Primary health care for hypertension by nurses in rural and urban sub-Saharan Africa

Effectiveness of team-based care interventions in improving blood pressure outcomes among adults with hypertension in Africa: a systematic review and meta-analysis

OBJECTIVE

We evaluated the effectiveness of team-based care interventions in improving blood pressure (BP) outcomes among adults with hypertension in Africa.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed, CINAHL, EMBASE, Cochrane Library, HINARI and African Index Medicus databases were searched from inception to March 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomised controlled trials (RCTs) and pre-post study designs published in English language focusing on (1) Adults diagnosed with hypertension, (2) Team-based care hypertension interventions led by non-physician healthcare providers (HCPs) and (3) Studies conducted in Africa.

DATA EXTRACTION AND SYNTHESIS

We extracted study characteristics, the nature of team-based care interventions, team members involved and other reported secondary outcomes. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs and the National Heart, Lung, and Blood Institute assessment tool for pre-post studies. Findings were summarised and presented narratively including data from pre-post studies. Meta-analysis was conducted using a random effects model for only RCT studies. Overall certainty of evidence was determined using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool for only the primary outcome (systolic BP).

RESULTS

Of the 3375 records screened, 33 studies (16 RCTs and 17 pre-post studies) were included and 11 RCTs were in the meta-analysis. The overall mean effect of team-based care interventions on systolic BP reduction was -3.91 mm Hg (95% CI -5.68 to -2.15, I² = 0.0%). Systolic BP reduction in team-based care interventions involving community health workers was -4.43 mm Hg (95% CI -5.69 to -3.17, I² = 0.00%) and nurses -3.75 mm Hg (95% CI -10.62 to 3.12, I² = 42.0%). Based on the GRADE assessment, we judged the overall certainty of evidence low for systolic BP reduction suggesting that team-based care intervention may result in a small reduction in systolic BP.

CONCLUSION

Evidence from this review supports the implementation of team-based care interventions across the continuum of care to improve awareness, prevention, diagnosis, treatment and control of hypertension in Africa. PROSPERO registration number CRD42023398900.

Effectiveness of a nurse-led management intervention on systolic blood pressure among type 2 diabetes patients in Uganda: a cluster randomized trial

BACKGROUND

Hypertension (HT) is an orchestrator of atherosclerotic cardiovascular disease (ASCVD) in people living with type 2 diabetes (T2D). Control of systolic blood pressure (SBP) and HT as a whole is suboptimal in diabetes, partly due to the scarcity of doctors. While nurse-led interventions are pragmatic and cost-effective in the control of HT in primary health care, their effectiveness on SBP control among patients with T2D in Uganda is scantly known.

AIM

We evaluated the effectiveness of a nurse-led management intervention on SBP among T2D patients with a high ASCVD risk in Uganda.

METHODS

A two-armed cluster randomized controlled trial compared the nurse-led management intervention with usual doctor-led care. The intervention involved training nurses to provide structured health education, protocol-based HT/CVD management, 24-h phone calls, and 2-monthly text messages for 6 months. The primary outcome was the mean difference in SBP change among patients with T2D with a high ASCVD risk in the intervention and control groups after 6 months. The secondary outcome was the absolute difference in the number of patients at target for SBP, total cholesterol (TC), fasting blood glucose (FBG), glycated hemoglobin (HbA1C), low-density lipoprotein (LDL), triglycerides (TG), and body mass index (BMI) after the intervention. The study was analyzed according to the intention-to-treat principle. Generalized estimating equations were used to assess intra-cluster effect modifiers. Statistical significance was set at 0.05 for all analyses.

RESULTS

Eight clinics (n = 388 patients) were included (intervention 4 clinics; n = 192; control 4 clinics; n = 196). A nurse-led intervention reduced SBP by -11.21 ± 16.02 mmHg with a mean difference between the groups of -13.75 mmHg (95% CI -16.48 to -11.02, p < 0.001). An increase in SBP of 2.54 ± 10.95 mmHg was observed in the control group. Diastolic blood pressure was reduced by -6.80 ± 9.48 mmHg with a mean difference between groups of -7.20 mmHg (95% C1 -8.87 to -5.48, p < 0.001). The mean differences in the change in ASCVD score and glycated hemoglobin were -4.73% (95% CI -5.95 to -3.51, p = 0.006) and -0.82% (95% CI -1.30 to -0.35, p = 0.001), respectively. There were significant absolute differences in the number of patients at target in SBP (p = 0.001), DBP (p = 0.003), and TC (p = 0.008).

CONCLUSION

A nurse-led management intervention reduces SBP and ASCVD risk among patients with T2D. Such an intervention may be pragmatic in the screening and management of HT/ASCVD in Uganda.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, PACTR202001916873358, registered on 6th October 2019.

Role and knowledge of nurses in the management of non-communicable diseases in Africa: A scoping review

BACKGROUND

31.4 million people in low- and middle-income countries die from chronic diseases annually, particularly in Africa. To address this, strategies such as task-shifting from doctors to nurses have been proposed and have been endorsed by the World Health Organization as a potential solution; however, no comprehensive review exists describing the extent of nurse-led chronic disease management in Africa.

AIMS

This study aimed to provide a thorough description of the current roles of nurses in managing chronic diseases in Africa, identify their levels of knowledge, the challenges, and gaps they encounter in this endeavor.

METHODS

We performed a scoping review following the key points of the Cochrane Handbook, and two researchers independently realized each step. Searches were conducted using five databases: MEDLINE, PyscINFO, CINAHL, Web of Science, and Embase, between October 2021 and April 2023. A descriptive analysis of the included studies was conducted, and the quality of the studies was assessed using the Downs and Black Scale.

RESULTS

Our scoping review included 111 studies from 20 African countries, with South Africa, Nigeria, and Ghana being the most represented. Findings from the included studies revealed varying levels of knowledge. Nurses were found to be actively involved in managing common chronic diseases from diagnosis to treatment. Facilitating factors included comprehensive training, close supervision by physicians, utilization of decision trees, and mentorship. However, several barriers were identified, such as a shortage of nurses, lack of essential materials, and inadequate initial training.

CONCLUSION

There is significant potential for nurses to enhance the screening, diagnosis, and treatment of chronic diseases in Africa. Achieving this requires a combination of rigorous training and effective supervision, supported by robust policies. To address varying levels of knowledge, tailored training programs should be devised. Further research is warranted to establish the effectiveness of nurse-led interventions on population health outcomes.

Task Sharing and Task Shifting (TSTS) in the Management of Africans with Hypertension: A Call For Action-Possibilities and Its Challenges

Hypertension is a leading cause of mortality globally and one of the most common risk factors for cardiovascular disease. Diagnosis, awareness, and optimal treatment rates are suboptimal, especially in low- and middle-income countries, with attendant high health consequences and grave socioeconomic impact. There is an enormous gap between disease burden and physician-patient ratios that needs to be bridged. Task sharing and task shifting (TSTS) provide a viable temporary solution. However, sociocultural, demographic, and economic factors influence the effective uptake of such interventions. This review discusses the dynamics of TSTS in the African context looking at challenges, feasibility, and approach to adopt it in the management of hypertension in Africa.

Assessing the Readiness to Provide Integrated Management of Cardiovascular Diseases and Type 2 Diabetes in Kenya: Results from a National Survey

Introduction

Integrated chronic disease management is the desired core function of a responsive healthcare system. However, many challenges surround its implementation in Sub-Saharan Africa. The current study assessed the readiness of healthcare facilities to provide integrated management of cardiovascular diseases (CVDs) and type 2 diabetes in Kenya.

