Patients' experiences on accessing health care services for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: A qualitative study

Assessing implementation outcomes for launching balanced energy protein supplementation: A formative study in rural Bangladesh

Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. We conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

Factors affecting patient retention to hypertension treatment in a North Indian State: A mixed-method study

Hypertension is a global health challenge, especially in low-to-middle-income countries, where awareness and control are suboptimal. Despite available treatments, poor medication adherence hampers blood pressure control, leading to adverse outcomes and increased costs. In response, the GOI has initiated national action plans to address noncommunicable diseases, including hypertension. The study aimed to analyze patient retention rates in hypertension treatment across healthcare levels and understand providers' and patients' perspectives on control factors. Using a mixed-method concurrent design in a North Indian district, retrospective data collection covered hypertensive patients registered from January 2020 to July 2020, followed for a year (August 2020-July 2021). Quantitative data included socio-demographic characteristics and patient follow-up rates. Qualitative data comprised focus group discussions (FGD) and in-depth interviews (IDI) with healthcare providers (HCPs) and patients. Findings identified challenges in patient retention and medication adherence, notably among females and at higher-level healthcare facilities, leading to substantial loss of follow-up. Only 63% of hypertensive outpatients maintained controlled blood pressure in the past year. Male patients exhibited more consistent attendance than females. Despite sufficient HCP knowledge, patient retention was better at Health and Wellness Centers (HWCs) levels, while blood pressure control was poorer at higher facilities. Barriers such as medication side effects, pill burden, and limited healthcare access hindered hypertension control, highlighting the need for improved primary care services, including extended clinic hours and diagnostic facilities. Improving hypertension control requires addressing medication adherence and healthcare access barriers. Strengthening primary care services and implementing patient-centered interventions are crucial steps.

Effectiveness of a Community Pharmacy-Based Health Promotion Program on Hypertension in Bangladesh and Pakistan: Study Protocol for a Cluster-Randomized Controlled Trial

The aim of this multi-country, cluster-randomized trial is to test the impact of pharmacy-based health promotion to reduce the blood pressure of individuals with hypertension over a 12-month period in Bangladesh and Pakistan. The trial will be implemented with two arms. In Bangladesh, the estimated sample size is around 3600 hypertensive patients. In Pakistan, we will select samples equivalent to 10% of the participants from Bangladesh, comprising 360 hypertensive patients from four pharmacies. Community pharmacies will be randomized into one of two parallel groups (allocation ratio 1:1). Pharmacy professionals in the treatment arm will provide their patients with educational training and counseling, as well as phone calls/mobile text messages and care coordination in the health sector, as part of the intervention. The study will be conducted in three phases: a baseline survey with intervention, a midline survey with intervention and follow-up, and an endline survey with impact evaluation. The primary outcome of the study will be BP. The secondary outcomes will be BP controlled to target, treatment adherence, quality of life, mortality or hospital admission rates resulting from hypertension and its related complications, incremental cost per health-related quality of life gained, knowledge on healthy lifestyle and dietary behavior, and change in the prevalence of current smoking status.

Assessing Barriers to Primary Prevention of Cardiovascular Diseases in Low and Middle-Income Countries: A Systematic Review

The incidence of cardiovascular diseases (CVDs) in low- and middle-income countries (LMICs) has greatly increased. Previously dominated by infectious diseases, LMICs are the new epicentre of CVDs. CVD is a common problem amongst the population in the African continent; however, many countries in LMICs lack the resources to stem the rise of CVDs. A systematic review was conducted between March and July 2023 to assess barriers to the primary prevention of CVDs in studies conducted in LMICs. Online databases, such as Embase, Cochrane, Scopus, and MEDLINE, were consulted. Keywords included primary prevention, cardiovascular diseases, diabetes, weight loss, and physical fitness, all of which focused on LMICs. To enrich the literature review, efforts were made to check other listed references and more papers were retrieved. The inclusion criteria were countries in LMICs, CVD, full-text, and peer-reviewed journals. Qualitative and quantitative studies were included. Exclusion criteria included high-income countries, secondary prevention, and research unrelated to CVDs, such as barriers in oncology or mental health. A total of 1089 papers were retrieved from the search engines. After applying the exclusion criteria for LMICs, only 186 papers were retained. A further search for quality, relevance, and duplicity reduced the qualifying number to 50 papers. Further efforts to retrieve the data and examine the quality of the studies resulted in 18 final selected studies. Three categories emerged based on the type of barriers: physician barriers, patient barriers, and health system barriers. Evidently, in several LMICs, guidelines for CVD prevention were lacking, and too much emphasis was placed on secondary prevention at the expense of primary prevention, a lack of human resources, and inadequate infrastructure. Overworked healthcare providers were unable to allocate adequate time to the patients. There was no shared decision-making process. Patient barriers included lack of motivation, no symptoms, low level of education, no insurance, long physical distances to the facilities, and inadequate medication or stock out. Some of the major barriers included closing and opening hours, poor operating space, inadequate funding from the government or donors, and lack of electronic medical services. There are many barriers to accessing primary prevention services for CVDs. These barriers can be divided into patient, physician, or health system barriers. More research needs to be conducted in LMICs to address the increasing risk factors for CVDs. Greater investment is required by national governments to provide more resources. Task shifting and shared decision-making are some of the quick wins.

Lived experiences of people living with HIV and hypertension or diabetes access to care in Ethiopia: a phenomenological study

BACKGROUND

People living with HIV (PLWH) are more likely to develop hypertension and diabetes than people without HIV. Previous studies have shown that HIV stigma, discrimination and exclusion make it difficult for PLWH to access care for hypertension and diabetes.

OBJECTIVES

This study aimed to explore the lived experiences of PLWH with comorbid hypertension or diabetes to access hypertension and diabetes care in southern Ethiopia.

DESIGN

We conducted a qualitative study using a semistructured interview guide for an in-depth, in-person interview.

SETTINGS

From 5 August to 25 September 2022, PLWH with comorbid hypertension or diabetes were purposefully selected from five primary healthcare (PHC) facilities in the Wolaita zone of southern Ethiopia.

PARTICIPANTS

A total of 14 PLWH with comorbid hypertension or diabetes who were receiving antiretroviral therapy from PHC were interviewed. Among them, 10 were women, and 4 were men.

METHODS

In-person, in-depth interviews were conducted. Qualitative data analysis software (NVivo V.12) was used to assist with the data organisation, and Colaizzi's (1978) inductive thematic analyses were conducted to explore key concepts.

RESULT

This study yielded two main themes: Theme 1: barriers to accessing care as individual barriers to access (low awareness of non-communicable diseases, misperceptions, lack of health insurance and cost of treatment); healthcare system barriers (shortage of supplies, drugs and equipment; long wait times; lack of integrated services; absence of routine screening and lack of respect from providers); community barriers (lack of support from families, friends and the community) and stigma and discrimination access to hypertension and diabetes. Theme 2: accessibility facilitators (support from family, friends and organisations; health insurance coverage).

