Implementation of a non-communicable disease clinic in rural Sierra Leone: early experiences and lessons learned

Non-communicable disease care in Sierra Leone: a mixed-methods study of the drivers and barriers to retention in care for hypertension

OBJECTIVE

To retrospectively analyse routinely collected data on the drivers and barriers to retention in chronic care for patients with hypertension in the Kono District of Sierra Leone.

DESIGN

Convergent mixed-methods study.

SETTING

Koidu Government Hospital, a secondary-level hospital in Kono District.

PARTICIPANTS

We conducted a descriptive analysis of key variables for 1628 patients with hypertension attending the non-communicable disease (NCD) clinic between February 2018 and August 2019 and qualitative interviews with 21 patients and 7 staff to assess factors shaping patients' retention in care at the clinic.

OUTCOMES

Three mutually exclusive outcomes were defined for the study period: adherence to the treatment protocol (attending >80% of scheduled visits); loss-to-follow-up (LTFU) (consecutive 6 months of missed appointments) and engaged in (but not fully adherent) with treatment (<80% attendance).

RESULTS

57% of patients were adherent, 20% were engaged in treatment and 22% were LTFU. At enrolment, in the unadjusted variables, patients with higher systolic and diastolic blood pressures had better adherence than those with lower blood pressures (OR 1.005, 95% CI 1.002 to 1.009, p=0.004 and OR 1.008, 95% CI 1.004 to 1.012, p<0.001, respectively). After adjustment, there were 14% lower odds of adherence to appointments associated with a 1 month increase in duration in care (OR 0.862, 95% CI 0.801 to 0.927, p<0.001). Qualitative findings highlighted the following drivers for retention in care: high-quality education sessions, free medications and good interpersonal interactions. Challenges to seeking care included long wait times, transport costs and misunderstanding of the long-term requirement for hypertension care.

CONCLUSION

Free medications, high-quality services and health education may be effective ways of helping NCD patients stay engaged in care. Facility and socioeconomic factors can pose challenges to retention in care.

Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh

OBJECTIVE

The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.

DESIGN AND SETTING

The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh.

PARTICIPANTS

A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female).

OUTCOMES

Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics.

RESULTS

The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.

CONCLUSION

The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.

Health systems interventions for hypertension management and associated outcomes in Sub-Saharan Africa: A systematic review

Hypertension is a significant global health problem, particularly in Sub-Saharan Africa (SSA). Despite the effectiveness of medications and lifestyle interventions in reducing blood pressure, shortfalls across health systems continue to impede progress in achieving optimal hypertension control rates. The current review explores the health system interventions on hypertension management and associated outcomes in SSA. The World Health Organization health systems framework guided the literature search and discussion of findings. We searched PubMed, CINAHL, and Embase databases for studies published between January 2010 and October 2022 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We assessed studies for the risk of bias using the tools from the Joanna Briggs Institute. Twelve studies clustered in 8 SSA countries met the inclusion criteria. Two thirds (8/12) of the included studies had low risk of bias. Most interventions focused on health workforce factors such as providers' knowledge and task shifting of hypertension care to unconventional health professionals (n = 10). Other health systems interventions addressed the supply and availability of medical products and technology (n = 5) and health information systems (n = 5); while fewer interventions sought to improve financing (n = 3), service delivery (n = 1), and leadership and governance (n = 1) aspects of the health systems. Health systems interventions showed varied effects on blood pressure outcomes but interventions targeting multiple aspects of health systems were likely associated with improved blood pressure outcomes. The general limitations of the overall body of literature was that studies were likely small, with short duration, and underpowered. In conclusion, the literature on health systems internventions addressing hypertension care are limited in quantity and quality. Future studies that are adequately powered should test the effect of multi-faceted health system interventions on hypertension outcomes with a special focus on financing, leadership and governance, and service delivery interventions since these aspects were least explored.

High Prevalence of Chronic Kidney Disease Among People Living with Hypertension in Rural Sierra Leone: A Cross-Sectional Study

INTRODUCTION

Currently, there are no data on prevalence and associated risk factors of chronic kidney disease (CKD) among patients with hypertension in rural Sierra Leone.

PURPOSE

To estimate the prevalence and associated risk factors of CKD in rural Sierra Leone.

PATIENTS AND METHODS

A cross-sectional study of hypertension patients aged between 18 and 75 years attending a non-communicable disease clinic at Koidu Government Hospital, Kono District, Sierra Leone was conducted between February and December 2020. Using systematic random sampling, a structured questionnaire, which comprised of questions on social demographic characteristics and past and current clinical history, was administered followed by measurement of creatinine and urinary protein and glucose. Estimated glomerular filtration rate (eGFR) was estimated using CKD-epidemiology formula without race as a factor. Baseline eGFR between 60-89 min/mL/1.73m2 and <60 min/mL/1.73m2 defined reduced eGFR and renal impairment, respectively. Estimated GFR less than 60 min/mL/1.73m2 measured two times at least 3 months apart was used to define CKD.

RESULTS

Ninety-six percent (n = 304) patients out of 317 patients were included in the study. Among all included patients, only 3.9% (n = 12) had eGFR of 90 min/mL/1.73m2 and above. The prevalence of renal impairment and CKD was 52% (158/304, CI 46.2-57.7) and 29.9% (91/304, CI 24.8-34.5), respectively. In adjusted logistic regression analysis, currently taking herbal medications as treatment of hypertension (OR 4.11 (CI 1.14-14.80), p = 0.03) and being overweight and/or obese (OR 2.16 (CI 1.24-3.78), p < 0.001) was associated with CKD. Additionally, receiving some education was associated with a 48% (OR 0.52 (CI 0.29-0.91), p = 0.02) reduced likelihood of CKD.

CONCLUSION

The prevalence of renal impairment and CKD is high among hypertensive patients in rural Sierra Leone. CKD was associated with current history of taking herbal medications and being overweight and/or obese. Additionally, CKD was associated with reduced likelihood in patients who received some education.