European Journal of Cardiovascular Medicine

Non-communicable diseases (NCDs) are now the leading cause of death and disability in every state of India, and their share of the disease burden has risen steadily since 1990 [1]. Cardiovascular disease is the largest contributor and affects Indians at a younger age than people in high-income countries [2]. The ICMR-INDIAB study found a diabetes prevalence of 7.3% across 15 states; prevalence in rural areas was 5.2%, and within rural areas it was higher in people of higher socioeconomic status [3]. A nationally representative study of 1.3 million adults showed that hypertension and diabetes were common in both rural and urban areas, and that the richest households had only a modestly higher probability of diabetes than the poorest [4].

A large share of these conditions goes undetected. In the same national data, only about three quarters of adults with hypertension had ever had their blood pressure measured, fewer than half were aware of their diagnosis, and control was achieved in only a small fraction [5]. Early detection is therefore the first and weakest step in the NCD care cascade. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) has faced gaps in human resources, drugs, diagnostics and information systems, which have limited its reach at the primary level [6].

In 2018 the Government of India launched Ayushman Bharat. One of its two pillars was the upgrading of sub-centres and primary health centres into Health and Wellness Centres (HWCs) to deliver comprehensive primary health care, with population-based screening for hypertension, diabetes and oral, breast and cervical cancers in adults aged 30 years and above [7]. Under this model, ASHAs enumerate the eligible population and complete a Community Based Assessment Checklist (CBAC), and a mid-level Community Health Officer leads screening and follow-up at the centre [8]. In November 2023 the HWCs were renamed Ayushman Arogya Mandirs. Integrating NCD care into primary care in this way is widely seen as the most practical route to reaching large populations [9].

Evidence from before the national roll-out shows both promise and difficulty. In a rural pilot, a dedicated cadre of community health workers screened about 7,000 adults aged 30 to 60 years at home within six months, with a refusal rate below 10% [10]. In Karnataka, opportunistic screening in primary care settings reached most eligible persons, but overworked staff, poor documentation and inadequate training were reported as barriers [11]. Blood pressure and blood sugar screening by frontline workers fell short of target coverage and differed between men and women [12], and the uptake of breast and cervical examination recorded in the fourth National Family Health Survey was very low in most districts [13]. Even when people were found to be at high risk of diabetes, many did not visit a health facility for confirmation of the diagnosis [14]. Shortages of medicines and the fragmented organisation of NCD services at the primary level add further gaps [15,16].

Most of these studies were carried out in facilities or in programme pilots and describe the supply side. Fewer have examined, at the household level, how far adults actually use screening at HWCs and why some do not. Measuring utilisation in the community, among non-users as well as users, can show where the screening pathway breaks down. This study therefore aimed to estimate the utilisation of NCD screening services at HWCs among adults aged 30 years and above in a rural block and to identify the sociodemographic, health system and health-related factors associated with utilisation.

Study design

A community-based cross-sectional study was carried out. It is reported according to the STROBE statement for observational studies [17].

Study setting

The study was carried out in Rahata block of Ahmednagar (now Ahilyanagar) district, Maharashtra, in which Pravara Institute of Medical Sciences, Loni, is located and which forms part of its field practice area. The block had a population of 320,485 at the 2011 Census. The Ministry of Health and Family Welfare lists 29 rural Health and Wellness Centres (Ayushman Arogya Mandirs) as operational in the block, functioning from upgraded primary health centres and sub-centres.

Study population. Adults aged 30 years and above who had lived in the study villages for at least six months were eligible. People who were seriously ill, unable to communicate, or pregnant were excluded, as were those who did not give consent.

Sample size. In the absence of a local estimate, the proportion of adults using HWC screening was assumed to be 50%, which gives the largest sample. With 95% confidence and an absolute precision of 5%, the minimum sample was 384. Allowing for a design effect of 1.5 for cluster sampling gave 576, and adding 10% for non-response gave a final sample of 634, rounded to 640.

