Non-communicable diseases (NCDs) are a leading cause of death globally, with rural populations in India being particularly vulnerable due to limited healthcare access. This study aims to evaluate the effectiveness and challenges of a Community-Based Assessment Checklist (CBAC)-based screening program for NCDs in underserved rural areas of Jaipur, Rajasthan. A mixed-methods approach was employed, combining quantitative analysis of NCD risk factors (blood pressure, blood sugar, BMI, chronic kidney disease) and qualitative data on community engagement and operational challenges. Screening camps were organized in 10 underserved villages, where 404 individuals were screened. Results revealed that 47% of participants were classified as high-risk for NCDs based on CBAC scores. Significant associations were found between high-risk CBAC scores and hypertension, diabetes, and obesity. However, qualitative findings highlighted critical barriers to participation, including lack of awareness, logistical challenges, and mistrust in the process. Despite these barriers, the study demonstrated the potential of CBAC as a valuable tool for early NCD detection, though addressing community engagement and operational challenges is essential for its broader implementation.
Non-communicable diseases (NCDs) pose a significant and growing public health challenge globally, accounting for 41 million annual deaths, with 77% of these occurring in low- and middle-income countries. In India, NCDs contribute to 63% of all deaths, with cardiovascular diseases, chronic respiratory diseases, cancers, and diabetes leading the burden. The rapid epidemiological transition in India has resulted in a steep rise in lifestyle-related chronic NCDs, disproportionately affecting rural populations where health systems are less equipped to diagnose, manage, or control these diseases effectively (1).
Rural populations face unique vulnerabilities, including limited access to screening facilities, delayed diagnoses, and significant gaps in treatment and control of conditions such as hypertension, diabetes, chronic obstructive pulmonary disease (COPD), cancer, and common mental disorders. Studies have shown that hypertension affects up to 14% of the rural population in Jaipur District, with pre-hypertension affecting over 40% (2). Similarly, the prevalence of COPD ranges from 1.2% to 22%, highlighting a significant disease burden (3). Despite government programs aimed at addressing these issues, their implementation in rural areas has been slow, leaving substantial gaps in care.
Community-based models that integrate screening with locally adaptable interventions are critical for bridging these gaps. Tools like the Community-Based Assessment Checklist (CBAC) have been introduced to identify individuals at risk for NCDs in resource-limited settings, providing an opportunity for early intervention and management.
This study aims to test the effectiveness of a CBAC-based community screening program for identifying NCD risk factors in the underserved rural population of Jamwaramgarh block, Jaipur District. It also seeks to identify barriers influencing the model's utilization in rural areas. By addressing the gaps in current NCD care strategies, this study provides critical insights into the effectiveness and challenges of implementing scalable community interventions to reduce the burden of NCDs in rural India.
Study Design: This study employed a mixed-methods design combining both quantitative and qualitative approaches. It utilized a community-based intervention model to assess the effectiveness and challenges of a camp-based screening approach aimed at improving the screening and diagnosis of non-communicable diseases (NCDs) in rural populations. The intervention involved setting up health camps in underserved areas, where individuals were screened for various NCDs. This exploratory study focuses on evaluating the practicality of this model, with a particular emphasis on community engagement, operational challenges, and the effectiveness of scaling this approach for broader use.
Study Area: The study was conducted in the Jamwaramgarh block of Jaipur, Rajasthan, which is field practice area of Model Rural Health Research Unit (MRHRU), Jaipur, Rajasthan.
Sampling Strategy: The Jamwaramgarh block consists of 65 health sub-centres, 37 of which are currently engaged in ongoing government-sponsored NCD screening programs under the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD). The remaining 28 sub-centres, which do not participate in these programs, were identified as underserved and prioritized for this study. Villages associated with these 28 sub-centres were listed, and 10 sub-centres were randomly selected for this exploratory study. Screening camps were then organized in the selected villages to engage directly with the target population. This selection process was guided by the objective of evaluating the effectiveness of a camp-based NCD screening model in underserved communities, with a focus on community engagement and operational challenges.
