The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial

Lay advisor interventions for hypertension outcomes: A Systematic Review, Meta-analysis and a RE-AIM evaluation

Introduction

Lay advisor interventions improve hypertension outcomes; however, the added benefits and relevant factors for their widespread implementation into health systems are unknown. We performed a systematic review to: (1) summarize the benefits of adding lay advisors to interventions on hypertension outcomes, and (2) summarize factors associated with successful implementation in health systems using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

Methods

We systematically searched several databases, including Ovid MEDLINE, CINAHL, PsycINFO from January 1981 to May 2023. All study designs of interventions delivered solely by lay advisors for adults with hypertension were eligible. If both arms received the lay advisor intervention, the study arm with lower intensity was assigned as the low-intensity intervention.

Results

We included 41 articles, of which 22 were RCTs, from 7,267 screened citations. Studies predominantly included socially disadvantaged populations. Meta-analysis (9 RCTs; n = 4,220) of eligible lay advisor interventions reporting outcomes showed improved systolic blood pressure (BP) [-3.72 mm Hg (CI -6.1 to -1.3; I2 88%)], and diastolic BP [-1.7 mm Hg (CI -1 to -0.9; I2 7%)] compared to control group. Pooled effect from six RCTs (n = 3,277) comparing high-intensity with low-intensity lay advisor interventions showed improved systolic BP of -3.6 mm Hg (CI -6.7 to -0.5; I2 82.7%) and improved diastolic BP of -2.1 mm Hg (CI -3.7 to -0.4; I2 70.9%) with high-intensity interventions. No significant difference in pooled odds of hypertension control was noted between lay advisor intervention and control groups, or between high-intensity and low-intensity intervention groups. Most studies used multicomponent interventions with no stepped care elements or reporting of efficacious components. Indicators of external validity (adoption, implementation, maintenance) were infrequently reported.

Discussion

Lay advisor interventions improve hypertension outcomes, with high intensity interventions having a greater impact. Further studies need to identify successful intervention and implementation factors of multicomponent interventions for stepped upscaling within healthcare system settings as well as factors used to help sustain interventions.

Feasibility and acceptability of a contextualized physical activity and diet intervention for the control of hypertension in adults from a rural subdistrict: a study protocol (HYPHEN)

INTRODUCTION

In rural and remote South Africa, most strokes and ischaemic heart diseases are as a consequence of hypertension, which is a modifiable risk factor. The widely recommended therapeutic approaches to control hypertension are through physical activity and diet modifications. However, there is a lack of culturally sensitive community-based, lifestyle interventions to control hypertension among rural African adult populations. We designed an intervention which recommends adjusting daily routine physical activity and dietary behaviour of adults with hypertension. This study aims to evaluate the feasibility and acceptability of HYPHEN in a rural community setting.

METHODS

We aim to recruit 30 adult participants with a self-report hypertension diagnosis. A one-arm, prospective design will be used to assess the feasibility and acceptability of recruitment, uptake, engagement, and completion of the 10-week intervention. Recruitment rates will be assessed at week 0. Intervention uptake, engagement, and adherence to the intervention will be assessed weekly via telephone. Blood pressure, body mass index, waist-hip ratio, urinary sodium, accelerometer-measured physical activity, and 24-h diet recall will be assessed at baseline and at 10 weeks. Qualitative semi-structured interviews will be conducted at 10 weeks to explore feasibility and acceptability.

DISCUSSION

This study offers a person-centred, sociocultural approach to hypertension control through adaptations to physical activity and dietary intake. This study will determine whether HYPHEN is feasible and acceptable and will inform changes to the protocol/focus that could be tested in a full trial.

TRIAL REGISTRATION NUMBER

PACTR202306662753321.

Process evaluation in the field: global learnings from seven implementation research hypertension projects in low-and middle-income countries

BACKGROUND

Process evaluation is increasingly recognized as an important component of effective implementation research and yet, there has been surprisingly little work to understand what constitutes best practice. Researchers use different methodologies describing causal pathways and understanding barriers and facilitators to implementation of interventions in diverse contexts and settings. We report on challenges and lessons learned from undertaking process evaluation of seven hypertension intervention trials funded through the Global Alliance of Chronic Diseases (GACD).