Sampling. A multistage cluster design was used. In the first stage, 8 HWCs were selected by simple random sampling from the functional rural HWCs in the block. In the second stage, four villages were selected from the catchment area of each selected HWC by probability proportional to size, giving 32 villages. In each village, 20 households were selected by systematic random sampling from the household list held by the ASHA, and one eligible adult was selected per household using the Kish grid.

Study tool. A pretested, structured interview schedule in Marathi was used. It covered sociodemographic characteristics, presence of known hypertension or diabetes, behavioural risk factors, awareness of the HWC and its services, whether the CBAC had been completed by an ASHA, and the use of each screening service (blood pressure measurement, blood glucose testing, oral visual examination, clinical breast examination and visual inspection with acetic acid) at the HWC in the preceding 12 months. Selection of explanatory variables followed the behavioural model of health services use, which groups them into predisposing, enabling and need factors [18]. The schedule was pretested on 30 adults in a non-study village and modified accordingly. Self-reported screening was cross-checked with the HWC register or the participant’s health card where available.

Outcome definitions. The primary outcome was utilisation of NCD screening, defined as screening for hypertension or diabetes, or both, at an HWC in the preceding 12 months. Secondary outcomes were screening for each of the five conditions and use of the complete age- and sex-appropriate package. Participants already diagnosed with hypertension or diabetes were analysed separately for follow-up visits.

Statistical analysis. Data were entered in Microsoft Excel and analysed in Python version 3.14 with the statsmodels library version 0.15. Categorical variables were summarised as frequencies and percentages, with 95% confidence intervals that used cluster-robust standard errors to account for sampling by village. The association of each variable with utilisation was tested with the chi-square test. Crude odds ratios were estimated for each variable. All ten explanatory variables, chosen in advance from the behavioural model of health services use, were entered together into a multivariable logistic regression model with cluster-robust standard errors, so that each estimate is adjusted for the others, and results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals. Multicollinearity was checked with the variance inflation factor, and model fit with the Hosmer-Lemeshow test and McFadden pseudo-R2. A p-value < 0.05 was taken as significant.

Ethical considerations

The study was approved by the Institutional Ethics Committee of Pravara Institute of Medical Sciences, Loni. Written informed consent was taken from all participants in Marathi; thumb impressions with an independent witness were taken from those who could not write. Participants found to have raised blood pressure or symptoms suggestive of NCDs were referred to the nearest HWC or primary health centre.

Characteristics of participants

A total of 640 adults from 32 villages (20 per village) were interviewed. Their mean age was 48.8 ± 13.2 years, 314 (49.1%) were women and 161 (25.2%) had no formal education (Table 1). Half of the participants (49.7%) belonged to socioeconomic classes IV and V, and 441 (68.9%) lived 2 km or more from the HWC. Known hypertension was reported by 117 (18.3%), known diabetes by 73 (11.4%), and either condition by 173 (27.0%). Current tobacco use was reported by 116 (18.1%).

Table 1. Sociodemographic and health characteristics of participants (N = 640)

HWC: Health and Wellness Centre (Ayushman Arogya Mandir).

Awareness and utilisation of screening services

Overall, 454 (70.9%) participants knew of the HWC serving their village and 404 (63.1%) knew that it offered NCD screening. The CBAC had been completed by an ASHA for 369 (57.7%), and 313 (48.9%) reported contact with an ASHA in the past 12 months. In the preceding 12 months, 296 (46.2%; 95% CI 42.3-50.2) had been screened for hypertension and 245 (38.3%; 95% CI 33.7-42.9) for diabetes at an HWC, and 398 (62.2%; 95% CI 57.9-66.5) had received at least one of these (Table 2, Figure 1). Screening for cancers was much less common. Oral visual examination was reported by 95 (14.8%) participants, clinical breast examination by 33 of 314 women (10.5%) and visual inspection with acetic acid by 15 of 267 women aged 30 to 65 years (5.6%). Only 15 (2.3%) had received the complete age- and sex-appropriate package. Among the 398 who reported screening, 295 (74.1%) could be confirmed from the HWC register or a health card. Of the 173 participants with known hypertension or diabetes, 87 (50.3%) had attended the HWC for follow-up in the past year.

