REVIEW

A Narrative Review of the Patient Journey Throughthe Lens of Non-communicable Diseases in Low-and Middle-Income Countries

Ratna Devi . Komal Kanitkar . R. Narendhar . Kawaldip Sehmi .

Kannan Subramaniam

Received: August 6, 2020 / Accepted: September 28, 2020 / Published online: October 14, 2020� The Author(s) 2020

ABSTRACT

Low- and middle-income countries (LMICs) arechallenged with a disproportionately high bur-den of noncommunicable diseases (NCDs) andlimited healthcare resources at their disposal totackle the NCD epidemic. Understanding thepatient journey for NCDs from the patients’perspective can help healthcare systems in thesesettings evolve their NCD care models to addressthe unmet needs of patients, enhance patientparticipation in their management, and progresstowards better outcomes and quality of life. Thispaper aims to provide a theoretical frameworkoutlining common touchpoints along thepatient journey for NCDs in LMICs. It further

aims to review influencing factors and recom-mend strategies to improve patient experience,satisfaction, and disease outcomes at eachtouchpoint. The co-occurrence of major NCDsmakes it possible to structure the patient journeyfor NCDs into five broad touchpoints: awareness,screening, diagnosis, treatment, and adherence,with integration of palliative care along the carecontinuum pathway. The patients’ perspectivemust be considered at each touchpoint in orderto inform interventions as they experience first-hand the impact of NCDs on their quality of lifeand physical function and participate substan-tially in their disease management. Collabora-tively designed health communicationprograms, shared decision-making, use ofappropriate risk assessment tools, therapeuticalliances between the patient and provider fortreatment planning, self-management tools, andimproved access to palliative care are somestrategies to help improve the patient journeys inLMICs. Long-term management of NCDs entailssubstantial self-management by patients, whichcan be augmented by pharmacists and nurse-ledinterventions. The digital healthcare revolutionhas heralded an increase in patient engagement,support of home monitoring of patients, opti-mized accurate diagnosis, personalized careplans, and facilitated timely intervention. Thereis an opportunity to integrate digital technologyinto each touchpoint of the patient journey,while ensuring minimal interruption to patients’care in the face of global health emergencies.

R. Devi (&)Dakshayani and Amaravati Health and Education,Gurgaon, Indiae-mail: ratna.devi@dakshamahealth.org

R. Devi � K. SehmiInternational Alliance of Patient Organizations,London, England

K. KanitkarEPI (Immunization), Municipal Corporation ofGreater Mumbai, Mumbai, India

R. NarendharAlzheimer’s Related Disorders Society of India(ARDSI), New Delhi, India

K. SubramaniamUpjohn—A Pfizer Division, Sydney, Australia

Adv Ther (2020) 37:4808–4830

https://doi.org/10.1007/s12325-020-01519-3

Keywords: Noncommunicable disease; Patientengagement; Patient journey; Patient journeymapping; Patient journey touchpoints

Key Summary Points

In low- and middle-income countries withlimited healthcare resources, where overthree-quarters of noncommunicabledisease (NCD) deaths occur, mapping thepatient journey for NCDs can informdecision-making for designing andprioritizing interventions to optimizedisease control and management.

This review summarizes the keytouchpoints that are common along thepatient journey for NCDs in the context oflow- and middle-income countries:awareness of disease and knowledge ofassociated risk factors; screening and riskassessment; diagnosis and treatmentdecision; treatment experience and accessto care; adherence to treatment forchronic management; and palliative carealong the care continuum pathway.

In order to effectively improve the overallquality of care, it is important to adoptpatient-centric strategies along thesecommon touchpoints. Examples of suchstrategies include collaboratively designedhealth communication programs, shareddecision-making, use of appropriate riskassessment tools, therapeutic alliancesbetween the patient and provider fortreatment planning, self-managementtools, and improved access to palliativecare.

Digital health technologies should beintegrated into the patient journey to helphealthcare systems and providers remainpatient-centric while moving towards apublic health approach focused onprevention and delay of onset of NCDs orcomplications, early and accuratediagnosis, and ensuring good adherenceto treatment.

DIGITAL FEATURES

This article is published with digital features tofacilitate understanding of the article. You canaccess the digital features on the article’s asso-ciated Figshare page. To view digital features forthis article go to https://doi.org/10.6084/m9.figshare.13014350.

PLAIN LANGUAGE SUMMARY

In low- and middle-income countries, patientsliving with noncommunicable diseases faceseveral challenges due to limited healthcareresources, access to accurate information, andprevailing social, economic, and cultural con-ditions. These factors influence care pathways,patient behavior, and consequently the patientjourney. A patient journey is defined as thesequence of steps beginning with a patient’sawareness that something is not right or theyare not feeling well and seeking interaction withhospital, healthcare professional, or otherstakeholders in a healthcare system. Under-standing these interactions can provide manyinsights into patient experience and the out-comes of their disease. In the context of patientssuffering from noncommunicable diseases,these interactions can be broadly categorized as(1) awareness of disease and knowledge ofassociated risk factors; (2) screening and riskassessment; (3) diagnosis and treatment deci-sion; (4) treatment experience and access tocare; and (5) adherence to treatment for long-term management. The examination of thesekey patient journey touchpoints highlightsopportunities in noncommunicable diseasemanagement and can help in prioritizinginterventions for improving prevention andcontrol. Strategies to improve the patient jour-ney must integrate the patients’ perspective ateach touchpoint. Digital health technologiesand widespread use of mobile phones in low-and middle-income countries allow patients toactively participate in their care through homemonitoring devices, healthcare apps, wearabletechnology, and telehealth services.

Adv Ther (2020) 37:4808–4830 4809

INTRODUCTION

Noncommunicable diseases (NCDs) are theleading cause of deaths globally, particularly inlow- and middle-income countries (LMICs) [1].The NCD mortality burden is disproportion-ately higher in LMICs, with over 75% of globalNCD-related deaths [1]. Apart from the impacton health and well-being, NCDs also pose highfinancial burden on the national healthcaresystems and often lead to catastrophic expen-diture by households, particularly the poor whoare the most affected [2]. Research on the majorNCDs, i.e., cardiovascular (CV) diseases, dia-betes, cancer, chronic respiratory diseases, andmental health disorders, informs that theseconditions are associated with modifiable riskfactors (tobacco and excessive alcohol use,unhealthy diet, and physical inactivity) that arecommon to them, and contribute to the diseaseonset [3]. Despite global commitment to reduceNCD-related premature mortality, progress isslow particularly in the LMICs [4]. This high-lights the need to recalibrate the existing NCDcare model.

Patient Journey Mapping

Patient journey mapping—also called health-care process mapping—is an exercise used byhealthcare leaders for viewing the managementof specific conditions from the patients’ per-spective, as a series of consecutive events oractivities between patients and healthcare sys-tems that shape the patient experience [5, 6].From a hospital or healthcare system perspec-tive, most patient journeys typically comprisesix sequential stages as described in Table 1.Mapping reveals every facet of interactionbetween the patient and the health system,including appointment reminders, phone callswith admitting staff, prescription reminders,physical care, and with adequate surveillance,even points in the clinical journey that happenout-of-network [5]. This exercise helps locateany gaps in the patient care experience, lendingthe opportunity to redesign patient pathways tomaximize clinical efficiency by focusing onactivities most valued by patients [6]. To get the

most out of the patient journey mapping exer-cise, it is important to identify various elementsof the patient and health system interaction, aslisted in Table 2. Despite their usefulness, thereis no consensus on a universally accepted defi-nition of the patient journey ratified by patientsor patient organizations, varying between dis-ease conditions, regions, and mapping processemployed [7, 8].

Published studies have attempted to mappatient journeys for individual NCDs in multi-ple countries and regions (Table 3) [9–14]. Asexpected, most evidence comes from high-in-come countries and the corresponding data forLMICs is sparse. Notably, most patient journeysfor NCDs begin long before the ‘‘trigger’’ orpoint of access into the health system [9]—a factthat is commonly missed by healthcare provi-ders and results in remedial counselling at orafter the trigger. Being ‘‘aware’’ of NCD riskfactors and adopting healthy lifestyles can pre-vent or delay the onset of a disease [15]. It is alsoimportant to recognize that NCDs do not occurin silos; many patients face multimorbidity,with each morbidity prompting its own uniquejourney [16]. Patients’ perspectives and value-added inclusion can provide both unique andcritical insights to healthcare delivery teams injourney mapping. Patients living with NCDs(PLWNCDs) have direct, extensive experienceof living with the disease and understand first-hand the impact of the disease on their qualityof life and physical function. Chronically illpatients are expected to participate substan-tially through self-care in managing theiradherence to therapy and the safe use of pre-scribed medicines based on labelling and otherinformation provided to them [17].

