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Schwab J, Wachinger J, Munana R, Nabiryo M, Sekitoleko I, Cazier J, Ingenhoff R, Favaretti C, Subramonia Pillai V, Weswa I, Wafula J, Emmrich JV, Bärnighausen T, Knauf F, Knauss S, Nalwadda CK, Sudharsanan N, Kalyesubula R, McMahon SA. Design Research to Embed mHealth into a Community-Led Blood Pressure Management System in Uganda: Protocol for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e46614. [PMID: 38032702 PMCID: PMC10722357 DOI: 10.2196/46614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Uncontrolled hypertension is a leading risk factor for cardiovascular diseases. In Uganda, such diseases account for approximately 10% of all deaths, with 1 in 5 adults having hypertension (>90% of the hypertensive cases are uncontrolled). Although basic health care in the country is available free of cost at government facilities, regularly accessing medication to control hypertension is difficult because supply chain challenges impede availability. Clients therefore frequently suspend treatment or buy medication individually at private facilities or pharmacies (incurring significant costs). In recent years, mobile health (mHealth) interventions have shown increasing potential in addressing health system challenges in sub-Saharan Africa, but the acceptability, feasibility, and uptake conditions of mobile money approaches to chronic disease management remain understudied. OBJECTIVE This study aims to design and pilot-test a mobile money-based intervention to increase the availability of antihypertensive medication and lower clients' out-of-pocket payments. We will build on existing local approaches and assess the acceptability, feasibility, and uptake of the designed intervention. Furthermore, rather than entering the study setting with a ready-made intervention, this research will place emphasis on gathering applied ethnographic insights early, which can then inform the parameters of the intervention prototype and concurrent trial. METHODS We will conduct a mixed methods study following a human-centered design approach. We will begin by conducting extensive qualitative research with a range of stakeholders (clients; health care providers; religious, cultural, and community leaders; academics; and policy makers at district and national levels) on their perceptions of hypertension management, money-saving systems, and mobile money in the context of health care. Our results will inform the design, iterative adaptation, and implementation of an mHealth-facilitated pooled financing intervention prototype. At study conclusion, the finalized prototype will be evaluated quantitatively via a randomized controlled trial. RESULTS As of August 2023, qualitative data collection, which started in November 2022, is ongoing, with data analysis of the first qualitative interviews underway to inform platform and implementation design. Recruitment for the quantitative part of this study began in August 2023. CONCLUSIONS Our results aim to inform the ongoing discourse on novel and sustainable pathways to facilitate access to medication for the management of hypertension in resource-constrained settings. TRIAL REGISTRATION German registry of clinical trials DRKS00030922; https://drks.de/search/en/trial/DRKS00030922. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46614.
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Affiliation(s)
- Josephine Schwab
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Jonas Wachinger
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Richard Munana
- African Community Center for Social Sustainability, Nakaseke District, Uganda
| | - Maxencia Nabiryo
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Isaac Sekitoleko
- African Community Center for Social Sustainability, Nakaseke District, Uganda
| | | | - Rebecca Ingenhoff
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Caterina Favaretti
- Professorship of Behavioral Science for Disease Prevention and Health Care, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Vasanthi Subramonia Pillai
- Professorship of Behavioral Science for Disease Prevention and Health Care, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Ivan Weswa
- African Community Center for Social Sustainability, Nakaseke District, Uganda
| | - John Wafula
- African Community Center for Social Sustainability, Nakaseke District, Uganda
| | - Julius Valentin Emmrich
- mTOMADY gGmbh, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, United States
| | - Samuel Knauss
- mTOMADY gGmbh, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christine K Nalwadda
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nikkil Sudharsanan
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Professorship of Behavioral Science for Disease Prevention and Health Care, TUM School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Robert Kalyesubula
- African Community Center for Social Sustainability, Nakaseke District, Uganda
- Department of Physiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Shannon A McMahon
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
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Duan L, Zhang L, Zhang X, Lu S. Trends in output of hypertension management and associated factors in primary care facilities: a latent trajectory analysis in China from 2009 to 2017. BMC PRIMARY CARE 2023; 24:178. [PMID: 37674136 PMCID: PMC10483735 DOI: 10.1186/s12875-023-02139-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The prevalence of hypertension is high (25.2% in 2012) and there were a large number of patients with hypertension (more than 200 million) in China. Township health centres in rural areas and community health centres in urban areas are responsible for hypertension management. This study aims to identify trends in hypertension management output and related facility-level, geographical and economic factors in primary care facilities and to assess the effect of the national project of basic public health services in China from 2009 to 2017. METHODS A cross-sectional survey (2018) was combined with retrospective data collection (2009-2017) from 685 primary care facilities in six provinces in China. The hypertension management output was indicated by the number of patients with hypertension under management per 10,000 population. Latent class growth analysis and group-based trajectory models were applied to classify trajectories and determine associations with facility-level, geographic and economic characteristics. RESULTS The trend in the output increased rapidly from 2009 to 2012 with an average growth rate of 54.58% and slowed down from 2012 to 2017 (growth rate of 5.94%). Five trajectories of the output were identified and labelled according to baseline status and increase rates: low-gradually increasing (16.9%), middle-slightly increasing (16.2%), low-sharply increasing (7.9%), middle-sharply increasing (34.2%) and persistently high (24.9%). The time-stable characteristics, including region (eastern, central or western), district (urban or rural), landform, were associated with hypertension management output of the facilities. Number of public health physicians was a significant time-dependent characteristic influencing management output. CONCLUSIONS Five latent trajectories of hypertension management output were identified. The output was still at a low level compared with the prevalence of hypertension. Hypertension screening in young people need to be emphasized. Facilities are recommended to establish good relationships with residents for better hypertension management outcomes especially in urban areas.