A convenience sampling approach was adopted, where all individuals attending the screening camps were included. To enhance representativeness and minimize bias, camps were organized with the active involvement of local health workers who mobilized participants across diverse demographics (age, gender, and socioeconomic backgrounds). This approach aimed to ensure inclusivity, though it should be noted that convenience sampling may limit generalizability.
Data Collection: The quantitative aspect focused on NCD risk factor screening. The screening was conducted using the Community-Based Assessment Checklist (CBAC) form, which is a well-established tool used for the early detection of NCDs and tuberculosis. This tool helps identify individuals at risk based on lifestyle factors, medical history, and reported symptoms. Additionally, various NCD risk factors such as Blood Pressure (BP), Blood Sugar levels, Body Mass Index (BMI), and chronic kidney disease (CKD) were measured as part of the screening process. These tests were included to assess the effectiveness of the CBAC based screening process and to provide a more comprehensive evaluation of the model's impact.
The qualitative component explored the challenges faced by communities in utilizing these services. Qualitative data was collected through interviews and feedback sessions with camp participants, non-participants, and local healthcare workers to identify barriers and facilitators of community participation in the such screening programs.
Study Period: These screening camps were organized between July to August 2024.
Statistical Analysis: Quantitative data from the CBAC form and test results were analysed using descriptive statistics and Chi-square tests to identify associations between various health factors with CBAC generated NCD risk score. Qualitative data was analysed thematically to understand the challenges in implementing the screening model.
Ethical Consideration: Study was carried out as per the ethical guidelines of the Indian Council of Medical Research (4). The study was approved by the Institutional Ethics Committee vide approval number IEC-ICMR NIIRNCD/2022/27/6 dated 15th March 2022. Informed and written consent was obtained from every participant before registering them in the study
A total of 404 participants were screened, with a higher representation of females (57%) compared to males (43%). The age distribution showed that 31% of participants were aged 29 years or less, followed by 22% in the 30-39 years group, 16% in the 40-49 years group, 13% in the 50-59 years group, and 18% aged 60 years or above. Across most age groups, females outnumbered males, particularly in the 30-39 years age group, where females accounted for 67% of the participants. Conversely, males slightly outnumbered females in the 50-59 years group (53% male vs. 47% female). This demographic profile highlights the engagement of diverse age groups, with higher female participation across the study (Table-1). A total number of 47% individuals were tested as high-risk population for Non-Communicable Diseases (NCDs) based on CBAC scoring.
Table 1: Distribution of Study Participants
Age group |
Male |
Female |
Total |
|||
N |
% |
N |
% |
N |
% |
|
29 years or less |
57 |
45% |
69 |
55% |
126 |
100% |
30-39 years |
29 |
33% |
58 |
67% |
87 |
100% |
40-49 years |
25 |
39% |
39 |
61% |
64 |
100% |
50-59 years |
28 |
53% |
25 |
47% |
53 |
100% |
60 years and above |
35 |
47% |
39 |
53% |
74 |
100% |
The association between gender and NCD risk scores shows that a significantly higher proportion of males (54%) were classified into the high-risk group (score ≥4), compared to females (41%). This significant difference (Chi-square value: 6.888, p-value: 0.0087) suggests that the screening was effective in detecting risk factors across genders, but males in this rural population appeared to be at greater risk of developing NCDs such as hypertension, diabetes, and CKD (Table-2).