Table 2. Awareness and utilisation of NCD screening services at HWCs in the preceding 12 months

CBAC: Community Based Assessment Checklist; ASHA: Accredited Social Health Activist; CI: confidence interval with cluster-robust standard errors.

*Denominator: 314 women. **Denominator: 267 women aged 30-65 years. Error bars show 95% confidence intervals adjusted for clustering.

Factors associated with utilisation

Utilisation of hypertension or diabetes screening was similar across age groups, sexes, education levels, socioeconomic classes and occupations, and was not related to tobacco use (Table 3). It was higher among those whose CBAC had been completed (80.8% vs 36.9%), those aware of the HWC (75.1% vs 30.6%), those living within 2 km (70.9% vs 58.3%) and those with known hypertension or diabetes (73.4% vs 58.0%). After adjustment for all other variables, CBAC completion (aOR 5.13, 95% CI 3.37-7.82), awareness of the HWC (aOR 4.43, 95% CI 2.79-7.03), living within 2 km of the HWC (aOR 2.17, 95% CI 1.39-3.40) and known hypertension or diabetes (aOR 1.80, 95% CI 1.16-2.80) remained independently associated with utilisation. Age, sex, education, occupation, socioeconomic class and tobacco use were not associated with utilisation after adjustment; the closest to significance was being a homemaker compared with working in agriculture (aOR 0.57, 95% CI 0.31-1.05, p = 0.07). There was no multicollinearity (highest variance inflation factor 1.41). The model fitted the data well (Hosmer-Lemeshow χ2 = 6.86, df = 8, p = 0.55) and explained a moderate share of variation (McFadden pseudo-R2 0.24).

Table 3. Factors associated with utilisation of hypertension or diabetes screening at HWCs (N = 640)

OR: odds ratio; aOR: adjusted odds ratio. All variables shown were entered together in one multivariable model. All confidence intervals use cluster-robust standard errors (32 villages). Hosmer-Lemeshow χ2 = 6.86, df = 8, p = 0.55; McFadden pseudo-R2 = 0.24.

This community-based study measured the use of NCD screening at HWCs by adults aged 30 years and above in a rural block. Nearly two thirds (62.2%) had been screened for hypertension or diabetes at an HWC in the past year, but fewer than one in six had received oral cancer screening, about one in ten women had had a clinical breast examination, one in eighteen eligible women had been screened for cervical cancer, and only 2.3% had received the full package. Use was strongly linked with CBAC completion by the ASHA and awareness of the HWC, and less strongly with distance and known disease, but not with age, sex, education or socioeconomic class.

Screening for hypertension and diabetes in this block appears higher than the levels reported before the HWC roll-out. In nationally representative data, about a quarter of adults with hypertension had never had their blood pressure measured [5]. In primary care facilities in Karnataka, most eligible persons were screened once the documentation process was changed [11], and home-based screening by community health workers was well accepted in a rural pilot [10]. Our figure of 46.2% for blood pressure screening within one year at the HWC alone is not directly comparable with ever-screened estimates, but it suggests that the HWC platform has extended screening to a large part of the rural population. The gap between hypertension (46.2%) and diabetes screening (38.3%) may reflect intermittent supply of glucometer strips or the extra time needed for a finger-prick test.