METHODS

Preliminary data collected from the GACD hypertension teams in 2015 were used to inform a template for data collection. Case study themes included: (1) description of the intervention, (2) objectives of the process evaluation, (3) methods including theoretical basis, (4) main findings of the study and the process evaluation, (5) implications for the project, policy and research practice and (6) lessons for future process evaluations. The information was summarized and reported descriptively and narratively and key lessons were identified.

RESULTS

The case studies were from low- and middle-income countries and Indigenous communities in Canada. They were implementation research projects with intervention arm. Six theoretical approaches were used but most comprised of mixed-methods approaches. Each of the process evaluations generated findings on whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation. The most important learning was that although process evaluation is time consuming, it enhances understanding of factors affecting implementation of complex interventions. The research highlighted the need to initiate process evaluations early on in the project, to help guide design of the intervention; and the importance of effective communication between researchers responsible for trial implementation, process evaluation and outcome evaluation.

CONCLUSION

This research demonstrates the important role of process evaluation in understanding implementation process of complex interventions. This can help to highlight a broad range of system requirements such as new policies and capacity building to support implementation. Process evaluation is crucial in understanding contextual factors that may impact intervention implementation which is important in considering whether or not the intervention can be translated to other contexts.

Dilemmas of Ethics in Practice in Longitudinal Health Research: Identifying Opportunities for Widening Participation of Residents

Background: Mechanisms for widening participation of local participants in research studies can improve governance of public health research. Research conducted in longitudinal health study areas depends on there being mutual trust and respect over time between the local residents and researchers. Ethics in practice needs consideration alongside procedural ethics. By widening participation of the experimental public-local residents and resident service providers-ethics in practice and accountability are strengthened. Methods: The study was undertaken in a longitudinal health study area in rural South Africa using multiple qualitative methods. The sample included 35 individual and five group interviews with resident local leaders and service providers, 24 individual and eight group interviews with residents of the study area, and ten researchers' reflections on two critical incidents from ethnographic field notes on dilemmas of ethics in practice. The interviews were all audio-recorded (besides one where consent to record was not given) and then transcribed verbatim and translated from Shangaan into English. Thematic analysis was conducted. Results: Residents requested the reporting back of personal screening test results from research studies, and raised informed consent issues. Researchers recognized the importance of mechanisms to increase their accountability to residents throughout the research process, and the complexity of informed consent and fieldwork procedures within research studies. Conclusion: This study elicited the views of residents and researchers in a longitudinal health study area to seek guidance on how to strengthen participation in research governance. Three strategies were identified by participants to widen participation of the experimental public. Firstly, increasing study budgets so that individual screening test results could be personally delivered back to participants. Secondly, more rigorous field staff training in informed consent and study procedures with ongoing monitoring and supervision from researchers. Thirdly, increased earlier involvement of residents in research protocol development through study advisory groups. Additional strategies include deeper involvement of Community Advisory Groups and more focused dissemination of research results to specific audiences. In general, there is a need to identify strategies for increased accountability of researchers and participatory governance through involvement of the experimental public in all aspects of longitudinal public health research as part of the ethics in practice and democratization of science.

Outcomes of patients lost to follow-up after antiretroviral therapy initiation in rural north-eastern South Africa

Objective

The vital status of patients lost to follow‐up often remains unknown in antiretroviral therapy (ART) programmes in sub‐Saharan Africa because medical records are no longer updated once the patient disengages from care. Thus, we aimed to assess the outcomes of patients lost to follow‐up after ART initiation in north‐eastern South Africa.

Methods

Using data from a rural area in north‐eastern South Africa, we estimated the cumulative incidence of patient outcomes (i) after treatment initiation using clinical records, and (ii) after loss to follow‐up (LTFU) using data from clients that have been individually linked to Agincourt Health and Demographic Surveillance System (AHDSS) database. Aside from LTFU, we considered mortality, re‐engagement and migration out of the study site. Cox proportional hazards regression was used to identify covariates of these patient outcomes.

Results

Between April 2014 and July 2017, 3700 patients initiated ART and contributed a total of 6818 person‐years of follow‐up time. Three years after ART initiation, clinical record‐based estimates of LTFU, mortality and documented transfers were 41.0% (95% CI: 38.5–43.4%), 1.9% (95% CI 1.0–3.2%) and 0.1% (95% CI 0.0–0.9%), respectively. Among those who were LTFU, the cumulative incidence of re‐engagement, out‐migration and mortality at 3 years were 38.1% (95% CI 33.1–43.0%), 49.4% (95% CI 43.1–55.3%) and 4.7% (95% CI 3.5–6.2%), respectively. Pregnant or breastfeeding women, foreigners and those who initiated ART most recently were at an increased risk of LTFU.