Table 2:Association of NCD risk score with variables
Variables |
NCD Risk Score |
Chi Square Value |
p Value |
||||||
Low Risk (3 and below) |
High Risk (4 and above) |
Total |
|||||||
N |
% |
N |
% |
N |
% |
||||
Gender |
Male |
80 |
46% |
94 |
54% |
174 |
100% |
6.888 |
0.009 |
Female |
136 |
59% |
94 |
41% |
230 |
100% |
|||
Body Mass Index (BMI) |
Underweight (less than 18.5) |
58 |
60% |
39 |
40% |
97 |
100% |
3.751 |
0.289 |
Normal Weight (18.5-24.9) |
126 |
53% |
114 |
48% |
240 |
100% |
|||
Overweight (25-29.9) |
28 |
51% |
27 |
49% |
55 |
100% |
|||
Obese (30 and above) |
4 |
33% |
8 |
67% |
12 |
100% |
|||
Blood Pressure |
Hypotension (Below 90/ Below 60 mmHg) |
1 |
33% |
2 |
67% |
3 |
100% |
30.94 |
0.000000876 |
Normal (90-119/ 60-79 mmHg) |
131 |
66% |
69 |
35% |
200 |
100% |
|||
Pre-hypertension (120-139/ 80-89 mmHg) |
72 |
47% |
80 |
53% |
152 |
100% |
|||
Hypertension (140 mmHg or above/90 mmHg or above) |
12 |
24% |
37 |
76% |
49 |
100% |
|||
Random Blood Sugar |
Hypoglycaemia (below 70 mg/dL) |
3 |
100% |
0 |
0% |
3 |
100% |
11.9 |
0.008 |
Normal (70 – 139 mg/dL) |
191 |
56% |
150 |
44% |
341 |
100% |
|||
Pre-diabetic (140 –199mg/dL) |
21 |
40% |
32 |
60% |
53 |
100% |
|||
Diabetic (>200mg/dL) |
1 |
14% |
6 |
86% |
7 |
100% |
|||
Chronic Kidney Disease (CKD) |
KA Negative |
26 |
51% |
25 |
49% |
51 |
100% |
3.591 |
0.309 |
Normal albumin (ACR <30 mg/g) |
5 |
71% |
2 |
29% |
7 |
100% |
|||
Microalbuminuria (ACR30–300 mg/g) |
2 |
29% |
5 |
71% |
7 |
100% |
|||
Proteinuria (ACR >300 mg/g) |
0 |
0% |
1 |
100% |
1 |
100% |
The association between BMI categories and NCD risk scores shows that individuals classified as obese (BMI ≥30) had a significantly higher proportion in the high-risk group (67%), compared to those with normal BMI (18.5-24.9), where only 48% were at high risk. The Chi-square value of 3.751 (p-value: 0.289) shows a trend but lacks statistical significance. However, the higher percentage of overweight and obese individuals in the high-risk group demonstrates that CBAC screening is effective in identifying individuals who are at higher risk for diseases like hypertension, diabetes, and cardiovascular conditions (Table-2).
Blood pressure (BP) is a key risk factor in this screening, and the data demonstrates a significant association between high blood pressure and the NCD risk score (Chi-square value: 30.94, p-value: 0.000000876). The highest proportion of high-risk individuals had hypertension (76%), followed by those with pre-hypertension (53%), while only 24% of those with hypertension were in the lower risk group. This highlights the high prevalence of hypertension in the high-risk group and reinforces that CBAC screening is highly effective in identifying individuals with elevated BP, who are at a much higher risk for heart disease and stroke (Table-2).
The association between random blood sugar levels and NCD risk scores reveals that pre-diabetic and diabetic individuals are more likely to fall into the high-risk category (60% and 86% respectively). With a Chi-square value of 11.9 (p-value: 0.008), this finding underscores that CBAC screening is effective in detecting elevated blood sugar levels in individuals, which is an important predictor of diabetes and metabolic syndrome (Table-2).
The CKD test results show that those with microalbuminuria (ACR 30-300 mg/g) and proteinuria (ACR >300 mg/g) were predominantly in the high-risk group, but the sample size was very small (66 participants) due to the test being administered only to symptomatic individuals. The association between albumin-to-creatinine ratio (ACR) and the NCD risk score was not statistically significant (Chi-square value: 3.591, p-value: 0.309), but the trends indicate that albuminuria is prevalent among high-risk individuals (Table-2).
The distribution of major non-communicable disease (NCD) risk factors, including obesity, hypertension, diabetes, and chronic kidney disease (CKD), was examined across CBAC risk categories. Among participants with CKD, 75% were classified in the high-risk group (CBAC ≥ 4), indicating a strong association between advanced chronic conditions and higher CBAC scores. Similarly, 63% of those with diabetes and 58% of those with hypertension were in the high-risk category, demonstrating the tool’s effectiveness in identifying individuals with significant disease burdens. For obesity, the distribution was relatively even, with 52% in the high-risk group, reflecting the CBAC’s comprehensive approach to capturing various risk factors (Fig-1).
