Opportunistic screening for diabetes mellitus and hypertension in primary care settings in Karnataka, India: a few steps forward but still some way to go

Background: Opportunistic screening for individuals aged ≥30 years at all levels of healthcare for early detection of diabetes mellitus (DM) and hypertension (HTN) is an integral strategy under the national program to control non-communicable diseases. There has been no systematic assessment of the screening process in primary care settings since its launch. The objective was to determine the number and proportion eligible for screening, number screened, diagnosed and treated for DM and HTN among persons aged ≥30 years in two selected primary health centres (PHCs) in Dakshina Kannada district, Karnataka, India during March-May 2019 and to explore the enablers and barriers in the implementation of screening from the perspective of the health care providers (HCPs) and beneficiaries . Methods: This was a sequential explanatory mixed-methods study with a quantitative (cohort design) and a descriptive qualitative component (in-depth interviews and focus group discussions) with HCPs and persons seeking care. Those that were not known DM/HTN and not screened for DM/HTN in one year were used to estimate persons eligible for screening. Results: Of 2697 persons, 512 (19%) were eligible for DM screening, 401 (78%) were screened; 88/401 (22%) were diagnosed and 67/88 (76%) were initiated on treatment. Of 2697, 337 (13%) were eligible for HTN screening, 327 (97%) were screened, 55 (17%) were diagnosed with HTN; of those diagnosed, 44/55 (80%) were initiated on treatment. The documentation changes helped in identifying the eligible population. Patient willingness to undergo screening and recognition of relevance of screening were screening enablers. Overworked staff, logistical and documentation issues, inadequate training were the barriers. Conclusion: Nearly 19% were eligible for DM screening and 13% were eligible for HTN screening. The yield of screening was high. We noted several enablers and barriers. The barriers require urgent attention to reduce the gaps in delivery and uptake of services.


Introduction
Non-communicable diseases (NCDs) kill 41 million people each year (71% of global deaths), disproportionately more (>75%) in the low-middle-income countries 1 . NCDs also account for a large share (75%) of deaths among those aged 30-69 years 2 . They are a threat to the Agenda for Sustainable Development 2030, which targets reduction of premature deaths from NCDs by one-third 3 .
India mirrors the global picture, with NCDs claiming 63% of all deaths in 2016 alone 2 . India has nearly 72 million persons with diabetes mellitus (DM), which accounts for 49% of global burden and 207 million people with hypertension (HTN) 4-7 .
Early identification and prompt management through an emboldened health system is the key to reduce premature mortality and morbidity due to NCDs 8 . To achieve this, India launched the National Programme for Prevention and Control of Cancer, DM, Cardiovascular Diseases and Stroke (NPCDCS) in 2010 9 . In Karnataka state, NPCDCS was introduced in a phased manner in various districts, starting from 2010-11 10 . In 2018, the programme was rolled out in Dakshina Kannada (DK) district, a coastal district in Karnataka. Opportunistic screening for persons aged ≥30 years at all public health facilities from sub-centres (SCs), primary health centres (PHCs) and above is an integral strategy for early detection of DM and HTN under the NPCDCS 9 .
There has been no systematic assessment of the screening process in programmatic settings, with previous studies conducted in project settings [11][12][13] . Furthermore, their focus was on the yield of screening. It is operationally important to know how many of the eligible population, could be screened, which to our knowledge has not been previously addressed 11,13 . Therefore, we conducted the present study among persons aged ≥30 years seeking health care from the outpatient department (OPD) of the selected PHCs in DK district of Karnataka from March to May, 2019 to determine i) the number and proportion eligible for screening of DM and HTN and ii) among those eligible, how many were screened, diagnosed and managed for the disease. Further, we qualitatively explored the enablers and barriers in the implementation of opportunistic screening from the perspective of the health care providers (HCPs) and persons availing the services.

Study design
This was a sequential explanatory mixed-methods study with a quantitative component (cohort study) and a descriptive qualitative component 14 .

Setting
General setting. Karnataka is the eighth largest state of India and is inhabited by 61.1 million with a literacy rate of 75.4% and is divided into 30 administrative districts 15 . DK, a coastal district of Karnataka, has a population of ~2.1 million and a literacy rate of 85.3%. It is divided into nine administrative divisions called Talukas 16 . The prevalence of DM and HTN in DK are 16% and 17% respectively, higher than the national figures 17,18 .
Specific setting. Mangaluru is a predominantly urban Taluka of DK district with a population of ~1 million and a literacy rate of 91% 19 . It has 22 PHCs and 12 urban primary health centres (UPHCs) which deliver primary health care to the population. We selected one UPHC located in Bunder, which caters to a population of 6,749 and one PHC located in Amblamogaru, a rural area with a population of 16,920. Yenepoya Medical College, where the Principal Investigator (PI) works, supports these centres by posting medical interns, as per a Memorandum of Understanding with the District Health and Family Welfare Office, DK.

Opportunistic screening process for DM and HTN at the PHC level
The PHCs run a general OPD where the basic demographics, diagnosis and treatment details are recorded in the OPD register. Under the NPCDCS, opportunistic screening is being conducted by the staff nurse under the supervision of the Medical Officer (MO) and details are recorded in aseparate register (NCD register).The laboratory technician plays a supporting role in opportunistic screening for DM by carrying out tests like random blood glucose (using a glucometer) and fasting blood sugar (FBS), and maintains records of the tests conducted. An additional NCD related activity being carried out in these PHCs include population-based screening (PBS). PBS is carried out by accredited social health activists (ASHAs) through home visits in their service areas and by auxiliary nurse midwives (ANMs) at the SC level.
Monthly reports of all NCD-related activities at the PHC level are collated in a reporting format which captures details like cumulative number of persons screened, diagnosed, treated and on follow-up care for DM, HTN and other NCDs. This report is submitted to the district NCD cell, which is responsible for effective implementation and supervision at the district level. The NCD cell is managed by the District Programme Coordinator of NPCDCS, who works under the overall supervision of the District Surveillance Officer (DSO).

Study population
For the quantitative phase all persons aged ≥30 years availing primary health care from the two selected PHCs from March to May 2019 were included. We excluded persons aged <30 years who sought primary health care from the two selected PHCs.
For the qualitative phase, HCPs working in the two selected PHCs, who were involved in screening for DM and HTN like staff nurses (n=4), laboratory technicians (n=2) and MO of the PHCs (n=3) were included. HCPs who were not involved in the screening process for DM and HTN at the two PHCs were excluded. The District Programme Coordinator, NPCDCS (n=1) was also interviewed. Persons who underwent DM and HN screening in the two PHCs from March to May 2019 (n=37) also constituted the study population.
Data variables, sources of data and data collection Phase 1: Quantitative data collection Setting up of a system for better documentation of opportunistic screening for DM and HTN at the selected PHCs Experiences from the field show that the existing recording system to document opportunistic screening carried has certain limitations, particularly with respect to determining the population eligible for screening among persons aged ≥30 years. It is not well documented whether a person has undergone screening previously or is already diagnosed as DM or HTN.
Thus, we set up a system to improve the existing documentation for opportunistic screening of DM and HTN.
After obtaining necessary permissions and building initial rapport with the HCPs, we conducted a stakeholder meeting at the PHCs. The limitations of the current recording system were discussed and additional variables were included in both the OPD and NCD registers. The variables include: a) whether the person has DM/HTN, b) whether screened for DM/HTN in the last one year. If the response to both a) and b) were "no", the person was considered to be eligible for screening. The was done to estimate the number of persons eligible for screening and to assess the feasibility of this strategy in such settings. Further, we made amendments in the NCD register to collect certain essential information.
The staff nurses and laboratory technicians were trained to enter the required information in dichotomous responses (Yes/No). This enabled us to assess the eligibility for screening.