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Affiliation(s)
- Lei Duan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China
| | - Liang Zhang
- School of Political Science and Public Administration, Wuhan University, Wuhan, 430072, China
| | - Xiang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shan Lu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Research Centre for Rural Health Service, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, China.
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Castillo-Laborde C, Hirmas-Adauy M, Matute I, Jasmen A, Urrejola O, Molina X, Awad C, Frey-Moreno C, Pumarino-Lira S, Descalzi-Rojas F, Ruiz TJ, Plass B. Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review. Public Health Rev 2022; 43:1604796. [PMID: 36120091 PMCID: PMC9479461 DOI: 10.3389/phrs.2022.1604796] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: Identify barriers and facilitators in access to medicines for diabetes, hypertension, and dyslipidemia, considering patient, health provider, and health system perspectives. Methods: Scoping review based on Joanna Briggs methodology. The search considered PubMed, Cochrane Library, CINAHL, Academic Search Ultimate, Web of Science, SciELO Citation Index, and grey literature. Two researchers conducted screening and eligibility phases. Data were thematically analyzed. Results: The review included 219 documents. Diabetes was the most studied condition; most of the evidence comes from patients and the United States. Affordability and availability of medicines were the most reported dimension and specific barrier respectively, both cross-cutting concerns. Among high- and middle-income countries, identified barriers were cost of medicines, accompaniment by professionals, long distances to facilities, and cultural aspects; cost of transportation emerges in low-income settings. Facilitators reported were financial accessibility, trained health workers, medicines closer to communities, and patients’ education. Conclusion: Barriers and facilitators are determined by socioeconomic and cultural conditions, highlighting the role of health systems in regulatory and policy context (assuring financial coverage and free medicines); providers’ role bringing medicines closer; and patients’ health education and disease management.
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Affiliation(s)
- Carla Castillo-Laborde
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
- *Correspondence: Carla Castillo-Laborde,
| | - Macarena Hirmas-Adauy
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Isabel Matute
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Anita Jasmen
- Biblioteca Biomédica, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Oscar Urrejola
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Xaviera Molina
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Camila Awad
- Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Catalina Frey-Moreno
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Sofia Pumarino-Lira
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Fernando Descalzi-Rojas
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Tomás José Ruiz
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Barbara Plass
- Carrera de Medicina, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
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Barriers to up-titrated antihypertensive strategies in 12 sub-Saharan African countries: the Multination Evaluation of hypertension in Sub-Saharan Africa Study. J Hypertens 2022; 40:1411-1420. [PMID: 35762480 DOI: 10.1097/hjh.0000000000003169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sub-Saharan Africa (SSA) faces the highest rate of hypertension worldwide. The high burden of elevated blood pressure (BP) in black people has been emphasized. Guidelines recommend two or more antihypertensive medications to achieve a BP control. We aimed to identify factors associated with prescription of up-titrated antihypertensive strategies in Africa. METHODS We conducted a cross-sectional study on outpatient consultations for hypertension across 12 SSA countries. Collected data included socioeconomic status, antihypertensive drugs classes, BP measures, cardiovascular risk factors and complication of hypertension. We used ordinal logistic regression to assess factors associated with prescription of up-titrated strategies. RESULTS The study involved 2123 treated patients with hypertension. Patients received monotherapy in 36.3 vs. 25.9%, two-drug in 42.2 vs. 45% and three and more drugs strategies in 21.5 vs. 29.1% in low (LIC) and middle (MIC) income countries, respectively. Patients with sedentary lifestyle [OR 1.4 (1.11-1.77)], complication of hypertension [OR 2.4 (1.89-3.03)], former hypertension [OR 3.12 (2.3-4.26)], good adherence [OR 1.98 (1.47-2.66)], from MIC [OR 1.38 (1.10-1.74)] and living in urban areas [OR 1.52 (1.16-1.99)] were more likely to be treated with up-titrated strategies. Stratified analysis shows that in LIC, up-titrated strategies were less frequent in rural than in urban patients (P for trend <0.01) whereas such difference was not observed in MIC. CONCLUSION In this African setting, in addition to expected factors, up-titrated drug strategies were associated with country-level income, patient location and finally, the interplay between both in LIC. These results highlight the importance of developing policies that seek to make multiple drug classes accessible particularly in rural and LIC.
