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Peniston S, Sivaramakrishnan D, Holloway A. Undiagnosed and uncontrolled hypertension in rural African adults: a scoping review protocol of primary health care interventions. BMJ Open 2024; 14:e081937. [PMID: 38589263 PMCID: PMC11015176 DOI: 10.1136/bmjopen-2023-081937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/04/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Non-communicable diseases cause 74% of global deaths, with cardiovascular diseases as the major contributor. Hypertension, a primary risk factor for cardiovascular disease, is highly prevalent in Africa. Diagnosis, treatment and control rates are notably limited in rural areas. This limitation results in increased risks of premature mortality and complications such as stroke due to socioeconomic, cultural and geographical challenges. Progress in African countries enhancing hypertension services through primary health care interventions exists. However, a comprehensive review of all primary health care interventions addressing undiagnosed and uncontrolled hypertension in rural African settings is lacking. This scoping review aims to categorise primary health care interventions targeting undiagnosed and uncontrolled hypertension in rural African adults. Intervention components will be mapped to the four stages outlined in the hypertension care cascade to develop a pilot intervention logic model for rural African adults with hypertension. METHOD AND ANALYSIS The scoping review protocol will adhere to the Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Studies considered for inclusion will include any intervention delivered by any healthcare provider in a rural African primary care setting targeting any stage of hypertension care. Eight databases will be searched without date restrictions, supplemented by grey literature and reference list searches. A two-stage screening process (title/abstract and full text) will determine evidence source eligibility. All eligible sources of evidence will be extracted, charted and evaluated using the Template for Intervention Description and Replication checklist. A pilot logic model categorising and mapping interventions to the four stages of the hypertension care cascade will be visually presented and analysed using narrative synthesis. ETHICS AND DISSEMINATION No primary data will be collected; therefore, ethics approval is not required. Findings will be disseminated to local health authorities in Ghana and other African Regions and through national and international conferences and publications in peer-reviewed journals.
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Affiliation(s)
- Sandra Peniston
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
- Scottish Collaboration for Public Health Research and Policy, The University of Edinburgh, Edinburgh, UK
- School of Nursing, Faculty of Health, York University, Toronto, ON, Canada
| | - Divya Sivaramakrishnan
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
- Scottish Collaboration for Public Health Research and Policy, The University of Edinburgh, Edinburgh, UK
| | - Aisha Holloway
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
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Wang J, Tan F, Wang Z, Yu Y, Yang J, Wang Y, Shao R, Yin X. Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review. JMIR Public Health Surveill 2024; 10:e51802. [PMID: 38149840 PMCID: PMC10907944 DOI: 10.2196/51802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/22/2023] [Accepted: 12/27/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade. OBJECTIVE This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade. METHODS The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management. RESULTS A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings. CONCLUSIONS This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.
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Affiliation(s)
- Jie Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fangqin Tan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenzhong Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yiwen Yu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jingsong Yang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yueqing Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruitai Shao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xuejun Yin
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Steffen HM, Mahanani MR, Neuhann F, Nhlema A, Kasper P, de Forest A, Chaweza T, Tweya H, Heller T, Chiwoko J, Winkler V, Phiri S. Blood pressure changes during tenofovir-based antiretroviral therapy among people living with HIV in Lilongwe, Malawi: results from the prospective LighTen Cohort Study. Clin Res Cardiol 2023; 112:1650-1663. [PMID: 37414923 PMCID: PMC10584708 DOI: 10.1007/s00392-023-02253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Sub-Saharan Africa is one of the regions in the world with the highest numbers of uncontrolled hypertension as well as people living with HIV/AIDS (PLHIV). However, the association between hypertension and antiretroviral therapy is controversial. METHODS Participant demographics, medical history, laboratory values, WHO clinical stage, current medication, and anthropometric data were recorded at study entry and during study visits at 1, 3, 6 months, and every 6 months thereafter until month 36. Patients who stopped or changed their antiretroviral therapy (tenofovir, lamivudine, efavirenz) were censored on that day. Office blood pressure (BP) was categorized using ≥ 2 measurements on ≥ 2 occasions during the first three visits. Factors associated with systolic and mean BP were analyzed using bivariable and multivariable multilevel linear regression. RESULTS 1,288 PLHIV (751 females, 58.3%) could be included and 832 completed the 36 months of observation. Weight gain and a higher BP level at study entry were associated with an increase in BP (p < 0.001), while female sex (p < 0.001), lower body weight at study entry (p < 0.001), and high glomerular filtration rate (p = 0.009) protected against a rise in BP. The rate of uncontrolled BP remained high (73.9% vs. 72.1%) and despite indication treatment, adjustments were realized in a minority of cases (13%). CONCLUSION Adherence to antihypertensive treatment and weight control should be addressed in patient education programs at centers caring for PLHIV in low-resources settings like Malawi. Together with intensified training of medical staff to overcome provider inertia, improved control rates of hypertension might eventually be achieved. TRIAL REGISTRATION NCT02381275.