Barriers to NCD Care Pathways in LMICs

Patient journeys are context-specific and relianton national healthcare systems and invest-ments. Since LMICs tend to have fragmentedhealth service delivery, uneven quality of care,and a large informal healthcare sector providingsubstantial chronic healthcare, the patientjourney from initial outreach to continued careis rarely seamless [18]. Equitable access to health

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services is far from optimal in many LMICs, asevident from poor patient-to-provider ratiosand high out-of-pocket (OOP) expenditure onhealthcare [19, 20]. Whereas in developednations the OOP expenditure for completehealthcare (data for NCD OOP expenditure isnot reported separately) is about 20–25%, itrises to a massive 60% in developing countrieslike India [21, 22]. Contributing to the burden,most LMICs invest only a small proportion of

their gross domestic product into healthcareexpenditure (ca. 4%), much lower than what isneeded [23].

In LMICs, several factors outside the healthsystem also influence decisions to enter or exitthe patient journey, and often these choicesinfluence the disease trajectory. Poor healthliteracy and lack of awareness about risk factorsand appropriate entry points into the health-care system contribute to poor patient

Table 1 A healthcare system perspective of a patient journey

Trigger event/awareness The patient self-assesses his or her symptoms, conducts research, considers potential health

conditions that may require treatment, and may even reach out to online communities (posing

questions on social media, etc.)

Help The patient makes initial contact with a health system via a call center, chat, email, mobile, or an

in-person visit

Care The patient is assessed at a medical facility (physician’s office, hospital, etc.)

Treatment The health system provides the patient with both on-site and follow-up care (prescriptions,

physical therapy, counselling, or suggested lifestyle changes)

Behavioral/lifestyle

change

The patient makes changes to daily routines and takes part in proactive healing in order to reduce

readmissions and promote long-term well-being

Ongoing care/proactive

health

The patient manages his or her care between clinical visits; meanwhile, the health system fosters

engagement between the patient and physician in order to enable the patient to address

symptoms and maintain good health

Table 2 Key elements of a patient journey map

Touchpoints Any point of interaction between a patient and the healthcare system

Timeline It is important to denote the amount of time that each interaction (or touchpoint) lasts, the amount of

time in between touchpoints, and the overall length of the patient journey

External

influences

Any factors that impact the patient journey that are beyond the health system’s control. For instance, if

patient lives at some distance from a healthcare facility

Internal

influences

Any factors that impact the patient journey as a result of the health system’s own operations. For

instance, a long wait time to schedule a surgery due to the renovation of a surgical wing within the

hospital

Barriers Any factors that may prevent the patient journey from moving forward. Examples of common barriers

within the patient journey include cost (if the patient is unable to afford continued treatment), time

conflicts (such as a hectic work schedule or family obligation), the patient’s mental or emotional state,

socioeconomic pressures, and many others

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Table 3 Comparison of patient journey mapping approaches for select NCDs

Study NCD Regiona Stages outlined

Thrift-Perry

et al. [9]

Breast cancer HIC, LIC, MIC Awareness/recognition

Diagnosis

Coordinated care

Treatment

Ongoing management

Mohr et al.

[10]

Schizophrenia HIC (Europe) Premorbid phase/preventive measures

Prodromal phase/early detection, early intervention

Acute episode/treatment initiation

Long-term phase/relapse prevention

Recover

Fennelly et al.

[11]

Musculoskeletal

disorders

HIC (Ireland) First clinician appointment

Subsequent clinician appointment

Investigations

APP appointment

Initial referral

Additional APP appointment

Skold et al.

[12]

Idiopathic

pulmonary

fibrosis

HIC (Sweden) Time to disease diagnosis

Medication use

Treatment pattern

Adherence, persistence, and length of treatment

Kassouf et al.

[13]

Bladder cancer HIC (Canada) Pre-diagnosis (signs/symptoms)

Time of diagnosis/pre-treatment

During treatment

After treatment (living ‘‘the new normal’’)

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outcomes [24, 25]. In resource-limited settings,unauthorized practitioners propagate igno-rance, misconceptions, and misleading guid-ance that complicate patient pathways further[26]. Health and morbidity are influenced bybehavioral decisions of individuals or theirfamilies, genetically inherited health endow-ments, or the health environment in whichpeople reside. Illness is, therefore, systemati-cally linked to household- and community-levelfactors [27]. Other factors shaping health-seek-ing behavior include age, socioeconomic con-ditions, presence of comorbidities, perceivedfamily support, duration of disease, and historyof early treatment at diagnosis [28]. The socialdeterminants of health in LMICs, governed bythe policy choices and the amount of money,power, and resources that people have, are keyto discerning care pathways followed by

patients when accessing healthcare [29]. Thedifferences in healthcare systems, socioeco-nomic and cultural factors, and populationhealth literacy warrant the need for examiningpatient journeys independently in the LMICsetting.

Scope of the Study

NCDs often co-occur and share commonbehavioral and environmental risk factors. TheWorld Health Organization (WHO) has longadvocated for an integrated approach for pre-vention and control of NCDs both at systemand service levels, rather than in disease-specificsilos [30]. Therefore, this paper aims to providea theoretical framework outlining the sharedpatient journey touchpoints for people livingwith the major NCDs, particularly CV diseases,

Table 3 continued

Study NCD Regiona Stages outlined

Alkandari et al. [14] Peripheral

neuropathy

HIC (Kuwait) GP visit in primary care

Blood test

General pain management

Referral to general hospital

Complete investigations

Continue general pain management

Referral to neurologist in general hospital

Advanced investigations

Continue general pain management and

first-line treatment

Referral to neurology specialist in national hospital

Advanced investigations and physical examination

Continue general pain management and

first-line treatment and start second-line

or third-line treatment

Follow-up, monitoring, and review medications

APP advanced practice physiotherapist, GP general physician, HIC high-income countries, LIC low-income countries, MICmiddle-income countries, NCD noncommunicable diseasea Classified according to the World Bank income classification

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diabetes, and mental health disorders, as theleading contributors of NCD-related mortalityand morbidity in LMICs [1]. It further aims todraw upon published literature and secondarysources to review influencing factors and rec-ommend patient-centered strategies to improvethe patient journey at each touchpoint.

METHODS

The PubMed database was searched to identifyrelevant literature using the search terms ‘‘pa-tient-centered care’’, ‘‘patient journey’’, ‘‘non-communicable diseases’’, ‘‘cardiovasculardiseases’’, ‘‘diabetes’’, ‘‘hypertension’’, ‘‘dyslipi-demia’’, ‘‘mental health’’, ‘‘depression’’, ‘‘anxi-ety’’, ‘‘awareness’’, ‘‘health promotion’’, ‘‘healthliteracy’’, ‘‘patient education’’, ‘‘screening’’, ‘‘riskassessment’’, ‘‘diagnosis’’, ‘‘treatment decision’’,‘‘treatment experience’’, ‘‘treatment monitor-ing’’, ‘‘treatment access’’, ‘‘adherence’’, ‘‘compli-ance’’. As a result of the sparse availability ofpeer-reviewed literature on the topic in LMICs,additionally, relevant articles and reports cura-ted by the authors from the Google databaseand gray literature were also utilized in thisstudy.

This article is based on previously reportedstudies and does not contain any studies withhuman participants or animals conducted byany of the authors.

RESULTS

Common Touchpoints of the PatientJourney for NCD in LMICs

Suffice to say that patient journeys are notsimilar for all diseases; however, there arecommonalities in patient journeys of closelylinked groups of diseases and specific needs forindividual conditions [31]. The WHO recom-mends integrated management of NCDs withequitable access to a nationally determined setof promotive, preventive, curative, rehabilita-tive, and palliative basic health services [32].Aligned with the WHO recommendation andcommon risk factors linking the major NCDs

[33], the patient journey for NCDs can bestructured into five broad touchpoints: aware-ness, screening, diagnosis, treatment, andadherence with integration of palliative carealong the care continuum pathway (Fig. 1).

The importance of the concept of primordialprevention, which focuses on health educationeven before risk factors arise, cannot be down-played in the context of NCDs [34]. Awarenessof health-promoting habits and knowledge ofdisease form the first stage of the patient jour-ney, before the onset of NCDs [35]. Periodic oropportunistic screening for risk factors and co-occurring NCDs is an effective strategy forlowering the morbidity and mortality due tothese diseases by detecting undiagnosed casesand initiating early treatment [36]. At theremedial phase, the treatment decision follow-ing diagnosis, treatment experience influencedby treatment goals, access to services, follow-up,and adherence to the recommended therapeuticor lifestyle modification interventions deter-mine the course of the patient journey for NCDsand the outcomes. Palliative care is recognizedas an integral component of universal healthcoverage and must be available throughout thelife course of PLWNCDs particularly in LMICs,where approximately 80% of the global popu-lation in need of palliative care resides [37, 38].Palliative care is essential for better control ofsymptoms and an improved quality of life forpatients and also improves the physical andpsychosocial well-being of families and care-givers [38].