Data collection
The screening process was implemented by the HCPs from March to May 2019 at the two PHCs. To mitigate bias, none of the members of the study team were in contact with the HCPs of the two PHCs during the above-mentioned period of implementation. Thereafter, we collected details from the OPD and the NCD registers for the duration, March to May 2019 in a structured data collection proform a (available as Extended data 20 ) which had two parts. Data for the first part were extracted from the OPD register and data for the second part data came from the NCD register. The first part collected demographic details and eligibility criteria for screening. The second part collected information on whether persons were screened, diagnosed or managed for DM and HTN. Epidemiological diagnosis for DM, HTN and eligibility for screening are given in Table 1.
Phase 2: Qualitative data collection Systematic qualitative enquiry was carried out through key informant interviews (KIIs) among HCPs and focus group discussions (FGDs) among persons aged ≥30 years, who underwent screening for DM and HTN.
The PI has a master's degree in Community Medicine/Public Health and is trained in qualitative research methods. The investigators were not a part of the programme implementation team.
The PI conducted the KIIs among HCPs at their workplace in Kannada (vernacular language), or English as applicable, until information saturation was attained. Participants were explained the purpose and their expected role prior to the interview about. Interview guides consisting of broad openended questions and probes were prepared for different cadres. Each KII lasted for around 30 minutes. Interview and FGD guides are available as Extended data 20 .
The PI also conducted FGDs among persons aged ≥30 years, who underwent screening at the PHC. A total of 6-8 participants were included in each FGD. FGDs. Each FGD lasted for about 45 minutes and were held in Kannada language separately for men and women.
Only the participants, the PI and the note-maker were present during the KIIs and FGDs. Audio recording and verbatim notes were taken. In case the participants did not consent for audio recording prior to the discussion, notes were taken. After the KII/FGD was over, the summary was read back to the participants to ensure validation. A total of two repeat interviews were conducted among a staff nurse and laboratory technician working in one of the two PHCs. A Table 1. Epidemiological diagnosis used in the study.

Variable
Epidemiological diagnosis

Diabetes mellitus (DM)
DM screening was being carried out using glucometers and a random blood sugar reading of >140 mg/dl was confirmed by fasting blood sugar. A fasting venous blood sugar level of ≧≥126 mg/dl was considered as DM. Fasting was defined as no caloric intake for at least 8 hours 21

Hypertension (HTN)
Blood pressure was measured using sphygmomanometers in the right arm, sitting position. A blood pressure of ≥140/90 mm of Hg with at least two measurements, five minutes apart was labelled as HTN 22 .

Eligible for screening
Persons aged >30 years who are not diagnosed to have DM/HTN previously or not screened within the last one year in the PHC or community repeat FGD was conducted among men aged ≥30 years who underwent screening for DM and HTN in one of the PHCs.
Statistical and data analysis Quantitative data Quantitative data were double-entered and validated using Epi Data version 3.1 for entry. The data was analysed using Epi Data version 2.2.2.183 (Epi Data Association, Odense, Denmark) and STATA (v12.1) software.
Continuous data were summarized using mean and standard deviation (SD). Categorical data were summarized as proportions. Key indicators like proportion of eligible population screened, diagnosed and managed for DM and HTN are presented in a flow diagram ( Figure 1 and Figure 2). To assess the factors associated with 'not screened for DM and HTN', we used Poisson regression. Adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs) were calculated to eliminate the confounders. A p value of <0.05 was considered as the criterion of statistical significance.

Qualitative data
The audio-recorded interviews and FGDs were transcribed by the PI (PR) in Kannada within 48 hours. Thematic analysis by manual coding was carried out by three researchers (PR, ASN and SN) independently to generate various categories or themes under the broad topics: HCP-related and patient-related enablers and barriers. Any discrepancy in coding was resolved through discussion and referral back to the audio files if necessary. If the discrepancy was still not resolved, a third investigator (PRN) reviewed the transcripts and codes. The transcripts and analysis were reviewed by other investigators (TA, JT) to reduce subjectivity in analysis and increase interpretive credibility. The codes were then organised into categories and common themes and presented in flow diagrams ( Figure 3 and Figure 4). A mix of inductive and deductive coding was done. Verbatim quotes are also presented (translated into English) within double quotations 23,24 . To ensure confidentiality, we have deliberately not mentioned the designation of HCPs in the quotes. The findings have been reported by using 'Consolidated Criteria for Reporting Qualitative Research' (COREQ) guidelines 25 .

Ethics and consent
Ethics approval was received from Yenepoya Ethics Committee-1,Yenepoya (Deemed to be University), Mangaluru (2019/085)and the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease, Paris, France (126/18). Written informed consent was obtained from the study participants interviewed. Permission to carry out the study was obtained from the District Health and Family Welfare Officer, DK district.