Conclusion

LTFU among patients starting ART in north‐eastern South Africa is relatively high and has increased in recent years as more asymptomatic patients have initiated treatment. Even though this tendency is of concern in light of the prevention of onwards transmission, we also found that re‐engagement in care is common and mortality among persons LTFU relatively low.

Task shifting to improve the provision of integrated chronic care: realist evaluation of a lay health worker intervention in rural South Africa

Introduction

Task shifting is a potential solution to the shortage of healthcare personnel in low/middle-income countries, but contextual factors often dilute its effectiveness. We report on a task shifting intervention using lay health workers to support clinic staff in providing chronic disease care in rural South Africa, where the HIV epidemic and an ageing population have increased demand for care.

Methods

We conducted a realist evaluation in a cluster randomised controlled trial. We conducted observations in clinics, focus group discussions, in-depth interviews and patient exit interviews, and wrote weekly diaries to collect data.

Results

All clinic managers had to cope with an increasing but variable patient load and unplanned staff shortages, insufficient space, poorly functioning equipment and erratic supply of drugs. These conditions inevitably generated tension among staff. Lay health workers relieved the staff of some of their tasks and improved care for patients, but in some cases the presence of the lay health worker generated conflict with other staff. Where managers were able to respond to the changing circumstances, and to contain tension among staff, facilities were better able to meet patient needs. This required facility managers to be flexible, consultative and willing to act on suggestions, sometimes from junior staff and patients. While all facilities experienced an erratic supply of drugs and poorly maintained equipment, facilities where there was effective management, teamwork and sufficient space had better chronic care processes and a higher proportion of patients attending on their appointed day.

Conclusion

Lay health workers can be valuable members of a clinic team, and an important resource for managing increasing patient demand in primary healthcare. Task shifting will only be effective if clinic managers respond to the constantly changing system and contain conflict between staff. Strengthening facility-level management and leadership skills is a priority.

Trial registration number

ISRCTN12128227.

Time to review policy on screening for, and managing, hypertension in South Africa: Evidence from primary care

BACKGROUND

Current policy in South Africa requires measurement of blood pressure at every visit in primary care. The number of patients regularly visiting primary care clinics for routine care is increasing rapidly, causing long queues, and unmanageable workloads.

METHODS

We used data collected during a randomised control trial in primary care clinics in South Africa to estimate how changes in policy might affect workloads and improve identification of undiagnosed hypertension.

RESULTS

The prevalence of raised blood pressure increased with age; 65% of individuals aged over 60 years had a raised blood pressure, and 49% of them were not on any treatment. Over three months, eight health facilities saw 8,947 individual chronic disease patients, receiving 22,323 visits from them. Of these visits, 60% were related to hypertension, with or without HIV, and a further 35% were related to HIV alone. Long waits for blood pressure checks caused friction at all levels of the clinics. Blood pressure machines frequently broke down due to heavy use, and high blood pressures readings were often ignored. If chronic disease patients without a diagnosis of hypertension had their blood pressure checked only once a year, the number of checks would be reduced by more than 80%. Individuals with hypertension had a blood pressure check on average once every 7 weeks, but South African guidelines recommend that this should be done every 3 months at most.

CONCLUSIONS

The numbers of chronic disease patients in primary care clinics in South Africa is rising rapidly. New policies for measuring blood pressure in these patients attending clinics are urgently needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12128227 5th March 2014.

Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases

Task-shifting to non-physician health workers (NPHWs) has been an effective model for managing infectious diseases and improving maternal and child health. There is inadequate evidence to show the effectiveness of NPHWs to manage cardiovascular diseases (CVDs). In 2012, the Global Alliance for Chronic Diseases funded eight studies which focused on task-shifting to NPHWs for the management of hypertension. We report the lessons learnt from the field. From each of the studies, we obtained information on the types of tasks shifted, the professional level from which the task was shifted, the training provided and the challenges faced. Additionally, we collected more granular data on ‘lessons learnt ’ throughout the implementation process and ‘design to implementation’ changes that emerged in each project. The tasks shifted to NPHWs included screening of individuals, referral to physicians for diagnosis and management, patient education for lifestyle improvement, follow-up and reminders for medication adherence and appointments. In four studies, tasks were shifted from physicians to NPHWs and in four studies tasks were shared between two different levels of NPHWs. Training programmes ranged between 3 and 7 days with regular refresher training. Two studies used clinical decision support tools and mobile health components. Challenges faced included system level barriers such as inability to prescribe medicines, varying skill sets of NPHWs, high workload and staff turnover. With the acute shortage of the health workforce in low-income and middle-income countries (LMICs), achieving better health outcomes for the prevention and control of CVD is a major challenge. Task-shifting or sharing provides a practical model for the management of CVD in LMICs.

Formative evaluation of a training intervention for community health workers in South Africa: A before and after study

BACKGROUND

Community Health Workers (CHWs) have a crucial role in improving health in their communities and their role is being expanded in many parts of the world. However, the effectiveness of CHWs is limited by poor training and the education of CHWs has received little scientific attention.

METHODS

Our study was carried out in two districts of KwaZulu-Natal, South Africa. We developed and piloted an inexpensive (two day) training intervention covering national government priorities: HIV/AIDS, sexually transmitted disease and Tuberculosis; and Women's Sexual and Reproductive Health and Rights. Sixty-four CHWs consented to participate in the main study which measured knowledge gains using a modified Solomon design of four different testing schedules to distinguish between the effects of the intervention, testing and any interaction between intervention and testing. We also measured confidence, satisfaction and costs.

RESULTS

Following the training intervention, improvements in knowledge scores were seen across topics and across districts. These changes in knowledge were statistically significant (p<0.001) and of large magnitude (over 45 percentage points or four standard deviations). However, the CHWs assigned to the test-test-train schedule in one district showed high gains in knowledge prior to receiving the training. All CHWs reported high levels of satisfaction with the training and marked improvements in their confidence in advising clients. The training cost around US$48 per CHW per day and has the potential to be cost-effective if the large gains in knowledge are translated into improved field-based performance and thus health outcomes.

CONCLUSION

Training CHWs can result in large improvements in knowledge with a short intervention. However, improvements seen in other studies could be due to test 'reactivity'. Further work is needed to measure the generalisability of our results, retention of knowledge and the extent to which improved knowledge is translated into improved practice.

Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa

Introduction

In low/middle-income countries with substantial HIV and tuberculosis epidemics, health services often neglect other highly prevalent chronic conditions, such as hypertension, which as a result are poorly managed. This paper reports on a study to assess the effect on hypertension management of lay health workers (LHW) working in South African rural primary healthcare clinics to support the provision of integrated chronic care.

Methods

A pragmatic cluster randomised trial with a process evaluation in eight rural clinics assessed the effect of adding two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months. Control clinics continued with usual care. The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure (BP) before and after the intervention, as measured by two cross-sectional population surveys.

Results

There was no improvement in BP control among users of intervention clinics as compared with control clinics. However, the LHWs improved clinic functioning, including overall attendance, and attendance on the correct day. All clinics faced numerous challenges, including rapidly increasing number of users of chronic care, unreliable BP machines and cuffs, intermittent drug shortages and insufficient space.

Conclusion

LHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients, the dominance of the vertically funded HIV programme and the poor standards of equipment in clinics.

Trial registration number

ISRCTN12128227.

Mobile phone use among patients and health workers to enhance primary healthcare: A qualitative study in rural South Africa

Mobile phones have the potential to improve access to healthcare information and services in low-resourced settings. This study investigated the use of mobile phones among patients with chronic diseases, pregnant women, and health workers to enhance primary healthcare in rural South Africa. Qualitative research was undertaken in Mpumalanga in 2014. Semi structured in-depth interviews were conducted with 113 patients and 43 health workers from seven primary healthcare clinics and one district hospital. Data were thematically analysed. We found that some health workers and patients used their own mobile phones for healthcare, bearing the cost themselves. Patients used their mobile phones to remind themselves to take medication or attend their clinic visits, and they appreciated receiving voice call reminders. Some patients and health workers accessed websites and used social media to gather health information, but lacked web search strategies. The use of the websites and social media was intermittent due to lack of financial ability to afford airtime among these patients and health workers. Many did not know what to search for and where to search. Doctors have developed their own informal mobile health solutions in response to their work needs and lack of resources due to their rurality. Physical and social factors influence the usability of mobile phones for healthcare, and this can shape communication patterns such as poor eyesight. The bottom-up use of mobile phones has been evolving to fill the gaps to augment primary care services in South Africa; however, barriers to access remain, such as poor digital infrastructure and low digital literacy.