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Ojji DB, Baldridge AS, Orji IA, Shedul GL, Ojo TM, Ye J, Chopra A, Ale BM, Shedul G, Ugwuneji EN, Egenti NB, Omitiran K, Okoli RC, Eze H, Nwankwo A, Banigbe B, Tripathi P, Kandula NR, Hirschhorn LR, Huffman MD. Characteristics, treatment, and control of hypertension in public primary healthcare centers in Nigeria: baseline results from the Hypertension Treatment in Nigeria Program. J Hypertens 2022; 40:888-896. [PMID: 35034080 PMCID: PMC9081131 DOI: 10.1097/hjh.0000000000003089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are limited data on large-scale, multilevel implementation research studies to improve hypertension diagnosis, treatment, and control rates at the primary healthcare (PHC) level in Africa. We describe the characteristics, treatment, and control rates of patients with hypertension in public PHC centers in the Hypertension Treatment in Nigeria Program. METHODS Data were collected from adults at least 18 years at 60 public PHC centers between January 2020 and November 2020. Hypertension treatment rates were calculated at registration and upon completion of the initial visit. Hypertension control rates were calculated based on SBP and DBPs less than 140/90 mmHg. Regression models were created to evaluate factors associated with hypertension treatment and control status. RESULTS Four thousand, nine hundred and twenty-seven individuals [66.7% women, mean (SD) age = 48.2 (12.9) years] were included. Mean (SD) SBP was higher in men compared with women [152.9 (20.0) mmHg versus 150.8 (21) mmHg, P = 0.001]. Most (58.3%) patients were on treatment at the time of registration, and by the end of the baseline visit, 89.2% of patients were on treatment. The baseline hypertension control rate was 13.1%, and control was more common among patients who were older [adjusted OR (95% CI) 1.01 [1.01 -1.02)], women [adjusted OR (95% CI) 1.30 (1.05- 1.62)], who used fixed dose combination therapy [adjusted OR (95% CI) 1.83 (1.49 -2.26)], and had higher education levels. CONCLUSION This baseline report of the largest facility-based hypertension study in Africa demonstrates high hypertension treatment rates but low control rates.
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Affiliation(s)
- Dike B. Ojji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- University of Abuja, Abuja, Nigeria
| | | | - Ikechukwu A. Orji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Gabriel L. Shedul
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Tunde M. Ojo
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Jiancheng Ye
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aashima Chopra
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Boni M. Ale
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Grace Shedul
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Eugenia N. Ugwuneji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Nonye B. Egenti
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Kasarachi Omitiran
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | | | - Helen Eze
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Ada Nwankwo
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Bolanle Banigbe
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Priya Tripathi
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Lisa R. Hirschhorn
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mark D. Huffman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- The George Institute for Global Health, Sydney, Australia
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Okoli RCB, Shedul G, Hirschhorn LR, Orji IA, Ojo TM, Egenti N, Omitiran K, Akor B, Baldridge AS, Huffman MD, Ojji D, Kandula NR. Stakeholder perspectives to inform adaptation of a hypertension treatment program in primary healthcare centers in the Federal Capital Territory, Nigeria: a qualitative study. Implement Sci Commun 2021; 2:97. [PMID: 34462016 PMCID: PMC8404273 DOI: 10.1186/s43058-021-00197-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 08/05/2021] [Indexed: 12/01/2022] Open
Abstract
Background Implementing an evidence-based hypertension program in primary healthcare centers (PHCs) in the Federal Capital Territory, Nigeria is an opportunity to improve hypertension diagnosis, treatment, and control and reduce deaths from cardiovascular diseases. This qualitative research study was conducted in Nigerian PHCs with patients, non-physician health workers, administrators and primary care physicians to inform contextual adaptations of Kaiser Permanente Northern California's hypertension model and the World Health Organization’s HEARTS technical package for the system-level, Hypertension Treatment in Nigeria (HTN) Program. Methods Purposive sampling in 8 PHCs identified patients (n = 8), non-physician health workers (n = 12), administrators (n = 3), and primary care physicians (n = 6) for focus group discussions and interviews. The Primary Health Care Performance Initiative (PHCPI) conceptual framework and Consolidated Framework for Implementation Research (CFIR) domains were used to develop semi-structured interviews (Appendix 1, Supplemental Materials) and coding guides. Content analysis identified multilevel factors that would influence program implementation. Results Participants perceived the need to strengthen four major health system inputs across CFIR domains for successful adaptation of the HTN Program components: (1) reliable drug supply and blood pressure measurement equipment, (2) enable and empower community healthcare workers to participate in team-based care through training and education, (3) information systems to track patients and medication supply chain, and (4) a primary healthcare system that could offer a broader package of health services to meet patient needs. Specific features of the PHCPI framework considered important included: accessible and person-centered care, provider availability and competence, coordination of care, and proactive community outreach. Participants also identified patient-level factors, such as knowledge and beliefs about hypertension, and financial and transportation barriers that could be addressed with better communication, home visits, and drug financing. Participants recommended using existing community structures, such as village health committees and popular opinion leaders, to improve knowledge and demand for the HTN Program. Conclusions These results provide information on specific primary care and community contextual factors that can support or hinder implementation and sustainability of an evidence-based, system-level hypertension program in the Federal Capital Territory, Nigeria, with the ultimate aim of scaling it to other parts of the country. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00197-8.
