Table 5 Prevention of NCDs in PHC

 Biological and environmental Risk Maps.

“The health promoters make the identification of medical, environmental and social risk factors for every individual and family within same health unit, establishing a ranking of high, medium and low risk, drawing a risk map (…) home visits of the PHC team are scheduled according to risk” Departmental Coordinator.

 Comprehensive diet programs.

“After detecting that a person has an unhealthy diet, not only the nutritional part is evaluated. We also visit their homes and detect the economic and geographic barriers that may limited them from accessing healthy food and from adapting our recommendations to each context”. Nurse.

 “Healthy passport, Exercise is medicine” program.

“A strategy called ‘Healthy passport’ has been implemented in PHC leaded by the National institute of Sports (INDES), which is specifically for non-communicable diseases. It is a card that targets what we call ‘exercise is medicine’, where patients are given a prescription of exercises, not just medications. The specialist doctor gives them a prescription of exercises, and then the nurse explains how to do those exercises and fill out the healthy passport” Health Educator.

 Screening programs for Chronic Kidney Disease (CKD).

“One of the proposals that was driven from this health unit was the screening of people with traditional and non-traditional risk factors for CKD (mostly farmers working with agrochemicals)” Sanitary inspector.

 Information talks of the Specialized ECOS with special focus in NCDs.

“We organized informative talks in every health unit that we visited weekly before the consultation, which are already organized in a chronogram. We inform about chronic diseases, another day about vaccination, gender violence, etc. We are an interdisciplinary team, and we all attend to this information talks and it takes around 15–20 min. We always give those talks because it is part of the primary care that is provided, of the integral approach” Family doctor

 Community-based peer groups for people living with an NCD

“The self-help groups are conformed by chronic patients talking about their own experience with diseases, how they have overcome, or how they feel, and there is self-development. We firstly give a small information talk, and then they share about their chronic disease” Health Educator.

“Regarding the educational part of NCD in PHC, the IHSDNs indicators include how many ECOs have self-help groups for NCDs and which ones still don’t have them in order to encourage them to start conforming them with chronic patients” Regional Director.

 Prevention of complication of Diabetes

“We also check diabetic patients’ feet and explain what the shoe should be like and the hygienic measures to prevent complications” Nurse.

 Prevention of complication of CKD.

“There are people living with a kidney damage that is maintained, that does not reach dialysis, and that is because they understand the need to be treated by the psychologist and the nutritionist, because nutrition and good hydration is basic, and also the guidance of the psychologist” Sanitary inspector.