The 'experimental public' in longitudinal health research: views of local leaders and service providers in rural South Africa

BACKGROUND

The concept of 'experimental public' has been recently applied to publics involved in clinical trials. This term could also be applied to publics involved in longitudinal research such as health and demographic surveillance systems. The ethics of practice and public engagement with these experimental publics are of key importance and include issues of informed consent, confidentiality, collection of body tissue samples and fair local benefit.

METHODS

Individual (n = 11) and focus group (n = 5) qualitative semi-structured interviews were conducted with 56 local leaders and service providers regarding their views about research activities in a longitudinal health research study site run by the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in rural South Africa. Deductive and inductive thematic analysis was undertaken using NVivo software to identify the emergent themes.

RESULTS

There was an understanding of the usefulness of collecting demographic data, but reasons for gathering other contextual data such as on food security, as well as the reasons for collection of blood was less clear. While appreciation was expressed for feedback of individual results such as blood pressure levels during home-based data collection, there were requests for more results from biomarkers, and for these to be given at home, rather than at the clinic. There were reports of indirect refusals, and offers by leaders to assist in reducing refusal rates. There were concerns about confidentiality, especially in the publication of results. Some leaders would have liked to receive more individual level data for planning of services, although they understood this would breach confidentiality. Service providers were concerned about the withdrawal of some services post intervention trials.

CONCLUSIONS

This experimental public has, over time, developed a nuanced understanding of the reasons for research and the procedures undertaken. Discussions concerning fair benefit ranged from requests for more individual clinically-relevant results for participants, to understanding how research results could assist in planning of public health services at local and national levels. The concerns illustrate the complexity of the ethics of practice which has implications for policy, practice and governance for those working in longitudinal health research sites globally.

Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries

Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control.

Burden of stroke attributable to selected lifestyle risk factors in rural South Africa

BACKGROUND

Rural South Africa (SA) is undergoing a rapid health transition characterized by increases in non-communicable diseases; stroke in particular. Knowledge of the relative contribution of modifiable risk factors on disease occurrence is needed for public health prevention efforts and community-oriented health promotion. Our aim was to estimate the burden of stroke in rural SA that is attributable to high blood pressure, excess weight and high blood glucose using World Health Organization's comparative risk assessment (CRA) framework.

METHODS

We estimated current exposure distributions of the risk factors in rural SA using 2010 data from the Agincourt health and demographic surveillance system (HDSS). Relative risks of stroke per unit of exposure were obtained from the Global Burden of Disease Study 2010. We used data from the Agincourt HDSS to estimate age-, sex-, and stroke specific deaths and disability adjusted life years (DALYs). We estimated the proportion of the years of life lost (YLL) and DALY loss attributable to the risk factors and incorporate uncertainty intervals into these estimates.

RESULTS

Overall, 38 % of the documented stroke burden was due to high blood pressure (12 % males; 26 % females). This translated to 520 YLL per year (95 % CI: 325-678) and 540 DALYs (CI: 343-717). Excess Body Mass Index (BMI) was calculated as responsible for 20 % of the stroke burden (3.5 % males; 16 % females). This translated to 260 YLLs (CI: 199-330) and 277 DALYs (CI: 211-350). Burden was disproportionately higher in young females when BMI was assessed.

CONCLUSIONS

High blood pressure and excess weight, which both have effective interventions, are responsible for a significant proportion of the stroke burden in rural SA; the burden varies across age and sex sub-groups. The most effective way forward to reduce the stroke burden requires both population wide policies that have an impact across the age spectra and targeted (health promotion/disease prevention) interventions on women and young people.

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme

Background

The Global Alliance for Chronic Diseases comprises the majority of the world’s public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects.

Methods

Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings.

Results

There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation.

Conclusions

The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0331-0) contains supplementary material, which is available to authorized users.