CONCLUSION

PLWH recommended that access to services can be improved by service integration, awareness-raising activities, no user fee charges for hypertension and diabetes care and routine screening.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.

METHODS

A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.

CONCLUSION

Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.

TRIAL REGISTRATION

PROSPERO registration number CRD42022340059 .

Association of socio-demographic characteristics with hypertension awareness, treatment, and control in Bangladesh

Hypertension has been rapidly growing in Bangladesh. However, there has been limited analysis of differences in the hypertension cascade across socio-demographic groups. This study was a secondary analysis of the 2017-18 Bangladesh Demographic and Health Survey. Four dichotomous outcome variables - hypertension prevalence, awareness among those with hypertension, treatment among those aware, and control among those treated - were analyzed. The variation of each outcome was assessed across socio-demographic factors. The association between socio-demographic characteristics and outcomes was analyzed using logistic regression. Less than half of the hypertensive individuals were aware of their hypertension (42.5%), and awareness was higher among those who were older, female, of higher household wealth, and living in urban areas. Among those aware, most were receiving treatment (87.4%), and this proportion was higher in older individuals (89.2% among 65 + , 70.4% among 18-24; p < 0.001). One-third of those treated (33.8%) had their blood pressure controlled, and this was higher among younger and more educated individuals. In multivariable models stratified by rural/urban community, most of the aforementioned trends remained with additional differences between communities. Notably, the association of higher education level with treatment odds differed in rural and urban communities (OR 0.34 [95%CI 0.16, 0.75] in rural; OR 2.83 [95%CI 1.04, 7.73] in urban). Efforts to improve hypertension awareness among individuals who are younger, male, of lower household wealth, and in rural areas are required to address disparities in care. Socio-demographic variations in hypertension awareness, treatment, and control must be considered to design targeted interventions for each step of the cascade.

Facilitators and barriers to hypertension management in urban Nepal: findings from a qualitative study

INTRODUCTION

In Nepal, one-fourth of the adult population has hypertension. Despite provision of comprehensive hypertension services through the primary healthcare system, huge gaps in treatment and control of hypertension exist. Our study explored the individual, interpersonal, health system and community-level barriers and facilitators affecting hypertension management in urban Nepal.

METHODS

We used a qualitative methodology informed by Kaufman's socioecological model, conducting focus group discussions with hypertension patients and their family members. In-depth interviews with hypertension patients, healthcare providers and municipal officials were also conducted.

RESULTS

We found that inadequate knowledge about hypertension and harmful cultural beliefs hindered effective treatment of hypertension. Interrupted medical supply and distrust in primary healthcare providers affected the poor's access to hypertension services. Poor communication between family members and gender norms affected adaptation of treatment measures. This study emphasised the role of family members in supporting patients in adhering to treatment measures and rebuilding community trust in primary healthcare providers for better access to hypertension services. The findings guided the development of a manual to be used by community health workers during home visits to support patients to control high blood pressure.

CONCLUSION

The study highlights the importance of integrating various aspects of care to overcome the multiple barriers to hypertension management in urban settings in low-resource countries. Participatory home visits have the potential to empower individuals and families to develop and implement feasible and acceptable actions for home management of hypertension through improved adherence to antihypertensive medication, and behaviour change.

Blood Parameter Profiles and Their Clinical Implications in Hypertensive Patients: A Retrospective Chart Review

Introduction Hypertension (HTN) is a chronic condition that serves as a major risk factor for cardiovascular diseases, leading to increased mortality and morbidity. It is a frequent modifiable illness affecting global health, resulting in catastrophic fatalities and morbidity. Aim This study aims to investigate blood parameter profiles and their clinical implications in hypertensive patients at the Prince Faisal bin Khalid Cardiac Center in Abha, Saudi Arabia. Methods Utilizing retrospective data from 121 patients at the Prince Faisal bin Khalid Cardiac Center in Abha, Saudi Arabia. The hematological parameter examined were hemoglobin (HB), platelets, hematocrit (HCT), calcium, phosphorus, sodium, potassium, urea, creatinine, and uric acid. The SPSS version 28 software was used for data analysis. Results Significant correlations between various hematological parameters were found in the results, pointing to potential connections between kidney function, the production of blood cells, and electrolyte balance in hypertensive patients. The results align with earlier studies carried out in the area and offer insightful information for clinicians and researchers interested in managing HTN and its complications. Conclusion The study emphasized the significance of considering hypertensive patients' age, gender, and lifestyle when interpreting their blood parameter profiles. The findings imply that a thorough comprehension of these blood parameter values and their potential effects on HTN is necessary for effectively managing HTN in this population. This study on the blood parameter profiles in hypertensive patients in Saudi Arabia provides the relationships between various hematological parameter and their clinical implications. These findings should be considered when creating targeted interventions and strategies to address the specific requirements and difficulties of managing HTN and its associated complications in this population. More research is required to comprehend the underlying reasons for the observed variations in hematological parameter profiles and their effects on the management of HTN.

Challenges of managing hypertension in Pakistan - a review

BACKGROUND

This review aims to describe existing evidence on the state of hypertension in Pakistan, including the prevalence, associated risk factors, preventive strategies, and challenges in the management of hypertension.

METHODS

A comprehensive literature search was conducted electronically using PubMed and Google Scholar. Using specific screening methodology, 55 articles were selected to be included.

RESULTS

We found from this extensive review that several small studies report high prevalence of hypertension but there is a lack of population based prevalence of hypertension in Pakistan. Lifestyle risk factors such as obesity, unhealthy diet, decreased physical activity, low socioeconomic status, and lack of access to care were the main associated factors with hypertension. Lack of blood pressure monitoring practices and medication non-adherence were also linked to uncontrolled hypertension in Pakistan and were more evident in primary care setups. The evidence presented is essential for delineating the burden of the disease, hence allowing for better management of this underserved population.

CONCLUSION

There is a need for updated surveys to depict the true prevalence and management of hypertension in Pakistan. Cost-effective implementation strategies and policies at the national level are needed for both prevention and control of hypertension.

Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019

INTRODUCTION

Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension.

METHODS

We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence.

RESULTS

We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02).

CONCLUSION

Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Prevalence and factors associated with treatment and control of hypertension among adults with hypertension in Myanmar

BACKGROUND

Due to a dearth in the number of studies conducted in low- and middle-income countries, this study aimed to identify the prevalence and determinants of the treatment and control of hypertension among patients with hypertension in Myanmar.

METHODS

This community-based cross-sectional study was conducted among 410 adults who were registered for hypertensive treatment in health centers in Myitkyina Township, Kachin State, Myanmar. Multiple logistic regression was used to identify the associated factors.

