Implementation factors of non-communicable disease policies and programmes for children and youth in low-income and middle-income countries: a systematic review

Abstract

Introduction: Despite declared life-course principles in non-communicable disease (NCD) prevention and management, worldwide focus has been on older rather than younger populations. However, the burden from childhood NCDs has mounted; particularly in low-income and middle-income countries (LMICs). There is limited knowledge regarding the implementation of paediatric NCD policies and programmes in LMICs, despite their disproportionate burden of morbidity and mortality. We aimed to understand the barriers to and facilitators of paediatric NCD policy and programme implementation in LMICs.

Methods: We systematically searched medical databases, Web of Science and WHOLIS for studies on paediatric NCD policy and programme implementation in LMICs. Screening and quality assessment were performed independently by researchers, using consensus to resolve differences. Data extraction was conducted within the WHO health system building-blocks framework. Narrative thematic synthesis was conducted.

Results: 93 studies (1992-2020) were included, spanning 86 LMICs. Most were of moderate or high quality. 78% reported on paediatric NCDs outside the four major NCD categories contributing to the adult burden. Across the framework, more barriers than facilitators were identified. The most prevalently reported factors were related to health service delivery, with system fragmentation impeding the continuity of age-specific NCD care. A significant facilitator was intersectoral collaborations between health and education actors to deliver care in trusted community settings. Non-health factors were also important to paediatric NCD policies and programmes, such as community stakeholders, sociocultural support to caregivers and school disruptions.

Conclusions: Multiple barriers prevent the optimal implementation of paediatric NCD policies and programmes in LMIC health systems. The low sociopolitical visibility of paediatric NCDs limits their prioritisation, resulting in fragmented service delivery and constraining the integration of programmes across key sectors impacting children, including health, education and social services. Implementation research is needed to understand specific contextual solutions to improve access to paediatric NCD services in diverse LMIC settings.

Keywords: adolescent health; child health; developing countries; health services research; noncommunicable diseases.

Figure 1

Selection process for literature inclusion.

Figure 2

Year of publication.

Figure 3

Geographic distribution of articles.

Figure 4

Non-communicable disease (NCD) classifications. (A) Classification by WHO’s main four NCDs framework; cardiovascular disease (n=6), chronic respiratory disease (n=1), diabetes mellitus (n=0), cancer (n=13) and others (n=73). (B) Classification of NCDs not encompassed by the framework; metabolic (n=13), haematological (n=11), otolaryngological (n=11), child and adolescent mental health (n=8), intellectual development (n=7), musculoskeletal (n=6), ophthalmic (n=6), congenital abnormalities (n=4), nutrition-related (n=3), renal (n=1), neurological (n=1), odonatological (n=1) and rheumatological conditions (n=1).

Figure 5

Components of care continuum represented in studies. NCD, non-communicable disease.

Figure 6

Frequency of implementation barriers and facilitators across health system building-blocks.