Abstract
<title>Abstract</title> <p>Background Non-communicable diseases (NCDs) are responsible for significant proportion of deaths worldwide. World Health Organization Package of Essential Non-communicable Disease (PEN) interventions was designed to strengthen NCD care at the primary health care level. Nepal adopted the PEN protocol in 2016, yet evidence on provider adherence and its determinants remains limited, particularly at the district level. This study assessed the level of adherence to the PEN protocol and identified factors associated with adherence among service providers in primary health care facilities of Chitwan district, Nepal. Methods A cross-sectional quantitative study was conducted among 176 PEN-trained NCD service providers selected through proportionate stratified random sampling across 91 primary health care facilities in Chitwan district. Adherence was assessed using an eight-item observation-based checklist and dichotomized into good and poor adherence using the median score. Cabana framework was employed to assess perceived barriers across seven domains (familiarity, awareness, motivation, self-efficacy, outcome expectancy, agreement, and external environment). Bivariate chi-square tests and multivariable binary logistic regression were used to identify independent predictors of adherence, with variance inflation factor used to screen for multicollinearity. Results Of 176 participants, 99 (56.2%) demonstrated good adherence to the PEN protocol. In bivariate analysis, work experience duration, training duration, health facility type, local government type, type of service available, resource availability (medicine, equipment, diagnostic services), and several domains were significantly associated with adherence. After adjusting for confounders, four factors remained independently associated with good adherence: working in a referral-level facility (adjusted odds ratio [AOR] = 6.06, 95% confidence interval [CI]: 1.65–22.33, p = 0.007), adequate familiarity with the protocol (AOR = 2.68, 95% CI: 1.11–6.46, p = 0.028), agreement with protocol recommendations (AOR = 2.36, 95% CI: 1.04–5.36, p = 0.041), and a favourable external work environment (AOR = 3.12, 95% CI: 1.43–6.82, p = 0.040). Conclusions Adherence to the PEN protocol among trained providers in Chitwan district remains moderate. Facility-level conditions and providers’ understanding of and trust in the protocol, rather than individual sociodemographic characteristics, were the dominant predictors of adherence. Strengthening first-contact facility readiness, reinforcing familiarity through structured refresher training, and reducing organizational barriers are recommended to improve PEN protocol adherence and NCD service delivery. Trial Registration Clinical trial number: not applicable</p>