RESULTS

The prevalence of treatment and control of hypertension was 48.1% and 20.5%, respectively. The factors associated with treatment were age (OR=2.60 for 46-60 y and OR=2.29 for 61-70 y compared with 30-45 y), ethnicity (OR=1.87), monthly family income (OR=1.90), comorbidity (OR=2.33), knowledge (OR=2.63) and adherence to physical activity (OR=1.86). Controlled hypertension was associated with age (OR=3.03 for 46-60 y and OR=2.27 for 61-70 y compared with 30-45 y), education (OR=1.81), comorbidity (OR=1.67) and adherence to medication (OR=3.45).

CONCLUSIONS

The prevalence of treated and controlled hypertension was relatively low in this study. To improve the prevalence of hypertension treatment and control in this study population, effective and culturally sensitive intervention programs under universal health coverage should be established with an emphasis on individuals with lower educational attainment and younger ages.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.

METHODS

We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.

RESULTS

CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.

CONCLUSIONS

CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Post-intervention acceptability of multicomponent intervention for management of hypertension in rural Bangladesh, Pakistan, and Sri Lanka- a qualitative study

BACKGROUND

COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multicomponent, community health-worker (CHW)-led hypertension management program, has been shown to be effective in rural communities in South Asia. This paper presents the acceptability of COBRA-BPS multicomponent intervention among the key stakeholders.

METHODS

We conducted post-implementation interviews of 87 stakeholder including 23 community health workers (CHWs), 19 physicians and 45 patients in 15 rural communities randomized to COBRA-BPS multicomponent intervention in in Bangladesh, Pakistan, and Sri Lanka. We used Theoretical Framework for Acceptability framework (TFA) with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy.

RESULTS

COBRA-BPS multicomponent intervention was acceptable to most stakeholders. Despite some concerns about workload, most CHWs were enthusiastic and felt empowered. Physicians appreciated the training sessions and felt trusted by their patients. Patients were grateful to receive the intervention and valued it. However, patients in Pakistan and Bangladesh expressed the need for supplies of free medicines from the primary health facilities, while those in Sri Lanka were concerned about supplies' irregularities. All stakeholders favoured scaling-up COBRA-BPS at a national level.

CONCLUSIONS

COBRA-BPS multicomponent intervention is acceptable to the key stakeholders in Bangladesh, Pakistan and Sri Lanka. Community engagement for national scale-up of COBRA-BPS is likely to be successful in all three countries.

Barriers to Treatment Adherence Among Older Adults With Type 2 Diabetes: A Qualitative Study

The current qualitative study aimed to determine the barriers to treatment adherence among older adults with type 2 diabetes (T2D). This study was performed using a content analysis approach. Semi-structured interviews were conducted with 25 older adults with T2D between May and September 2021. Data were organized using MAXQDA-10 software and analyzed using the Elo and Kyngäs qualitative content analysis method. Three themes emerged from the analysis: Patient-Specific Barriers, Health Care Provider- and Heath Care System-Specific Barriers, and Social-Specific Barriers. Results of this study can be used to develop targeted interventions to promote and facilitate treatment adherence among older adults with T2D. [Journal of Gerontological Nursing, 49(1), 42-49.].

Geographic accessibility to childhood tuberculosis care in Pakistan

Background

Tuberculosis (TB) in children is difficult to detect and often needs specialists to diagnose; the health system is supposed to refer to higher level of health care when diagnosis is not settled in a sick child. In Pakistan, the primary health care level can usually not diagnose childhood TB and will refer to a paediatricians working at a secondary or tertiary care hospital. We aimed to determine the health services access to child TB services in Pakistan.

Objective

We aimed to determine the geographical access to child TB services in Pakistan.

Method

We used geospatial analysis to calculate the distance from the nearest public health facility to settlements, using qGIS, as well as population living within the World Health Organization’s (WHO) recommended 5-km distance.

Result

At primary health care level, 14.1% of facilities report child TB cases to national tuberculosis program and 74% of the population had geographical access to general primary health care within 5-km radius. To secondary- and tertiary-level health care, 33.5% of the population had geographical access within 5-km radius. The average distance from a facility for diagnosis of childhood TB was 26.3 km from all settlement to the nearest child TB sites. The population of one province (Balochistan) had longer distances to health care services.

Conclusion

With fairly good coverage of primary health care but lower coverage of specialist care for childhood TB, the health system depends heavily on a good referral system from the communities.

A Nationally Representative Survey of COVID-19 in Pakistan, 2021-2022

We conducted 4,863 mobile phone and 1,715 face-to-face interviews of adults >18 years residing in Pakistan during June 2021-January 2022 that focused on opinions and practices related to COVID-19. Of those surveyed, 26.3% thought COVID-19 was inevitable, and 16.8% had tested for COVID-19. Survey participants who considered COVID-19 an inevitability shared such traits as urban residency, concerns about COVID-19, and belief that the virus is a serious medical threat. Survey respondents who had undergone COVID-19 testing shared similarities regarding employment status, education, mental health screening, and the consideration of COVID-19 as an inevitable disease. From this survey, we modeled suspected and confirmed COVID-19 cases and found nearly 3 times as many suspected and confirmed COVID-19 cases than had been reported. Our research also suggested undertesting for COVID-19 even in the presence of COVID-19 symptoms. Further research might help uncover the reasons behind undertesting and underreporting of COVID-19 in Pakistan.

Exploring challenges to nutrition intervention adherence using COM-B model among patients with wet age-related macular degeneration: a qualitative study

OBJECTIVES

To explore challenges to nutrition intervention adherence using the Capability, Opportunity and Motivation-Behaviour (COM-B) model among wet age-related macular degeneration (AMD) patients. These factors should be considered in the development of potential support and intervention programmes to address these problems.

DESIGN

A qualitative study was conducted with one-to-one and face-to-face interviews with wet AMD patients using a semi-structured question guide. Data were analysed based on COM-B model: capability (physical and psychological), opportunity (physical and social) and motivation (reflective and automatic).

SETTING

Southwest Hospital of Chongqing Province in China.

PARTICIPANTS

A convenient and purposive sample of 24 wet AMD patients were recruited.

RESULTS

The themes and subthemes were identified: psychological capability: (1) insufficient knowledge of nutrition; (2) misconceptions about the disease and treatment; (3) knowledge conflict; physical capability: (1) physical restriction; (2) limited access to nutrition knowledge; physical opportunity: (1) communication between providers and patients; (2) health insurance and extra charges; (3) food environment; social opportunity: (1) stigma of disease; (2) family influence; reflective motivation: (1) self-efficacy; (2) attitude; (3) outcome expectancies; (4) lack of professional support; automatic motivation: (1) difficulties in changing eating habits; (2) mindset.

CONCLUSION

Medical staff should pay much attention to the process of patients' nutrition intervention. In addition, it is also necessary to develop professional and internet-based intervention to modify the dietary behaviour and improve the management skills of the patients.

The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh

BACKGROUND

Low- and middle-income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh.

METHODS

The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016-2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service-related factors with patients' preferences for healthcare services.

RESULTS

The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56-0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80-9.86) or affordability of healthcare services (RRR = 3.13; 2.25-4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15-1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70-5.04) than the quality of treatment in the health facility, when compared with private service providers.