Participant backgrounds
Of the total 4120 persons seeking health care, 2697 fulfilled the eligibility for the study and were included in the analysis.

Qualitative
Opportunistic screening was acknowledged by HCPs and persons screened for DM and HTN as a useful strategy for early detection. We have summarized the potential enablers and barriers for implementation of opportunistic screening for DM and HTN under two broad organizing themes, HCP-related (health care staff of the PHCs and District Programme Coordinator, NPCDCS) and patient-related (persons screened for DM and HTN from March to May 2019 in the two PHCs)( Figure 3 and Figure 4).

Knowledge of screening
The HCPs demonstrated satisfactory knowledge of the process and relevance of screening and acknowledged its role in early detection. "Now they (adult population) are coming early. Early screening is better because the disease onset is early and if undetected, could lead to complications." (HCP, 34 years, female)

Willingness to deliver services
HCPs expressed willingness to implement opportunistic screening in their settings, despite facing challenges like staff shortages. In spite of acceptance of this initiative by both HCPs and persons undergoing screening, several implementation barriers were noted. De-identified transcripts from interviews and FGDs are available as Underlying data 26 .

Discussion
To our knowledge, this is one of the first mixed methods studies from India assessing the implementation of opportunistic screening for DM and HTN under NPCDCS in primary care settings. We made certain amendments in the OPD register to capture the population eligible for screening and in the NCD register to determine the number screened, diagnosed and treated for DM and HTN. We found that 19% were eligible for DM screening, of which 78% underwent screening and 13% were eligible for HTN screening, among whom 97% were screened. Willingness for screening both on the part of HCPs and persons seeking health care was a key facilitator. Several barriers like staff, logistics, documentation and waiting time were noted. The key findings are discussed below.
First, we found that a substantially low proportion were eligible for opportunistic screening (19.0% for DM and 13.0% for HTN). More than half were screened for DM and HTN in the last year. This is probably due to the PBS conducted in the rural community, an ongoing activity under carried out by ANMs/ASHAs who approach persons aged ≥30 years in the community through home visits or outreach camps. Community-based assessment checklists (CBAC) are filled out and those with high risk are referred to the SC for screening. If found positive, they are referred to the PHC for further investigations and treatment 27 . Further, in urban areas of Mangaluru, special outreach camps with a focus on screening for DM and HTN are carried out once a month, which could have contributed to our finding of low proportion of eligible population.
Second, nearly 22% of the population screened were diagnosed with DM and 19% were diagnosed with HTN, which is much higher than the National Family Health Survey-4 (NFHS-4) data for DK district, in which ≈7.0% had high blood sugar and ≈12.0% had hypertension 28 . This could be ascribed to the fact that our study was a facility-based assessment while NFHS-4 was a community-based survey. Similarly, a community-based survey in coastal Karnataka reported the prevalence of DM to be 16%, lower than the yield in our study. (19) A study conducted in a semi-urban population of Mangaluru reported a prevalence of 41% hypertension, which was much higher than our finding 29 . Despite these variations, the high burden of DM and HTN is a matter of concern which requires both population and individual level interventions.
Third, women were more likely 'not to be screened' for DM when compared to men. This finding of our study could be attributed to the fact that women may be preoccupied with household work. This was substantiated in the qualitative component, where women listed reasons like domestic work and looking after children for not undergoing FBS. It could also be speculated that women are more likely to prioritize their family and may tend to neglect their own health. A qualitative study which assessed the barriers for screening of DM among Iranian women found that many women perceived screening for DM as difficult and also expressed reluctance to undergo blood sugar testing 30 .
Fourth, we found that both the PHCs were staffed by HCPs who displayed a positive attitude towards delivery of NCD screening services. We also found that many persons seeking health care expressed readiness to undergo screening. Willingness is an important predictor for the success of screening for DM and HTN, as reported by previous studies 31,32 . The key reason for this finding could be the good rapport that the HCPs shared with the community.
Fifth, most of the HCPs were satisfied with the amendments made in both the OPD and NCD registers and believed that this made their job easier in terms of determining the eligible population. One drawback of the registers prescribed by the programme is that the eligible population could not be identified. The HCPs felt that the NCD registers prescribed by the programme include too many variables. We have tried to address this through modifications in the recording registers.
Sixth, few HCPs recommended half-yearly screening for persons without DM and HTN. This would lead to unnecessary screening and wasted resources There is a need to sensitize HCPs on restricting to once a year screening for judicious use of resources. The NPCDCS training manuals also advocate screening once a year for DM and HTN among the general population 27,21 . This needs to be emphasized in future training programmes conducted under the NPCDCS.
Seventh, staff challenges, logistical issues and documentation issues were the major barriers, as perceived by HCPs. The health care staff seem to be overburdened with many programmes. This is likely to affect their productivity and in turn hamper the implementation of opportunistic screening. Further, timely submission of reports to the district NCD cell becomes difficult.
Eighth, despite being aware of the relevance, many eligible persons failed to get themselves screened. Moreover, many who screened positive for DM did not undergo FBS. This was mainly due to preoccupation with work in the morning hours. Fear and uncertainty surrounding test results may have further contributed to this attrition. It is imperative to sensitize persons seeking care about the importance of FBS as a diagnostic test.
Increased waiting time was another challenge. It was also noted that laboratory technicians get deputed to other PHCs on certain days to address the issue of staff shortage. This may affect timely reporting of tests like FBS, which in turn results in a missed opportunity to initiate prompt treatment of DM.