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Affiliation(s)
- Hans-Michael Steffen
- Department of Gastroenterology and Hepatology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
- Hypertension Center, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | | | - Florian Neuhann
- Institute for Global Health, University of Heidelberg, Heidelberg, Germany
- School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia
| | | | - Philipp Kasper
- Department of Gastroenterology and Hepatology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Andrew de Forest
- Institute for Global Health, University of Heidelberg, Heidelberg, Germany
| | | | - Hannock Tweya
- International Training and Education Center for Health, University of Washington, Seattle, WA, USA
| | - Tom Heller
- Lighthouse Clinic, Lilongwe, Malawi
- International Training and Education Center for Health, University of Washington, Seattle, WA, USA
| | | | - Volker Winkler
- Institute for Global Health, University of Heidelberg, Heidelberg, Germany
| | - Sam Phiri
- Lighthouse Clinic, Lilongwe, Malawi
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Public Health and Family Medicine, Kamuzu University of Health Sciences, Lilongwe, Malawi
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Kibone W, Bongomin F, Okot J, Nansubuga AL, Tentena LA, Nuwamanya EB, Winyi T, Balirwa W, Sarah Kiguli, Baluku JB, Makhoba A, Kaddumukasa M. High blood pressure prevalence, awareness, treatment, and blood pressure control among Ugandans with rheumatic and musculoskeletal disorders. PLoS One 2023; 18:e0289546. [PMID: 37549138 PMCID: PMC10406225 DOI: 10.1371/journal.pone.0289546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/20/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Rheumatic and musculoskeletal disorders (RMDs) are associated with cardiovascular diseases (CVDs), with hypertension being the most common. We aimed to determine the prevalence of high blood pressure (HBP), awareness, treatment, and blood pressure control among patients with RMDs seen in a Rheumatology clinic in Uganda. METHODS We conducted a cross-sectional study at the Rheumatology Clinic of Mulago National Referral Hospital (MNRH), Kampala, Uganda. Socio-demographic, clinical characteristics and anthropometric data were collected. Multivariable logistic regression was performed using STATA 16 to determine factors associated with HBP in patients with RMDs. RESULTS A total of 100 participants were enrolled. Of these, majority were female (84%, n = 84) with mean age of 52.1 (standard deviation: 13.8) years and median body mass index of 28 kg/m2 (interquartile range (IQR): 24.8 kg/m2-32.9 kg/m2). The prevalence of HBP was 61% (n = 61, 95% CI: 51.5-70.5), with the majority (77%, n = 47, 95% CI: 66.5-87.6) being aware they had HTN. The prevalence of HTN was 47% (n = 47, 37.2-56.8), and none had it under control. Factors independently associated with HBP were age 46-55years (adjusted prevalence ratio (aPR): 2.5, 95% confidence interval (CI): 1.06-5.95), 56-65 years (aPR: 2.6, 95% CI: 1.09-6.15), >65 years (aPR: 2.5, 95% CI: 1.02-6.00), obesity (aPR: 3.7, 95% CI: 1.79-7.52), overweight (aPR: 2.7, 95% CI: 1.29-5.77). CONCLUSION There was a high burden of HBP among people with RMDs in Uganda with poor blood pressure control, associated with high BMI and increasing age. There is a need for further assessment of the RMD specific drivers of HBP and meticulous follow up of patients with RMDs.