Methods

We used data from a nationally representative cross-sectional survey of 258 public and private health facilities conducted in Kenya between 2019 and 2020. Data were collected using a standardised facility assessment questionnaire and observation checklists modified from the World Health Organization Package of Essential Non-communicable Diseases. The primary outcome was the readiness to provide integrated care for CVDs and diabetes-defined as the mean availability of tracer items comprising trained staff and clinical guidelines, diagnostic equipment, essential medicines, diagnosis, treatment and follow-up. A cut-off threshold of ≥70% was used to classify facilities as 'ready'. Gardner-Altman plots and modified Poisson regression were used to examine the facility characteristics associated with care integration readiness.

Results

Of the surveyed facilities, only a quarter (24.1%) were ready to provide integrated care for CVDs and type 2 diabetes. Care integration readiness was lower in public versus private facilities [aPR = 0.6; 95% CI 0.4 to 0.9], and primary healthcare facilities were less likely to be ready compared to hospitals [aPR = 0.2; 95% CI 0.1 to 0.4]. Facilities located in Central Kenya [aPR = 0.3; 95% CI 0.1 to 0.9], and the Rift Valley region [aPR = 0.4; 95% CI 0.1 to 0.9], were less likely to be ready compared to the capital Nairobi.

Conclusions

There are gaps in the readiness of healthcare facilities particularly primary healthcare facilities in Kenya to provide integrated care services for CVDs and diabetes. Our findings inform the review of current supply-side interventions for integrated management of CVDs and type 2 diabetes, especially in lower-level public health facilities in Kenya.

Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review

BACKGROUND

Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations.

METHODS

We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively.

RESULTS

Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively.

CONCLUSION

Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria

Introduction

Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial.

Methods

We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders.

Results

Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community.

Discussion

While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.

Use of technology to prevent, detect, manage and control hypertension in sub-Saharan Africa: a systematic review

OBJECTIVE

To identify and assess the use of technologies, including mobile health technology, internet of things (IoT) devices and artificial intelligence (AI) in hypertension healthcare in sub-Saharan Africa (SSA).

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, Scopus and Web of Science.

ELIGIBILITY CRITERIA

Studies addressing outcomes related to the use of technologies for hypertension healthcare (all points in the healthcare cascade) in SSA.

METHODS

Databases were searched from inception to 2 August 2021. Screening, data extraction and risk of bias assessment were done in duplicate. Data were extracted on study design, setting, technology(s) employed and outcomes. Blood pressure (BP) reduction due to intervention was extracted from a subset of randomised controlled trials. Methodological quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

1717 hits were retrieved, 1206 deduplicated studies were screened and 67 full texts were assessed for eligibility. 22 studies were included, all reported on clinical investigations. Two studies were observational, and 20 evaluated technology-based interventions. Outcomes included BP reduction/control, treatment adherence, retention in care, awareness/knowledge of hypertension and completeness of medical records. All studies used mobile technology, three linked with IoT devices. Short Message Service (SMS) was the most popular method of targeting patients (n=6). Moderate BP reduction was achieved in three randomised controlled trials. Patients and healthcare providers reported positive perceptions towards the technologies. No studies using AI were identified.

CONCLUSIONS

There are a range of successful applications of key enabling technologies in SSA, including BP reduction, increased health knowledge and treatment adherence following targeted mobile technology interventions. There is evidence to support use of mobile technology for hypertension management in SSA. However, current application of technologies is highly heterogeneous and key barriers exist, limiting efficacy and uptake in SSA. More research is needed, addressing objective measures such as BP reduction in robust randomised studies.

PROSPERO REGISTRATION NUMBER

CRD42020223043.

Assessing service availability and readiness of healthcare facilities to manage diabetes mellitus in Bangladesh: Findings from a nationwide survey

Introduction

Diabetes Mellitus (DM) is one of the most prevalent non-communicable diseases (NCDs)as well as a major cause of morbidity and mortality worldwide. Around 80% diabetic patients live in low- and middle-income countries. In Bangladesh, there is a scarcity of data on the quality of DM management within health facilities. This study aims to describe service availability and readiness for DM at all tiers of health facilities using the World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA) standard tool.

Methods

This cross-sectional survey was conducted in 266 health facilities all across Bangladesh using the WHO SARA standard tool. Descriptive analyses for the availability of DM services was carried out. Composite scores for facility readiness index (RI) were calculated in four domains: staff and guideline, basic equipment, diagnostic capacity, and essential medicines. Indices were stratified by facility level and a cut off value of 70% was considered as ‘ready’ to manage diabetes at each facility level.

Results

The mean RI score of tertiary and specialized hospitals was above the cutoff value of 70% (RI: 79%), whereas for District Hospitals (DHs), Upazila Health Complexes (UHCs) and NGO and Private hospitals the RI scores were other levels of 65%, 51% and 62% respectively. This indicating that only the tertiary level of health facilities was ready to manage DM. However, it has been observed that the RI scores of the essential medicine domain was low at all levels of health facilities including tertiary-level.

Conclusions

The study revealed only tertiary level facilities were ready to manage DM. However, like other facilities, they require an adequate supply of essential medicines. Alongside the inadequate supply of medicines, shortage of trained staff and unavailability of guidelines on the diagnosis and treatment of DM also contributed to the low RI score for rest of the facilities.

Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

BACKGROUND

This study aimed to describe the burden, treatment patterns and, age threshold for predicting hypertension among rural adults in Nyive in the Ho Municipality of the Volta Region, Ghana.

METHODS

A population-based cross-sectional study design was employed. A total of 417 adults aged 20 years and above were randomly selected from households within the Nyive community. The WHO STEPwise approach for non-communicable diseases risk factor surveillance (STEPS) instrument was used to obtain socio-demographic and clinical information including age, gender, educational background, marital status, and occupation as well as hypertension treatment information. Blood pressure was measured using standard methods. The risk of hypertension and the critical age at risk of hypertension was determined using binary logistic regression model and the receiver-operator characteristics (ROC) analysis.

RESULTS

The direct and indirect age-standardized hypertension prevalence was higher in males (562.58/487.34 per 1000 residents) compared to the females (489.42/402.36 per 1000 residents). The risk of hypertension among the study population increased by 4.4% (2.9%-5.9% at 95% CI) for one year increase in age while the critical age at risk of hypertension was >39 years among females and >35 years among males. About 64(46.72%) of the hypertensive participants were not on treatment whereas only 42(30.66%) had their blood pressure controlled.

CONCLUSION

Rural hypertension is high among adults in Nyive. The critical age at risk of hypertension was lower among males. The estimated annual increase of risk of hypertension was 4.7% for females and 3.1% for males. High levels of undiagnosed and non-treatment of hypertension and low levels of blood pressure control exist among the rural folks.

Phone-Based Intervention under Nurse Guidance after Stroke (PINGS II) Study: Protocol for a Phase III Randomized Clinical Trial

OBJECTIVES

The Sub-Saharan African (SSA) region now has the highest estimated effect size of hypertension for stroke causation worldwide. An urgent priority for countries in SSA is to develop and test self-management interventions to control hypertension among those at highest risk of adverse outcomes. Thus the overall objective of the Phone-based Intervention under Nurse Guidance after Stroke II study (PINGS-2) is to deploy a hybrid study design to assess the efficacy of a theoretical-model-based, mHealth technology-centered, nurse-led, multi-level integrated approach to improve longer term blood pressure (BP) control among stroke survivors.