CONCLUSIONS

Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management.

PATIENT OR PUBLIC CONTRIBUTION

Our research team includes four researchers (co-authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases.

Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review

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.

NDSP-10: The Cardiometabolic Risk Profile with Various Degrees of Dysglycemia in Younger and Older Adults: Findings from the Second National Diabetes Survey of Pakistan 2016-2017

Background: To assess and compare the cardiometabolic risk profile of the Pakistani population between younger (<45 years) and older adults (≥45 years). Methods: This is a substudy of a nationally representative community-based epidemiological second National Diabetes Survey of Pakistan (NDSP) 2016-2017. Out of 12,486 individuals approached, 10,834 participants agreed to be included (response rate 87%). Cardiovascular risk factors assessed were obesity, central obesity, hypertension, diabetes, hyperlipidemia, and tobacco use. Participants were stratified into young adults (<45 years) and older adults (≥45 years) and was subcategorized into four groups that is, diagnosed diabetes mellitus (DM), undiagnosed DM, prediabetes, and without diabetes. Results: Around 14.3% were prediabetes, 8.8% were undiagnosed DM, and 24% were diagnosed diabetes. Most participants in dysglycemic (prediabetes, undiagnosed DM, and diagnosed DM) groups were females and were from rural regions. Cardiovascular disease (CVD) risk factors were more noted in dysglycemic states, compared with without diabetes. Overall CVD risk profile was worse in males in both age categories, although the accumulation of four or five CVD risk factors at one point was more predominant in females in either age group. Conclusion: Overall, the preponderance of CVD risk factors, such as overweight, obesity, central obesity, tobacco use, ex-tobacco uses, and dyslipidemia, were substantially more prevalent in dysglycemia groups of young adults (<45 years) compared with older adults (≥45 years). Early and targeted intervention in young may prevent poor CVD outcomes as they age.

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Background

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

Methods

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Results

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Salt Consumption and Blood Pressure in Rural Hypertensive Participants: A Community Filed Trial

Purpose. Hypertension is a major cause of morbidity and mortality in the world. This study aimed to evaluate an intervention based on the Health Belief Model regarding the whole family’s salt consumption and blood pressure among hypertensive patients in rural areas in Iran. Methods. This clinical multicenter trial (clinical and community) with a control and an intervention group was conducted on the residents of 14 villages covered by 14 health houses. Totally, 200 hypertensive patients (n = 100 in each group) were selected via multistage random sampling. The intervention included a two-day workshop on blood pressure and reducing salt consumption based on HBM structures for health personnel and an eight-session workshop on how to reduce salt intake and blood pressure for mothers who were responsible for the families’ diets. Participants completed the questionnaires before and immediately after the intervention. Results. Compared to the control group, in the intervention group, a significant reduction was observed in salt consumption by the families (urine sodium and creatinine reduced by 35 mEq/l and 7.5 mg/dL, respectively). The results also revealed a significant decrease in blood pressure in the intervention group. Conclusion. The results showed that the mothers’ model-based education could effectively improve the diet of the whole family members and, as a result, reduce the associated diseases. The main advantage of this study was the involvement of the rural health personnel, which helped run longer and larger-scale health-promotion programs in the communities.

Out-of-pocket payment for healthcare among urban citizens in Dhaka, Bangladesh

Objectives

Out-of-pocket (OOP) payment is the major payment strategy for healthcare in Bangladesh, and the share of OOP expenditure has increased alarmingly. Dhaka is recognised as one of the fastest-growing megacities in the world. The objective of this study is to capture the self-reported illnesses among urban citizens and to identify whether and to what extent socioeconomic, demographic and behavioural factors of the population influence OOP healthcare expenditures.

Subject and methods

This study utilises cross-sectional survey data collected from May to August 2019 in urban Dhaka, Bangladesh. A total of 3,100 households were randomly selected. Simple descriptive statistics including frequencies, percentage, mean (95% CI), median and inter-quartile range were presented. Bivariate analysis and multivariate regression models were employed.

Results

We observed that acute illnesses (e.g., fever, flu/cough) were dominant among participants. Among the chronic illnesses, approximately 9.6% of people had diabetes, while 5.3% had high/low blood pressure. The richest quintile only spent 5.2% of their household income on healthcare, while the poorest households spent approximately six times more than the richest households. We noted that various factors such as marital status, religion, source of care, access to safe water, income quintile and even the location of households had a significant relationship with OOP expenditure.

Conclusions

Our findings can serve as important source of data in terms of disease- specific symptoms and out-of-pocket cost among urban citizens in Dhaka. The people belonging to wealthier households tended to choose better healthcare facilities and spend more. A pro-poor policy initiative and even an urban health protection scheme may be necessary to ensure that healthcare services are accessible and affordable, in line with the Bangladesh National Urban Health Strategy.

Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review

Background: Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. However, no systematic investigation of factors influencing hypertension treatment and control in Nepal is available. This study aimed to systematically review the published literature and synthesise the findings on barriers, enablers, and strategies for hypertension treatment and control in Nepal.

Methods: Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, and Nepali journals and government websites were searched for qualitative, quantitative, and mixed-methods studies on factors or strategies related to hypertension treatment and control in Nepal. Information from qualitative studies was analysed using template analysis, while results from quantitative studies were narratively synthesised. Summary findings were framed under “health system”, “provider”, and “patient” domains. The protocol was registered in PROSPERO (registration number: CRD42020145823).

Results: We identified 15 studies; ten related to barriers and enablers and five to strategies. The identified barriers associated with the health system were: lack of affordable services and lack of resources. The barriers at the provider's level were: communication gaps, inadequate counselling, long waiting hours for appointments, lack of national guidelines for hypertension treatment, and provider's unsupportive behaviours. Non-adherence to medication, irregular follow-up visits, lack of awareness on blood pressure target, poor help-seeking behaviours, reluctance to change behaviours, perceived side-effects of anti-hypertensive medication, self-medication, lack of family support, financial hardship, lack of awareness on blood pressure complications, and comorbidity were barriers identified at patient level. The following enablers were identified: free essential health care services, family support, positive illness perception, and drug reminders. Strategies implemented at the health system, provider and patient levels were: establishing digital health records at health centres, health worker's capacity development, and health education.

Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, health providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

Prevalence, awareness, treatment, and control of hypertension in Bangladesh: Findings from National Demographic and Health Survey, 2017-2018

The purpose of this study was to estimate the age-standardised prevalence, awareness, treatment, and control of hypertension and to identify their risk factors in Bangladeshi adults. Data from 12 904 adults aged 18-95 years, available from the most recent nationally representative 2017-2018 Bangladesh Demographic and Health Survey were used. Hypertension was defined as having systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mmHg, and/or taking anti-hypertensive drugs to control blood pressure. Age-standardized prevalence of hypertension and management were estimated with direct standardisation. A multilevel mixed-effects Poisson regression model with a robust variance was used to identify risk factors associated with hypertension and its awareness, treatment, and control. The overall age-standardized prevalence of hypertension was 26.2% (95% CI, 25.5-26.9); (men: 23.5%, women: 28.9%). Among those with hypertension (n = 3531), 36.7% were aware that they had the condition, and only 31.1% received anti-hypertensive medication. The prevalence of controlled hypertension was 12.7% among those with hypertension and 43.6% among those treated for hypertension (n = 1306). Factors independently associated with hypertension were increasing age, higher body mass index, being women, having diabetes, and residing in selected administrative divisions. A declining trend of hypertension control was observed with increasing age and low education. Hypertension is highly prevalent (one in four) in Bangladeshi adults, while awareness, treatment, and control are low. Irrespective of the risks associated with hypertension and its management, programs to increase its awareness, treatment, and control should be given high priority in reducing hypertension prevalence and improving hypertension control in Bangladesh.

An ecological approach to understanding stroke experience and access to rehabilitation services in Ghana: A cross-sectional study

Despite a growing burden of stroke in low-middle-income countries, research on patient's experiences and access to rehabilitation services remains limited. This study explores the experiences of stroke patients in relation to access and use of stroke rehabilitation services, coping strategies and strategies to improve care in Ghana. A cross-sectional study was conducted. A total of 136 adult stroke patients hospitalised and subsequently discharged in three major referral hospitals in Ghana participated in the study. A paper-based questionnaire was used to collect data. Data were inputted into STATA version 12, cleaned and analysed using descriptive statistics and Chi-Square tests. Findings showed that stroke patients experience stroke differently. Early detection (awareness) of stroke symptoms at onset was low (29.4%). Hypertension was the major (58.1%) predisposing risk factor for stroke, followed by diabetes (14.7%). Multiple barriers impede access to outpatient rehabilitation services: high cost of medications (43.4%), transportation constraints (10.3%), long waiting time (6.6%), forgetfulness about appointment (4.4%), limited education on rehabilitation (20.6%), lack of community support (12.5%) and ineffective communication with healthcare providers (5.2%). Recommended strategies to improve access to rehabilitation care included public education on stroke and its associated risk, reduction in the cost of drugs and increased stroke rehabilitation funding by the NHIS, especially for physiotherapy consultation and training support to caregivers on patient care. Given the difference in stroke experience and barriers in accessing rehabilitation care, multi-level health policy and service delivery reforms are needed to improve access to rehabilitation care, including national public awareness campaigns on early signs of stroke and subsidised cost of stroke rehabilitation.

Barriers and facilitators for treatment and control of high blood pressure among hypertensive patients in Kathmandu, Nepal: a qualitative study informed by COM-B model of behavior change

Background

Nepal has a high prevalence of hypertension which is a major risk factor for cardiovascular diseases globally. It is inadequately controlled even after its diagnosis despite the availability of effective treatment of hypertension. There is a need for an in-depth understanding of the barriers and facilitators using theory to inform interventions to improve the control of hypertension. This formative study was conducted to address this gap by exploring the perceived facilitators and barriers to treatment and control of hypertension in Nepal.

Methods

We conducted in-depth interviews (IDIs) among hypertensive patients, their family members, healthcare providers and key informants at primary (health posts and primary health care center) and tertiary level (Kathmandu Medical College) facilities in Kathmandu, Nepal. Additionally, data were collected using focus group discussions (FGDs) with hypertensive patients. Recordings of IDIs and FGDs were transcribed, coded both inductively and deductively, and subthemes generated. The emerging subthemes were mapped to the Capability, Opportunity, and Motivation-Behaviour (COM-B) model using a deductive approach.

Results

Major uncovered themes as capability barriers were misconceptions about hypertension, its treatment and difficulties in modifying behaviour. Faith in alternative medicine and fear of the consequences of established treatment were identified as motivation barriers. A lack of communication between patients and providers, stigma related to hypertension and fear of its disclosure, and socio-cultural factors shaping health behaviour were identified as opportunity barriers in the COM-B model. The perceived threat of the disease, a reflective motivator, was a facilitator in adhering to treatment.

Conclusions

This formative study, using the COM-B model of behaviour change identified several known and unknown barriers and facilitators that influence poor control of blood pressure among people diagnosed with hypertension in Kathmandu, Nepal. These findings need to be considered when developing targeted interventions to improve treatment adherence and blood pressure control of hypertensive patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11548-4.

Patients' understanding, management practices, and challenges regarding hypertension: A qualitative study among hypertensive women in a rural Bangladesh

Background

Hypertension, as one of the main predisposing factors of many non-communicable diseases, is generally underdiagnosed among women with a significant uncontrolled rate. This study explores the understanding, management practice and challenges related to hypertension among hypertensive women in rural Bangladesh.

Methods

A qualitative study was conducted among hypertensive rural women at Kumarkhali Upazilla, Kushtia, Bangladesh, using purposive and snowball sampling technique. Data was collected through in-depth interviews among twenty-three hypertensive women until they reached saturation. Data were analyzed thematically.

Results

Findings of the study found that a small number of participants perceived the symptoms, risk factors, management and treatment of hypertension based on biomedical understanding. Also, their awareness level and adherence to preventive practices reflected a significant gap between biomedical preventive practices and local practices. A substantial number of participants preferred home management and alternative treatment for hypertension over the medication adherence and hospital treatment. This investigation revealed that poor socio-economic conditions, such as financial insufficiency, and, gender-based negligence impacted women's perception of and practice for hypertension and resulted in risky hypertension management behaviors.

Conclusion

Based on the study, formulation of a comprehensive health education program for creating awareness, provisioning of significant interventions services related to hypertensive care are needed. Further intensive research is needed at the community-level to manage this chronic disease.

•

Lack of awareness and underestimation of hypertension is prevalent more than a quarter of the adult world population.

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Knowledge gap about symptoms, risk factors, and management practices of hypertension are predominant among participants.

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Study participants prefer the self-management practices of hypertension without taking medication.

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Financial hardship, forgetfulness in taking medication, anxiety, and stigmas create challenges to manage hypertension.

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Comprehensive, integrated and structured intervention programs should be develop to control hypertension.

Exploring Barriers to Medication Adherence Using COM-B Model of Behaviour Among Patients with Cardiovascular Diseases in Low- and Middle-Income Countries: A Qualitative Study

INTRODUCTION

In 2016, cardiovascular diseases (CVDs) led to 17.9 million deaths worldwide, representing 31% of all global deaths. CVDs are the leading cause of mortality worldwide and significant barriers to achieving the sustainable development goals. Modern medicines have been significant in improving health outcomes. However, non-adherence to medication is one of the reasons behind adverse health-related outcomes among patients suffering from atherosclerotic cardiovascular disease in low- and middle-income countries.

PATIENTS AND METHODS

This qualitative study was conducted at two tertiary care hospitals in India and Ghana. A total of 35 in-depth interviews were conducted with atherosclerosis cardiovascular disease (ASCVD) patients. The data were analysed thematically using the Capability Opportunity and Motivation (COM-B) framework.