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Affiliation(s)
- Winnie Kibone
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Jerom Okot
- Faculty of Medicine, Gulu University, Gulu, Uganda
| | - Angel Lisa Nansubuga
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Titus Winyi
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Whitney Balirwa
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Kiguli
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Anthony Makhoba
- Department of Medicine, St. Francis Hospital Nsambya, Kampala, Uganda
| | - Mark Kaddumukasa
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Hines JZ, Prieto JT, Itoh M, Fwoloshi S, Zyambo KD, Sivile S, Mweemba A, Chisemba P, Kakoma E, Zachary D, Chitambala C, Minchella PA, Mulenga LB, Agolory S. Hypertension among persons living with HIV-Zambia, 2021; A cross-sectional study of a national electronic health record system. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001686. [PMID: 37428721 DOI: 10.1371/journal.pgph.0001686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/07/2023] [Indexed: 07/12/2023]
Abstract
Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. We did a cross-sectional study of hypertension prevalence among PLHIV aged ≥18 years during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with ≥2 clinical visits in 2021 were included. Hypertension was defined as ≥2 elevated blood pressure readings (systolic ≥140 mmHg/diastolic ≥90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR ≤5 years. Logistic regression was used to assess for associations between hypertension and demographic characteristics. Among 750,098 PLHIV aged ≥18 years with ≥2 visits during 2021, 101,363 (13.5%) had ≥2 recorded blood pressure readings. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension. Only 8.9% of PLHIV with hypertension had an anti-hypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for ≥60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and on ART for ≥6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Hypertension was common among PLHIV in Zambia, with few having documentation of treatment. Most PLHIV were excluded from the analysis because of missing BP measurements. Strengthening integrated management of non-communicable diseases in HIV clinics might help to diagnose and treat hypertension in Zambia. Addressing missing data of routine clinical data (like blood pressure) could improve non-communicable diseases surveillance in Zambia.
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Affiliation(s)
- Jonas Z Hines
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Megumi Itoh
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Sombo Fwoloshi
- Ministry of Health, Lusaka, Zambia
- University of Zambia, School of Medicine, Lusaka, Zambia
| | | | | | | | | | | | - Dalila Zachary
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | | | | | - Simon Agolory
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
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Wamuti B, Owuor M, Magambo C, Ndegwa M, Sambai B, Temu TM, Farquhar C, Bukusi D. 'My people perish for lack of knowledge': barriers and facilitators to integrated HIV and hypertension screening at the Kenyatta National Hospital, Nairobi, Kenya. Open Heart 2023; 10:openhrt-2022-002195. [PMID: 36707130 PMCID: PMC9884934 DOI: 10.1136/openhrt-2022-002195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/04/2023] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION HIV and cardiovascular disease (CVD) are the two main causes of death in Kenya with hypertension as CVD's leading risk factor and HIV infection a risk factor for hypertension. We qualitatively evaluated the feasibility of integrated HIV and hypertension screening at Kenyatta National Hospital. METHODS We conducted two focus group discussions (FGDs) in November 2020 (female FGD: n=7; male FGD: n=8) to elicit facilitators, barriers and viability of integrated diagnosis and management of both conditions at HIV testing service (HTS) facilities. Participants were selected using convenience sampling and were not pair matched. All participants had received HTS. All female clients had confirmed hypertension, while male relatives had been contacted for HIV and hypertension screening through a modified assisted partner services model-where a trained healthcare provider supports notification. Transcripts were coded independently, and the codebook was developed and revised through consensus discussion. Data were analysed using thematic content analysis. RESULTS Main barriers to diagnosis and management included limited public awareness of hypertension risk factors and on improved treatment outcomes for those on lifelong HIV treatment, high cost of hypertension care despite free HIV care and healthcare system challenges especially medication stockouts. Strong support systems at family and healthcare levels facilitated care and treatment for both conditions. Participants recommended improved public awareness through individual-level communication and mass media campaigns, decentralised screening services for both HIV and hypertension, and either free or subsidised hypertension care services delivered alongside HIV treatment services. Most felt that an integrated HIV and hypertension service model was viable and would improve healthcare outcomes. CONCLUSION Patient-centred care models combining HIV and hypertension services hold promise for integrated service delivery.