Strengths
This is the first study providing information on persons eligible for opportunistic screening in a primary care setting. Our study was conducted under programmatic conditions and the findings reflect the ground realities. We have used a sequential mixed-methods design, which helped in a comprehensive assessment of the enablers and barriers for implementation to guide further refinement of the programme. This will guide the programme managers to take corrective measures.
Most of the studies on this topic are focussed on populationbased screening approaches and do not highlight facilitybased implementation challenges. Since the investigators were not a part of the programme implementation team, this ensured objectivity in analysis and interpretation. Further, we included all persons aged ≥30 years seeking health care from the two PHCs, thereby ensuring internal validity. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and COREQ guidelines for reporting quantitative and qualitative components, respectively 25,33 .

Limitations
The findings of our study need to be interpreted cautiously as it was conducted in two PHCs.The findings cannot be extrapolated to other settings or geographical areas. There were some gaps in accurately recording the information about having underwent opportunistic screening in the last one year. There could be an element of recall bias as this was a self-reported variable.

Program implications
First, urgent attention should be given to address staff challenges which includes filling of vacant posts and hands-on training for documentation. Second, we need to capitalize on the health seeking behaviour of persons seeking health care by timely delivery of services. Third, we need to nurture positive attitudes in HCPs by supportive supervision, training, regular supply of medicines and provision of incentives. Fourth, some eligible beneficiaries werenot screened. This needs to be addressed by digital solutions like line listing of the eligible population. Fifth, the modifications that we made in the registers helped in identifying the eligible population. However, this needs cautious interpretation and may require further studies before being implemented across all PHCs.

Conclusion
Our study found a low proportion eligible for DM and HTN screening. Among those screened, a high number had DM and HTN. We made modifications in the documentation of screening which were well-received by the HCPs. We observed several enablers and barriers to implementation of opportunistic screening. The NPCDCS must address the barriers if it has to strengthen opportunistic screening in primary care settings.

Data availability
Underlying data Figshare: Opportunistic screening for diabetes mellitus and hypertension in primary care settings of Karnataka, India: few steps forward but still some way to go-Raw Data.

Open Peer Review
aRRs were calculated only for DM and not for HTN. Further, I think we adjust or control for other variables in the multiple variable models instead of "eliminate the confounders". Only three variables (viz. age group, gender, and residence) were included in the models.

7.
There were only 10 eligible individuals who were not screened for hypertension and only 2 women were not screened. This analysis may best be done away with. If Table 4 is retained then the last three columns of Table 4, which are empty and not relevant, could be removed.
8. Table 2 shows information about the study participants, not all "persons aged ≥30 years seeking health care". Therefore, the table title may need to be rephrased for clarity.

9.
Gender and sex are very related words but they have different meanings. Usually, the administrative data of health is on sex rather than gender. Therefore, I suggest a review of its usage in the manuscript.

10.
Not including those who were not screened, in the qualitative interviews, to understand the barriers seems to be one of the limitations of this study.