MATERIALS AND METHODS

A phase III randomized controlled trial involving 500 recent stroke survivors to be enrolled across 10 Ghanaian hospitals. Using a computer-generated sequence, patients will be randomly assigned 1:1 into the intervention or usual care arms. The intervention comprises of (i) home BP monitoring at least once weekly with nurse navigation for high domiciliary BP readings; (2) medication reminders using mobile phone alerts and (3) education on hypertension and stroke delivered once weekly via audio messages in preferred local dialects. The intervention will last for 12 months. The control group will receive usual care as determined by local guidelines. The primary outcome is the proportion of patients with systolic BP <140 mm Hg at 12 months. Secondary outcomes will include medication adherence, self-management of hypertension, major adverse cardiovascular events, health related quality of life and implementation outcomes.

CONCLUSION

An effective PINGS intervention can potentially be scaled up and disseminated across healthcare systems in low-and-middle income countries challenged with resource constraints to reduce poor outcomes among stroke survivors.

Effect of Nurse-Based Management of Hypertension in Rural Western Kenya

Background

Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates remain very low. An expanding literature supports the strategy of task redistribution of hypertension care to nurses.

Objective

We aimed to evaluate the effect of a nurse-based hypertension management program in Kenya.

Methods

We conducted a retrospective data analysis of patients with hypertension who initiated nurse-based hypertension management care between January 1, 2011, and October 31, 2013. The primary outcome measure was change in systolic blood pressure (SBP) over one year, analyzed using piecewise linear mixed-effect models with a cut point at 3 months. The primary comparison of interest was care provided by nurses versus clinical officers. Secondary outcomes were change in diastolic blood pressure (DBP) over one year, and blood pressure control analyzed using a zero-inflated Poisson model.

Results

The cohort consisted of 1051 adult patients (mean age 61 years; 65% women). SBP decreased significantly from baseline to three months (nurse-managed patients: slope -4.95 mmHg/month; clinical officer-managed patients: slope -5.28), with no significant difference between groups. DBP also significantly decreased from baseline to three months with no difference between provider groups. Retention in care at 12 months was 42%.

Conclusions

Nurse-managed hypertension care can significantly improve blood pressure. However, retention in care remains a challenge. If these results are reproduced in prospective trial settings with improvements in retention in care, this could be an effective strategy for hypertension care worldwide.

Adapting and implementing training, guidelines and treatment cards to improve primary care-based hypertension and diabetes management in a fragile context: results of a feasibility study in Sierra Leone

Background

Sierra Leone, a fragile country, is facing an increasingly significant burden of non-communicable diseases (NCDs). Facilitated by an international partnership, a project was developed to adapt and pilot desktop guidelines and other clinical support tools to strengthen primary care-based hypertension and diabetes diagnosis and management in Bombali district, Sierra Leone between 2018 and 2019. This study assesses the feasibility of the project through analysis of the processes of intervention adaptation and development, delivery of training and implementation of a care improvement package and preliminary outcomes of the intervention.

Methods

A mixed-method approach was used for the assessment, including 51 semi-structured interviews, review of routine treatment cards (retrieved for newly registered hypertensive and diabetic patients from June 2018 to March 2019 followed up for three months) and mentoring data, and observation of training. Thematic analysis was used for qualitative data and descriptive trend analysis and t-test was used for quantitative data, wherever appropriate.

Results

A Technical Working Group, established at district and national level, helped to adapt and develop the context-specific desktop guidelines for clinical management and lifestyle interventions and associated training curriculum and modules for community health officers (CHOs). Following a four-day training of CHOs, focusing on communication skills, diagnosis and management of hypertension and diabetes, and thanks to a CHO-based mentorship strategy, there was observed improvement of NCD knowledge and care processes regarding diagnosis, treatment, lifestyle education and follow up. The intervention significantly improved the average diastolic blood pressure of hypertensive patients (n = 50) three months into treatment (98 mmHg at baseline vs. 86 mmHg in Month 3, P = 0.001). However, health systems barriers typical of fragile settings, such as cost of transport and medication for patients and lack of supply of medications and treatment equipment in facilities, hindered the optimal delivery of care for hypertensive and diabetic patients.

Conclusion

Our study suggests the potential feasibility of this approach to strengthening primary care delivery of NCDs in fragile contexts. However, the approach needs to be built into routine supervision and pre-service training to be sustained. Key barriers in the health system and at community level also need to be addressed.

Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries:a scoping review

BACKGROUND

Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs.

METHODS

Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results.

RESULTS

198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%).

CONCLUSION

Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.

Non-communicable disease (NCD) corners in public sector health facilities in Bangladesh: a qualitative study assessing challenges and opportunities for improving NCD services at the primary healthcare level

OBJECTIVE

To explore healthcare providers' perspective on non-communicable disease (NCD) prevention and management services provided through the NCD corners in Bangladesh and to examine challenges and opportunities for strengthening NCD services delivery at the primary healthcare level.

DESIGN

We used a grounded theory approach involving in-depth qualitative interviews with healthcare providers. We also used a health facility observation checklist to assess the NCD corners' service readiness. Furthermore, a stakeholder meeting with participants from the government, non-government organisations (NGOs), private sector, universities and news media was conducted.

SETTING

Twelve subdistrict health facilities, locally known as upazila health complex (UHC), across four administrative divisions.

PARTICIPANTS

Participants for the in-depth qualitative interviews were health service providers, namely upazila health and family planning officers (n=4), resident medical officers (n=6), medical doctors (n=4) and civil surgeons (n=1). Participants for the stakeholder meeting were health policy makers, health programme managers, researchers, academicians, NGO workers, private health practitioners and news media reporters.

RESULTS

Participants reported that diabetes, hypertension and chronic obstructive pulmonary disease were the major NCD-related problems. All participants acknowledged the governments' initiative to establish the NCD corners to support NCD service delivery. Participants thought the NCD corners have contributed substantially to increase NCD awareness, deliver NCD care and provide referral services. However, participants identified challenges including lack of specific guidelines and standard operating procedures; lack of trained human resources; inadequate laboratory facilities, logistics and medications; and poor recording and reporting systems.

CONCLUSION

The initiative taken by the Government of Bangladesh to set up the NCD corners at the primary healthcare level is appreciative. However, the NCD corners are still at nascent stage to provide prevention and management services for common NCDs. These findings need to be taken into consideration while expanding the NCD corners in other UHCs throughout the country.

Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) in western Kenya: a study protocol of a cluster randomized trial

Background

Hypertension is a major risk factor for cardiovascular disease (CVD), yet treatment and control rates for hypertension are very low in low- and middle-income countries (LMICs). Lack of effective referral networks between different levels of the health system is one factor that threatens the ability to achieve adequate blood pressure control and prevent CVD-related morbidity. Health information technology and peer support are two strategies that have improved care coordination and clinical outcomes for other disease entities in other settings; however, their effectiveness and cost-effectiveness in strengthening referral networks to improve blood pressure control and reduce CVD risk in low-resource settings are unknown.

Methods/design

We will use the PRECEDE-PROCEED framework to conduct transdisciplinary implementation research, focused on strengthening referral networks for hypertension in western Kenya. We will conduct a baseline needs and contextual assessment using a mixed-methods approach, in order to inform a participatory, community-based design process to fully develop a contextually and culturally appropriate intervention model that combines health information technology and peer support. Subsequently, we will conduct a two-arm cluster randomized trial comparing 1) usual care for referrals vs 2) referral networks strengthened with our intervention. The primary outcome will be one-year change in systolic blood pressure. The key secondary clinical outcome will be CVD risk reduction, and the key secondary implementation outcomes will include referral process metrics such as referral appropriateness and completion rates. We will conduct a mediation analysis to evaluate the influence of changes in referral network characteristics on intervention outcomes, a moderation analysis to evaluate the influence of baseline referral network characteristics on the effectiveness of the intervention, as well as a process evaluation using the Saunders framework. Finally, we will analyze the incremental cost-effectiveness of the intervention relative to usual care, in terms of costs per unit decrease in systolic blood pressure, per percentage change in CVD risk score, and per disability-adjusted life year saved.