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Affiliation(s)
- Beatrice Wamuti
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Mercy Owuor
- Independent Qualitative Researcher, Nairobi, Kenya
| | - Christine Magambo
- Voluntary counselling and testing (VCT) and HIV prevention unit, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Betsy Sambai
- University of Washington - Kenya, Nairobi, Kenya
| | - Tecla M Temu
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, Washington, USA,Department of Medicine, University of Washington, Seattle, Washington, USA,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - David Bukusi
- Voluntary counselling and testing (VCT) and HIV prevention unit, Kenyatta National Hospital, Nairobi, Kenya
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Buzaalirwa L, Nambala L, Banturaki G, Amor PI, Katahoire A, Geng E, Semeere A. Implementing screening for hypertension in archetypal HIV primary care: a mixed-methods assessment. BMC Health Serv Res 2022; 22:1041. [PMID: 35971141 PMCID: PMC9380283 DOI: 10.1186/s12913-022-08362-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High prevalence of HIV and hypertension in sub-Saharan Africa puts adults living with HIV (ALWH) at high risk of end-organ complications. Both World Health Organization (WHO) and national guidelines recommend screening and treatment of hypertension among ALWH on antiretroviral therapy (ART). We evaluated the implementation of hypertension screening among adults on ART at three Uganda Cares Primary care facilities. METHODS Using a sequential explanatory mixed-methods approach, we reviewed patient records, and interviewed both patients and providers during 2018 and 2019. We obtained demographics, clinical and blood pressure (BP) measurements via records review. We estimate the period prevalence of screening and use adjusted modified Poisson regression models to evaluate predictors of screening. In-depth interviews were analysed using a thematic approach to explain the observed prevalence and predictors of BP screening. RESULTS Records for 1426 ALWH were reviewed. Patients had a median age of 35 years and 65% of them were female. Most were on ART (89% on first-line) with a median duration of 4 years. Only 262 (18%) were overweight or obese with a body mass index (BMI) > 25 Kg/M2. In 2017 or 2018 patients made a median of 3 visits and 783 patients had a BP recorded, hence a period prevalence 55%. Older age, male sex, more clinic visits, and clinic site were associated with screening in the adjusted analyses. Erratic BP screening was corroborated by patients' and providers' interviews. Challenges included; high patient numbers, low staffing, provider apathy, no access to treatment, and lack of functioning of BP equipment. CONCLUSION Almost half of regular HIV clinic attendees at these prototypical primary care HIV clinics were not screened for hypertension for a whole year. Improving BP screening requires attention to address modifiable challenges and ensure local buy-in beyond just providing equipment.
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Affiliation(s)
| | - Lydia Nambala
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grace Banturaki
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elvin Geng
- Washington University St. Louis, St. Louis, MO, USA
| | - Aggrey Semeere
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
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Basenero A, Neidel J, Ikeda DJ, Ashivudhi H, Mpariwa S, Kamangu JWN, Mpalang Kakubu MA, Hans L, Mutandi G, Jed S, Tjituka F, Hamunime N, Agins BD. Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach. PLoS One 2022; 17:e0272727. [PMID: 35951592 PMCID: PMC9371294 DOI: 10.1371/journal.pone.0272727] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia. Methods Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions. Results Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges. Conclusions Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions—such as task sharing and supply chain strengthening—should be pursued to further improve delivery of HTN care among PWH beyond initial screening.
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Affiliation(s)
| | - Julie Neidel
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Daniel J. Ikeda
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | | | | | - Linea Hans
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Gram Mutandi
- U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Suzanne Jed
- Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Pretoria, South Africa
| | | | | | - Bruce D. Agins
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
- * E-mail:
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Peters MA, Noonan CM, Rao KD, Edward A, Alonge OO. Evidence for an expanded hypertension care cascade in low- and middle-income countries: a scoping review. BMC Health Serv Res 2022; 22:827. [PMID: 35761254 PMCID: PMC9235242 DOI: 10.1186/s12913-022-08190-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance. Methods A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage. Results The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment. Conclusion There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08190-0.