FINDINGS

The findings were summarised under three important broad themes of the COM-B framework: capability, opportunity and behaviour. Under capability, comprehension of disease, medication schedule, and unplanned travel affected adherence among patients. Cost of medication, insurance and access were the critical factors under opportunity, which negatively influenced medication adherence. Mood, beliefs about treatment and outcome expectations under motivation led to non-adherence among patients. Apart from these factors, some important health system factors such as health care experience and trust in the facilities and reliance on alternative medication also affected adherence in both countries.

CONCLUSION

This study has highlighted that the health system factors have dominantly influenced adherence to medication in India and Ghana. In India, we found participants to be satisfied with their health care provided at the government hospitals. However, limited time for consultation, lack of well-stocked pharmacy and unclear prescription negatively influenced adherence among participants in India and Ghana. The study emphasises that the health system needs to be strengthened, and the patients' belief system needs to be explored to address the issue of medication adherence in LMICs.

Accuracy of the clinical indicators for Readiness for enhanced health management

PURPOSE

to analyze accuracy measures of the clinical indicators of Readiness for enhanced health management in patients with arterial hypertension and/or diabetes mellitus METHODS: prospective diagnostic accuracy study conducted with 359 patients with hypertension and/or diabetes mellitus, followed up in primary healthcare. Stratified random sampling was used to recruit participants. An assessment form was applied with sociodemographic data, health conditions, and information related to the clinical indicators under investigation. Sensitivity, specificity, predictive values, and likelihood ratios were analyzed FINDINGS: the sample was composed of 359 participants. The prevalence of Readiness for enhanced health management was 93.8%. There was a statistically significant association between the diagnosis and age under 60 years (p < 0.001), having only one chronic condition (p < 0.001), having normal blood pressure (p = 0.017) and blood glucose (p = 0.013) values, and having a nonsedentary (p = 0.026) and nonalcoholic (p = 0.044) lifestyle. All clinical indicators had high predictive values in predicting the nursing diagnosis under investigation. The indicator expresses desire to enhance management of symptoms was the most sensitive (99.7%) and specific (100%). The indicator expresses desire to enhance management of prescribed regimens was also highly specific (100%) CONCLUSION: all clinical indicators were accurate in predicting Readiness for enhanced health management IMPLICATIONS FOR NURSING PRACTICE: knowing which clinical indicators and sociodemographic/clinical characteristics best predict Readiness for enhanced health management, nurses in primary care can better plan nursing interventions and direct their goals.

The Role of Health Care Quality in Hypertension Self-Management: A Qualitative Study of the Experience of Patients in a Public Hospital, North-West Ethiopia

Purpose

Hypertension is becoming a global epidemic in all population groups. For its effective management and control, patients should have enhanced self-management skills and get adequate support from care providers. Although the quality of health care is critical in enhancing self-management behaviors of patients with hypertension, the issue has not been fully explored in the Ethiopian context. Therefore, the purpose of this study was to explore the experience of hypertensive patients on the quality of health care and the self-management practice in a public hospital in North-west Ethiopia.

Patients and Methods

This qualitative study involves a phenomenological approach. Participants were hypertension patients who are on treatment follow-up. They were recruited purposively with maximum variation approach. Eleven in-depth interviews and two key informant interviews were undertaken using a semi-structured interview guide with hypertensive patients and nurses respectively. Interviews were audio recorded, transcribed verbatim, translated into English, and then analyzed thematically by the investigators.

Results

The analysis identified two main themes and seven sub-themes. The first theme “experience in self-management practice” describes medication adherence, lifestyle modification, and self-monitoring of blood pressure. The second theme “experience in the quality of health care” discusses access to health services, patient-centered care, behavior of health care providers, and time and patient flow management.

Conclusion

The self-management practice of hypertensive patients is sub-optimal. Although several individual patient issues were identified, facility-level problems are mainly responsible for poor self-management practice. The main facility-level barriers, as reported by participants, include shortage of medicines, high cost of medicines, busyness of doctors due to high patient load, lack of appropriate education and counseling services, poor patient-provider interaction, and long waiting times. Intervention areas should focus on providing appropriate training for health care providers to enhance the patient–provider relationship. Improving the supply of hypertensive medications is also paramount for better medication adherence.

Budget impact and cost-effectiveness analyses of the COBRA-BPS multicomponent hypertension management programme in rural communities in Bangladesh, Pakistan, and Sri Lanka

BACKGROUND

COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multi-component hypertension management programme that is led by community health workers, has been shown to be efficacious at reducing systolic blood pressure in rural communities in Bangladesh, Pakistan, and Sri Lanka. In this study, we aimed to assess the budget required to scale up the programme and the incremental cost-effectiveness ratios.

METHODS

In a cluster-randomised trial of COBRA-BPS, individuals aged 40 years or older with hypertension who lived in 30 rural communities in Bangladesh, Pakistan, and Sri Lanka were deemed eligible for inclusion. Costs were quantified prospectively at baseline and during 2 years of the trial. All costs, including labour, rental, materials and supplies, and contracted services were recorded, stratified by programme activity. Incremental costs of scaling up COBRA-BPS to all eligible adults in areas covered by community health workers were estimated from the health ministry (public payer) perspective.

FINDINGS

Between April 1, 2016, and Feb 28, 2017, 11 510 individuals were screened and 2645 were enrolled and included in the study. Participants were examined between May 8, 2016, and March 31, 2019. The first-year per-participant costs for COBRA-BPS were US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka. Per-capita costs were $0·63 for Bangladesh, $0·29 for Pakistan, and $1·03 for Sri Lanka. Incremental cost-effectiveness ratios were $3430 for Bangladesh, $2270 for Pakistan, and $4080 for Sri Lanka, per cardiovascular disability-adjusted life year averted, which showed COBRA-BPS to be cost-effective in all three countries relative to the WHO-CHOICE threshold of three times gross domestic product per capita in each country. Using this threshold, the cost-effectiveness acceptability curves predicted that the probability of COBRA-BPS being cost-effective is 79·3% in Bangladesh, 85·2% in Pakistan, and 99·8% in Sri Lanka.

INTERPRETATION

The low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study.

FUNDING

The UK Department of Health and Social Care, the UK Department for International Development, the Global Challenges Research Fund, the UK Medical Research Council, Wellcome Trust.

Barriers in access to healthcare for women with disabilities: a systematic review in qualitative studies

Background

Studies show that different socio-economic and structural factors can limit access to healthcare for women with disabilities. The aim of the current study was to review barriers in access to healthcare services for women with disabilities (WWD) internationally.

Methods

We conducted a systematic review of relevant qualitative articles in PubMed, Web of Science and Scopus databases from January 2009 to December 2017. The search strategy was based on two main topics: (1) access to healthcare; and (2) disability. In this review, women (older than 18) with different kinds of disabilities (physical, sensory and intellectual disabilities) were included. Studies were excluded if they were not peer-reviewed, and had a focus on men with disabilities.