The patient’s touchpoints with healthcaresystems along their journey is further influ-enced by the accessibility of services across fivedimensions, i.e., approachability, acceptability,availability and accommodation, affordability,and appropriateness (Fig. 2) [39]. These dimen-sions in access to care are in turn governed bythe patient’s ability to perceive, ability to seek,ability to reach, ability to pay, and ability toengage, respectively [39]. Strategies designed toimprove the patient journey must considerthese factors to ensure a patient-centeredperspective.

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Strategies to Improve the Patient Journeyfor NCDs Along Common Touchpoints

Improving the patient journey for NCDsrequires cost-effective and efficient solutionscustomized to LMIC settings [40]. It is impor-tant to review problems and prospects of influ-encing factors at the micro, meso, and macrolevels of healthcare, i.e., at the level of individ-uals, their households, and communities, aswell as at the policy level [41]. Some recom-mendations are listed in Table 4.

Disease Awareness and Knowledgeof Associated Risk Factors: Effective HealthCommunication

The limited impact of the medical monologuebetween the doctor and the patient, guised asmedical communication, has necessitated thedevelopment of health communication strate-gies that are collaboratively designed, imple-mented, and comprehensively evaluated toensure sustainable health improvements[42, 43]. The overarching component of aneffective health communication programremains a powerful, well-articulated, long-termvision. In chronic conditions like heart failure,transition from home to hospital can be high

risk. Preventing rehospitalization requires inte-gration of care across hospitals, home careagencies, and outpatient clinics and patienteducation [44]. Evidence suggests that increas-ing ‘‘patient activation’’ interventions—theskills and confidence that equip patients tobecome actively engaged in their healthcare—islinked to improved outcomes and reducedrelapses and rehospitalizations [45].

Although physicians report attempts toeducate patients on the causes of their dis-ease and the importance of adhering to sec-ondary prophylaxis, patients in LMICs still havevery low levels of understanding of their disease[46]. There is potential to address the underly-ing issues by involving caregivers during con-sultation, use of native language whileproviding therapy or counselling, observingcultural nuances and levels of literacy. Aware-ness of the patients’ needs and cultural back-ground should take precedence in theconversation around expectations of adherenceof follow-up; physicians explanations and thelevel of patients’ understanding significantlyaffect treatment adherence, treatment outcome,and patients’ satisfaction [47]. Healthcare pro-viders need to be critically aware of these issueswhen communicating with patients and theircaregivers, select health information that isappropriate to the patients’ level of

Fig. 1 Key touchpoints of the patient journey for noncommunicable disease. HCP healthcare professional

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understanding, and employ a systematicapproach using a basket of tools (e.g., printedmaterial, displays, videos, and discussions) toeducate and improve awareness and stressmotivating principles, cultural relevance, andfeasibility [47].

Screening and Risk Assessment: IntegratedAssessment Tools for NCDsScreening for risk factors is a cost-effectivemethod for early diagnosis and further preven-tion of complications. As a result of limitedknowledge on the prevention aspects of CVdiseases, people living in LMICs often delayvisiting hospitals at the first sign/symptom [48].

CV risk screening and stratification of high-CV-risk individuals, based on multiple risk factors(age, sex, blood pressure, blood lipids, smoking,diabetes), can detect subclinical CV diseases andavert future CV events [49]. The WHO PENpackage tools provide specific guidance forscreening, risk stratification, and managementof patients with the main NCDs in low-resourcesettings [49]. Notably, failure to detect under-lying mental illnesses leads to underestimationof overall CV risk, deters prognosis and adher-ence to treatment, and can impact the patientjourney [50]. Mental health issues often co-oc-cur with other NCDs [33]. People with debili-tating neurological disorders like stroke,Parkinson’s disease, and epilepsy are often

Fig. 2 A conceptual framework of barriers and facilitatorsin access to healthcare. Reprinted from ‘‘Levesque, J.,Harris, M.F. and Russell, G. Patient-centered access tohealth care: conceptualizing access at the interface ofhealth systems and populations. Int J Equity Health 12, 18

(2013)’’ [Copyright � 2013, Springer Nature] publishedunder license to BioMed Central Ltd. as indicated underthe terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/2.0)

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Table 4 Summary of recommendations to improve the patient journey for NCDs

Touchpoint during patientjourney for NCDs

Recommendations

Awareness Utilize integrated communication messages combining disease information with

health-promoting habits, where possible

Utilize mobile phones, web-based technologies, and electronic and social media to

provide cost-effective education solutions for large populations

Involve the local community with a strong consultative process to align with language,

cultural, and religious differences

Apply integrated services (e.g., physiotherapy and counselling) across all NCDs

Screening Develop risk stratification tools for primary and secondary prevention of CVDs

Screen for mental health issues during routine checkups in primary care settings

Perform age-appropriate screening to inform best-fit treatment options

Diagnosis Promote shared decision-making to improve decision-related outcomes

Utilize decision aids to inform patients on the potential benefits, risks, and costs of

available treatments

Engage families and caregivers in decision-making

Treatment Ensure supply of good-quality affordable generic medicines

Include essential NCD medicines in healthcare benefits packages

Maintain uninterrupted supply chain of medicines

Follow patient-centered care approach to treating NCDs

Utilize personalized treatment goals

Adherence Encourage pharmacist-led interventions for education and counselling for medication-

related issues

Expand role of nurses in patient follow-up particularly for adult patients

Train community health workers to drive health literacy

Develop ‘‘expert patient’’ programs

Utilize e-health technologies to improve medication adherence

Palliative care Integrate palliative care in national health policies

Ensure access to essential pain medicines

Train health professionals in imparting palliative care

Adv Ther (2020) 37:4808–4830 4817

treated for the disease alone and the mentalhealth aspect is excluded. On the other hand,mental health issues like depression are oftenhidden and overlooked during routine check-ups. Primary care clinics are an ideal setting toidentify and address mental health problemsearly, although integration of mental healthservices within primary care and in community-based settings remains low [51].

Age-appropriate screening is important tounderstand the best fit for treatment optionsand care pathways. A pediatric patient withcancer would need a different approach com-pared with an elderly patient with stroke. Theguidance provided, choice of treatment plans,and discharge advice should be based on the ageand fitness of the patient, which is often over-looked in busy clinical practice. For senior citi-zens, a geriatric assessment is a valid strategy tostratify patients and prepare them for carepathways. A variety of fitness/frailty scores areavailable to appropriately assess the status ofelderly patients [52].

Diagnosis and Treatment Decision: SharedDecision-MakingThe true extent of those at risk for NCDs orthose who have NCDs is likely underestimated,given that many persons with raised blood

pressure and diabetes remain undiagnosed[53, 54]. Early diagnosis is critical to preventcomplications and ensure optimal treatmentoutcomes. However, this is based on severalcritical factors of access, awareness, and afford-ability. Clinician–patient risk discussions mustfollow the approach of shared decision-makingin which the patient and physician consider thepotential benefits of treatment, risk of adverseevents, and patient preferences before making afinal decision to initiate treatment [55].

Shared decision-making and self-directedsupport have the potential for being effectivetools for recovery [56]. It is important to con-sider patients and their families as critical part-ners in the diagnostic process. Theirengagement will result in a valuable contribu-tion to facilitate an accurate and timely diag-nosis and improve shared decision-making ontreatment and continued care [57]. In condi-tions like advanced heart failure, the treatmentgoal is to improve quality of life and prolongsurvival [56]. Shared decision-making foradvanced therapies in these conditions must beconsidered in the context of the caregivers’ability to manage tailored treatment [56]. Forpatients who are unable to make decisionsthemselves or independently follow the treat-ment and care pathways, clinicians need to

Table 4 continued

Touchpoint during patientjourney for NCDs

Recommendations

Digital health Merge biomarkers with social media footprint to predict risk more accurately and

prompt customized interventions

Develop affordable wearable technology

Develop applications for home monitoring of treatment outcomes

Support patient self-management linked with healthcare teams via ‘‘digital umbilical

cord’’

Innovate on patient facing tools for elderly patients to improve quality of life, facilitate

communication with providers, and aid decision support

CVD cardiovascular diseases, NCD noncommunicable diseases

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effectively engage with caregivers and family[56].

Decision aids can facilitate shared decision-making and improve decision-related out-comes, particularly involving multiple treat-ment choices [58]. Often the choice oftreatment is weighed down heavily by thepatients’ ability to pay at the time of treatment.However, the benefit of choosing a seeminglyexpensive option with better outcomes thatsaves on long-term treatment and fewer com-plications is often not explained well enough tothe patient [59]. Use of decision aids reduceddecisional conflict, and increased knowledgeand satisfaction without any change in anxietyor depression, in many studies [58, 59]. Addi-tionally, the utility of clinical practice guideli-nes to aid diagnosis and treatment cannot beignored. The guidelines contain recommenda-tions that are based on evidence from rigoroussystematic reviews and synthesis of the pub-lished medical literature [60].

