/ Outreach Camp	32 (55.17%)
4.	100% role performed		Supervisor role · Shortage of time	20 (34.48%)

Note: Here ‘n’ is not mutually exclusive

Table 4: Frequency and percentage distribution of responses of community nurses regarding challenges towards providing NCDs Services n=100 (n_ANM=76, n_CHO=24)

Sl No	Challenges towards providing NCD Services	Frequency	(%)
1.	Lack of infrastructure	7	7
2.	Lack of awareness among community people regarding accessing non-communicable diseases services	14	14
3.	Inadequate training facilities	47	47
4.	Overloaded with documentation	69	69
5.	Overburden with high inflow of patients	78	78

Note: Here responses are not mutually exclusive

Table 5: Association between role of community nurses (ANM) towards NCDs services and selected demographic characteristics. n_ANM=76

Demographic characteristics	Community nurses’ role in score		Chi Square Value	P Value
Demographic characteristics	< median (41)	≥median (41)	Chi Square Value	P Value
Age
< 40 years	12	18	0.450	0.502
≥ 40 years	22	24	0.450	0.502
Distance of work place from residence
< 5 km	26	22	4.686	0.030
≥ 5 km	8	19	4.686	0.030
Population served
< 8000	25	32	0.071	0.789
≥ 8000	9	10	0.071	0.789
Professional working experience
< 10 years	13	13	0.443	0.506
≥ 10 years	21	29	0.443	0.506

Table 10: Association between role of community nurses (CHO) towards NCDs services and selected demographic characteristics. n_CHO=24

Demographic characteristics	Community nurses’ role in score		Chi square value	p value
Demographic characteristics	< median (48)	≥median (48)	Chi square value	p value
Age
< 40 years	7	12	0.505 after Yates correction 0.032	0.477 0.859
≥ 40 years	1	4	0.505 after Yates correction 0.032	0.477 0.859
Population served
< 8000	6	11	0.101 after Yates correction 0.025	0.751 0.874
≥ 8000	2	5	0.101 after Yates correction 0.025	0.751 0.874
Professional working experience
< 10 years	2	6	0.375 after Yates correction 0.023	0.540 0.878
≥ 10 years	6	10	0.375 after Yates correction 0.023	0.540 0.878

DISCUSSION:

The present study showed that community nurses performed various roles i.e., care provider (97.59%), educator (99.35%), administrator (92.23%), supervisor (96.9%), rehabilitator (98.6%) role respectively whereas only 69.35% performed collaborator role towards NCDs services (Fig-1). The findings of the current study are consistent with the studies conducted by Tsolekile LP et al⁶ and Rawal LB et al⁹ in which they presented that community health workers performed multiple roles such as advisor, provision of direct services and monitoring of clients, linking clients with the health system, administration and referral services.

There are statistically significant role difference in collaborator role, supervisor role and rehabilitator role among ANM and CHO Community nurses (table-2). This may be explained that community nurses (CHO) are more qualified than community nurses (ANM) and CHOs are especially trained in providing NCDs services.

The current study also showed that community nurses could not provide 100% NCD services due to some reasons i.e., inadequate training, shortage of staff, inadequate support from Panchayat members for VHND sessions, shortage of time (table-3). The findings of the present study are congruent with the findings of several studies^6,10. They also reported that community health workers could not provide comprehensive NCDs care due to lack of human resources, lack of training services.

The findings of present study revealed that community nurses faced various challenges in different areas while providing services such as lack of infrastructure, lack of training, high OPD attendance, overloaded with written document and online data entry and lack of awareness for accessing NCDs services (table-4). The findings are consistent with the studies conducted by Rawal LB et al¹⁰, Heller DJ et al¹¹ and Sasmal J et al¹²in which they reported that health workers faced challenges due to lack of infra-structure, lack of transport and communication facilities, high caseload and inadequate training.

In this study there is a significant association between role of community nurses (ANM) towards NCDs services and the selected demographic characteristics like distance of work place from residence and there is no significant association between role of community nurses (CHO) towards NCDs services and the selected demographic characteristics at 0.05 levels of significance (table-5). There are lacks of published quantitative studies related to role of community nurses to support the findings of the present study.

This study explored individualized challenges by using open-ended questions and further it was strengthened by high response rate which reflects the true representative data. This study has limitation too. Firstly, sample size is small. Secondly, the study is confined to only role of community nurses towards NCDs services.

Recommendations: Similar study can be conducted through qualitative study design on challenges faced by community people towards providing NCDs

Conclusion: The study concluded that community nurses perform various roles like care provider, educator, administrator, collaborator, supervisor, rehabilitator and coordinator role towards NCD services and they are facing various challenges too. So, there is a need to overcome these challenges faced by the community nurses in order to maintain the comprehensive care rendered. Adequate training, overcoming staff and infrastructure shortage is the need of the hour to subdue such challenges.

ACKNOWLEDGEMENT:

The investigators expressed sincere gratitude to CMOH of particular district and BMOH and PHN of selected three blocks for their constant support and help throughout the study. The investigators are indebted to all community nurses or their kind co-operation and support during data collection.

SOURCES OF FUNDING:

Self funded

CONFLICT OF INTEREST:

None

REFERENCES:

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11. Heller D, Kumar A, Kishore S, Horowitz C, Joshi R, Vedanthan R. Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis. JAMA Netw Open 2019;2(12): e1916545.

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Received on 08.03.2022 Modified on 23.03.2022

Asian J. Nursing Education and Research. 2022; 12(2):229-234.

DOI: 10.52711/2349-2996.2022.00047