Figure 1: Proportion of Major NCD Conditions Across CBAC Risk Categories
These findings highlight a consistent trend of increasing prevalence of severe NCD conditions among individuals with higher CBAC scores, suggesting its utility as a stratification tool for community-based NCD screening. However, despite the tool's demonstrated effectiveness, the qualitative insights reveal critical gaps in community participation and engagement, emphasizing that effective screening tools alone are insufficient to ensure high attendance and utilization of screening services.
The qualitative findings highlight key challenges that hinder participation in community-based NCD screening programs, even when effective screening tools are used. A lack of awareness, trust deficits due to unmet expectations, and logistical barriers, such as timing and transport, were significant obstacles. Camp participants valued the screening camps but emphasized the need for holistic services, including doctor consultations and medicines, which align with rural health-seeking behaviours. Non-participants cited fear of diagnoses, mistrust in the process, and unawareness as primary reasons for their absence (Table-3).
Table 3: Challenges and Suggestions for Enhancing Community-Based NCD Screening Programs: Feedback from Participants, Non-Participants, and Healthcare Workers
Theme |
Findings |
Implications |
Awareness and Publicity |
· Many non-participants were unaware of camps. · Word-of-mouth from participants was influential (both positively and negatively). |
Enhancing awareness campaigns using local leaders, WhatsApp, and loudspeakers is critical for improving outreach. |
Trust and Expectations |
· Lack of doctor availability and medicines eroded trust. · Participants expected comprehensive services but felt let down by limited offerings. |
Addressing unmet expectations with better resource allocation can improve trust and future participation. |
Perceived Value of Camps |
· Participants appreciated testing but wanted expanded services (e.g., doctor consultations, medicines). |
Holistic services combining diagnostics and treatment are crucial for higher participation. |
Barriers to Participation |
· Timing, logistical challenges, fear of diagnoses, and mistrust were major barriers. · Gender comfort and transport issues affected attendance. |
Customizing camp schedules, ensuring female staff availability, and providing transport can mitigate attendance issues. |
Preferred Services |
· Villagers valued free medicines, diagnosis of local diseases, and consultations over standalone testing. |
Integrating preventive and curative care can align with rural health-seeking behaviours and preferences. |
Systemic Challenges |
· Government NCD screening program and screening camps lacked awareness-building, resources, and logistical flexibility. · Private providers were preferred due to trust issues with public health systems. |
Strengthening collaborations between government programs and community-based initiatives could enhance program delivery. |
Healthcare workers echoed these concerns, noting limitations in both government NCD screening program and camp based approaches, and stressed the importance of resource upgrades, targeted awareness campaigns, and logistical improvements. Suggestions for engagement included leveraging local leaders, using diverse communication channels, and aligning camp operations with community needs (Table-3).
The results of this study provide a multifaceted perspective on the effectiveness and challenges of implementing community-based NCD screening programs using the CBAC tool in rural underserved populations. Quantitative findings revealed that 47% of individuals in this study were classified as high-risk for NCDs based on CBAC scoring, demonstrating the tool's utility in identifying at-risk populations. This finding aligns with other rural community-based studies, such as those by Choudhry et al. and Kaur et al., who reported high-risk prevalences of 48% and 57.7%, respectively, in rural areas (5,6). However, variations in findings across rural settings, such as the study by Jaacks et al. in rural Punjab, which reported a significantly lower proportion (14.4%) of individuals with CBAC scores >4, suggest that local demographics, risk factors, and program implementation strategies play a key role in determining NCD risk prevalence (7). These disparities highlight the need for context-specific adaptations in screening and outreach to improve the effectiveness of community-based interventions in rural areas. At the same time, these findings must be contextualized within the broader challenges revealed by qualitative insights, which underscore the critical importance of addressing community-specific barriers to participation and trust in preventive health programs.
Gender and NCD Risk Score
The finding that 54% of men were categorized as at risk, compared to only 41% of women and a statistically significant association between gender and CBAC based NCD risk score suggests that men in rural Jamwaramgarh are at a higher risk for developing non-communicable diseases compared to women. Kalasker et. al (8) and Kaur et al (6) also reported the same trend during their study.