The importance of integrated primaryhealthcare services and management of chronicdiseases is gaining momentum and the artificialdichotomy between diseases is slowly recedingin favor of a combined approach that benefitsall conditions [61]. This integration of compre-hensive services, especially within existing andestablished primary and secondary healthcarestructures, should be strongly encouraged byclinicians, policy makers, and the community.

Treatment Experience and Access: Patient-Centered ApproachOnce diagnosed, PLWNCDs face many chal-lenges in accessing treatment due to availabilityand affordability of essential NCD medicines inthese settings. Governments must commit tolong-term strategies to address access-relatedissues pertaining to regulatory (ensure goodquality of medicines in circulation and accep-tance of affordable generic medicines), health-care financing (inclusion of priority NCDmedicines in benefits packages and reduce OOPexpenditure), and supply chain matters (effi-cient procurement and distribution of medici-nes) [62].

Many experts have indicated that ‘‘chronicdiseases are managed most effectively when

patients take an active role in this themselves’’[63]. Empowerment is the result of effectivecommunication in healthcare and determinesconsequent participation and self-management[64]. ‘‘Therapeutic alliance’’ is a concept in thefield of psychiatry that refers to the relationshipbetween a healthcare provider and patient [65].An optimal therapeutic alliance is achievedwhen the patient and the therapist share beliefsin the relevance of treatment goals and efficacyof the strategies to achieve those goals. A posi-tive therapeutic alliance is a predictor of patientactivation and positive clinical outcomes[65, 66].

Patient-centered care (PCC) identifiespatients as partners with their healthcare pro-viders and recognizes an individual’s specifichealth needs and preferences as the drivingforce in all healthcare decisions [63]. PCCencourages the presence of family members incare settings and respects their values, culturaltraditions, and socioeconomic conditions. PCChas the benefit of improving patient satisfactionlevels, improving the productivity of cliniciansand ancillary staff, and reduces expenses acrossthe continuum of care. Management of chronicconditions is moving toward an individualizedtherapy approach; personalized treatment goalsfor conditions such as diabetes can be valuablein providing effective care and also combatingnegative long-term outcomes [67].

Adherence for Long-Term Management: Self-Management ToolsThe medication adherence rate, defined as theextent to which patients take medication asprescribed by their healthcare professionals,among patients in LMICs suffering fromchronic diseases is about 50%, a worrisomestatistic [68]. Evidence has demonstrated thatinterventions led by clinical pharmacistsencompassing services such as education,counselling, and assessing each medication andmedication-related problem for patients withdiabetes are effective in increasing adherence toclinical guidelines and medications leading toimproved outcomes [69]. Older adults often faceadherence issues following hospital dischargedue to complex treatment plans and poorcommunication with the patient. Nurses are

Adv Ther (2020) 37:4808–4830 4819

well placed to follow-up with these patients andkeep them adherent to their therapies. Addi-tionally, frontline community health workersand patient support groups can be instrumentalin driving patient health literacy, empower-ment, and ultimately medication adherence[70, 71]. Developing ‘‘expert patient’’ programsimparting peer education, training, and skilldevelopment can be a cost-effective strategy fordriving adherence in LMICs [18]. Other toolsapplying innovative e-health technologiescombined with pill counts can improve medi-cation adherence among the vulnerable andolder patients [68].

Palliative Care: Integrating with HealthServicesPalliative care is still in its nascent stages inmost developing countries. Pain and respiratoryissues are the main complaints from patients inneed of palliative care. As per the WHO, accessto palliative care is a human right and nationalhealth systems must include palliative care inthe continuum of care linking it to prevention,early detection, and treatment programs forchronic and life-threatening conditions [38].The immediate actions include integrating pal-liative care into national health policy or actionplans and ensuring funding and affordability ofpalliative care service delivery; building thecapacity of health workforce to delivery pallia-tive care through training and updating medicalcurricula; and ensuring the availability ofessential medicines including opioids for painrelief [38, 72]. Choice of palliative care servicedelivery models must be based on the cultural,spiritual, and economic needs of the people.Home-based palliative care is the most commonservice delivery model in LMICs [72]. Othermodels include outpatient clinics and day carewhere patients visit a palliative care facility forservices [72, 73]. However, these models needinvolvement of families and volunteers formanaging essential symptoms supplementedwith healthcare professionals for necessarymedicines and backup support [72, 73].

Integrating Digital Technologiesinto the Patient JourneyWith the advent of smart phones, tablets,nimble wearables relying on big data, healthinformatics, and analytics, digital technologieshave afforded the opportunity to monitor thecomplete patient journey in real time and pro-vide patients with tools to better manage theirjourney [74, 75]. The penetration of mobiletelephones in LMICs has exceeded that ofdeveloped nations, leading to new possibilitiesin the field of healthcare [76]. This rise intechnology adoption is shaping the medicalecosystems in many ways; within the NCDarena it provides health systems the opportu-nity to shift the balance from secondary topreventative care [77]. In the near future,physicians will have access to electronic medi-cal records, real-world data, and patient-re-ported outcomes at their fingertips, which willrestore patient-centricity within personalizedhealthcare. Recognizing this imminent trans-formation in healthcare, the WHO releasedguidelines on evidence-based digital healthinterventions for health system strengthening[78].

In the digital health age, the start of the newpatient journey should ideally begin with themerging of patients’ social media, geo-location,and other digital footprints with theirbiomarkers. Merging these digital footprintswith biomarkers like blood pressure, glucoselevels, and body mass index can predict raisedrisk levels [79]. Following that, a revised sched-ule of physical activity, diet and nutrition, andother routines drawn up with the health pro-fessional and fed into the patient’s smartphones could drive the appropriate lifestylechanges.

Good personalized healthcare involveshome-based supported self-care [80]. Digitalsolutions allow patients to benefit from home-based self-care while still being attached to theirhealthcare team through a ‘‘digital umbilicalcord’’. Secondary prevention in self-care entailspatients maintaining their blood pressure,blood glucose, lipids, and other endocrinalmarkers within a safe level either through pro-phylactic therapies or through lifestyle modifi-cations [81]. With advances in home

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monitoring devices, these markers can be easilymonitored by patients and the results trans-mitted to their health teams for analysis andtreatment optimization. Use of simple finger-prick tests or automated machine learningsolutions such as the flash glucose monitor orthe continuous glucose monitor for diabetesmellitus and home blood pressure monitoringdevices for hypertension have reported betteroutcomes for patients [82, 83]. These tech-nologies provide a high resolution view of eachpatient and can facilitate the choice of indi-vidual optimal therapy.

As with all technological advancements,there is an expected lag in the adoption of dig-ital developments by healthcare professionalcommunities due to a lack of awareness, lack ofunderstanding, resistance to digital technolo-gies, and working within protected silos thatdiscourage information sharing. Lastly, thereare concerns from the patient communityregarding data privacy and ownership, and fearof discrimination against certain genetic dis-eases [84].

DISCUSSION

The growing number of people living withchronic diseases is both a measure of success, anoutcome of increased life expectancy, and achallenge for healthcare systems in LMICs [85].Despite international commitment, themomentum for impeding NCD-related mor-bidity and mortality has waned since 2010 [86].In contrast to developed countries wherehealthcare delivery remains relatively accessibleand inclusive, LMICs require substantialimprovements in healthcare delivery to meetthe Sustainable Development Goals and achieveUniversal Healthcare Coverage [87]. To effec-tively alter the current trajectory of NCDs, it isimportant to review problems and prospects ofinfluencing factors at the micro, meso, andmacro levels of healthcare, i.e., at the level ofindividuals, their households, and communi-ties, as well as at the policy level [41]. Evidencesuggests that patient experience is a key pillar ofhealthcare quality; therefore, instead of limitingit to in-person interactions between the patient

and physician, mapping the entire patientjourney is the best way to understand thepatient experience and identify existing lacunae[88].

Traditionally, a patient journey is viewedfrom the perspective of healthcare providers. Itis often perceived to be linear, following asequential process in a care continuum pathwaywith a single entry and exit point. The entrypoint or the start of the patient journey isbelieved to begin after a ‘‘trigger’’—an onset of asign or symptom of a disease. Redesigning ofpatient pathways based on journey mapping isoften undertaken with the purpose of improv-ing healthcare system performance or meetingregulatory constraints [6]. Traditional patientjourney maps also miss the impact of medicalprotocols followed in patient care [6].

