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Jafar TH, Tan NC, Shirore RM, Ramakrishnan C, Yoon S, Chen C, Aravindhan A. Post-Intervention Acceptability of a Multicomponent Intervention for Hypertension Management in Primary Care Clinics by Health Care Providers and Patients: A Qualitative Study of a Cluster RCT in Singapore. Patient Prefer Adherence 2024; 18:1603-1618. [PMID: 39104596 PMCID: PMC11299726 DOI: 10.2147/ppa.s469855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
Background Hypertension is a major public health challenge, globally. Recently, we reported findings from cluster randomized trial in 8 primary care clinics in Singapore and showed that a multicomponent "SingHypertension" intervention comprising 1) motivational conversation by trained nurses, 2) telephone-based follow-ups, 3) standardized algorithm with single-pill combination (SPC) antihypertensive medications, and 4) subsidy on SPC antihypertensive drugs was effective on improving BP control. This paper presents the acceptability of SingHypertension multicomponent intervention among the key stakeholders. Methods We conducted post-implementation interviews of 38 stakeholders, including 18 patients and 20 healthcare providers (HCPs) in 4 primary care clinics randomized to the multicomponent "SingHypertension" intervention in Singapore. We used Theoretical Framework for Acceptability (TFA) framework with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy to assess stakeholders' acceptability of the intervention. Results SingHypertension multicomponent intervention had high perceived effectiveness and a good fit with the value system and ethics of patients and HCPs. Physicians appreciated the guidance from standardized training in hypertension management. Although workload was increased, the nurses felt rewarded for their positive interactions with the patients during motivational conversation sessions and the telephone follow-ups. Most patients reported high self-efficacy levels, improved lifestyles, and adherence to antihypertensive medications. The limited choice of SPC medication, lack of subsidy beyond the trial duration, and shortage of nurses were significant challenges to wide-scale implementation. All HCPs and patients supported scaling up the intervention across primary care clinics. Conclusion SingHypertension multicomponent intervention is acceptable to the key stakeholders in Singapore. Taken together with the effectiveness of the intervention, our findings make a compelling case for scaling-up SingHypertension in primary care clinics in Singapore and possibly other countries with similar healthcare infrastructure.
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Affiliation(s)
- Tazeen H Jafar
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
- Global Health, Duke Global Health Institute, Durham, NC, USA
| | | | - Rupesh M Shirore
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Chandrika Ramakrishnan
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Sungwon Yoon
- Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Christina Chen
- PhD Student, Duke-NUS Medical School, Singapore, Singapore
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Satheesh G, Gyawali B, Sun MFC, Huffman MD, Banerjee A, Perel P, Murphy A. A Survey of Availability and Affordability of Polypills for Cardiovascular Disease in Selected Countries. Glob Heart 2024; 19:56. [PMID: 38973984 PMCID: PMC11225556 DOI: 10.5334/gh.1335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/10/2024] [Indexed: 07/09/2024] Open
Abstract
Background The recent inclusion of polypills-fixed-dose combinations of antihypertensive medicines and a statin with or without aspirin-in the World Health Organization's Essential Medicines List (EML) reiterates the potential of this approach to improve global treatment coverage for cardiovascular diseases (CVDs). Although there exists extensive evidence on the effectiveness, safety and acceptability of polypills, there has been no research to date assessing the real-world availability and affordability of polypills globally. Methods We conducted a cross-sectional survey, based on the WHO/Health Action International methodology, in 13 countries around the world. In the surveyed countries, we first ascertained whether any polypill was authorised for marketing and/or included in EMLs and clinical guidelines. In each country, we collected retail and price data for polypills from at least one public-sector facility and three private pharmacies using convenience sampling. Polypills were considered unaffordable if the lowest-paid worker spent more than a day's wage to purchase a monthly supply. Results Polypills were approved for marketing in four of the 13 surveyed countries: Spain, India, Mauritius and Argentina. None of these countries included polypills in national guidelines, formularies, or EMLs. In the four countries, no surveyed public pharmacies stocked polypills. In the private sector, we identified seven unique polypill combinations, marketed by eight different companies. Private sector availability was 100% in Argentina and Spain. Most combinations (n = 5) identified were in India. Combinations found in India and Spain were affordable in the local context. A lowest-paid government worker would spend between 0.2 (India) and 2.8 (Mauritius) days' wages to pay the price for one month's supply of the polypills. Polypills were likely to be affordable if they were manufactured in the same country. Conclusion Low availability and affordability of polypills in the public sector suggest that implementation remains poor globally. Context-specific multi-disciplinary health system research is required to understand factors affecting polypill implementation and to design and evaluate appropriate implementation strategies.