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Affiliation(s)
| | - Gabriel Shedul
- University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria
| | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, 420 E Superior, 6th Floor, Chicago, IL, 60611, USA
| | - Ikechukwu A Orji
- University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria
| | - Tunde M Ojo
- University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria
| | - Nonye Egenti
- University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria
| | | | - Blessing Akor
- University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria
| | - Abigail S Baldridge
- Feinberg School of Medicine, Northwestern University, 420 E Superior, 6th Floor, Chicago, IL, 60611, USA
| | - Mark D Huffman
- Feinberg School of Medicine, Northwestern University, 420 E Superior, 6th Floor, Chicago, IL, 60611, USA
| | - Dike Ojji
- University of Abuja Teaching Hospital Gwagwalada, Abuja, Nigeria
| | - Namratha R Kandula
- Feinberg School of Medicine, Northwestern University, 420 E Superior, 6th Floor, Chicago, IL, 60611, USA.
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7
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Edward A, Campbell B, Manase F, Appel LJ. Patient and healthcare provider perspectives on adherence with antihypertensive medications: an exploratory qualitative study in Tanzania. BMC Health Serv Res 2021; 21:834. [PMID: 34407820 PMCID: PMC8371775 DOI: 10.1186/s12913-021-06858-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/04/2021] [Indexed: 01/20/2023] Open
Abstract
Background Poor medication adherence is an extraordinarily common problem worldwide that contributes to inadequate control of many chronic diseases, including Hypertension (HT). Globally, less than 14% of the estimated 1.4 billion patients with HT achieve optimal control. A myriad of barriers, across patient, healthcare provider, and system levels, contributes to poor medication adherence. Few studies have explored the reasons for poor medication adherence in Tanzania and other African countries. Methods A qualitative study applying grounded theory principles was conducted in the catchment area of two semi-urban clinics in Dar es Salaam, Tanzania, to determine the perceived barriers to HT medication adherence. Ten key informant interviews were conducted with healthcare providers who manage HT patients. Patients diagnosed with HT (SBP ≥ 140 and DBP ≥ 90), were randomly selected from patient registers, and nine focus group discussions were conducted with a total 34 patients. Inductive codes were developed separately for the two groups, prior to analyzing key thematic ideas with smaller sub-categories. Results Affordability of antihypertensive medication and access to care emerged as the most important barriers. Fee subsidies for treatment and medication, along with health insurance, were mentioned as potential solutions to enhance access and adherence. Patient education and quality of physician counseling were mentioned by both providers and patients as major barriers to medication adherence, as most patients were unaware of their HT and often took medications only when symptomatic. Use of local herbal medicines was mentioned as an alternative to medications, as they were inexpensive, available, and culturally acceptable. Patient recommendations for improving adherence included community-based distribution of refills, SMS text reminders, and family support. Reliance on religious leaders over healthcare providers emerged as a potential means to promote adherence in some discussions. Conclusions Effective management of hypertensive patients for medication adherence will require several context-specific measures. These include policy measures addressing financial access, with medication subsidies for the poor and accessible distribution systems for medication refill; physician measures to improve health provider counseling for patient centric care; and patient-level strategies with reminders for medication adherence in low resource settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06858-7.
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Affiliation(s)
- Anbrasi Edward
- Department of International Health, Johns Hopkins University, Baltimore, USA.
| | - Brady Campbell
- University of Iowa Carver College of Medicine, Iowa City, USA
| | - Frank Manase
- Community Center for Preventive Medicine, Dar es Salaam, Tanzania
| | - Lawrence J Appel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, and Johns Hopkins School of Nursing, Baltimore, MD, USA
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Stephens JH, Alizadeh F, Bamwine JB, Baganizi M, Chaw GF, Yao Cohen M, Patel A, Schaefle KJ, Mangat JS, Mukiza J, Paccione GA. Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic. PLoS One 2020; 15:e0234049. [PMID: 32502169 PMCID: PMC7274420 DOI: 10.1371/journal.pone.0234049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/17/2020] [Indexed: 11/19/2022] Open
Abstract
The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.