The patient journey for NCDs starts wellbefore an episode of care and continues afterdischarge [89, 90]. The patient journey is alsocomplex with multiple entry and exit points. Inpractice, care provided to patients with multi-morbidity is fragmented, resulting in innumer-able hospital appointments with differentspecialists and concurrent use of multiplemedications or polypharmacy. The ‘‘treatment-in-silos’’ approach impacts patients’ lifelongcompliance to treatment and further incapaci-tates patients with advancing age and disability.There is a need to reframe the patient journey asone with touchpoints, where a patient mayenter at any one point but often may needsupport and care at other points. For example,in the framework presented in Fig. 1, the NCDpatient’s first touchpoint may well be at ‘‘Diag-nosis’’ during an encounter with the healthsystem. They will benefit from education toincrease their ‘‘Awareness’’ to help themunderstand and participate in their care; theymay benefit from ‘‘Screening’’ for comorbidity;and enriched monitoring and counselling for‘‘Adherence’’.

The concept of ‘‘healthcare’’ has been delin-eated from ‘‘medical care’’ years ago; still, mosthealthcare systems today subject PLWNCDs toonly physical and laboratory evaluations with-out properly assessing their mental, social, andemotional well-being [91]. Following diagnosis,treatment modalities are tailored to the disease

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rather than the person, leading to altered life-style to suit protocols set up for the condition.There is a strong call to action in LMICs tointegrate the management of NCDs combinedwith the ‘‘holistic medicine’’ concept that fol-lows the approach of putting patients’ perceivedneeds first in providing care not just for physicalbut also mental, emotional, and spiritual needs[71].

This can only be achieved through criticalassessment of the underlying complexities inpatient journeys for NCDs—awareness levels,screening opportunities, treatment protocols,access to care, issues with compliance—to avoidmissteps in providing timely and optimalintervention.

It is increasingly evident that manyPLWNCDs have specialized expertise and canplay a crucial role in identifying what is mostmeaningful to them and their conditions. The‘‘expert patient’’ concept where patients withsignificant knowledge about their disease andtreatment take on a larger role in self-manage-ment has been explored in the West with notedimprovements in symptoms, quality of life, andadherence [18]. Many healthcare systems indeveloped countries have found value in mov-ing towards a self-management approach forchronic diseases, utilizing the knowledge andexpertise held by ‘‘expert patients’’ [18, 92, 93].Replication of this approach in LMICs has seensome success in positively impacting the patientjourney. A diabetes peer education program(MoPoTsyo) initiated in rural and urban slumareas of Cambodia trained patients from localcommunities as peer educators who could thencoach other patients in self-management,counsel them on lifestyle changes, and conductfollow-ups [94]. MoPoTsyo patients had betterhealth outcomes in terms of a higher propor-tion of patients achieving target glycosatedhemoglobin (HbA1C) levels, lower systolicblood pressure, and reduced presence of dia-betes foot lesions and also had lower diabetes-related healthcare expenditure compared withdiabetes care programs in two other LMICs,Democratic Republic of Congo and the Philip-pines [95]. Access to more external resourcesand a stronger focus on self-management andchronic illness may have contributed to the

success of MoPoTsyo [95]. Meaningfullyinvolving PLWNCDs along common touch-points in the patient journey for NCDs will helpinform the value assessment in healthcare,provide better outcomes, and increase adher-ence to therapy, leading to a happier and morerewarding patient experience.

Use of mobile- and web-based computingcan help in educating individuals at the level ofprevention by emphasizing the control of NCDrisk factors and, once made aware of their con-ditions, aids in self-management and adherenceto their treatment. A systematic review identi-fied that mobile solutions are more widelyavailable than other technology-based solutionsfor education on NCDs owing to ease of access,convenient delivery of educational content,and potential to gamify educational learning forchronic illnesses [96]. Another review fromdeveloped countries demonstrated that the useof information and communication technology(ICT) in health promotion behavior resulted inincreased physical activity, reduced weight, andhealthy behavior change among the partici-pants [97]. However, there is a dearth of data onthe long-term effectiveness of ICT on health-promoting behaviors in LMICs. There is anurgent need to build evidence for ICT use inpromoting health behaviors among healthyadults in LMICs and move towards personalizedassistance supported by ubiquitous learning[96, 97].

Social environments have a significantinfluence on an individual’s health and, in thisdigital age, online social networks play animportant role in health as they control accessto resources and opportunities to model one’sbehavior [98]. Several models have been devel-oped and evaluated the use of social media tofoster better health behaviors among popula-tions. For example, the Pompilos model wasdeveloped to enhance healthcare applicationswith social media content and ascertain to whatextent a person’s health behavior influences thehealth of others in their social network [98].Preliminary evaluation of the model indicatedthat NCD prevention messages directed to userscorrelated with increased access to the applica-tion and warrants further research [98]. MostLMICs are progressing towards an ageing

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population that will accompany a rise inchronic conditions and increased healthcarecosts [99]. From an elderly patient setting inLMICs, technology must prioritize patient-fac-ing innovations that improve quality of life,facilitate communication with providers, andprovide decision-support [99]. Redesigninghealthcare models to sustain increased self-management will improve outcomes andreduce healthcare costs. Healthcare applicationscan be further enhanced by integrating theminto ‘‘smart city’’ infrastructures, e.g., theU’Ductor architecture developed in Brazil canincrease social collaboration by integrating withcity information systems to guide users to hos-pitals on the basis of the availability of beds,provide traffic updates in medical emergencies,recommend modes of transport on the basis ofreal-time air quality data, etc. [100].

Future Perspectives

The COVID-19 pandemic accelerated the digi-tization of healthcare services as health systemshad to adopt telemedicine and other technolo-gies to flatten the curve and help patients inself-isolation receive access to healthcare [101].A WHO survey of 194 countries in May 2020reported severe disruption to prevention andtreatment services for NCDs since the beginningof the COVID-19 pandemic [102]. Preexistinginequities in LMIC health systems will likelyexacerbate the effects of the COVID-19 pan-demic among vulnerable populations and thecare for chronic diseases will likely furtherworsen along with health outcomes. This maybe the result of health system capacity beingexceeded, redeployment of health personnel tothe frontline of COVID-19 infection, or becauseof measures placed to address the spread of thepandemic such as lockdowns and restrictionson people’s movement [103]. A prescientinsight into the patient journey for NCDs canhelp with adopting the WHO guidance tomaintain essential services for NCDs. Theguidance offers programs of activities acrosschronic disease management including aware-ness; prevention and screening; diagnosis; spe-cialist treatment; rehabilitation; and palliative

care [104]. Increase in home-based service sup-port by appropriately trained communityhealth volunteers helps promote self-care, riskassessment, and referral for uncomplicatedpatients, a cost-effective strategy for prioritizingNCD management [105]. Being readily accessi-ble healthcare practitioners in LMICs during thepandemic, community pharmacists are wellpositioned to help manage chronic conditions,promote medication adherence, and help easethe burden on already strained health systems[103].

Setting healthcare priorities is of particularimportance in the LMICs in order to allocatetheir limited resources toward the most effec-tive interventions. Evidence-based decision-making for NCD prevention and control poli-cies requires reliable and timely data [106]. Thelack of mechanisms to collect high-quality datais a major barrier to successful implementationand monitoring of NCD programs in LMICs[107]. As a result, NCD policy recommendationsat the national and local levels in LMICs arebased on evidence from communicable diseasesor from studies conducted in high-incomecountries, which can potentially impact theoutcomes of these policies [107]. Similarly,mapping patient journey for NCDs will requirelocal evidence generation and continual moni-toring of evidence to inform strategies toimprove the patient journeys in LMICs.

The mounting mental health burden is agrowing concern in LMICs, as poverty is knownto be associated with increased risk of mentalillness. Limited access to psychiatrists andmental health facilities in many LMICs hastriggered the pursuit for innovative solutionssuch as employing community-based healthworkers to deliver psychosocial therapies sup-ported remotely by specialists [108]. Addition-ally, technology-based solutions are beingexplored in the domain of mental health edu-cation and information dissemination, digitalscreening tools and diagnosis, self-managementprograms, and system-level efforts to improvemental health [108]. Several models of ubiqui-tous computing have been proposed to informpsychotherapeutic practice, often used in thetreatment of depression and anxiety disorders[109]. Mobile and wearable technologies can be

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utilized to collect an individual’s physiologicaland environmental measurements and providepsychophysiological insights [110]. Patientengagement and adherence to online programsin psychotherapeutic treatment can beimproved by employing gamification tech-niques [109]. Applications monitoring socialactivities of people with depression can contactcaregivers as needed and aid providers inpatient follow-up [111].

CONCLUDING REMARKS

In the past, the patient journey for chronicdiseases was marred with late diagnosis, ‘‘one-size-fits-all’’ treatment, and access issues creat-ing bottlenecks in the health system. Treatmentwas often location bound and the patient’s lifeoscillated between hospitals, providers, andhealthcare facilities. Unlike in developed coun-tries, healthcare systems in LMICs continue tofollow the traditional, provider-driven, disease-focused approach which must move towardsperson-centered care integrating patient prefer-ences, needs, and experiences into every phaseof the patient journey [112]. In order to create,implement, and support successful patientjourney maps, healthcare organizations musthave a deep understanding of the populationsthey serve—as well as those they wish to servein the future. The patient needs to be recog-nized as an integral part of this journey andinvolved in all stages embracing the ‘‘nothingfor us without us’’ sentiment [113].