Discussion

This study will provide evidence for the implementation of innovative strategies for strengthening referral networks to improve hypertension control in LMICs. If effective, it has the potential to be a scalable model for health systems strengthening in other low-resource settings worldwide.

Trial registration

Clinicaltrials.gov, NCT03543787. Registered on 29 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3661-4) contains supplementary material, which is available to authorized users.

Non-communicable disease clinics in rural Ethiopia: why patients are lost to follow-up

Background

Providing medical care for non-communicable diseases (NCDs) in rural sub-Saharan Africa has proved to be difficult because of poor treatment adherence and frequent loss to follow-up (LTFU). The reasons for this are poorly understood.

Objective

To investigate LTFU among patients with two different but common NCDs who attended rural Ethiopian health centres.

Method

The study was based in five health centres in southern Ethiopia with established NCD clinics run by nurses and health officers. Patients with epilepsy or hypertension who were lost to follow-up and non-LTFU comparison patients were identified and traced; a questionnaire was administered enquiring about the reasons for LTFU.

Results

Of the 147 LTFU patients successfully located, 62 had died, moved away or were attending other medical facilities. The remaining 85 patients were compared with 211 non-LFTU patients. The major factors associated with LTFU were distance from the clinic, associated costs and a preference for traditional treatments, together with a misunderstanding of the nature of NCD management.

Conclusions

The delivery of affordable care closer to the patients' homes has the greatest potential to address the problem of LTFU. Also needed are increased levels of patient education and interaction with traditional healers to explain the nature of NCDs and the need for life-long management.

Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Task sharing for the management of hypertension could be useful for understaffed and resource-poor health systems. We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries.

METHODS

We searched the Cochrane Library, PubMed, Embase, and CINAHL for studies published up to December 2018. We included intervention studies involving a task-sharing strategy for management of blood pressure and other cardiovascular risk factors. We extracted data on population, interventions, blood pressure, and task sharing groups. We did a meta-analysis of randomised controlled trials.

FINDINGS

We found 3012 references, of which 54 met the inclusion criteria initially. Another nine studies were included following an updated search. There were 43 trials and 20 before-and-after studies. We included 31 studies in our meta-analysis. Systolic blood pressure was decreased through task sharing in different groups of health-care workers: the mean difference was -5·34 mm Hg (95% CI -9·00 to -1·67, I2=84%) for task sharing with nurses, -8·12 mm Hg (-10·23 to -6·01, I2=57%) for pharmacists, -4·67 mm Hg (-7·09 to -2·24, I2=0%) for dietitians, -3·67 mm Hg (-4·58 to -2·77, I2=24%) for community health workers, and -4·85 mm Hg (-6·12 to -3·57, I2=76%) overall. We found a similar reduction in diastolic blood pressure (overall mean difference -2·92 mm Hg, -3·75 to -2·09, I2=80%). The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure, but low for diastolic blood pressure.

INTERPRETATION

Task-sharing interventions are effective in reducing blood pressure. Long-term studies are needed to understand their potential impact on cardiovascular outcomes and mortality.

FUNDING

Wellcome Trust/DBT India Alliance.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Hypertension Treatment Rates and Health Care Worker Density

Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates for hypertension are low. Here, we analyze the relationship between physician and nurse density and hypertension treatment rates worldwide. Data on hypertension treatment rates were collected from the STEPwise approach to Surveillance country reports, individual studies resulting from a PubMed search for articles published between 1990 and 2010, and manual search of the reference lists of extracted studies. Data on health care worker density were obtained from the Global Atlas of the Health Workforce. We controlled for a variety of variables related to population characteristics and access to health care, data obtained from the World Bank, World Development Indicators, United Nations, and World Health Organization. We used clustering of SEs at the country level. Full data were available for 154 hypertension treatment rate values representing 68 countries between 1990 and 2010. Hypertension treatment rate ranged from 3.4% to 82.5%, with higher treatment rates associated with higher income classification. Physician and nurse/midwife generally increased with income classification. Total healthcare worker density was significantly associated with hypertension treatment rate in the unadjusted model ( P<0.001); however, only nurse density remained significant in the fully adjusted model ( P=0.050). These analyses suggest that nurse density, not physician density, explains most of the relationship with hypertension treatment rate and remains significant even after adjusting for other independent variables. These results have important implications for health policy, health system design, and program implementation.

Pharmacy-based hypertension care employing mHealth in Lagos, Nigeria - a mixed methods feasibility study

BACKGROUND

Access to quality hypertension care is often poor in sub-Saharan Africa. Some community pharmacies offer hypertension monitoring services, with and without involvement of medical doctors. To directly connect pharmacy staff and cardiologists a care model including a mobile application (mHealth) for remote patient monitoring was implemented and pilot tested in Lagos, Nigeria. Pharmacists provided blood pressure measurements and counselling. Cardiologists enrolled patients in the pilot program and remotely monitored them, for which patients paid a monthly fee. We evaluated the feasibility of this care model at five private community pharmacies. Outcome measures were retention in care, blood pressure change, quality of care, and patients' and healthcare providers' satisfaction with the care model.

METHODS

Patients participated in the care model's pilot at one of the five pharmacies for approximately 6-8 months from February 2016. We conducted structured patient interviews and blood pressure measurements at pilot entry and exit, and used exports of the mHealth-application, in-depth interviews and focus group discussions with patients, pharmacists and cardiologists.

RESULTS

Of 336 enrolled patients, 236 (72%) were interviewed at pilot entry and exit. According to the mHealth data 71% returned to the pharmacy after enrollment, with 3.3 months (IQR: 2.2-5.4) median duration of activity in the mHealth-application. Patients self-reported more visits than recorded in the mHealth data. Pharmacists mentioned use of paper records, understaffing, the application not being user-friendly, and patients' unwillingness to pay as reasons for underreporting. Mean systolic blood pressure decreased 9.9 mmHg (SD: 18). Blood pressure on target increased from 24 to 56% and an additional 10% had an improved blood pressure at endline, however this was not associated with duration of mHealth activity. Patients were satisfied because of accessibility, attention, adherence and information provision.

CONCLUSION

Patients, pharmacists and cardiologists adopted the care model, albeit with gaps in mHealth data. Most patients were satisfied, and their mean blood pressure significantly reduced. Usage of the mHealth application, pharmacy incentives, and a modified financing model are opportunities for improvement. In addition, costs of implementation and availability of involved healthcare providers need to be investigated before such a care model can be further implemented.

Assessing the readiness of health facilities for diabetes and cardiovascular services in Bangladesh: a cross-sectional survey

OBJECTIVE

The objective of this study was to assess the readiness of health facilities for diabetes and cardiovascular services in Bangladesh.

DESIGN

This study was a cross-sectional survey.

SETTING

This study used data from a nationwide Bangladesh Health Facility Survey conducted by the Ministry of Health and Social Welfare in 2014.

PARTICIPANTS

A total of 319 health facilities delivering services focused on diabetes and cardiovascular diseases (CVD) were included in the survey. Some of these facilities were run by the public sector while others were managed by the private sector and non-governmental organisations. It was a mix of primary and secondary care facilities.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was readiness of health facilities for diabetes and cardiovascular services. We analysed relevant data following the Service Availability and Readiness Assessment manual of the WHO to assess the readiness of selected health facilities towards services for diabetes and CVD.