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Affiliation(s)
- Joseph H. Stephens
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York, United States of America
- * E-mail:
| | - Faraz Alizadeh
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Boston Children’s Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Boston Medical Center/Boston University, Boston, Massachusetts, United States of America
| | - John Bosco Bamwine
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
| | | | - Gloria Fung Chaw
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York, United States of America
| | - Morgen Yao Cohen
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York, United States of America
| | - Amit Patel
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York, United States of America
| | - K. J. Schaefle
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York, United States of America
| | - Jasdeep Singh Mangat
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
| | - Joel Mukiza
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
| | - Gerald A. Paccione
- Kisoro District Hospital, Kisoro, Uganda
- Doctors for Global Health, Kisoro, Uganda
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York, United States of America
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9
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van der Linden EL, Agyemang C, van den Born BJH. Hypertension control in sub-Saharan Africa: Clinical inertia is another elephant in the room. J Clin Hypertens (Greenwich) 2020; 22:959-961. [PMID: 32431011 PMCID: PMC7383612 DOI: 10.1111/jch.13874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/05/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Eva L van der Linden
- Department of Public Health, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal and Vascular Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Agyemang
- Department of Public Health, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert-Jan H van den Born
- Department of Public Health, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal and Vascular Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
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10
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Nutakor JA, Dai B, Gavu AK, Antwi OA. Relationship between chronic diseases and sleep duration among older adults in Ghana. Qual Life Res 2020; 29:2101-2110. [PMID: 32100183 DOI: 10.1007/s11136-020-02450-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Aging increases the prevalence of health problems that are often chronic, resulting in more sleep problems for people with poor health or chronic conditions. Relatively fewer studies have been conducted on the relationship between sleep duration and chronic conditions in Sub-Saharan Africa compared to Western or Asian populations. This study uses a nationally representative sample of older adults in Ghana to examine the association between sleep duration and chronic conditions. METHOD Data were gathered from the World Health Organization Study on Global AGEing and Adult Health (SAGE) Wave 1 in Ghana (n = 3617). Data on duration of sleep and chronic conditions were derived from self-reported data and validated symptom reporting. Multinomial logistic regression was conducted to examine the association between sleep duration and chronic conditions. RESULTS Women had a significantly longer period of sleep than men. Older people (> 60 years) were more likely than people under 60 years old to sleep for longer periods. The prevalence of stroke, depression, and chronic lung disease among long sleepers was high compared with short and medium sleepers. Our study found that respondents with stroke, arthritis, depression, chronic lung disease, asthma, and hypertension were likely to sleep for a long time. CONCLUSION This study showed a significant association between long hours of sleep and chronic conditions. To health professionals, paying particular attention to this association among older adults is medically important.
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Affiliation(s)
- Jonathan Aseye Nutakor
- Department of Health Policy and Management, School of Management, Jiangsu University, 301 Xuefu Road, Zhenjiang, Jiangsu Province, China
| | - Baozhen Dai
- Department of Health Policy and Management, School of Management, Jiangsu University, 301 Xuefu Road, Zhenjiang, Jiangsu Province, China.
| | | | - Osei-Asibey Antwi
- Kwame Nkrumah University of Science and Technology, PMB, Kumasi, Ghana
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11
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Heller DJ, Kumar A, Kishore SP, Horowitz CR, Joshi R, Vedanthan R. Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis. JAMA Netw Open 2019; 2:e1916545. [PMID: 31790570 PMCID: PMC6902752 DOI: 10.1001/jamanetworkopen.2019.16545] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood. OBJECTIVE To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries. DATA SOURCES All systematic reviews in PubMed published by May 1, 2018. STUDY SELECTION The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed. DATA EXTRACTION AND SYNTHESIS Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive. MAIN OUTCOMES AND MEASURES All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems. RESULTS This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles. CONCLUSIONS AND RELEVANCE Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.
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Affiliation(s)
- David J. Heller
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anirudh Kumar
- Department of Medicine, New York University School of Medicine, New York
| | - Sandeep P. Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Carol R. Horowitz
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rohina Joshi
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Rajesh Vedanthan
- Department of Population Health, New York University School of Medicine, New York
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12
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Hertz JT, Sakita FM, Manavalan P, Madut DB, Thielman NM, Mmbaga BT, Staton CA, Galson SW. The Burden of Hypertension and Diabetes in an Emergency Department in Northern Tanzania. Ethn Dis 2019; 29:559-566. [PMID: 31641323 DOI: 10.18865/ed.29.4.559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa. Methods A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL. Results Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic complications, the most common admission diagnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%). Conclusions The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hypertension and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hospitalizations highlights the urgent need for improvements in primary preventative care in Tanzania.