Health systems in LMICs must recognize thatthe patient journey for NCDs starts long beforethe onset of symptoms and signs. Strategiesdesigned to improve the patient journey mustincorporate the patient-centered perspective ateach touchpoint of their journey in thehealthcare system: awareness, screening, diag-nosis, treatment, and adherence. Effectivecommunication strategies for improving healthliteracy, patient activation, and incorporationof narrative medicine in physician educationpositively impact the awareness of patients. Useof appropriate risk assessment tools to tailortherapies, integrated management of chronicillness in primary healthcare, shared decision-

making, and decision aids ensure timely andaccurate diagnosis. Improved access to NCDtreatments, embodying the principles of per-son-centered care and positive therapeutic alli-ance, requires commitment at a policy level todeliver safe, affordable, and effective care equi-tably. Long-term management of NCDs entailssubstantial self-management of their conditionsby patients, which can be augmented by phar-macists and nurse-led interventions. The NCDcare continuum pathway needs to move fromthe traditional acute incident managementprotocol to a public health approach of pre-vention and delay of disease onset throughearly identification and management of riskfactors; early diagnosis and appropriate man-agement; and good adherence through effectivecommunication and follow-up. In addition,comprehensive palliative care models must beevaluated and integrated into national healthpolicy and action plans.

Digitization has heralded a healthcare revo-lution with a patient-centric and user-friendlyframework that will undoubtedly increasepatient engagement. eCare pathways allowbetter management of patient journeys byfacilitating early and accurate diagnosis at theoutset and then on the progress of the disease;aiding in personalized care plans tailored to thepatient’s genomic makeup and lifestyle; andremote monitoring of patients via digital algo-rithms to optimize timely treatment interven-tions. The reduced dependence of digital healthon healthcare facilities for care-seeking is anencouraging prospect for LMICs to help bridgegaps in the patient journey for NCDs throughempowering patients, improving access tohealthcare services, and enhancing efficiency ofhealth systems with innovative, cost-effective,and localized solutions.

ACKNOWLEDGEMENTS

Funding. This review, the Journal’s RapidService and Open Access Fees were funded byUpjohn—A Pfizer Division.

4824 Adv Ther (2020) 37:4808–4830

Authorship. All named authors meet theInternational Committee of Medical JournalEditors (ICMJE) criteria for authorship for thisarticle, take responsibility for the integrity ofthe work as a whole, and have given theirapproval for this version to be published.

Medical Writing Assistance. Editorial assis-tance in the preparation of this article wasprovided by Tanaya Bharatan, and Kaveri Sidhu,Upjohn—A Pfizer Division and was funded byUpjohn—A Pfizer Division.

Disclosures. Ratna Devi is the Chair Boardof Trustees of International Alliance of PatientOrganization (IAPO) and Kawaldip Sehmi is theChief Executive Officer for IAPO. IAPO hasreceived grants from Upjohn—A Pfizer Division.Ratna Devi has received funding from Upjohn, aPfizer division, that is unrelated to the submit-ted work. Kannan Subramaniam is an employeeof Pfizer. Komal Kanitkar and R. Narendharhave nothing to disclose. The views and opin-ions expressed in this article are those of theauthors. They do not represent or reflect in anyway the official policy or position of their cur-rent or previous employers.

Compliance with Ethics Guidelines. Thisarticle is based on previously conducted studiesand does not contain any studies with humanparticipants or animals performed by any of theauthors.

Data Availability. Data sharing is notapplicable to this article as no datasets weregenerated or analyzed during the current study.

Open Access. This article is licensed under aCreative Commons Attribution-Non-Commercial 4.0 International License, whichpermits any non-commercial use, sharing,adaptation, distribution and reproduction inany medium or format, as long as you giveappropriate credit to the original author(s) andthe source, provide a link to the CreativeCommons licence, and indicate if changes weremade. The images or other third party materialin this article are included in the article’sCreative Commons licence, unless indicated

otherwise in a credit line to the material. Ifmaterial is not included in the article’s CreativeCommons licence and your intended use is notpermitted by statutory regulation or exceeds thepermitted use, you will need to obtain permis-sion directly from the copyright holder. To viewa copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

REFERENCES

1. WHO. Noncommunicable diseases: Key facts.World Health Organization. 2018. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. Accessed Sept 10,2020.

2. Kankeu HT, Saksena P, Xu K, Evans DB. The finan-cial burden from non-communicable diseases inlow- and middle-income countries: a literaturereview. Health Res Policy Syst. 2013;11:31.

3. Allen L, Williams J, Townsend N, et al. Socioeco-nomic status and non-communicable diseasebehavioural risk factors in low-income and lower-middle-income countries: a systematic review.Lancet Glob Health. 2017;5(3):e277–e289289.

4. NCD Countdown 2030 collaborators. NCD Count-down 2030: pathways to achieving SustainableDevelopment Goal target 3.4. Lancet.2020;396(10255):918–34.

5. Trebble TM, Hansi N, Hydes T, Smith MA, Baker M.Process mapping the patient journey: an introduc-tion. BMJ. 2010;341:c4078.

6. McCarthy S, O’Raghallaigh P, Woodworth S, LimYL, Kenny LC, Adam F. An integrated patient jour-ney mapping tool for embedding quality inhealthcare service reform. J Decis Syst.2016;25(sup1):354–68.

7. Ben-Tovim DI, Dougherty ML, O’Connell TJ,McGrath KM. Patient journeys: the process of clin-ical redesign. Med J Aust. 2008;188(S6):S14–S1717.

8. Percival J, McGregor C. An evaluation of under-standability of patient journey models in mentalhealth. JMIR Hum Factors. 2016;3(2):e20.

9. Thrift-Perry M, Cabanes A, Cardoso F, Hunt KM,Cruz TA, Faircloth K. Global analysis of metastaticbreast cancer policy gaps and advocacy effortsacross the patient journey. Breast. 2018;41:93–106.

Adv Ther (2020) 37:4808–4830 4825

10. Mohr P, Galderisi S, Boyer P, et al. Value ofschizophrenia treatment I: the patient journey. EurPsychiatry. 2018;53:107–15.

11. Fennelly O, Blake C, FitzGerald O, et al. Advancedmusculoskeletal physiotherapy practice: the patientjourney and experience. Musculoskelet Sci Pract.2020;45:102077.

12. Skold CM, Arnheim-Dahlstrom L, Bartley K, et al.Patient journey and treatment patterns in adultswith IPF based on health care data in Sweden from2001 to 2015. Respir Med. 2019;155:72–8.

13. Kassouf W, Aprikian A, Saad F, et al. Improvingpatient journey and quality of care: summary fromthe second Bladder Cancer Canada-Canadian Uro-logical Association-Canadian Urologic OncologyGroup (BCC-CUA-CUOG) bladder cancer quality ofcare consensus meeting. Can Urol Assoc J.2018;12(7):E281–E297297.

14. Alkandari M, Ryan K, Hollywood A. The experiencesof people living with peripheral neuropathy inKuwait—a process map of the patient journey.Pharmacy (Basel). 2019;7(3):127.

15. Checkley W, Ghannem H, Irazola V, et al. Man-agement of NCD in low- and middle-incomecountries. Glob Heart. 2014;9(4):431–43.

16. Garin N, Koyanagi A, Chatterji S, et al. Globalmultimorbidity patterns: a cross-sectional, popula-tion-based, multi-country study. J Gerontol A BiolSci Med Sci. 2016;71(2):205–14.

17. Hearn J, Ssinabulya I, Schwartz JI, Akiteng AR, RossHJ, Cafazzo JA. Self-management of non-commu-nicable diseases in low- and middle-income coun-tries: a scoping review. PLoS One. 2019;14(7):e0219141.

18. Xiao Y. The, ‘‘expert patient’’ approach for non-communicable disease management in low andmiddle income settings: when the reality confrontsthe rhetoric. Chronic Dis Transl Med. 2015;1(3):145–51.

19. Puteh SEW, Almualm Y. Catastrophic healthexpenditure among developing countries. HealthSyst Policy Res. 2017;4(1). https://doi.org/10.21767/2254-9137.100069.

20. Aluttis C, Bishaw T, Frank MW. The workforce forhealth in a globalized context–global shortages andinternational migration. Glob Health Action.2014;7:23611.

21. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J,Murray CJ. Household catastrophic health expen-diture: a multicountry analysis. Lancet.2003;362(9378):111–7.

22. Pandey A, Ploubidis GB, Clarke L, Dandona L.Trends in catastrophic health expenditure in India:1993 to 2014. Bull World Health Organ. 2018;96(1):18–28.

23. Global Burden of Disease Health Financing Collab-orator Network. Evolution and patterns of globalhealth financing 1995–2014: development assis-tance for health, and government, prepaid private,and out-of-pocket health spending in 184 countries.Lancet. 2017;389(10083):1981–2004.

