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May 2023, Volume 73, Issue 5

Primary Care Diabetes

The 5A model for non- communicable disease advocacy

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India; University Center for Research & Development, Chandigarh University, Mohali, India. )
Madhur Verma  ( Department of Family and Community Medicine, AIIMS, Bathinda, India. )
Rakesh Sahay  ( Department of Endocrinology, Osmania Hospital, Hyderabad, India )


We share a comprehensive 5A model which puts in perspective a clear-cut method to approach and address non communicable disease (NCD) advocacy. We suggest that the first step towards NCD control is awareness amongst health care professionals, and acceptance of their responsibility towards public health.  Once this is done, active assertion follows, and leads to action on the ground. Regular audit, however, is necessary, to ensure effective and efficient advocacy for NCD. This model should be followed in all health care settings, including primary care diabetes.


Keywords: Cardiovascular disease, diabetes, heart disease, obesity, public health


DOI: 10.47391/JPMA.23-35



The challenge


Non communicable disease (NCD) has increased in prevalence over the past few decades, and is now a major contributor to morbidity and mortality across the world.1 The impact of NCD can be minimized if appropriate preventive and curative inventions are provided at primary care level.

Primary care physicians usually remain busy in management of acute illness, and in ensuring maternal and child health. The community, at large, also tends to play less attention to NCD, as these are often asymptomatic in the early stages of their natural history. Lack of focus on NCD by policy makers contributes to not only policy, but clinical inertia as well.2

Resistance is encountered at multiple levels when NCD care and management are discussed: the individual patient; his or her partner(spouse), progeny (children/family) and peers (friends, colleagues); the public (society at large); payers (such as insurance companies); policy makers (bureaucrats) and politicians (Table).



The solution


While all stakeholders share a collective responsibility to promote, protect and preserve health, physicians must take the lead in calling for adequate attention to NCD. This pro-activism is specifically required for disease states such as obesity,3 which are considered “normal” by society.


The 5A model


Multiple activities have been taken up by professional organisations, but a lot more needs to be done to sensitize all stakeholders to the need for NCD care. We share a virtuous cycle (Figure) and suggest a step wise approach towards kick-starting it. This “alpha attitude” will help primary care physicians initiate, and strengthen, NCD care in their practices.



The first step is to make oneself aware, that NCD is a real burden which must be tackled. This can easily be ensured by updating oneself with current epidemiological and clinical trends. Once this is done, acceptance of one’s responsibility towards NCD care dawns automatically. The challenge is to be assertive, to communicate, and to convince all partners (Table 1) about their roles, their responsibilities and their right.

Active assertion flows from awareness and acceptance, and leads to action on the ground. Action can be in the form of public awareness, preventive health checks, or clinical best practice. Appropriate use of screening, diagnostic and monitoring tools, along with non-pharmacological, medical and invasive therapy, also form part of action.

All these steps-awareness, acceptance, assertion, and action, must be coupled with a regular audit, designed to optimize both processes and outcomes. Audit findings help raise awareness about one’s strengths as well as weaknesses, and ensure that the virtuous cycle continues operating.




The simple model that we propose can be used by planners and leaders, as well as public health and clinical professionals, to advocate for NCD. The model is also useful in other settings, and will find utility beyond the health care profession as well.




1.      Asogwa OA, Boateng D, Marzà-Florensa A, Peters S, Levitt N, van Olmen J, et al. Multimorbidity of non-communicable diseases in low-income and middle-income countries: a systematic review and meta-analysis. BMJ open. 2022;12:e049133.

2.      Pathak A, Poulter NR, Kavanagh M, Kreutz R, Burnier M. Improving the management of hypertension by tackling awareness, adherence, and clinical inertia: a symposium report. Am J Cardiovasc Drugs. 2022; 22: 251-61.

3.      Busetto L, Sbraccia P, Vettor R. Obesity management: at the forefront against disease stigma and therapeutic inertia. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2022;27:761-8.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: