Hypertension Treatment Rates and Health Care Worker Density

The effectiveness of nurse-led interventions to manage frailty in community-dwelling older people: a systematic review

BACKGROUND

The global increase in the number of frail older people and the accompanying increase in chronic conditions underline the need to develop effective health promotion and preventive interventions for these population groups. Wide ranging of physical, psychological, and social health factors influence frailty in older people and leads to increased vulnerability to many adverse outcomes. To reverse or reduce the progression of frailty, nurses play a pivotal role in delivering health promotion and preventive interventions. The purpose of the review is to determine the effectiveness of nurse-led interventions in reducing frailty in community-dwelling older people.

METHODS

The following electronic databases: PubMed, MEDLINE, Web of Science, SCOPUS, CINAHL, PsychInfo, and WHO Global Index Medicus were searched until June 2022. Nurse-led, "nurse led", education, training, intervention, program, teaching, frail*, fragile*, "frailty syndrome", debility, infirmity, elder*, aged*, old*, geriatric, "community based settings", "community-based", "community setting", community were the search terms. Before data extraction, eligible articles were assessed for their methodological quality. The JBI critical appraisal checklist for reporting experimental studies was utilised to appraise the methodological quality of the studies. Data were systematically examined using a narrative review to determine the effectiveness of the intervention.

RESULTS

Of the 156 studies identified, from the search, six studies with samples ranging from 40 to 1387 older people were eligible for inclusion in the review. Two quasi-experimental studies and one Randomised Controlled Trial (RCT) showed a moderate risk of bias. The Nurse-led frailty interventions used a multi-component intervention approach across the studies. The interventions reversed frailty progression, improve physical functioning, nutritional status, and quality of life, enhance perceptions of social support, improve mental health, and reduce depression.

CONCLUSIONS

Few studies have explored the effectiveness of a nurse-led intervention to decrease frailty in older people. Evaluating physical functioning, nutritional status, mental health, and quality of life in community-dwelling frail older people can contribute to developing appropriate interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID of CRD42022348064.

Association of estimated white matter hyperintensity age with cognition in elderly with controlled hypertension

INTRODUCTION

Hypertension is associated with white matter hyperintensity (WMH) and cognitive impairment. Further, WMH is associated with cognitive impairment including executive, attention and visuospatial functions. The aim of this study was to investigate the effects of controlled hypertension (cHT) and previously developed concept, 'WMH age' on cognitive function and the mediating role of WMH in the effect of cHT on cognitive impairment.

METHODS

We enrolled 855 Koreans without dementia aged 60 years or older, 326 of whom completed 2-year follow-up assessment. We measured their blood pressure thrice in a sitting position using an automated blood pressure monitoring device. We estimated 'WMH age' of every participant using previously developed WMH probability map of healthy older Koreans. We analyzed the mediating effect of WMH age in the association of cHT and cognitive function using the PROCESS Macro model.

RESULTS

Old WMH age was associated with a faster decline in the Mini-Mental Status Examination (MMSE; p =.003), Consortium to Establish a Registry for Alzheimer's Disease total score (CERAD-TS; p =.003), and Frontal Assessment Battery (FAB; p =.007). Old WMH age showed an approximately-six times higher risk of incident mild cognitive impairment (OR = 6.47, 95 % CI = 1.37 - 9.50, p =.024) compared to young or normal WMH age over the 2-year follow-up period in the cHT group. WMH age mediated the effects of cHT on the MMSE, CERAD-TS, and FAB scores at baseline and two-year follow-up period.

CONCLUSIONS

WMH mediates the adverse effect of hypertension on cognitive function. Elders with cHT who have older WMH age may be at a higher risk of cognitive decline.

Primary care institutional characteristics associated with hypertension awareness, treatment, and control in the China PEACE-Million Persons Project and primary health-care survey: a cross-sectional study

BACKGROUND

Since 2010, China has made vast financial investments and policy changes to the primary care system. We aimed to assess how hypertension awareness, treatment, and control might be used to assess quality of primary care systems, which reflect the outcomes of public health services and medical care.

METHODS

We used The China Patient-centred Evaluative Assessment of Cardiac Events Million Persons Project, a government-funded public health project that focuses on cardiovascular disease risk in China. We linked primary care institution characteristics that were captured in the survey between 2016 and 2017 to the participant-level data gathered in baseline visits between 2014 and 2021. Participants were included if they had hypertension and lived in the towns or streets that took part in the primary care survey. Participants were excluded if they had missing data for blood pressure measurement, history of hypertension, sex, or age. Primary care institutions were excluded if the catchment area had fewer than 100 participants with hypertension. Hypertension awareness was defined as the proportion of participants with hypertension who self-reported a hypertension diagnosis. Hypertension treatment was defined as the proportion of participants who currently use antihypertensive medications among those who were aware. Hypertension control was defined as the proportion of participants with an average systolic blood pressure less than 140 mm Hg and an average diastolic blood pressure less than 90 mm Hg over two readings among those who were treated during the study. All patients were included in the analysis. This trial was registered at ClinicalTrials.gov, NCT02536456.

FINDINGS

Between Sept 15, 2014, and March 16, 2021, we assessed 503 township-level primary care institutions for eligibility. 70 institutions were excluded as they could not be linked with individual data or because their catchment area had fewer than 100 participants with hypertension. We analysed 433 township-level primary care institutions across all 31 provinces of mainland China, including 660 565 individuals with hypertension in their catchment areas. Across townships, age-sex standardised hypertension awareness varied from 8·2% to 81·0%, treatment varied from 2·6% to 96·5%, and control proportions varied from 0% to 62·4%. Hypertension awareness, treatment, and control were significantly associated with the following institutional characteristics: government funding through balance allocation (ie, institutions have their human resources funded by local government, but need to be self-supporting in other aspects; awareness odds ratio 0·88, 95% CI 0·78-0·99; p=0·027), having financial problems that interrupted routine service delivery (awareness 0·81, 0·72-0·92; p=0·0007, control 0·84; 0·75-0·94, p=0·0034), setting performance-based bonus (treatment 1·39, 1·07-1·80; p=0·013), basic salary defined by number of patient visits (control 0·85, 0·76-0·95; p=0·0053), using electronic referrals (treatment 1·41, 1·14-1·73; p=0·0012, control 1·17; 1·03-1·33, p=0·014), implementing family physician contract services (awareness 1·13, 1·00-1·28; p=0·045, control 1·30; 1·15-1·46, p<0·0001), and proportion of physicians who are formally licensed (awareness per 10% increase 1·04, 1·01-1·08; p=0·019, treatment 1·08; 1·02-1·14, p=0·0077; control per 10% increase 1·07, 1·03-1·10; p=0·0006).

INTERPRETATION

The role of primary care role in hypertension management might benefit from new strategies that promote best practices in institutional financing, performance appraisal, service delivery, and information technology.

FUNDING

Chinese Academy of Medical Sciences Innovation Fund for Medical Science, and the National High Level Hospital Clinical Research Funding.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Diet Quality Indices in Relation to Cardiovascular Risk Factors in T2DM Patients: A Systematic Review

BACKGROUND

Dietary quality indices are practical as an instrument to investigate the extent of adhering to a special diet to prevent cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM). Considering the lack of any systematic review with regards to this issue, our aim was to examine observational studies to test the relationship between dietary quality indices and CVD risk factors in T2DM.

METHODS

Systematic search was performed in Web of knowledge, PubMed, Cochrane, Science direct, Google Scholar and Scopus databases from January 1990 to July 2020. The studies exploring the relationship between dietary quality indices (diet quality score (DQS), dietary diversity score (DDS), healthy diet indicator (HDI), healthy eating index (HEI), diet quality index (DQI), Mediterranean diet score (MDS)) and lipid profile, anthropometric indices, glucose profile as well as blood pressure were eligible to be included in this review. Overall, mean changes, odd ratio (RR), correlation coefficients, and beta coefficient of outcomes were extracted, with the quality assessment of studies performed applying The Newcastle-Ottawa scale.

RESULTS

From among 1627 papers, 10 articles were included: Eight cross-sectional and two prospective (cohort) studies. The association between HEI as well as MDS and CVD risk factors was more evident in the included studies. Fasting blood sugar, hemoglobin A1c, body mass index, and waist circumference revealed the greatest inverse significant relationship with dietary quality indices in adults with T2DM.

CONCLUSION

Overall, the findings of this study suggest that the level of CVD risk factors in T2DM decreases significantly with increase in the score of dietary quality indices. Further studies in future are required to confirm these findings.

Longitudinal evidence on treatment discontinuation, adherence, and loss of hypertension control in four middle-income countries

Managing hypertension is a highly dynamic process, yet current evidence on hypertension control in middle-income countries (MICs) is largely based on cross-sectional data. Using multiple waves of population-based cohort data from four MICs (China, Indonesia, Mexico, and South Africa), we undertook a longitudinal investigation into how individuals with hypertension move through care over time. We classified adults aged 40 years and over (N = 8527) into care stages at both baseline and follow-up waves and estimated the probability of transitioning between stages using Poisson regression models. Over a 5- to 9-year follow-up period, only around 30% of undiagnosed individuals became diagnosed [Mexico, 27% (95% confidence interval: 23%, 31%); China, 30% (26%, 33%); Indonesia, 30% (28%, 32%); and South Africa, 36% (31%, 41%)], and one in four untreated individuals became treated [Indonesia, 11% (10%, 12%); Mexico, 24% (20%, 28%); China, 26% (23%, 29%); and South Africa, 33% (29%, 38%)]. The probability of reaching blood pressure (BP) control was lower [Indonesia, 2% (1%, 2%); China, 9% (7%, 11%); Mexico, 12% (9%, 14%); and South Africa, 24% (20%, 28%)] regardless of treatment status. A substantial proportion of individuals discontinued treatment [Indonesia, 70% (67%, 73%); China, 36% (32%, 40%); Mexico, 34% (29%, 39%); and South Africa, 20% (15%, 25%)], and most individuals lost BP control by follow-up [Indonesia, 92% (89%, 96%); Mexico, 77% (71%, 83%); China, 76% (69%, 83%); and South Africa 45% (36%, 54%)]. Our results highlight that policies solely aimed at improving diagnosis or initiating treatment may not lead to long-term hypertension control improvements in MICs.

Estimating the gap between demand and supply of medical appointments by physicians for hypertension care: a pooled analysis in 191 countries

INTRODUCTION

With a growing number of people with hypertension, the limited number of physicians could not provide treatment to all patients. We quantified the gap between medical appointments available and needed for hypertension care, overall and in relation to hypertension treatment cascade metrics.

METHODS

Ecological descriptive analysis. We combined country-year-specific data on hypertension prevalence, awareness, treatment and control (from Non-Communicable Disease Risk Factor Collaboration) and number of physicians (from WHO). We estimated from 1 to 12 medical appointments per year for patients with hypertension. We assumed that physicians could see 25 patients per day, work 200 days/year and dedicate 10% of their time to hypertension care.

RESULTS

We studied 191 countries. Forty-one countries would not have enough physicians to provide at least one medical appointment per year to all the population with hypertension; these countries were low/lower middle income and in sub-Saharan Africa or East Asia and Pacific. Regardless of the world region, ≥50% of countries would not have enough physicians to provide ≥8 medical appointments to their population with hypertension. Countries where the demand exceeded the offer of medical appointments for hypertension care had worse hypertension diagnosis, treatment and control rates than countries where the demand did not exceed the offer. There were positive correlations between the physician density and hypertension diagnosis (r=0.70, p<0.001), treatment (r=0.70, p<0.001) and control (r=0.59, p<0.001).

CONCLUSIONS

Where physicians are the only healthcare professionals allowed to prescribe antihypertensive medications, particularly in low and middle-income countries, the healthcare system may struggle to deliver antihypertensive treatment to patients with hypertension.

Constructing a Nurse-led Cardiovascular Disease Intervention in Rural Ghana: A Qualitative Analysis

Background

Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region.

Objective

This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure.

Methods

Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants.

Findings

Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies.

Conclusions

Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

A review of some common African spices with antihypertensive potential

Hypertension is the most common non-communicable disease, with about 1.28 billion hypertensive people worldwide. It is more prevalent in men than women and more common in the elderly. Hereditary, age, obesity, lifestyle, diet, alcohol, and chronic metabolic diseases are the major risk factors of hypertension. Treating hypertension is a complex process as there are several mechanisms responsible for its pathogenesis; hence, a combination of several drugs is used for managing hypertension. Drugs used in managing hypertension are expensive and often come with associated side effects; thus, there is need for alternative means of managing this life-threatening disease. These drugs do not achieve the recommended blood pressure target in most people; more so majority of people with hypertension do not follow the treatment regimen religiously. Some Africans have been reported to become normotensive as a result of dietary consumption of spices. Several spices have been used over the years in Africa to manage hypertension. The aim of this review is to evaluate the ethnomedicinal use, bioactive phytochemical composition, bioactive compounds present, and pharmacological applications of spices commonly used in Africa for managing hypertension. Most of the plants used contained polyphenols, flavonoids, tannins, anthraquinone, flavonoids, cardiac glycosides, and saponins. Dietary supplementation of Xylopia aethiopica and other spices in diet have been proven to significantly reduced plasma angiotensin-I-converting enzyme (ACE) than simvastatin (the reference drug). Toxicological, histological, and hematological evaluation revealed that acute and chronic consumption of most of these spices are safe. Studies have also revealed that some of the spices can be used as alternative therapy alongside usual antihypertensive medications. PRACTICAL IMPLICATION: The prevalent rate of hypertension is on the increase in both the developed and developing countries. People often skip medication due to their busy schedule and anti-hypertensive potential side effects; however, this is not the case with food/spices as most people consumed them daily. Deliberate, right combinations and consistent incorporation of spices with proven anti-hypertensive potential into our diet may be of great benefit in normalizing blood pressure and mitigate other complications on the heart and vital organs.

The effectiveness of nurse-led group interventions on hypertension lifestyle management: A mixed method study

PURPOSE

Hypertension is prevalent in Uganda and achieving treatment goals remains a challenge. Our aim was to assess the impact of a bundled nurse-led intervention on hypertension physiologic measures and lifestyle modification, and to explore perceptions of the interventions to enhance sustainability.

DESIGN AND SETTING

We employed a sequential explanatory mixed-method design. The study was conducted at a large urban private hospital in Uganda from September 2018 to May 2019.

SAMPLE

Participants were clinic patients with hypertension currently under care. A total of 54 participants were enrolled in two study groups. Two focus groups with 16 participants and 2 nurse-educator interviews were conducted.

METHODS

Blood pressure and weight were measured at baseline, three, six, and nine months. The Self-Care of Hypertension Inventory was used to assess lifestyle modification. Monthly education and group-support with text-message follow-up were implemented. Two focus-groups and nurse-educator interviews were conducted to assess perceptions post-implementation. The analysis included descriptive statistic, multivariate analysis and qualitative analysis for themes and subthemes.

FINDINGS

Overall, participants had a mean weight loss of 7.7 kg (p = 0.001) and a mean reduction in systolic blood pressure (SBP) of 9.5 mm Hg (p = 0.001). Improvement in biometric outcomes was associated with lifestyle modification such as taking medicine as prescribed (p = 0.008), eat lots of fruit and vegetables (p = 0.043), and control your body weight (p = 0.015). Thematic analysis yielded the following themes: Knowledge and understanding, Attitude change, Adherence-a real struggle, and Adapting to what suits us. Participants found group support, shared learning, and knowledge reinforcement enhanced their knowledge and self-efficacy. Nurse educators were motivated by the patients' favorable responses to the Bundled Education and Support with Text (BEST) intervention.

CONCLUSION

Findings support the use of nurse-led interventions to enhance the achievement of hypertension treatment goals. To sustain the achieved lifestyle modification and blood pressure outcomes, participants expressed a desire for continued support, information access, and inclusion of patients as champions for knowledge dissemination. Future studies need to explore the provision of enabling structures to support nurse-led interventions in routine non-Communicable disease (NCD) care.

CLINICAL RELEVANCE

Hypertension knowledge-gaps exist among patients and may reflect missed opportunities for patient engagement and education for behavior change. Bundled nurse-led hypertension interventions can significantly improve lifestyle modification and enhance hypertension outcomes. Persons supported and empowered with knowledge can act as conduits to wider communities in championing knowledge dissemination.

Estimation of the Global Gap in Clinic Visits for Hypertension Care Between Patient Need and Physician Capacity

[Figure: see text].

Provider perceptions of hypertension care in a low-resource setting

AIM

Globally, the rapid increase of hypertension is particularly prevalent in low- and middle-income countries. Hypertension is the most significant modifiable risk factor for stroke and ischaemic heart disease, the leading cause of mortality in Vietnam. The aim of this study was to gain insight into the provision of hypertension care in Vietnam by exploring provider perceptions.

METHODS

A sequential exploratory mixed-method design was selected to allow for the initial qualitative interview findings to be incorporated into the development of the hypertension education workshop. Data were collected through semistructured interviews of 15 Vietnamese clinicians involved in the care of patients with hypertension.

RESULTS

Anxiety related to diagnosis of hypertension and specifically fear of having a stroke was mentioned by half of the participants. Several themes also emerged regarding barriers to implementing lifestyle modification to improve patient hypertension outcomes. There were contradictory opinions on the nurse's role in providing patient education across clinical settings. A lack of systematic structure and evidence-based teaching resources was also noted.

CONCLUSIONS

Gaining the provider's perspective increases understanding of the regional culture and context of hypertension care. The increased understanding can be used to improve provider education and enhance hypertension population outcomes.

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.

Nurse-led interventions in the interim: waiting on universal health coverage

AIM

The aim of the study was to test a nurse-led intervention to enhance lifestyle modification and improve hypertension outcomes.

BACKGROUND

Hypertension is the leading modifiable contributor to non-communicable disease morbidity and mortality affecting more than 25% of adults in Uganda.

METHODS

A mixed-method study was conducted to evaluate nurse-led interventions for hypertension. Group education and support with text message follow-up was the bundled interventions implemented in an outpatient clinical setting.

CONCLUSION AND IMPLICATIONS

The statistically favourable outcomes of the nurse-led interventions support a cost-effective approach to, with policy support, sustainably improve practice outcomes.