RESULTS

58% and 24.1% of the facilities had diagnosis and treatment services for diabetes and CVD, respectively. Shortage of trained staff (18.8% and 14.7%) and lack of adequate medicine supply (23.5% and 43.9%) were identified to be factors responsible for inadequate services for diabetes and CVD. Among the facilities that offer services for diabetes and CVD, only 0.4% and 0.9% had all the four service readiness factors (guideline, trained staff, equipment and medicine).

CONCLUSIONS

The study suggests that health facilities suffered from numerous drawbacks, such as shortage of trained staff and required medicine. Most importantly, they lack effective guidelines on the diagnosis and treatment for diabetes and CVD. It is, therefore, essential now to ensure that there are trained staff, adequate medicine supply, and appropriate guidelines on the diagnosis and treatment for diabetes and CVD in Bangladesh.

Hypertension in Developing Countries: A Major Challenge for the Future

PURPOSE OF REVIEW

Outline recent epidemiologic data regarding hypertension in developing countries, distinguish differences from developed countries, and identify challenges in management and future perspectives.

RECENT FINDINGS

Increased sugar intake, air and noise pollution, and low birth weight are emerging hypertension risk factors. The major challenges in management are difficulties in accurate diagnosis of hypertension and adequate blood pressure control. In contrast to developed countries, hypertension prevalence rates are on the rise in developing countries with no improvement in awareness or control rates. The increasing burden of hypertension is largely attributable to behavioral factors, urbanization, unhealthy diet, obesity, social stress, and inactivity. Health authorities, medical societies, and drug industry can collaborate to improve hypertension control through education programs, public awareness campaigns, legislation to limit salt intake, encourage generic drugs, development and dissemination of national guidelines, and involving nurses and pharmacists in hypertension management. More epidemiologic data are needed in the future to identify reasons behind increased prevalence and poor blood pressure control and examine trends in prevalence, awareness, treatment, and control. National programs for better hypertension control based on local culture, economic characteristics, and available resources in the population are needed. The role of new tools for hypertension management should be tested in developing world.

Preparedness of lower-level health facilities and the associated factors for the outpatient primary care of hypertension: Evidence from Tanzanian national survey

INTRODUCTION

Sub-Saharan Africa is experiencing a rapid rise in the burden of non-communicable diseases in both urban and rural areas. Data on health system preparedness to manage hypertension and other non-communicable diseases remains scarce. This study aimed to assess the preparedness of lower-level health facilities for outpatient primary care of hypertension in Tanzania.

METHODS

This study used data from the 2014-2015 Tanzania Service Provision Assessment survey. The facility was considered as prepared for the outpatient primary care of hypertension if reported at least half (≥50%) of the items listed from each of the three domains (staff training and guideline, basic diagnostic equipment, and basic medicines) as identified by World Health Organization-Service Availability and Readiness Assessment manual. Data were analyzed using Stata 14. An unadjusted logistic regression model was used to assess the association between outcome and explanatory variables. All variables with a P value < 0.2 were fitted into the multiple logistic regression models using a 5% significance level.

RESULTS

Out of 725 health facilities involved in the current study, about 68% were public facilities and 73% located in rural settings. Only 28% of the assessed facilities were considered prepared for the outpatient primary care of hypertension. About 9% and 42% of the assessed facilities reported to have at least one trained staff and guidelines for hypertension respectively. In multivariate analysis, private facilities [AOR = 2.7, 95% CI; 1.2-6.1], urban location [AOR = 2.2, 95% CI; 1.2-4.2], health centers [AOR = 5.2, 95% CI; 3.1-8.7] and the performance of routine management meetings [AOR = 2.6, 95% CI; 1.1-5.9] were significantly associated with preparedness for the outpatient primary care of hypertension.

CONCLUSION

The primary healthcare system in Tanzania is not adequately equipped to cope with the increasing burden of hypertension and other non-communicable diseases. Rural location, public ownership, and absence of routine management meetings were associated with being not prepared. There is a need to strengthen the primary healthcare system in Tanzania for better management of chronic diseases and curb their rising impact on health outcomes.

Bridging Income Generation with Group Integrated Care for cardiovascular risk reduction: Rationale and design of the BIGPIC study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance.

METHODS/DESIGN

This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved.

DISCUSSION

This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.

Short-term pilot feasibility study of a nurse-led intervention to improve blood pressure control after stroke in Nigeria

BACKGROUND

Given the paucity of neurologists in Sub-Saharan Africa (SSA), task-shifting post-stroke care to nurses could be a viable avenue for enhancing post-stroke outcomes. This pilot study assessed the feasibility and short-term impact of a nurse-led intervention to manage blood pressure (BP) control in recent stroke survivors in Nigeria.

METHODS

A randomized pilot trial allocated patients within one month of an index stroke from two participating hospitals in Nigeria to either nurse-led group clinic or standard care for 14days. Key study endpoints were successful execution of the protocol, subject retention, and short-term BP effects.

RESULTS

There were no significant differences between the intervention (n=17) and control (n=18) groups at baseline. At the post-intervention clinic, patient retention rate was 100%. In the intervention group, both the systolic and diastolic BPs measured at home were lower than the clinic BPs post-intervention (127±12.88/78.13±19.26mmHg versus 137.50±23.05/84.06±9.67mmHg; p=0.05). However, there was no significant change in clinic blood pressure (BP) recordings in both the intervention and control groups.

CONCLUSION

It is possible to initiate a nurse-led group clinic intervention to address BP management among stroke survivors in SSA with good early retention of participants. A larger and longer-term trial is being planned.

Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial

BACKGROUND

In many low-income countries, care for patients with non-communicable diseases (NCDs) and mental health conditions is provided by nurses. The benefits of nurse substitution and supplementation in NCD care in high-income settings are well recognised, but evidence from low- and middle-income countries is limited. Primary Care 101 (PC101) is a programme designed to support and expand nurses' role in NCD care, comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions. We evaluated the effect of the programme on primary care nurses' capacity to manage NCDs.

METHODS AND FINDINGS

In a cluster randomised controlled trial design, 38 public sector primary care clinics in the Western Cape Province, South Africa, were randomised. Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an expanded range of drugs for several NCDs. Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) management tool and usual training. Patients attending these clinics with one or more of hypertension (3,227), diabetes (1,842), chronic respiratory disease (1,157) or who screened positive for depression (2,466), totalling 4,393 patients, were enrolled between 28 March 2011 and 10 November 2011. Primary outcomes were treatment intensification in the hypertension, diabetes, and chronic respiratory disease cohorts, defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo, and case detection in the depression cohort. Primary outcome data were analysed for 2,110 (97%) intervention and 2,170 (97%) control group patients. Treatment intensification rates in intervention clinics were not superior to those in the control clinics (hypertension: 44% in the intervention group versus 40% in the control group, risk ratio [RR] 1.08 [95% CI 0.94 to 1.24; p = 0.252]; diabetes: 57% versus 50%, RR 1.10 [0.97 to 1.24; p = 0.126]; chronic respiratory disease: 14% versus 12%, RR 1.08 [0.75 to 1.55; p = 0.674]), nor was case detection of depression (18% versus 24%, RR 0.76 [0.53 to 1.10; p = 0.142]). No adverse effects of the nurses' expanded scope of practice were observed. Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts, limited data on uptake of PC101 by users, reliance on process outcomes, and insufficient resources to measure important health outcomes, such as HbA1c, at follow-up.

