Interdisciplinary training on noncommunicable diseases and sustained change in primary health care in the context of health reform, COVID-19, and war in Ukraine: A repeated qualitative study, 2016–2022

Abstract

Background: Noncommunicable diseases (NCDs), account for nearly 90% of deaths in Ukraine, led by cardiovascular diseases and cancers. Common risk factors include tobacco and alcohol use, unhealthy diet, and physical inactivity. To improve the NCD care at the primary health care (PHC) level, the Ministry of Health and World Health Organization (WHO) introduced a two-day interdisciplinary training intervention for PHC providers – managers, doctors, nurses, and feldshers, grounded in the WHO Package of Essential Noncommunicable Disease Interventions (WHO PEN). Conducted across seven pilot regions between 2016 and 2018, the program trained over 10,000 PHC providers, about 55% of the PHC workforce. This study evaluated the scope and sustainability of practice improvements introduced by WHO PEN training, capturing PHC providers’ perspectives in the context of health reform, the COVID-19 pandemic, and war. Methods: We implemented a repeated qualitative study at two time points, informed by traditions of qualitative longitudinal research. At T1 (December 2018–February 2019), focus group discussions (n = 74) explored early adoption and practice transformation following the intervention. At T2 (February–March 2022), in-depth interviews (n = 56) examined sustained changes and contextual influences, including health reform, COVID-19, and war. Transcripts were analyzed using deductive thematic analysis guided by the Dynamic Sustainability Framework, complemented by inductive coding to capture emerging themes. Results: At T1, providers reported stronger focus on NCD prevention, early detection and management demonstrating greater confidence in routine NCD risk assessment, lifestyle counseling, and integrated management of hypertension and diabetes, supported by task shifting and managerial engagement. By T2, PHC providers showed resilience in sustaining these practices, but their frequency declined as COVID-19 curtailed preventive activities and redirected attention toward patients with established NCDs and complications. Sustainability was further undermined by administrative burdens, workforce shortages, and rising patient loads, while the war intensified stress and psychosomatic complaints among patients. Conclusions: WHO PEN–facilitated practice changes in Ukrainian PHC were sustained over five years, but their frequency diminished under systemic pressures, pandemic disruptions, and war. Despite these challenges, PHC providers demonstrated resilience, underscoring the need for continued investment in PHC capacity and integrated NCD care.