Results

Twenty four articles met the inclusion criteria for the final review. In each study, participants noted various barriers to accessing healthcare. Findings revealed that WWD faced different sociocultural (erroneous assumptions, negative attitudes, being ignored, being judged, violence, abuse, insult, impoliteness, and low health literacy), financial (poverty, unemployment, high transportation costs) and structural (lack of insurance coverage, inaccessible equipment and transportation facilities, lack of knowledge, lack of information, lack of transparency, and communicative problems) factors which impacted their access healthcare.

Conclusions

Healthcare systems need to train the healthcare workforce to respect WWD, pay attention to their preferences and choices, provide non-discriminatory and respectful treatment, and address stigmatizing attitudinal towards WWD. In addition, families and communities need to participate in advocacy efforts to promote WWD’s access to health care.

Factors related to mammography adherence among women in Brazil: A scoping review

AIM

To explore and synthesize the literature on factors related to mammography screening adherence among women in Brazil.

DESIGN

A scoping review.

METHODS

We searched 11 databases for studies published between 2006-January 2020. All identified articles were screened, and data were extracted from eligible studies. We used the UK Government Social Research Service weight of evidence appraisal tool to appraise the quality of the included study.

RESULTS

From a total of 1,384 identified articles, 22 were retained. All included studies used quantitative, non-experimental methods and all but two studies used cross-sectional data. Quality of evidence varied across studies. We identified 41 factors that were investigated across the set of studies. Demographic and socio-economic factors were the most commonly investigated, with older age, urban residence, living in the southeast of Brazil, higher level of education, higher income and private health insurance most consistently associated with mammography adherence.

Role of Dedicated Cardiac Emergency Unit in Early Identification and Management of Acute Myocardial Infarction in a Developing Country of South Asia

Background The care of patients presenting with chest pain to multidisciplinary services hospital gets compromised due to the busy triage system. A separate and specialized equipped cardiac emergency unit (CAR-ERU) can improve patient's outcomes. Objectives To enhance early recognition and treatment of acute myocardial infarction (AMI) patients. To sustain key performance quality indicators (KPIs) for AMI. Methods In October 2016, a separate CAR-ERU was established inside the multidisciplinary emergency department (MED). A dedicated specialized heart-lung and vascular teams were hired under the supervision of service line leadership. The KPIs that were identified benchmark with international practice guidelines. Data were collected and stored for analysis. Exemption from the ethical review committee was obtained. Results A total of 2914 patients visited CAR-ERU from October 2016 to September 2017 for a period of one year. Out of which 30% were diagnosed with acute coronary syndrome (ACS) and this included 8% diagnosis with ST-segment elevation myocardial infarction (STEMI). Over 98.8% of the electrocardiogram (ECG) was done within 10 minutes of arrival while aspirin was given to 96.5% of patients within one hour. The door to balloon time (DBT) of <90 min was achieved in 70% of patients. A significant reduction in length of stay in the emergency department and financial burden was noted. Sustainability of major KPI was observed over the subsequent years.  Conclusion The introduction of a dedicated CAR-EU improved clinical outcomes, reduced length of stay and financial burden in AMI patients managed in CAR-EU. Our tertiary care hospital is the first one of its kind to take this quality initiative in a lower-middle-income country (LMIC) Pakistan.

Sex differences in prevalence and determinants of hypertension among adults: a cross-sectional survey of one rural village in Bangladesh

OBJECTIVE

Prevention of mortality due to cardiovascular disease (CVD) through control of hypertension is a public health priority in Bangladesh. Our objective was to assess sex differences in prevalence and determinants of hypertension among adults in one rural area of Bangladesh.

STUDY DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

From January 2014 to December 2015, we conducted a cross-sectional study of 2600 men and women aged ≥18 years located in one rural district of Bangladesh. We collected data on demographics, behavioural factors, physical measurements and health history.

PRIMARY OUTCOME MEASURES

Our primary outcome was hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90 mm Hg).

RESULTS

The average age of participants was 41.6 years and 53.7% were women. Hypertension prevalence was 6.9% (95% CI 5.9 to 7.9), and was significantly higher among women (8.9%) than men (4.5%). The highest prevalence of hypertension was observed among women aged ≥60 years at 21.3% (95% CI 16.6 to 26.7). A higher proportion of men with hypertension were aware of their condition (72.2%) compared with women (52.4%). Determinants of hypertension included older age, higher education, current tobacco use, increasing body mass index, and hyperglycaemia.

CONCLUSION

Our research suggests that hypertension prevalence is higher among women than men in rural Bangladesh. Sex-specific interventions should be developed to inform adults of the necessary lifestyle changes that may reduce the risk of hypertension and subsequent CVDs.

Role expectations from doctors and effects on nonmedical outcomes

RATIONALE, AIMS, AND OBJECTIVES

The predominant assumption of doctor professionalism may be prone to unpredicted alterations in the face of "a new age of doctoring." The aim in this study is to explore one dimension in the doctor-patient dyadic relationship: the face-to-face interaction between doctors and patients and whether satisfaction of role expectations affects service outcomes as perceived by the patient-consumer.

METHODS

In the first qualitative phase, 10 physicians and 11 patients were interviewed in-depth for the purposes of understanding the variations in role expectations from doctors. These details were then used to construct the scenarios to be used in the second quantitative phase. Scenario-based experimental data were collected using a cross-sectional sample consisting of 432 individuals.

RESULTS

Although positive emotions lead to positive outcomes when the doctor is role-congruent, positive emotions lead to even better outcomes when the doctor is behaving too friendly. In addition, negative emotions lead to negative outcomes in both scenarios; however, outcomes become worse when the doctor is role-incongruent.

CONCLUSIONS

Role expectations play a moderating role between emotions and service outcomes. The medical performance can be perceived good or bad depending on whether the doctor smiles "too much" or not. Results are discussed within the context of role expectation theory and the changing nature of service relationships in the health care sector.

A Community-Based Intervention for Managing Hypertension in Rural South Asia

BACKGROUND

The burden of hypertension is escalating, and control rates are poor in low- and middle-income countries. Cardiovascular mortality is high in rural areas.

METHODS

We conducted a cluster-randomized, controlled trial in rural districts in Bangladesh, Pakistan, and Sri Lanka. A total of 30 communities were randomly assigned to either a multicomponent intervention (intervention group) or usual care (control group). The intervention involved home visits by trained government community health workers for blood-pressure monitoring and counseling, training of physicians, and care coordination in the public sector. A total of 2645 adults with hypertension were enrolled. The primary outcome was reduction in systolic blood pressure at 24 months. Follow-up at 24 months was completed for more than 90% of the participants.