Several factors may contribute to this gender disparity, including lifestyle choice, health-seeking behaviours, access to healthcare, and socio-cultural influences. This finding highlights the need for gender-specific interventions in NCD prevention and management. Health promotion campaigns targeted at men could be designed to address their specific needs and barriers to care, such as awareness campaigns, improving healthcare access, and promoting healthier lifestyles. Moreover, community-based screening programs could be tailored to encourage male participation, ensuring that both genders are equally represented and supported in efforts to control NCDs.
Body Mass Index (BMI) and NCD Risk Score
Despite the lack of statistical significance, the observed trend, where individuals classified as obese had a significantly higher proportion in the high-risk group compared to those with a normal BMI, aligns with the established role of obesity as a risk factor for NCDs. Similar findings have been reported in other studies, demonstrating a statistically significant association between BMI and NCD risk scores (8,9). This trend highlights the potential value of BMI as a screening tool in community-based settings, particularly in rural areas where obesity and its related complications may often be underrecognized. The complementary use of BMI along with the CBAC form, where feasible, could enhance risk screening efforts.
Blood Pressure and NCD Risk Score
The screening effectively identifies individuals at risk for cardiovascular diseases through blood pressure measurement, as evidenced by the strong association between blood pressure categories and CBAC-based NCD risk scores. The proportion of participants classified as at risk (CBAC Score ≥ 4) increases progressively with higher blood pressure categories, from 35% in the normal group to 76% in the hypertensive group. This significant trend highlights the utility of the CBAC tool in identifying individuals at risk of NCDs and indirectly helping to detect elevated blood pressure. Similar findings have been reported by Kalasker et al. (8) and Jaacks et al. (7), underscoring the importance of early detection through CBAC-based community screening programs to prevent long-term health complications.
While the tool performed well in identifying high-risk individuals, the small number of participants with hypotension (n = 3) limits conclusions about this group. Future studies could explore whether CBAC adjustments are needed for rare scenarios like hypotension, especially in populations with higher prevalence of malnutrition or chronic conditions.
Blood Sugar (Random Blood Sugar) and NCD Risk Score
The strong association between blood sugar categories and the high-risk group highlights the effectiveness of CBAC-based community screening programs in classifying individuals into appropriate risk categories, potentially identifying those at risk for NCDs, including previously unrecognized pre-diabetic or diabetic cases. Early detection can lead to better management of diabetes and reduce the risk of complications like kidney failure, heart disease, and blindness.
The analysis highlights that the proportion of participants classified as at risk (CBAC Score ≥ 4) increased progressively with higher blood sugar levels, from 44% in the normal range to 86% in the diabetic range. This finding aligns with the established role of elevated blood sugar levels as a critical NCD risk factor and also prove the CBAC tool's ability to identify individuals with diabetes risk.
The hypoglycaemia category (n = 3) and the diabetic category (n = 7) had very small sample sizes. This is a limitation of the analysis, as it may affect the reliability of chi-square results for these groups. Interpretations for these categories should be made cautiously. Despite the small size, the observed trends are consistent with clinical expectations, lending credibility to the results.
The identification of 44% of individuals with normal blood sugar levels as high risk for NCDs highlights the effectiveness of the CBAC tool in capturing a wide range of risk factors, independent of glycaemic status. This reinforces CBAC's utility as a comprehensive screening tool in community settings, especially in identifying individuals who may require further investigation or intervention even when blood sugar levels are normal.
CKD Test Results and NCD Risk Score
Although the sample size for the CKD test was limited, the findings suggest that CBAC screening can help detect early signs of kidney dysfunction in high-risk individuals, particularly those with proteinuria or microalbuminuria. This is important because it identifies individuals who may need further diagnostic tests and early interventions for chronic kidney disease (CKD), which is a growing concern in rural populations.
Although the chi-square test did not indicate a significant association, the proportion of participants classified as at risk (CBAC Score ≥ 4) increased with worsening kidney function, from 29% in the normal albumin level group to 100% in the proteinuria group.