CONCLUSIONS

Educational outreach to primary care nurses to train them in the use of a management tool involving an expanded role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases. This notwithstanding, the intervention, with adjustments to improve its effectiveness, has been adopted for implementation in primary care clinics throughout South Africa.

TRIAL REGISTRATION

The trial is registered with Current Controlled Trials (ISRCTN20283604).

Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.

OBJECTIVES

As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.

METHODS

We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.

RESULTS

From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.

CONCLUSIONS

The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

Barriers Influencing Linkage to Hypertension Care in Kenya: Qualitative Analysis from the LARK Hypertension Study

BACKGROUND

Hypertension, the leading global risk factor for mortality, is characterized by low treatment and control rates in low- and middle-income countries. Poor linkage to hypertension care contributes to poor outcomes for patients. However, specific factors influencing linkage to hypertension care are not well known.

OBJECTIVE

To evaluate factors influencing linkage to hypertension care in rural western Kenya.

DESIGN

Qualitative research study using a modified Health Belief Model that incorporates the impact of emotional and environmental factors on behavior.

PARTICIPANTS

Mabaraza (traditional community assembly) participants (n = 242) responded to an open invitation to residents in their respective communities. Focus groups, formed by purposive sampling, consisted of hypertensive individuals, at-large community members, and community health workers (n = 169).

APPROACH

We performed content analysis of the transcripts with NVivo 10 software, using both deductive and inductive codes. We used a two-round Delphi method to rank the barriers identified in the content analysis. We selected factors using triangulation of frequency of codes and themes from the transcripts, in addition to the results of the Delphi exercise. Sociodemographic characteristics of participants were summarized using descriptive statistics.

KEY RESULTS

We identified 27 barriers to linkage to hypertension care, grouped into individual (cognitive and emotional) and environmental factors. Cognitive factors included the asymptomatic nature of hypertension and limited information. Emotional factors included fear of being a burden to the family and fear of being screened for stigmatized diseases such as HIV. Environmental factors were divided into physical (e.g. distance), socioeconomic (e.g. poverty), and health system factors (e.g. popularity of alternative therapies). The Delphi results were generally consistent with the findings from the content analysis.

CONCLUSIONS

Individual and environmental factors are barriers to linkage to hypertension care in rural western Kenya. Our analysis provides new insights and methodological approaches that may be relevant to other low-resource settings worldwide.

Task Shifting the Management of Non-Communicable Diseases to Nurses in Kibera, Kenya: Does It Work?

BACKGROUND

In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses.

METHODS

Descriptive, retrospective review of routinely collected clinic data from two integrated primary health care facilities within an urban informal settlement, Kibera, Nairobi, Kenya (May to August 2014).

RESULTS

There were 3,554 consultations (2025 patients); 733 (21%) were by nurses out of which 725 met the inclusion criteria among 616 patients. Hypertension (64%, 397/616) was the most frequent NCD followed by asthma (17%, 106/616) and diabetes mellitus (15%, 95/616). Adherence to screening questions ranged from 65% to 86%, with an average of 69%. Weight and blood pressure measurements were completed in 89% and 96% of those required. Laboratory results were reviewed in 91% of indicated visits. Laboratory testing per NCD protocols was higher in those with hypertension (88%) than diabetes mellitus (67%) upon review. Only 17 (2%) consultations were referred back to clinical officers.

CONCLUSION

Nurses are able to adhere to protocols for managing stable NCD patients based on clear and standardized protocols and guidelines, thus paving the way towards task shifting of NCD care to nurses to help relieve the significant healthcare gap in developing countries.

Results of a hypertension and diabetes treatment program in the slums of Nairobi: a retrospective cohort study

Background

Cardiovascular diseases (CVD) are the world’s leading cause of death and their prevalence is rising. Diabetes and hypertension, major risk factors for CVD, are highly prevalent among the urban poor in Africa, but treatment options are often limited in such settings. This study reports on the results of an intervention for the treatment of diabetes and hypertension for adult residents of two slums in Nairobi, Kenya.

Methods

After setting up two clinics in two slums in Nairobi, hypertension and/or diabetes patients were seen by a clinician monthly. Socio-demographic characteristics and clinical data were collected over a 34-month period. Records were analyzed for 726 patients who visited the clinics at least once to determine clinic attendance and compliance patterns using survival analysis. We also examined changes in systolic blood pressure (SBP), diastolic blood pressure (DBP) and random blood glucose (RBG) during the course of the program.

Results

There was poor compliance with clinic attendance as only 3.4 % of patients attended the clinics on a regular (monthly) basis throughout the 34-month period. 75 % of hypertension patients were not compliant after four visits and 27 % of patients had only one clinic visit. Significant reduction of mean SBP and DBP (150.4 mmHg to 141.5 mmHg, P = .003, and 89.3 mmHg to 83.2 mmHg, P < .001) was seen for all patients that stayed in care for at least one year.

Conclusions

Establishing a preventative care and treatment system in low resource settings for CVD is challenging due to high dropout rates and non-compliance. Innovative strategies are needed to ensure that benefits of treatment programs are sustained for long-term CVD risk reduction in poor urban populations.

Capacity of Health Facilities to Manage Hypertension in Mukono and Buikwe Districts in Uganda: Challenges and Recommendations

Background

The burden of chronic diseases is increasing in both low- and middle-income countries. However, healthcare systems in low-income countries are inadequately equipped to deal with the growing disease burden, which requires chronic care for patients. The aim of this study was to assess the capacity of health facilities to manage hypertension in two districts in Uganda.

Methods

In a cross-sectional study conducted between June and October 2012, we surveyed 126 health facilities (6 hospitals, 4 Health Center IV (HCIV), 23 Health Center III (HCIII), 41 Health Center II (HCII) and 52 private clinics/dispensaries) in Mukono and Buikwe districts in Uganda. We assessed records, conducted structured interviews with heads of facilities, and administered questionnaires to 271 health workers. The study assessed service provision for hypertension, availability of supplies such as medicines, guidelines and equipment, in-service training for hypertension, knowledge of hypertension management, challenges and recommendations.

Results

Of the 126 health facilities, 92.9% reported managing (diagnosing/treating) patients with hypertension, and most (80.2%) were run by non-medical doctors or non-physician health workers (NPHW). Less than half (46%) of the facilities had guidelines for managing hypertension. A 10^th of the facilities lacked functioning blood pressure devices and 28% did not have stethoscopes. No facilities ever calibrated their BP devices except one. About a half of the facilities had anti-hypertensive medicines in stock; mainly thiazide diuretics (46%), beta blockers (56%) and calcium channel blockers (48.4%). Alpha blockers, mixed alpha & beta blockers and angiotensin II receptor antagonists were only stocked by private clinics/dispensaries. Most HCIIs lacked anti-hypertensive medicines, including the first line thiazide diuretics. Significant knowledge gaps in classification of patients as hypertensive were noted among respondents. All health workers (except 5, 1.9%) indicated that they needed additional training in hypertension management. Several provider and patient related challenges were also observed in this study.

Conclusions

Health facilities in this setting are inadequately equipped to provide services for management of hypertension. Diagnostic equipment, anti-hypertensive drugs and personnel present great challenges. To address the increasing burden of hypertension and other chronic diseases, measures are needed to substantially strengthen the healthcare facilities, including training of personnel in management of hypertension and other chronic diseases, and improving diagnostic and treatment supplies.

Preparedness of Tanzanian health facilities for outpatient primary care of hypertension and diabetes: a cross-sectional survey

Background

Historically, health facilities in sub-Saharan Africa have mainly managed acute, infectious diseases. Few data exist for the preparedness of African health facilities to handle the growing epidemic of chronic, non-communicable diseases (NCDs). We assessed the burden of NCDs in health facilities in northwestern Tanzania and investigated the strengths of the health system and areas for improvement with regard to primary care management of selected NCDs.

Methods

Between November, 2012, and May, 2013, we undertook a cross-sectional survey of a representative sample of 24 public and not-for-profit health facilities in urban and rural Tanzania (four hospitals, eight health centres, and 12 dispensaries). We did structured interviews of facility managers, inspected resources, and administered self-completed questionnaires to 335 health-care workers. We focused on hypertension, diabetes, and HIV (for comparison). Our key study outcomes related to service provision, availability of guidelines and supplies, management and training systems, and preparedness of human resources.

Findings

Of adult outpatient visits to hospitals, 58% were for chronic diseases compared with 20% at health centres, and 13% at dispensaries. In many facilities, guidelines, diagnostic equipment, and first-line drug therapy for the primary care of NCDs were inadequate, and management, training, and reporting systems were weak. Services for HIV accounted for most chronic disease visits and seemed stronger than did services for NCDs. Ten (42%) facilities had guidelines for HIV whereas three (13%) facilities did for NCDs. 261 (78%) health workers showed fair knowledge of HIV, whereas 198 (59%) did for hypertension and 187 (56%) did for diabetes. Generally, health systems were weaker in lower-level facilities. Front-line health-care workers (such as non-medical-doctor clinicians and nurses) did not have knowledge and experience of NCDs. For example, only 74 (49%) of 150 nurses had at least fair knowledge of diabetes care compared with 85 (57%) of 150 for hyptertension and 119 (79%) of 150 for HIV, and only 31 (21%) of 150 had seen more than five patients with diabetes in the past 3 months compared with 50 (33%) of 150 for hypertension and 111 (74%) of 150 for HIV.

Interpretation

Most outpatient services for NCDs in Tanzania are provided at hospitals, despite present policies stating that health centres and dispensaries should provide such services. We identified crucial weaknesses (and strengths) in health systems that should be considered to improve primary care for NCDs in Africa and identified ways that HIV programmes could serve as a model and structural platform for these improvements.

Funding

UK Medical Research Council.

A Concept Mapping Study of Physicians' Perceptions of Factors Influencing Management and Control of Hypertension in Sub-Saharan Africa

Hypertension, once a rare problem in Sub-Saharan Africa (SSA), is predicted to be a major cause of death by 2020 with mortality rates as high as 75%. However, comprehensive knowledge of provider-level factors that influence optimal management is limited. The objective of the current study was to discover physicians' perceptions of factors influencing optimal management and control of hypertension in SSA. Twelve physicians attending the Cardiovascular Research Training (CaRT) Institute at the University of Ghana, College of Health Sciences, were invited to complete a concept mapping process that included brainstorming the factors influencing optimal management and control of hypertension in patients, sorting and organizing the factors into similar domains, and rating the importance and feasibility of efforts to address these factors. The highest ranked important and feasible factors include helping patients accept their condition and availability of adequate equipment to enable the provision of needed care. The findings suggest that patient self-efficacy and support, physician-related factors, policy factors, and economic factors are important aspects that must be addressed to achieve optimal hypertension management. Given the work demands identified by physicians, future research should investigate cost-effective strategies of shifting physician responsibilities to well-trained no-physician clinicians in order to improve hypertension management.

A Narrative Synthesis of the Health Systems Factors Influencing Optimal Hypertension Control in Sub-Saharan Africa

Introduction

In sub-Saharan Africa (SSA), an estimated 74.7 million individuals are hypertensive. Reducing the growing burden of hypertension in sub-Saharan Africa will require a variety of strategies one of which is identifying the extent to which actions originating at the health systems level improves optimal management and control.

Methods and Results

We conducted a narrative synthesis of available papers examining health systems factors influencing optimal hypertension in SSA. Eligible studies included those that analyzed the impact of health systems on hypertension awareness, treatment, control and medication adherence. Twenty-five articles met the inclusion criteria and the narrative synthesis identified the following themes: 1) how physical resources influence mechanisms supportive of optimal hypertension control; 2) the role of human resources with enabling and/or inhibiting hypertension control goals; 3) the availability and/or use of intellectual resources; 4) how health systems financing facilitate and/or compromise access to products necessary for optimal hypertension control.

Conclusion

The findings highlight the need for further research on the health systems factors that influence management and control of hypertension in the region.

The Burden of Cardiovascular Disease in Low- and Middle-Income Countries: Epidemiology and Management

Cardiovascular disease (CVD) is the second leading cause of mortality worldwide, accounting for 17 million deaths in 2013. More than 80% of these cases were in low- and middle-income countries (LMICs). Although the risk factors for the development of CVD are similar throughout the world, the evolving change in lifestyle and health behaviours in LMICs-including tobacco use, decreased physical activity, and obesity-are contributing to the escalating presence of CVD and mortality. Although CVD mortality is falling in high-income settings because of more effective preventive and management programs, access to evidence-based interventions for combating CVD in resource-limited settings is variable. The existing pressures on both human and financial resources impact the efforts of controlling CVD. The implementation of emerging innovative interventions to improve medication adherence, introducing m-health programs, and decentralizing the management of chronic diseases are promising methods to reduce the burden of chronic disease management on such fragile health care systems.

Management of NCD in low- and middle-income countries

Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.

Task shifting for non-communicable disease management in low and middle income countries--a systematic review

BACKGROUND

One potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC.

METHODS

A search strategy with the following terms "task-shifting", "non-physician healthcare workers", "community healthcare worker", "hypertension", "diabetes", "cardiovascular disease", "mental health", "depression", "chronic obstructive pulmonary disease", "respiratory disease", "cancer" was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data.

FINDINGS

Our search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective.

CONCLUSIONS

Task-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.

Hypertension education and adherence in South Africa: a cost-effectiveness analysis of community health workers

Background

To determine whether training community health workers (CHWs) about hypertension in order to improve adherence to medications is a cost-effective intervention among community members in South Africa.

Methods

We used an established Markov model with age-varying probabilities of cardiovascular disease (CVD) events to assess the benefits and costs of using CHW home visits to increase hypertension adherence for individuals with hypertension and aged 25–74 in South Africa. Subjects considered for CHW intervention were those with a previous diagnosis of hypertension and on medications but who had not achieved control of their blood pressure. We report our results in incremental cost-effectiveness ratios (ICERs) in US dollars per disability-adjusted life-year (DALY) averted.

Results

The annual cost of the CHW intervention is about $8 per patient. This would lead to over a 2% reduction in CVD events over a life-time and decrease DALY burden. Due to reductions in non-fatal CVD events, lifetime costs are only $6.56 per patient. The CHW intervention leads to an incremental cost-effectiveness ratio of $320/DALY averted. At an annual cost of $6.50 or if the blood pressure reduction is 5 mmHg or greater per patient the intervention is cost-saving.

Conclusions

Additional training for CHWs on hypertension management could be a cost-effective strategy for CVD in South Africa and a very good purchase according to World Health Organization (WHO) standards. The intervention could also lead to reduced visits at the health centres freeing up more time for new patients or reducing the burden of an overworked staff at many facilities.

Evaluating linkage to care for hypertension after community-based screening in rural Uganda

OBJECTIVES

To determine the frequency and predictors of hypertension linkage to care after implementation of a linkage intervention in rural Uganda.