RESULTS

At baseline, the mean systolic blood pressure was 146.7 mm Hg in the intervention group and 144.7 mm Hg in the control group. At 24 months, the mean systolic blood pressure fell by 9.0 mm Hg in the intervention group and by 3.9 mm Hg in the control group; the mean reduction was 5.2 mm Hg greater with the intervention (95% confidence interval [CI], 3.2 to 7.1; P<0.001). The mean reduction in diastolic blood pressure was 2.8 mm Hg greater in the intervention group than in the control group (95% CI, 1.7 to 3.9). Blood-pressure control (<140/90 mm Hg) was achieved in 53.2% of the participants in the intervention group, as compared with 43.7% of those in the control group (relative risk, 1.22; 95% CI, 1.10 to 1.35). All-cause mortality was 2.9% in the intervention group and 4.3% in the control group.

CONCLUSIONS

In rural communities in Bangladesh, Pakistan, and Sri Lanka, a multicomponent intervention that was centered on proactive home visits by trained government community health workers who were linked with existing public health care infrastructure led to a greater reduction in blood pressure than usual care among adults with hypertension. (Funded by the Joint Global Health Trials scheme; COBRA-BPS ClinicalTrials.gov number, NCT02657746.).

Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators

Background

Despite the high and rising burden of chronic kidney disease (CKD) in South Asia, factors that influence access to CKD care at the community level have not been studied previously, especially in the rural areas. We conducted a mixed methods study and interviewed key stakeholders to explore the views and experiences of key stakeholders, and identify barriers and potential facilitators that influence access to CKD care at the primary care level in rural India.

Methods

A total of 21 stakeholders participated in the study. We conducted 15 in-depth interviews on a purposive sample of stakeholders (CKD patients, healthcare providers and health planners) and one focus group discussion with 6 community health workers. The interviews were audio-recorded and transcribed verbatim. We employed the Lévesque’s framework for access to care to base interview guides and structure the initial codes. By inductive and deductive approaches, thematic analysis was undertaken using QSR NVivo version 11.

Results

The major patient-level barriers to CKD care as reported by the most patients and healthcare providers was poor knowledge and awareness of CKD. Health system-level barriers included shortages of skilled healthcare professionals and medicines, fragmented referrals pathways to the specialists at the hospitals with inadequate follow up care. Many patients and healthcare providers, when asked about areas for improving access to CKD care, reported educational initiatives to increase awareness of CKD among healthcare providers and patients, provision of CKD related supplies, and a systems-level approach to care coordination including task shifting by engaging community health workers in CKD care, as potential facilitators.

Conclusions

We identified several barriers to access CKD care at the primary care level in rural India that need urgent attention. Targeted CKD screening programs and CKD specific educational initiatives may improve awareness of CKD. Additionally, primary care infrastructure needs to be strengthened for CKD care, ensuring trained staff, availability of essential diagnostics and medications, and creating efficient referral pathways for quality CKD care.

Patient perspectives on hypertension management in health system of Sri Lanka: a qualitative study

INTRODUCTION

Uncontrolled hypertension is the leading risk factor for mortality globally, including low-income and middle-income countries (LMICs). However, pathways for seeking hypertension care and patients' experience with the utilisation of health services for hypertension in LMICs are not well understood.

OBJECTIVES

This study aimed to explore patients' perspectives on different dimensions of accessibility and availability of healthcare for the management of uncontrolled hypertension in Sri Lanka.

SETTING

Primary care in rural areas in Sri Lanka.

PARTICIPANTS

20 patients with hypertension were purposively sampled from an ongoing study of Control of Blood Pressure and Risk Attenuation in rural Bangladesh, Pakistan, Sri Lanka.

METHOD

We conducted in-depth interviews with patients. Interviews were audio-recorded and transcribed into local language (Sinhala) and translated to English. Thematic analysis was used and patient pathways on their experiences accessing care from government and private clinics are mapped out.

RESULTS

Overall, most patients alluded to the fact that their hypertension was diagnosed accidentally in an unrelated visit to a healthcare provider and revealed lack of adherence and consuming alternatives as barriers to control hypertension. Referring to the theme 'Accessibility and availability of hypertension care', patients complained of distance to the hospitals, long waiting time and shortage of medicine supplies at government clinics as the main barriers to accessing health services. They often resorted to private physicians and paid out of pocket when they experienced acute symptoms attributable to hypertension. Considering the theme 'Approachability and ability to perceive', the majority of patients mentioned increasing public awareness, training healthcare professionals for effective communication as areas of improvement. Under the theme 'Appropriateness and ability to engage', few patients were aware of the names or purpose of their medications and reportedly missed doses frequently. Reminders from family members were considered a major facilitator to adherence to antihypertensive medications. Patients welcomed the idea of outreach services for hypertension and health education closer to home in the theme 'Things the patients reported to improve the system'.

CONCLUSION

Patients identified several barriers to accessing hypertension care in Sri Lanka. Measures recommended improving hypertension management in Sri Lanka including public education on hypertension, better communication between healthcare professionals and patients, and efforts to improve access and understanding of antihypertensive medications.

TRIAL REGISTRATION NUMBER

NCT02657746.

Prevalence and correlates of cardiometabolic multimorbidity among hypertensive individuals: a cross-sectional study in rural South Asia-Bangladesh, Pakistan and Sri Lanka

OBJECTIVE

To determinate the prevalence and correlates of cardiometabolic multimorbidity (CMM), and their cross-country variation among individuals with hypertension residing in rural communities in South Asia.

DESIGN

A cross-sectional study.

SETTING

Rural communities in Bangladesh, Pakistan and Sri Lanka.

PARTICIPANTS

A total of 2288 individuals with hypertension aged ≥40 years from the ongoing Control of Blood Pressure and Risk Attenuation- Bangladesh, Pakistan and Sri Lanka clinical trial.

MAIN OUTCOME MEASURES

CMM was defined as the presence of ≥2 of the conditions: diabetes, chronic kidney disease, heart disease and stroke. Logistic regression was done to evaluate the correlates of CMM.

RESULTS

About 25.4% (95% CI 23.6% to 27.2%) of the hypertensive individuals had CMM. Factors positively associated with CMM included residing in Bangladesh (OR 3.42, 95% CI 2.52 to 4.65) or Sri Lankan (3.73, 95% CI 2.48 to 5.61) versus in Pakistan, advancing age (2.33, 95% CI 1.59 to 3.40 for 70 years and over vs 40-49 years), higher waist circumference (2.15, 95% CI 1.42 to 3.25) for Q2-Q3 and 2.14, 95% CI 1.50 to 3.06 for Q3 and above), statin use (2.43, 95% CI 1.84 to 3.22), and higher levels of triglyceride (1.01, 95% CI 1.01 to 1.02 per 5 mg/dL increase). A lower odds of CMM was associated with being physically active (0.75, 95% CI 0.57 to 0.97). A weak inverted J-shaped association between International Wealth Index and CMM was found (p for non-linear=0.058), suggesting higher risk in the middle than higher or lower socioeconomic strata.

CONCLUSIONS

CMM is highly prevalent in rural South Asians affecting one in four individuals with hypertension. There is an urgent need for strategies to concomitantly manage hypertension, cardiometabolic comorbid conditions and associated determinants in South Asia.