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Affiliation(s)
- Julian T Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC.,Duke Global Health Institute, Duke University, Durham, NC
| | - Francis M Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Deng B Madut
- Department of Medicine, Duke University, Durham, NC
| | | | - Blandina T Mmbaga
- Kilimanjaro Christian Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Catherine A Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC.,Duke Global Health Institute, Duke University, Durham, NC
| | - Sophie W Galson
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, NC
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13
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Wamba AA, Takah NF, Johnman C. The impact of interventions for the primary prevention of hypertension in Sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2019; 14:e0219623. [PMID: 31323041 PMCID: PMC6641142 DOI: 10.1371/journal.pone.0219623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/27/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The prevalence of hypertension is highest in the African Region with 46% of adults aged 25 and above diagnosed with hypertension, while the lowest prevalence of 35% is found in the Americas. There is sparse evidence on the approaches used to prevent hypertension in Sub-Saharan Africa and the effectiveness of these approaches. It is therefore imperative that a systematic review; which synthesises all the available evidence on the approaches and their impact is conducted to inform public health policy and practice. OBJECTIVE To synthesise evidence on the interventions used for the primary prevention of hypertension in Sub-Saharan Africa and to evaluate the effectiveness of these interventions in reducing blood pressure, hypertension prevalence and the risk factors for hypertension. METHODS AND RESULTS This systematic review was reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Bibliographic databases were searched on the 4th-17th of January 2018 from 1970 to January 2018 and on the 5th of May 2019 from 1970 to May 2019, for studies focusing on the primary prevention of hypertension in communities in Sub-Saharan Africa. A narrative synthesis was conducted based on study interventions and outcomes. Also, a meta-analysis was carried out using pooled mean differences; using a random effects model of generic inverse variance option in RevMan. A total of 854 studies were identified after deduplication, with thirteen studies meeting the inclusion criteria. Six studies with varying interventions and methodologies observed a significant pooled reduction in systolic blood pressure of -3.3mmHg (95%CI -4.64 to -1.96) and a reduction of -2.26mmHg (95%CI -6.36 to 1.85) in diastolic blood pressure, which was not statistically significant (p = 0.28). Also, moderate to significant heterogeneity was observed (I2 = 68% and 99%) for the systolic and diastolic blood pressure respectively. Intervention and study design accounted for 100% heterogeneity for both systolic and diastolic blood pressure (r2 = 100%). CONCLUSION Health promotion and interventions targeting various risk factors of hypertension and, salt consumption restriction interventions have been employed in Sub-Saharan Africa with varying levels of success. We recommend that higher quality studies and a meta-analysis are needed to evaluate the impact of these interventions and to inform public health policy and practice.
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Affiliation(s)
- Akosua A. Wamba
- Emergency Department, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Noah F. Takah
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Cathy Johnman
- Institute of Health and Well-being, University of Glasgow, Glasgow, United Kingdom
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14
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Adopting Task-Shifting Strategies for Hypertension Control in Ghana:
Insights From a Realist Synthesis of Stakeholder Perceptions. Glob Heart 2019; 14:119-127. [DOI: 10.1016/j.gheart.2019.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 11/21/2022] Open
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15
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Nelissen HE, Cremers AL, Okwor TJ, Kool S, van Leth F, Brewster L, Makinde O, Gerrets R, Hendriks ME, Schultsz C, Osibogun A, van’t Hoog AH. Pharmacy-based hypertension care employing mHealth in Lagos, Nigeria - a mixed methods feasibility study. BMC Health Serv Res 2018; 18:934. [PMID: 30514376 PMCID: PMC6277995 DOI: 10.1186/s12913-018-3740-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/20/2018] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Heleen E. Nelissen
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
| | - Anne L. Cremers
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
- Department of Anthropology, University of Amsterdam, Nieuwe Achtergracht 166, Amsterdam, The Netherlands
- Department of Infectious Diseases, Division of Internal Medicine, Amsterdam UMC, University of Amsterdam, Center of Tropical Medicine and Travel Medicine, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tochi J. Okwor
- Centre for Epidemiology and Health Development, Ibeju, Lekki, Lagos Nigeria
- Department of Community Health, University of Nigeria Teaching Hospital Enugu, P.M.B, Enugu, 01129 Nigeria
| | - Sam Kool
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
| | - Frank van Leth
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
| | - Lizzy Brewster
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
| | - Olalekan Makinde
- Department of Community Health, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - René Gerrets
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
- Department of Anthropology, University of Amsterdam, Nieuwe Achtergracht 166, Amsterdam, The Netherlands
| | | | - Constance Schultsz
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
| | - Akin Osibogun
- Centre for Epidemiology and Health Development, Ibeju, Lekki, Lagos Nigeria
- Department of Community Health, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Anja H. van’t Hoog
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 25, Amsterdam, The Netherlands
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16