CKD testing was conducted only for symptomatic participants, leading to a small sample size (n = 66). This selective testing limits the generalizability of findings and introduces potential bias. The results may not represent the true distribution of kidney dysfunction among all participants in the screening program. While trends are observable, the chi-square test may lack power to detect significant associations in this context.
Overall, the quantitative results suggest that the community-based NCD screening program using the CBAC form was effective in identifying individuals at risk for a variety of NCDs, particularly hypertension, diabetes, and kidney dysfunction. The associations found between BMI, blood pressure, blood sugar, and CBAC risk score indicate that the CBAC based screening program successfully stratified the population into high-risk and low-risk categories. These findings highlight the usefulness of CBAC as a screening tool in identifying individuals who are at risk of developing major NCDs, enabling early interventions and better health management in underserved rural communities.
While the quantitative findings underscore the effectiveness of the CBAC tool in identifying high-risk individuals for NCDs, the qualitative insights provide a critical perspective on the persistent challenges that hinder broader participation and engagement in these type of community-based screening programs. These findings reveal a gap between the utility of the tool and its practical implementation in rural settings.
Camp participants valued the health check-ups and educational benefits offered during the camps; however, these efforts fell short of their expectations for holistic healthcare services. The absence of doctors, lack of medicines supplies, and limited diagnostic options were seen as major shortcomings, leading to dissatisfaction and, in some cases, eroding trust in the program. Non-participant individuals, on the other hand, remained sceptical due to limited publicity, fear of diagnosis, and a general mistrust in the quality and relevance of the services offered.
The findings point to a broader issue: in rural communities, health-seeking behaviours are heavily influenced by traditional expectations of healthcare. Villagers associate healthcare with visible markers of authority and care, such as doctors in white coats and the provision of medicines. Screening alone, even when supported by advanced diagnostic tests, is often perceived as incomplete or of little value. This cultural perception creates a barrier, making it challenging to sustain participation in programs that prioritize preventive care over curative services.
Healthcare workers corroborated this sentiment, highlighting the need for integrating government and camp-based approaches to bridge resource gaps. While screening camps offered on site advanced testing, their impact was diminished by logistical issues and the absence of critical resources like doctors and medicines. Government programs, although systematic, struggled with limited community trust and inadequate diagnostics.
These findings highlight a crucial reality for community-based NCD screening programs; effectiveness is not just about having the right tools or tests but also about aligning the program with the expectations and needs of the community. Building trust requires more than just awareness campaigns; it demands delivering tangible benefits that resonate with people’s perceptions of healthcare value. This includes providing doctor consultations, ensuring the availability of medicines, and addressing logistical barriers such as timing and transportation.
Without addressing these challenges, even the most effective screening tools may fail to achieve their intended impact, particularly in underserved rural areas. The qualitative insights emphasize the importance of designing interventions that are not only evidence-based but also culturally sensitive and community-oriented.
This study underscores the dual potential and limitations of CBAC-based community screening programs for NCDs in rural underserved areas. The CBAC tool demonstrated strong effectiveness in identifying individuals at risk for conditions such as hypertension, diabetes, and kidney dysfunction, enabling early referral for further care. However, the program's success was tempered by significant challenges in community engagement and participation, shaped by cultural perceptions of healthcare, logistical barriers, and unmet expectations for curative services.
Future initiatives should prioritize designing community health interventions that integrate preventive care with curative elements to align with community expectations. Enhancing trust through better publicity, the inclusion of healthcare providers such as doctors, and ensuring access to medicines will be critical for sustaining participation and maximizing impact.
Moreover, future studies should address the limitations of small sample sizes in specific categories to ensure more robust statistical power and generalizability of findings. Further research should also investigate the association of CBAC's cancer, mental health, and COPD components with corresponding health outcomes to validate and expand its utility as a comprehensive screening tool.
Funding: The study was funded by the Indian Council of Medical Research, New Delhi.
Data Availability Statement: The data will be available on request from the corresponding author. The data are not publicly available due to privacy.
Conflicts of Interest: The authors declare no conflicts of interest.
Acknowledgements: Authors are thankful to Sh. Ashish Sahu, Sh.Narendra Kumar and Sh. Manoj Kumar for providing assistance during the study period.