The wide gap between screening for hypertension and diabetes and screening for cancers in this study is consistent with earlier evidence. Breast and cervical examination was rare in most Indian districts in NFHS-4 [13]. Implementers and beneficiaries of the cervical screening programme described a lack of awareness, fear, embarrassment and limited provider capacity as barriers [19]. In our data, clinical breast examination (10.5%) and visual inspection with acetic acid (5.6%) were the least used services, which indicates that the HWC platform has not yet overcome these barriers for women. The low uptake matters because screening works in Indian settings: in a cluster-randomised trial in Kerala, oral visual screening reduced oral cancer mortality by 34% among users of tobacco or alcohol [20], and in rural Maharashtra a single round of HPV testing halved the number of advanced cervical cancers and cervical cancer deaths [21]. Oral screening, which needs no equipment, was also low at 14.8%.

Use of hypertension and diabetes screening did not differ by age, sex, education or socioeconomic class in this study, which suggests that the population-based approach has reached social groups fairly evenly in this block. This contrasts with the low coverage and differences between men and women reported from other states [12]. In terms of the behavioural model, the predisposing factors were not associated with use, whereas enabling factors (CBAC completion, awareness and short distance) and a need factor (known disease) were. CBAC completion had the strongest association: 80.8% of those enumerated by an ASHA had been screened, against 36.9% of those who had not, which places the ASHA at the centre of the screening pathway. Two thirds of participants lived 2 km or more from the HWC, and their lower use shows that physical access still matters even at sub-centre level. In the patient-centred access framework, awareness corresponds to the approachability of services and distance to their availability, and both dimensions were linked to use in this block [22]. Participants at high risk who were advised to attend the centre did not always do so [14], which shows that a positive CBAC score is not enough without active follow-up. Only half of the participants with known hypertension or diabetes had attended the HWC for follow-up in the past year, which shows that the pathway weakens after detection as well as before it.

On the supply side, earlier studies point to workload, record-keeping and the availability of drugs and test strips as barriers, and the lower coverage of glucose testing than of blood pressure measurement in our data fits this pattern. ASHAs have reported that they need clearer roles, training, supervision and incentives to deliver NCD care [23]. Non-physician health workers face similar limits in training, supplies and recognition [24]. Shortages of medicines for hypertension and diabetes at primary level have been documented [15], and a review of NCD care in India pointed to fragmented services and weak continuity of care [16]. Case studies of well-functioning primary care facilities showed that utilisation rises when staff, drugs, diagnostics and community engagement are in place together [25].

These findings have practical implications for the block and for the programme. Completing the CBAC for every eligible adult should be treated as the first priority, since it was the strongest predictor of use. Village-level awareness activities about HWC services, outreach screening camps for hamlets 2 km or more from the centre, women-led sessions for breast and cervical screening, and an assured supply of glucometer strips would address the other gaps identified. Reminders by ASHAs could improve follow-up of people with known disease. Such measures fit the stated aim of HWCs to bring comprehensive primary care closer to the community [8] and the wider case for integrating NCDs into primary care [9].

Strengths and limitations

The study measured utilisation in the community rather than in facilities, so it captured non-users as well as users. Cluster sampling with 20 adults in each of 32 villages and analysis that accounted for clustering strengthen the estimates. Several limitations should be noted. Screening was self-reported, although it was cross-checked with registers or health cards where possible, so recall and social desirability bias cannot be ruled out. The cross-sectional design does not allow causal inference. The study was carried out in a single block, and findings may not apply to other settings with different levels of HWC functioning. About a quarter of reported screenings could not be confirmed from records. Because CBAC completion and awareness may themselves result from contact with the HWC, their associations with utilisation should be read as markers of engagement rather than independent causes. Finally, the study did not include a qualitative component, so the reasons for non-use and the views of health workers could not be explored directly; this is an important area for future work.

Health and Wellness Centres in this rural block had screened nearly two thirds of adults aged 30 years and above for hypertension or diabetes in the past year, with no clear social gradient in use. Cancer screening, especially for breast and cervical cancer, and completion of the full package remained very low, and half of those with known disease were not followed up at the centre. Enumeration by ASHAs, awareness of the HWC and proximity were the main enabling factors. Strengthening CBAC coverage, outreach to distant hamlets and women-centred cancer screening should be the immediate priorities.

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