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Affiliation(s)
- Michael A Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Caitlin M Noonan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Olakunle O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Majumdar U, Nanyonga Clarke R, Moran AE, Doupe P, Gadikota-Klumpers DD, Gidio A, Ssentamu D, Heller DJ. Hypertension screening, prevalence, treatment, and control at a large private hospital in Kampala, Uganda: A retrospective analysis. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000386. [PMID: 36962239 PMCID: PMC10021338 DOI: 10.1371/journal.pgph.0000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 04/06/2022] [Indexed: 11/19/2022]
Abstract
Adult hypertension prevalence in Uganda is 27%, but only 8% are aware of their diagnosis, accordingly treatment and control levels are limited. The private sector provides at least half of care nationwide, but little is known about its effectiveness in hypertension control. We analyzed clinical data from 39 235 outpatient visits among 17 777 adult patients from July 2017 to August 2018 at Uganda's largest private hospital. We calculated blood pressure screening rate at every visit, and hypertension prevalence, medication treatment, and control rates among the 5 090 patients with two or more blood pressure checks who received any medications from the hospital's pharmacy. We defined hypertension in this group as 1) an average of two blood pressure measurements at separate consecutive visits, higher than 140 mm Hg systolic or 90 mm Hg diastolic, 2) receipt of any antihypertensive medication, or 3) the use of a hypertension electronic medical record code. We deemed hypertension control as normotensive at the most recent check. 12 821 (72.1%) of patients received at least 1 blood pressure check. Among the 5 090 patients above, 2 121 (41.6%) had hypertension (33.4% age-standardized to a world population standard): 1 915 (37.6%) with elevated blood pressure, and 170 (3.3%) were normotensive but receiving medication. 838 (39.4%) of patients with hypertension received medication at least once. Overall, 18.3% of patients achieved control (27% of treated patients, and 15% of untreated patients). Hypertension is common and incompletely controlled in this Ugandan private-sector population, suggesting several avenues for novel interventions.
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Affiliation(s)
- Usnish Majumdar
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | | | - Andrew E Moran
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | | | - Darinka D Gadikota-Klumpers
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Agaba Gidio
- Clarke International University, Kampala, Uganda
| | | | - David J Heller
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010751. [PMID: 34682492 PMCID: PMC8535610 DOI: 10.3390/ijerph182010751] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/31/2022]
Abstract
In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President’s Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.
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Moucheraud C, Phiri K, Hoffman RM. Health behaviours and beliefs among Malawian adults taking antihypertensive medication and antiretroviral therapy: A qualitative study. Glob Public Health 2021; 17:688-699. [PMID: 33471610 PMCID: PMC8289928 DOI: 10.1080/17441692.2021.1874468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In order to understand HIV-positive Malawian adults' experiences with hypertension management, we conducted qualitative interviews with 30 hypertensive adults who were also taking antiretroviral therapy. These interviews regarding hypertension management behaviours and beliefs were audio-recorded, transcribed, translated into English, and coded in Atlas.ti. Despite acknowledging the dangers of hypertension and the benefits of medication, many respondents missed their antihypertensive medication. Primary reasons included feeling healthy, health workers' advice to stop taking medicine when blood pressure normalised, side effects, and using herbs or non-prescription medicines to manage hypertension. Women highlighted difficulties with dietary modifications, and changes in their social relationships. Both men and women spoke about hypertension-related challenges with employment and household economics. These results suggest numerous challenges among adults managing hypertension and HIV in Malawi, and frequent suboptimal adherence to medication. We identified new key themes - the quality of adherence counselling for antihypertensive medication, the effects of hypertension on financial stability, and the role of social relationships in self-care - and encourage further investigation into these topics in low-income, high-burden countries.
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Affiliation(s)
- Corrina Moucheraud
- Department of Health Policy and Management, University of California Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Risa M Hoffman
- Division of Infectious Diseases, University of California Geffen School of Medicine, Los Angeles, CA, USA
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