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Ogedegbe G, Plange-Rhule J, Gyamfi J, Chaplin W, Ntim M, Apusiga K, Iwelunmor J, Awudzi KY, Quakyi KN, Mogaverro J, Khurshid K, Tayo B, Cooper R. Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana. PLoS Med 2018; 15:e1002561. [PMID: 29715303 PMCID: PMC5929500 DOI: 10.1371/journal.pmed.1002561] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/26/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage (HIC) alone versus a nurse-led task shifting strategy for hypertension control (TASSH) plus HIC on systolic blood pressure (SBP) reduction among patients with uncontrolled hypertension in Ghana. METHODS AND FINDINGS Using a pragmatic cluster randomized trial, 32 community health centers within Ghana's public healthcare system were randomly assigned to either HIC alone or TASSH + HIC. A total of 757 patients with uncontrolled hypertension were recruited between November 28, 2012, and June 11, 2014, and followed up to October 7, 2016. Both intervention groups received health insurance coverage plus scheduled nurse visits, while TASSH + HIC comprised cardiovascular risk assessment, lifestyle counseling, and initiation/titration of antihypertensive medications for 12 months, delivered by trained nurses within the healthcare system. The primary outcome was change in SBP from baseline to 12 months. Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months. Of the 757 patients (389 in the HIC group and 368 in the TASSH + HIC group), 85% had 12-month data available (60% women, mean BP 155.9/89.6 mm Hg). In intention-to-treat analyses adjusted for clustering, the TASSH + HIC group had a greater SBP reduction (-20.4 mm Hg; 95% CI -25.2 to -15.6) than the HIC group (-16.8 mm Hg; 95% CI -19.2 to -15.6), with a statistically significant between-group difference of -3.6 mm Hg (95% CI -6.1 to -0.5; p = 0.021). Blood pressure control improved significantly in both groups (55.2%, 95% CI 50.0% to 60.3%, for the TASSH + HIC group versus 49.9%, 95% CI 44.9% to 54.9%, for the HIC group), with a non-significant between-group difference of 5.2% (95% CI -1.8% to 12.4%; p = 0.29). Lifestyle behaviors did not change appreciably in either group. Twenty-one adverse events were reported (9 and 12 in the TASSH + HIC and HIC groups, respectively). The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits, if any, of the TASSH + HIC group. CONCLUSIONS Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone, among patients with uncontrolled hypertension in Ghana. Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost-benefit analysis. TRIAL REGISTRATION ClinicalTrials.gov NCT01802372.
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Affiliation(s)
- Gbenga Ogedegbe
- Department of Population Health, New York University School of Medicine, New York, New York, United States of America
- * E-mail:
| | - Jacob Plange-Rhule
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Joyce Gyamfi
- Department of Population Health, New York University School of Medicine, New York, New York, United States of America
| | - William Chaplin
- Department of Psychology, St. John’s University, Queens, New York, United States of America
| | - Michael Ntim
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kingsley Apusiga
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Juliet Iwelunmor
- College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri, United States of America
| | | | - Kofi Nana Quakyi
- College of Global Public Health, New York Unversity, New York, New York, United States of America
| | - Jazmin Mogaverro
- Department of Psychology, St. John’s University, Queens, New York, United States of America
| | - Kiran Khurshid
- Department of Psychology, St. John’s University, Queens, New York, United States of America
| | - Bamidele Tayo
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, United States of America
| | - Richard Cooper
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, United States of America
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17
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Nelissen HE, Okwor TJ, Khalidson O, Osibogun A, Van’t Hoog AH. Low uptake of hypertension care after community hypertension screening events in Lagos, Nigeria. Glob Health Action 2018; 11:1548006. [PMID: 30474518 PMCID: PMC6263098 DOI: 10.1080/16549716.2018.1548006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/07/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND In Lagos, Nigeria, approximately 33% of the population suffers from hypertension, yet antihypertensive treatment coverage is low. To improve access to care, a decentralized pharmacy-based hypertension care model was piloted. This study reports on the recruitment strategies used and is part of a larger study to evaluate the feasibility of the care model. OBJECTIVE To describe our experience executing three different strategies to recruit hypertensive patients in the program: community hypertension screenings, hospital and pharmacy referral. METHODS Individuals with elevated blood pressure and no history of cardiovascular disease were referred to the program's recruitment days to see a medical doctor for hypertension diagnosis and enrollment. Individuals were referred from community screenings, tertiary hospital outpatient clinics, and pharmacies participating in the program. For the community screenings, we report the number needed to screen (NNS) to find one individual with elevated blood pressure, the NNS to enroll one individual in the program, and factors associated with enrollment in the program among participants referred. RESULTS We recruited 226 individuals (69%) in the program via the pharmacies, 97 (30%) via the community screenings, and 2 (<1%) via hospital referral. At the community screenings 3,204 individuals participated, 729 (23%) had elevated blood pressure and 618 (85%) were eligible for referral of whom 142 (23%) visited the recruitment days, and 97 (16%) enrolled. The NNS to find one individual with elevated blood pressure was 5, and the NNS to enroll one individual was 34. Enrollment in the program was associated with advancing age, blood pressure ≥160/100 and currently using antihypertensive medication. CONCLUSIONS Despite the potential attractiveness of community screenings to identify and refer individuals with hypertension, enrollment in the program was low. For future programs we recommend pharmacy referral as individuals seem more inclined to access care through healthcare providers they are familiar with.