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Affiliation(s)
| | - Bishal Gyawali
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Mark D. Huffman
- Washington University in St. Louis, St. Louis, Missouri, USA
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
| | - Pablo Perel
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- World Heart Federation, Geneva, Switzerland
| | - Adrianna Murphy
- Department of Health Service Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Willis R, Akik C, El-Dirani Z, Truppa C, Zmeter C, Fleri F, Perone SA, Paci R, Frederiksen S, Haidar CA, Hamadeh RS, Fouad FM, Perel P, Roberts B, Ansbro É. Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001383. [PMID: 38055706 DOI: 10.1371/journal.pgph.0001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/19/2023] [Indexed: 12/08/2023]
Abstract
Humanitarian health care models increasingly incorporate care for non-communicable diseases (NCDs). Current research evidence focuses on burden of disease, service provision and access to care, and less is known about patient's experience of the continuum of care in humanitarian settings. To address this gap, this study explored experiences of displaced Syrian and vulnerable Lebanese patients receiving care for hypertension and/or diabetes at four health facilities supported by humanitarian organisations in Lebanon. We conducted in-depth, semi-structured qualitative interviews with a purposive sample of patients (n = 18) and their informal caregivers (n = 10). Data were analysed thematically using both deductive and inductive approaches. Both Syrian and Lebanese patients reported interrupted pathways of care. We identified three typologies of patient experience at the time of interview; (1) managing adequately from the patient's perspective; (2) fragile management and (3) unable to manage their condition(s) adequately, with the majority falling into typologies 2 and 3. Patients and their families recognised the importance of maintaining continuity of care and self-management, but experienced substantial challenges due to changing availability and cost of medications and services, and decreasing economic resources during a period of national crises. Family support underpinned patient's response to challenges. Navigating the changing care landscape was a significant burden for patients and their families. Interactions were identified between mental health and NCD management. This study suggests that patients experienced disrupted, non-linear pathways in maintaining care for hypertension and diabetes in a humanitarian setting, and family support networks were key in absorbing treatment burden and sustaining NCD management. Recommendations are made to reduce treatment burden for patients and their families and to support sustainable condition management.
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Affiliation(s)
- Ruth Willis
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chaza Akik
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Zeinab El-Dirani
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Claudia Truppa
- International Committee of the Red Cross, Beirut, Lebanon
| | - Carla Zmeter
- International Committee of the Red Cross, Beirut, Lebanon
| | - Fabrizio Fleri
- International Committee of the Red Cross, Beirut, Lebanon
| | - Sigiriya Aebischer Perone
- International Committee of the Red Cross, Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | | | | | - Randa S Hamadeh
- Primary Healthcare and Social Health Department, Ministry of Public Health, Lebanon
| | - Fouad M Fouad
- Faculty of Health Sciences, Department of Epidemiology and Population Health, American University of Beirut, Lebanon
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bayard Roberts
- Faculty of Public Health and Policy, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Éimhín Ansbro
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ansbro É, Masri S, Prieto-Merino D, Willis R, Aoun Bahous S, Molfino L, Boulle P, Perel P. Fixed dose combination drugs for cardiovascular disease in a prolonged humanitarian crisis in Lebanon: an implementation study. BMJ Open 2023; 13:e063668. [PMID: 36697043 PMCID: PMC9884866 DOI: 10.1136/bmjopen-2022-063668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 12/12/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES This pre-post implementation study evaluated the introduction of fixed dose combination (FDC) medications for atherosclerotic cardiovascular disease (ASCVD) secondary prevention into routine care in a humanitarian setting. SETTING Two Médecins sans Frontières (MSF) primary care clinics serving Syrian refugee and host populations in north Lebanon. PARTICIPANTS Consenting patients ≥18 years with existing ASCVD requiring secondary prevention medication were eligible for study enrolment. Those with FDC contraindication(s) or planning to move were excluded. Of 521 enrolled patients, 460 (88.3%) were retained at 6 months, and 418 (80.2%) switched to FDC. Of these, 84% remained on FDC (n=351), 8.1% (n=34) discontinued and 7.9% (n=33) were lost to follow-up by month 12. INTERVENTIONS Eligible patients, enrolled February-May 2019, were switched to Trinomia FDC (atorvastatin 20 mg, aspirin 100 mg, ramipril 2.5/5/10 mg) after 6 months' usual care. During the study, the COVID-19 pandemic, an economic crisis and clinic closures occurred. OUTCOME MEASURES Descriptive and regression analyses compared key outcomes at 6 and 12 months: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) and systolic blood pressure (SBP) control. We performed per-protocol, intention-to-treat and secondary analyses of non-switchers. RESULTS Among 385 switchers remaining at 12 months, total adherence improved 23%, from 63% (95% CI 58 to 68) at month 6, to 86% (95% CI 82 to 90) at month 12; mean non-HDL-C levels dropped 0.28 mmol/L (95% CI -0.38 to -0.18; p<0.0001), from 2.39 (95% CI 2.26 to 2.51) to 2.11 mmol/L (95% CI 2.00 to 2.22); mean SBP dropped 2.89 mm Hg (95% CI -4.49 to -1.28; p=0.0005) from 132.7 (95% CI 130.8 to 134.6) to 129.7 mm Hg (95% CI 127.9 to 131.5). Non-switchers had smaller improvements in adherence and clinical outcomes. CONCLUSION Implementing an ASCVD secondary prevention FDC improved adherence and CVD risk factors in MSF clinics in Lebanon, with potential for wider implementation by humanitarian actors and host health systems.
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Affiliation(s)
- Éimhín Ansbro
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, London, UK
| | | | - David Prieto-Merino
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, London, UK
| | - Ruth Willis
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| | - Sola Aoun Bahous
- Department of Internal Medicine, School of Medicine, Lebanese American University, Beirut, Lebanon
| | | | | | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Faculty of Epidemiology & Population Health, London, UK
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