24. Jayasinghe UW, Harris MF, Parker SM, et al. Theimpact of health literacy and life style risk factorson health-related quality of life of Australianpatients. Health Qual Life Outcomes. 2016;14:68.

25. Chow CK, Teo KK, Rangarajan S, et al. Prevalence,awareness, treatment, and control of hypertensionin rural and urban communities in high-, middle-,and low-income countries. JAMA. 2013;310(9):959–68.

26. Wang Y, McKee M, Torbica A, Stuckler D. System-atic literature review on the spread of health-relatedmisinformation on social media. Soc Sci Med.2019;240:112552.

27. Duraisamy P. Health status and curative health carein rural India. New Delhi: National Council ofApplied Economic Research. 2001. https://demo.ncaer.org/Downloads/WorkingPapers/WP78.pdf.Accessed June 2020.

28. Inche Zainal Abidin S, Sutan R, Shamsuddin K.Prevalence and determinants of appropriate healthseeking behaviour among known diabetics: resultsfrom a community-based survey. Adv Epidemiol.2014:793286. https://doi.org/10.1155/2014/793286.

29. WHO. Social determinants of health. World HealthOrganization. 2020. https://www.who.int/social_determinants/en/. Accessed June 2020.

30. WHO. WHO package of essential noncommunica-ble (PEN) disease interventions for primary healthcare. Geneva: World Health Organization; 2020.https://www.who.int/publications/i/item/who-package-of-essential-noncommunicable-(pen)-disease-interventions-for-primary-health-care.Accessed Sept 10, 2020.

31. Bolz-Johnson M, Meek J, Hoogerbrugge N. ‘‘PatientJourneys’’: improving care by patient involvement.Eur J Hum Genet. 2020;28(2):141–3.

32. WHO. Global action plan for the prevention andcontrol of noncommunicable diseases 2013–2020.Geneva: World Health Organization; 2014. https://apps.who.int/iris/bitstream/handle/10665/94384/

4826 Adv Ther (2020) 37:4808–4830

9789241506236_eng.pdf?sequence=1. AccessedSept 10, 2020.

33. Stein DJ, Benjet C, Gureje O, et al. Integratingmental health with other non-communicable dis-eases. BMJ. 2019;364:l295.

34. Kisling LA, Das JM. Prevention strategies. TreasureIsland: StatPearls; 2020.

35. Dobe M. Health promotion for prevention andcontrol of non-communicable diseases: unfinishedagenda. Indian J Public Health. 2012;56(3):180–6.

36. Srivastava RK, Bachani D. Burden of NCDs, policiesand programme for prevention and control ofNCDs in India. Indian J Community Med.2011;36(Suppl 1):S7–S12.

37. Munday D, Kanth V, Khristi S, Grant L. Integratedmanagement of non-communicable diseases in low-income settings: palliative care, primary care andcommunity health synergies. BMJ Support PalliatCare. 2019;9(4):e32.

38. WHO. Palliative care. World Health Organization;2020. https://www.who.int/news-room/fact-sheets/detail/palliative-care. Accessed Sept 10, 2020.

39. Levesque JF, Harris MF, Russell G. Patient-centredaccess to health care: conceptualising access at theinterface of health systems and populations. Int JEquity Health. 2013;12:18.

40. Ganju A, Goulart AC, Ray A, et al. Systemic solu-tions for addressing non-communicable diseases inlow- and middle-income countries. J MultidiscipHealthc. 2020;13:693–707.

41. WHO. Innovative care for chronic conditions:building blocks for action: global report. Geneva:World Health Organization; 2002. https://www.who.int/chp/knowledge/publications/icccglobalreport.pdf?ua=1. Accessed June 2020.

42. David R. Changing therapeutic paradigms in glau-coma management. Expert Opin Investig Drugs.1998;7(7):1063–86.

43. O’Sullivan GA, Yonkler JA, Morgan W, Merritt AP. Afield guide to designing a health communicationstrategy. Baltimore: Johns Hopkins BloombergSchool of Public Health/Center for CommunicationPrograms; 2003.

44. Albert NM, Barnason S, Deswal A, et al. Transitionsof care in heart failure: a scientific statement fromthe American Heart Association. Circ Heart Fail.2015;8(2):384–409.

45. Hibbard JH, Greene J. What the evidence showsabout patient activation: better health outcomes

and care experiences; fewer data on costs. HealthAff (Millwood). 2013;32(2):207–14.

46. Irazola VE, Gutierrez L, Bloomfield G, et al. Hyper-tension prevalence, awareness, treatment, andcontrol in selected LMIC communities: results fromthe NHLBI/UHG Network of Centers of Excellencefor Chronic Diseases. Glob Heart. 2016;11(1):47–59.

47. Clayton LH. Strategies for selecting effective patientnutrition education materials. Nutr Clin Pract.2010;25(5):436–42.

48. Chang H, Hawley NL, Kalyesubula R, et al. Chal-lenges to hypertension and diabetes managementin rural Uganda: a qualitative study with patients,village health team members, and health care pro-fessionals. Int J Equity Health. 2019;18(1):38.

49. Bovet P, Chiolero A, Paccaud F, Banatvala N.Screening for cardiovascular disease risk and subse-quent management in low and middle incomecountries: challenges and opportunities. PublicHealth Rev. 2015;36:13.

50. Mensah GA, Collins PY. Understanding mentalhealth for the prevention and control of cardio-vascular diseases. Glob Heart. 2015;10(3):221–4.

51. Godoy L, Hodgkinson S, Robertson HA, et al.Increasing mental health engagement from primarycare: the potential role of family navigation. Pedi-atrics. 2019;143(4):e20182418.

52. Walston J, Buta B, Xue QL. Frailty screening andinterventions: considerations for clinical practice.Clin Geriatr Med. 2018;34(1):25–38.

53. International Diabetes Federation. IDF DiabetesAtlas. 9th ed. Brussels: International Diabetes Fed-eration; 2019.

54. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterialhypertension: the Task Force for the managementof arterial hypertension of the European Society ofCardiology (ESC) and the European Society ofHypertension (ESH). Eur Heart J. 2018;39(33):3021–104.

55. Blaha MJ. Personalizing treatment: between pri-mary and secondary prevention. Am J Cardiol.2016;118(6 Suppl):4A–12A.

56. National Academies of Sciences, Engineering, andMedicine. Improving diagnosis in health care.Washington, DC: The National Academies Press;2015.

57. Allen LA, Stevenson LW, Grady KL, et al. Decisionmaking in advanced heart failure: a scientific

Adv Ther (2020) 37:4808–4830 4827

statement from the American Heart Association.Circulation. 2012;125(15):1928–52.

58. Padilla LM, Creem-Regehr SH, Hegarty M, Ste-fanucci JK. Decision making with visualizations: acognitive framework across disciplines. Cogn ResPrinc Implic. 2018;3:29.

59. O’Connor AM, Wennberg JE, Legare F, et al. Towardthe ’tipping point’: decision aids and informedpatient choice. Health Aff (Millwood). 2007;26(3):716–25.

60. Field MJ, Lohr KN, editors. Clinical practice guide-lines: directions for a new program. Washington,DC: National Academies Press; 1990.

61. Beaglehole R, Epping-Jordan J, Patel V, et al.Improving the prevention and management ofchronic disease in low-income and middle-incomecountries: a priority for primary health care. Lancet.2008;372(9642):940–9.

62. Beran D, Pedersen HB, Robertson J. Noncommuni-cable diseases, access to essential medicines anduniversal health coverage. Glob Health Action.2019;12(1):1670014.

63. Amelung V, Stein V, Goodwin N, Balicer R, Nolte E,Suter E. Handbook integrated care. Cham: SpringerInternational; 2017.

64. Small N, Bower P, Chew-Graham CA, Whalley D,Protheroe J. Patient empowerment in long-termconditions: development and preliminary testing ofa new measure. BMC Health Serv Res. 2013;13:263.

65. Ardito RB, Rabellino D. Therapeutic alliance andoutcome of psychotherapy: historical excursus,measurements, and prospects for research. FrontPsychol. 2011;2:270.

66. Allen ML, Cook BL, Carson N, Interian A, La RocheM, Alegria M. Patient-provider therapeutic alliancecontributes to patient activation in communitymental health clinics. Adm Policy Ment Health.2017;44(4):431–40.

67. Subramanian S, Hirsch IB. Personalized diabetesmanagement: moving from algorithmic to individ-ualized therapy. Diabetes Spectr. 2014;27(2):87–91.

68. Verloo H, Chiolero A, Kiszio B, Kampel T, SantschiV. Nurse interventions to improve medicationadherence among discharged older adults: a sys-tematic review. Age Ageing. 2017;46(5):747–54.