METHODS

During a multidisease screening campaign for HIV, diabetes and hypertension in rural Uganda, hypertensive adults received education, appointment to a local health facility and travel voucher. We measured frequency and predictors of linkage to care, defined as visiting any health facility for hypertension management within 6 months. Predictors of linkage to care were calculated using collaborative-targeted maximum likelihood estimation (C-TMLE). Participants not linking were interviewed using a standardised instrument to determine barriers to care.

RESULTS

Over 5 days, 2252 adults were screened for hypertension and 214 hypertensive adults received a linkage intervention for further management. Of these, 178 (83%) linked to care within 6 months (median = 22 days). Independent predictors of successful linkage included older age, female gender, higher education, manual employment, tobacco use, alcohol consumption, hypertension family history and referral to local vs. regional health centre. Barriers for patients who did not see care included expensive transport (59%) and feeling well (59%).

CONCLUSIONS

A community health campaign that offered hypertension screening, education, referral appointment and travel voucher achieved excellent linkage to care (83%). Young adults, men and persons with low levels of formal education were among those least likely to seek care.

Status report on hypertension in Africa--consultative review for the 6th Session of the African Union Conference of Ministers of Health on NCD's

Hypertension has always been regarded as a disease of affluence but this has changed drastically in the last two decades with average blood pressures now higher in Africa than in Europe and USA and the prevalence increasing among poor sections of society. We have conducted a literature search on PubMed on a broad range of topics regarding hypertension in Africa, including data collection from related documents from World Health Organization and other relevant organizations that are available in this field. We have shared the initial results and drafts with international specialists in the context of hypertension in Africa and incorporated their feedback. Hypertension is the number one risk factor for CVD in Africa. Consequently, cardiovascular disease (CVD) has taken over as number one cause of death in Africa and the total numbers will further increase in the next decades reflecting on the growing urbanization and related lifestyle changes. The new epidemic of hypertension and CVD is not only an important public health problem, but it will also have a big economic impact as a significant proportion of the productive population becomes chronically ill or die, leaving their families in poverty. It is essential to develop and share best practices for affordable and effective community-based programs in screening and treatment of hypertension. In order to prevent and control hypertension in the population, Africa needs policies developed and implemented through a multi-sectoral approach involving the Ministries of Health and other sectors including education, agriculture, transport, finance among others.

Efficiency of an intervention package for arterial hypertension comprising telemanagement in a Cameroonian rural setting: The TELEMED-CAM study

Introduction

Sub-Saharan Africa has a disproportionate burden of disease and an extreme shortage of health workforce. Therefore, adequate care for emerging chronic diseases can be very challenging. We implemented and evaluated the effectiveness of an intervention package comprising telecare as a mean for improving the outcomes of care for hypertension in Rural Sub-Saharan Africa.

Methods

The study involved a telemedicine center based at the Yaounde General Hospital (5 cardiologists) in the Capital city of Cameroon, and 30 remote rural health centers within the vicinity of Yaoundé (20 centers (103 patients) in the usual care group, and 10 centers (165 patients) in the intervention groups). The total duration of the intervention was 24 weeks.

Results

Participants in the intervention group had higher baseline systolic (SBP) and diastolic (DBP) blood pressure, and included fewer individuals with diabetes than those in the usual care group (all p < 0.01). Otherwise, the baseline profile was mostly similar between the two groups. During follow-up, more participants in the intervention groups achieved optimal BP control, driven primarily by greater improvement of BP control among High risk participants (hypertension stage III) in the intervention group.

Conclusion

An intervention package comprising tele-support to general practitioners and nurses is effective in improving the management and outcome of care for hypertension in rural underserved populations. This can potentially help in addressing the shortage of trained health workforce for chronic disease management in some settings. However context-specific approaches and cost-effectiveness data are needed to improve the application of telemedicine for chronic disease management in resource-limited settings.

Global health and primary care: increasing burden of chronic diseases and need for integrated training

Noncommunicable diseases, including cardiovascular disease, chronic respiratory disease, diabetes, cancer, and mental illness, are the leading causes of death and disability worldwide. These diseases are chronic and often mediated predominantly by social determinants of health. Currently there exists a global-health workforce crisis and a subsequent disparity in the distribution of providers able to manage chronic noncommunicable diseases. Clinical competency in global health and primary care could provide practitioners with the knowledge and skills needed to address the global rise of noncommunicable diseases through an emphasis on these social determinants. The past decade has seen substantial growth in the number and quality of US global-health and primary-care training programs, in both undergraduate and graduate medical education. Despite their overlapping competencies, these 2 complementary fields are most often presented as distinct disciplines. Furthermore, many global-health training programs suffer from a lack of a formalized curriculum. At present, there are only a few examples of well-integrated US global-health and primary-care training programs. We call for universal acceptance of global health as a core component of medical education and greater integration of global-health and primary-care training programs in order to improve the quality of each and increase a global workforce prepared to manage noncommunicable diseases and their social mediators.

Review of community-based interventions for prevention of cardiovascular diseases in low- and middle-income countries

BACKGROUND

An increasing burden of cardiovascular disease (CVD) is occurring in low- and middle-income countries (LMICs) as a result of urbanisation and globalisation. Low rates of awareness and treatment of risk factors worsen the prognosis in these settings. Prevention of CVD is proven to be cost effective and should be the main intervention. Insight into prevention programmes in LMIC is important in addressing the rising levels of these diseases.

OBJECTIVE

To evaluate the effectiveness of the community-based interventions for CVD prevention programmes in LMIC.

DESIGN

A literature review with searches in the databases of PubMed, EMBASE, CINAHL, LILACS, African Index Medicus and Google Scholar between 1990 and May 2012.

RESULTS

Twenty-six studies involving population-based and high-risk interventions have been included in this review. The content of the population intervention was mainly health promotion through media and health education, and the high-risk approach focused often on education of patients, training of health care providers and implementing treatment guidelines. A few studies had a single intervention on exercising or salt reduction. Most studies showed a significant reduction of cardiovascular risk ranging from lifestyle changes on diet, smoking and alcohol to biomedical outcomes like blood pressure, glucose levels or weight. Some studies showed improved management of risk factors like increased control of hypertension or adherence to medication.

CONCLUSION

There have been effective community-based programmes aimed at reducing cardiovascular risk factors in LMIC but these have generally been limited to the urban poor. Health education with a focus on diet and salt, training of health care providers and implementing treatment guidelines form key elements in successful programmes.

The lesson of Monsieur Nouma: effects of a culturally sensitive communication tool to improve health-seeking behavior in rural Cameroon

OBJECTIVE

To test the effect of patient counseling using educational tools, on rates of return for follow-up in newly diagnosed hypertensive and/or diabetic patients in a rural African context.

METHODS

Free screening for hypertension and elevated blood glucose was offered in primary health care centers in central Cameroon during 9 campaigns of 3 days each. Individuals with untreated hypertension and/or diabetes were divided into 2 groups: a control group receiving counseling according to routine procedures, and an intervention group receiving counseling with different educational tools to explain the diagnosis and its implications to the patient.

RESULTS

Prevalence of hypertension and/or diabetes in the screened population was 41%. At 3 months from screening, rates of return visits were higher in the intervention group than in the control group: 55/169 (32%) vs. 15/92 (16%), OR 2.4; 95%CI 1.3-4.7; p<0.001.

CONCLUSION

Screening may identify untreated individuals efficiently. Rates of return visits after screening, although low in both groups, could be doubled by a short communication intervention.

PRACTICE IMPLICATIONS

This study suggests that modest communication interventions, e.g., the application of educational tools, may bring important benefits and increase the effectiveness of public health measures to combat chronic diseases in settings of limited resources.