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Affiliation(s)
- Heleen Elise Nelissen
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Tochi Joy Okwor
- Centre for Epidemiology and Health Development, Lagos, Nigeria
- Department of Community Health, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria
| | | | - Akin Osibogun
- Centre for Epidemiology and Health Development, Lagos, Nigeria
- Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Anja Helena Van’t Hoog
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
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18
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Cole HV, Owusu-Dabo E, Iwelunmor J, Newsome V, Meeks K, Agyemang C, Jean-Louis G. Sleep duration is associated with increased risk for cardiovascular outcomes: a pilot study in a sample of community dwelling adults in Ghana. Sleep Med 2017; 34:118-125. [PMID: 28522079 DOI: 10.1016/j.sleep.2017.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 02/08/2017] [Accepted: 03/06/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Associations between sleep duration and cardiovascular disease (CVD) risk factors have been demonstrated in past studies. However, previous studies have not investigated these relationships using objective sleep measures in sub-Saharan Africa. Our objective was to investigate the association between sleep duration and cardiovascular risk factors in a sample of community-dwelling Ghanaian adults. METHODS We used wrist actigraphy along with a seven-day sleep diary to measure sleep duration, wake after sleep onset, sleep latency, and sleep quality. Participants were randomly selected from among those participating in the RODAM study in rural and urban Ghana. Outcome measurements included 10-year risk of CVD events, prevalent CVD, and metabolic syndrome. Additional participant characteristics were assessed using a structured questionnaire. Linear and logistic regression analyses were used to assess the relationships between sleep measures and CVD risk. RESULTS A total of 263 participants from rural and urban Ghana participated. Total sleep time was positively associated with a 10-year CVD risk; this association remained after adjusting for age, sex, urban vs rural location, socio-economic status, physical activity, and sleep disturbance (β = 0.990, p = 0.015). Short sleep, defined as sleeping less than seven hours per night on average, was negatively associated with a 10-year CVD risk, and this relationship remained in the fully adjusted model (β = -2.100, p = 0.011). Sleep duration was not associated with prevalence of CVD or metabolic syndrome. CONCLUSION Using actigraphy to measure sleep duration among a population of community-dwelling adults in sub-Saharan Africa is feasible. We found a positive association between sleep and CVD risk. No association was found between sleep duration and prevalent CVD or metabolic syndrome. The implications and new directions relating to these findings are stated.
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Affiliation(s)
- Helen V Cole
- Center for Healthful Behavior Change, Division of Health Behavior, Department of Population Health, NYU School of Medicine, 227 E. 30th St, 6th Floor, New York, NY 10016, USA.
| | - Ellis Owusu-Dabo
- School of Public Health, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Kumasi Centre for Collaborative Research, College of Health Sciences, Kwame Nkrumah University of Science and Technology, KCCR, UPO, PMB, KNUST, Kumasi, Ghana
| | - Juliet Iwelunmor
- Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, 123 Huff Hall, 1206 South 4th Street, Champaign, IL 61820, USA
| | - Valerie Newsome
- Center for Healthful Behavior Change, Division of Health Behavior, Department of Population Health, NYU School of Medicine, 227 E. 30th St, 6th Floor, New York, NY 10016, USA
| | - Karlijn Meeks
- Department of Public Health, Academic Medical Center, University of Amsterdam, Meibergdreef 9 1105AZ, Amsterdam, The Netherlands
| | - Charles Agyemang
- Department of Public Health, Academic Medical Center, University of Amsterdam, Meibergdreef 9 1105AZ, Amsterdam, The Netherlands
| | - Girardin Jean-Louis
- Center for Healthful Behavior Change, Division of Health Behavior, Department of Population Health, NYU School of Medicine, 227 E. 30th St, 6th Floor, New York, NY 10016, USA
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Odusola AO, Stronks K, Hendriks ME, Schultsz C, Akande T, Osibogun A, van Weert H, Haafkens JA. Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers. Glob Health Action 2016; 9:29041. [PMID: 26880152 PMCID: PMC4754020 DOI: 10.3402/gha.v9.29041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 12/18/2015] [Accepted: 01/12/2016] [Indexed: 11/14/2022] Open
Abstract
Background Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. Objective We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Design Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. Results Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider–insurer relationships; automated administration systems; and tailoring guidelines/patient education. Conclusions By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.
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Affiliation(s)
- Aina O Odusola
- Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.,Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; ; ;
| | - Karien Stronks
- Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marleen E Hendriks
- Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Constance Schultsz
- Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Tanimola Akande
- Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Akin Osibogun
- Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Henk van Weert
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Joke A Haafkens
- Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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A Concept Mapping Study of Physicians' Perceptions of Factors Influencing Management and Control of Hypertension in Sub-Saharan Africa. Int J Hypertens 2015; 2015:412804. [PMID: 26550488 PMCID: PMC4621343 DOI: 10.1155/2015/412804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/20/2015] [Indexed: 11/17/2022] Open
Abstract
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.
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