69. Jeong S, Lee M, Ji E. Effect of pharmaceutical careinterventions on glycemic control in patients withdiabetes: a systematic review and meta-analysis.Ther Clin Risk Manag. 2018;14:1813–29.

70. Newman PM, Franke MF, Arrieta J, et al. Commu-nity health workers improve disease control andmedication adherence among patients with dia-betes and/or hypertension in Chiapas, Mexico: anobservational stepped-wedge study. BMJ GlobHealth. 2018;3(1):e000566.

71. Ganguli A, Clewell J, Shillington AC. The impact ofpatient support programs on adherence, clinical,humanistic, and economic patient outcomes: atargeted systematic review. Patient Prefer Adher-ence. 2016;10:711–25.

72. Ddungu H. Palliative care: what approaches aresuitable in developing countries? Br J Haematol.2011;154(6):728–35.

73. Poudel A, Kc B, Shrestha S, Nissen L. Access to pal-liative care: discrepancy among low-income andhigh-income countries. J Glob Health. 2019;9(2):020309.

74. Dunn J, Runge R, Snyder M. Wearables and themedical revolution. Pers Med. 2018;15(5):429–48.

75. Bates DW, Saria S, Ohno-Machado L, Shah A,Escobar G. Big data in health care: using analytics toidentify and manage high-risk and high-costpatients. Health Aff (Millwood). 2014;33(7):1123–31.

76. Bastawrous A, Armstrong MJ. Mobile health use inlow- and high-income countries: an overview of thepeer-reviewed literature. J R Soc Med. 2013;106(4):130–42.

77. Widmer RJ, Collins NM, Collins CS, West CP, Ler-man LO, Lerman A. Digital health interventions forthe prevention of cardiovascular disease: a system-atic review and meta-analysis. Mayo Clin Proc.2015;90(4):469–80.

78. World Health Organization. WHO guideline: rec-ommendations on digital interventions for healthsystem strengthening. Geneva: World HealthOrganization; 2019. https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf?ua=1. Accessed June 2020.

79. Ratzan SC, Weinberger MB, Apfel F, Kocharian G.The digital health scorecard: a new health literacymetric for NCD prevention and care. Glob Heart.2013;8(2):171–9.

80. Greaves CJ, Campbell JL. Supporting self-care ingeneral practice. Br J Gen Pract. 2007;57(543):814–21.

81. Hobbs FD. Cardiovascular disease: different strate-gies for primary and secondary prevention? Heart.2004;90(10):1217–23.

4828 Adv Ther (2020) 37:4808–4830

82. Olczuk D, Priefer R. A history of continuous glucosemonitors (CGMs) in self-monitoring of diabetesmellitus. Diabetes Metab Syndr. 2018;12(2):181–7.

83. Kario K, Park S, Buranakitjaroen P, et al. Guidanceon home blood pressure monitoring: a statement ofthe HOPE Asia Network. J Clin Hypertens (Green-wich). 2018;20(3):456–61.

84. Otlowski M, Taylor S, Bombard Y. Genetic discrim-ination: international perspectives. Annu RevGenom Hum Genet. 2012;13:433–54.

85. GBD 2016 Disease and Injury Incidence and Preva-lence Collaborators. Global, regional, and nationalincidence, prevalence, and years lived with disabil-ity for 328 diseases and injuries for 195 countries,1990–2016: a systematic analysis for the GlobalBurden of Disease Study 2016. Lancet.2017;390(10100):1211–59.

86. World Health Organization. World health statistics2020: monitoring health for the SDGs, sustainabledevelopment goals. World Health Organization;2020. https://apps.who.int/iris/handle/10665/332070. Accessed June 2020.

87. Bitton A, Fifield J, Ratcliffe H, et al. Primaryhealthcare system performance in low-income andmiddle-income countries: a scoping review of theevidence from 2010 to 2017. BMJ Glob Health.2019;4(Suppl 8):e001551.

88. Doyle C, Lennox L, Bell D. A systematic review ofevidence on the links between patient experienceand clinical safety and effectiveness. BMJ Open.2013;3(1):e001570.

89. Blythe A. The patient journey—patient-orientedapproaches to care. 2016. https://www.ausmed.com/cpd/articles/the-patient-journey. AccessedJune 2020.

90. Pomey MP, Ghadiri DP, Karazivan P, Fernandez N,Clavel N. Patients as partners: a qualitative study ofpatients’ engagement in their health care. PLoSOne. 2015;10(4):e0122499.

91. National Research Council (US), Institute of Medi-cine (US). In: Woolf SH, Aron L, editors. Health ininternational perspective: shorter lives, poorerhealth. Washington (DC): National AcademiesPress; 2013.

92. Tattersall RL. The expert patient: a new approach tochronic disease management for the twenty-firstcentury. Clin Med (Lond). 2002;2(3):227–9.

93. Fromer L. Implementing chronic care for COPD:planned visits, care coordination, and patientempowerment for improved outcomes. Int J ChronObstruct Pulmon Dis. 2011;6:605–14.

94. MoPoTsyo. Peer Education. 2010. https://www.mopotsyo.org/peereducation.html. Accessed July28, 2020.

95. Van Olmen J, Marie KG, Christian D, et al. Content,participants and outcomes of three diabetes careprogrammes in three low and middle incomecountries. Prim Care Diabetes. 2015;9(3):196–202.

96. Larentis AV, Barbosa DNF, da Silva CR, Barbosa JLV.Applied computing to education on noncommu-nicable chronic diseases: a systematic mappingstudy. Telemed J E Health. 2020;26(2):147–63.

97. Joseph-Shehu EM, Ncama BP, Mooi N, Mashamba-Thompson TP. The use of information and com-munication technologies to promote healthy life-style behaviour: a systematic scoping review. BMJOpen. 2019;9(10):e029872.

98. Vianna HD, Barbosa JLV. Pompilos, a model foraugmenting health assistant applications withsocial media content. J Univ Comput Sci.2020;21(1):4–32.

99. Bhattacharyya O, Mossman K. Technological inno-vations for aging populations: what are the oppor-tunities for learning across low- and high-incomecountries? Health Manag Policy Innov. 2018;3(1).

100. Vianna HD, Barbosa JLVV, Pittoli F. In the pursuit ofHygge Software. IEEE Softw. 2017;34(6):48–52.

101. Keesara S, Jonas A, Schulman K. Covid-19 andhealth care’s digital revolution. N Engl J Med.2020;382(23):e82.

102. World Health Organization. COVID-19 and NCDs.2020. https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic. Accessed Aug 3,2020.

103. Kretchy IA, Asiedu-Danso M, Kretchy JP. Medica-tion management and adherence during theCOVID-19 pandemic: perspectives and experiencesfrom low-and middle-income countries. Res SocialAdm Pharm. 2020. https://doi.org/10.1016/j.sapharm.2020.04.007.

104. World Health Organization. Maintaining essentialhealth services: operational guidance for theCOVID-19 context. 2020. https://www.who.int/publications/i/item/10665-332240. Accessed Aug 3,2020.

105. Mathur P, Rangamani S. COVID-19 and noncom-municable diseases: identifying research prioritiesto strengthen public health response. Int J Non-commun Dis. 2020;5(2):76–82.

Adv Ther (2020) 37:4808–4830 4829

106. Pariyo GW, Wosu AC, Gibson DG, Labrique AB, AliJ, Hyder AA. Moving the agenda on noncommuni-cable diseases: policy implications of mobile phonesurveys in low and middle-income countries. J MedInternet Res. 2017;19(5):e115.

107. Haregu TN, Byrnes A, Singh K, et al. A scopingreview of non-communicable disease researchcapacity strengthening initiatives in low and mid-dle-income countries. Glob Health Res Policy.2019;4:31.

108. Frankish H, Boyce N, Horton R. Mental health forall: a global goal. Lancet. 2018;392(10157):1493–4.

109. Dias LPS, Barbosa JLV, Feijo LP, Vianna HD. Devel-opment and testing of iAware model for ubiquitouscare of patients with symptoms of stress, anxietyand depression. Comput Methods ProgramsBiomed. 2020;187:105113.

110. Bavaresco R, Barbosa J, Vianna H, Buttenbender P,Dias L. Design and evaluation of a context-awaremodel based on psychophysiology. Comput Meth-ods Programs Biomed. 2020;189:105299.

111. Petry MM, Barbosa JLV, Rigo SJ, Dias LPS, Butten-bender PC. Toward a ubiquitous model to assist thetreatment of people with depression. Univ AccessInf Soc. 2020;19:841–54.

112. Bokhour BG, Fix GM, Mueller NM, et al. How canhealthcare organizations implement patient-cen-tered care? Examining a large-scale cultural trans-formation. BMC Health Serv Res. 2018;18(1):168.

113. Paul T. ‘‘Nothing about us without us’’: towardpatient- and family-centered care. AMA J Ethics.2016;18(1):3–5.

4830 Adv Ther (2020) 37:4808–4830