11.
Few typos: The was done to estimate the number of persons eligible for screening and to assess the feasibility of this strategy in such settings.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Reviewer Report 19 June 2020 https://doi.org/10.5256/f1000research.25200.r64187 © 2020 Patil S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Subita P. Patil
Department of Preventative Oncology, Tata Memorial Centre, HBNI, Mumbai, Maharashtra, India The article is written very well.

○
The design of the study is a good mix of qualitative & quantitative methods in current settings.

○
The conclusion, the strengths of the study are well narrated.

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The outcome of the study is service-oriented for the benefit of the community.

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The study can be accepted as it is.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility? Yes

Yes
How is it a cohort design? There is no clear exposure. If we take age, gender and residence as exposure and outcome as screened for which analysis has been done, all these variables were collected at the same time for each participant with respect to the participants time.
The quantitative part of this study has a cross-sectional design and should be mentioned as cross-sectional. 1.
a) In results give denominator for 401. b) For the sentence -'The documentation changes helped in identifying the eligible population' -this needs to be reworded to bring more clarity. c) Is willingness not a result of other factors such as recognition of relevance of screening rather being an independent enabler in itself? 2.

(B) Main manuscript:
Under Study Population subheading -How was the sample size for qualitative study reached at? What was the sampling technique used? These need to be mentioned.

1.
Under subheading -Data variables, sources of data and data collection -While improving the system by developing better documentation systems has helped the researchers to get to the number screened, diagnosed and put on treatment, the qualitative part would not correctly reflect on the real field level functioning of the health centres under programmatic settings. For instance, some participants of in-depth interviews might liked to have mentioned the original documentation system (before improvement) as one of the main barriers. Since introducing the change in the recording system and seeing its outcome was not the objective, this should be mentioned as one of the limitations of the qualitative part.

2.
Under data collection subheading -Were interns posted also taken as HCWs and interviewed? 3.
Under Phase 2: Qualitative data collection subheading: a) Since the PI himself interviewed the health workers of health centres, which he supports administratively, there is a definite element of bias while the HCWs would have given their views. Also, during the initial improvement of the documentation systems, the same stakeholders would have participated. It is quite possible they got motivated during this phase which would have had an impact on their responses. Also, they understood the study objectives during this phase, which would have also had an impact on their responses. This should be highlighted as a limitation.
b) It is not clear how many KIIs and FGDs were conducted initially. This should be mentioned.

4.
Under Statistical and data analysis subheading -Analysis should be as per cross-sectional study design and not cohort.

5.
In Figure 2 -some statements are incomplete/incorrect: a) Care at PHC OPD -Initial part of the statement is missing. b) Diagnosed as HTN-8/63 -I think this should be 'not diagnosed as HTN'.

6.
Under results section: Quantitative -Testing the association of socio-demographic characteristics with not being screened. Was this also a study objective?
Qualitative: a) "We have trained all staff including attendants on Glucometer usage. Therefore, the screening is going on smoothly despite staff shortage."(HCP, 55 years, male) -Was this training given before the study or after they came to know about the study as a result of initial documentation improvement discussions? Since this would influence the results. Clarity is needed on this.
b) Strength of PBS -It needs to be explained how this links to the study objectives that are related to opportunistic screening and not PBS.
c) Patient-related enablers -Awareness of screening -Only persons who underwent screening have been interviewed. Since quantitative analysis was done to understand the factors associated with those 'not screened', it was equally important to know their perspective in qualitative interviews. This should be mentioned as a limitation. d) Documentation and reporting challenges -It needs to be explained more as the HCPs have also found the new reporting system as an enabler, although it would have made the new documentation/reporting format a bit more lengthy. This discrepancy needs to be explained well in the discussion part. e) Patient related barriers -Waiting time and inconvenience barrier and the reluctance for FBS barrier is contradictory to patient related enablers which has listed greater readiness to undergo screening and awareness and satisfaction with services. This needs to be explained in discussion section.
f) In the limitations section -Also, asking the patient if the patient has already got DM/HTN is subject to wrong recoding of information if it was only based on verbal information from patients. Unless documentary evidence was sought to confirm, this should also be mentioned as a limitation.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound? Partly