Patient pathways and perceptions of hypertension treatment, management, and control in rural Bangladesh: a qualitative study

Disparities and factors affecting hypertension diagnosis from qualified doctors in Bangladesh and its impact on receiving hypertension control advice: Analysis of demographic & health survey 2017-18

The burden of hypertension is increasing in many low- and middle-income countries, including Bangladesh, and a large proportion of Bangladeshi people seek healthcare from unqualified medical practitioners, such as paramedics, village doctors, and drug store salesmen; however, there has been limited investigation regarding diagnosis and care provided by qualified doctors. This study investigated the factors associated with hypertension diagnosis by qualified doctors (i.e., registered medically trained doctors or medical doctors with at least an MBBS degree) and how this diagnosis is related to hypertension-controlling advice and treatment among Bangladeshi adults. This cross-sectional study used data from Bangladesh Demographic and Health Survey 2017-18. After describing sample characteristics, we conducted simple and multivariable logistic regression analyses to investigate the associated factors and associations. Among 1710 participants (68.3% females, mean age: 50.1 (standard error: 0.43) years) with self-reported hypertension diagnosis, about 54.9% (95% confidence interval (CI): 51.8-58.0) had a diagnosis by qualified doctors. The following variables had significant associations with hypertension diagnoses from qualified doctors: 40-54- or 55-year-olds/above (ref: 18-29-year-olds), overweight/obesity (ref: not overweight/obese), college/above education (ref: no formal education), richest wealth quintile (ref: poorest), urban residence (ref: rural), and residence in Chittagong, Barisal, and Sylhet divisions (ref: Dhaka division). Lastly, compared to people who had not been diagnosed by qualified doctors, those with the diagnosis from qualified doctors had higher odds of receiving any hypertension-controlling advice and treatment, including drugs (1.73 (95% CI: 1.27-2.36), salt intake reduction (AOR: 2.36, 95% CI: 1.80-3.10), weight reduction (AOR: 2.58, 95% CI: 1.97-3.37), smoking cessation (AOR: 2.22, 95% CI: 1.66-2.96),), and exercise promotion (AOR: 2.34, 95% CI: 1.77-3.09). This study showed significant socioeconomic and rural-urban disparities regarding hypertension diagnosis from qualified doctors. Diagnosis by qualified doctors was also positively associated with receiving hypertension-controlling advice and treatment. Reducing these inequalities would be crucial to reducing the country's hypertension burden.

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.

Patient journey mapping: emerging methods for understanding and improving patient experiences of health systems and services

Patient journey mapping is an emerging field of research that uses various methods to map and report evidence relating to patient experiences and interactions with healthcare providers, services, and systems. This research often involves the development of visual, narrative, and descriptive maps or tables, which describe patient journeys and transitions into, through, and out of health services. This methods corner paper presents an overview of how patient journey mapping has been conducted within the health sector, providing cardiovascular examples. It introduces six key steps for conducting patient journey mapping and describes the opportunities and benefits of using patient journey mapping and future implications of using this approach.

Patient experiences of diabetes and hypertension care during an evolving humanitarian crisis in Lebanon: A qualitative study

Humanitarian health care models increasingly incorporate care for non-communicable diseases (NCDs). Current research evidence focuses on burden of disease, service provision and access to care, and less is known about patient's experience of the continuum of care in humanitarian settings. To address this gap, this study explored experiences of displaced Syrian and vulnerable Lebanese patients receiving care for hypertension and/or diabetes at four health facilities supported by humanitarian organisations in Lebanon. We conducted in-depth, semi-structured qualitative interviews with a purposive sample of patients (n = 18) and their informal caregivers (n = 10). Data were analysed thematically using both deductive and inductive approaches. Both Syrian and Lebanese patients reported interrupted pathways of care. We identified three typologies of patient experience at the time of interview; (1) managing adequately from the patient's perspective; (2) fragile management and (3) unable to manage their condition(s) adequately, with the majority falling into typologies 2 and 3. Patients and their families recognised the importance of maintaining continuity of care and self-management, but experienced substantial challenges due to changing availability and cost of medications and services, and decreasing economic resources during a period of national crises. Family support underpinned patient's response to challenges. Navigating the changing care landscape was a significant burden for patients and their families. Interactions were identified between mental health and NCD management. This study suggests that patients experienced disrupted, non-linear pathways in maintaining care for hypertension and diabetes in a humanitarian setting, and family support networks were key in absorbing treatment burden and sustaining NCD management. Recommendations are made to reduce treatment burden for patients and their families and to support sustainable condition management.

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.

Reporting and conducting patient journey mapping research in healthcare: A scoping review

AIM

To identify how patient journey mapping is being undertaken and reported.

DESIGN

A scoping review of the literature was undertaken using JBI guidance.

DATA SOURCES

Databases were searched in July 2021 (16th-21st), including Ovid's Medline, Embase, Emcare and PsycINFO; Scopus; Web of Science Core Collection, the Directory of Open Access Journals; Informit and; ProQuest Dissertations and Theses Global.

REVIEW METHODS

Eligible articles included peer-reviewed literature documenting journey mapping methodologies and studies conducted in healthcare services. Reviewers used Covidence to screen titles and abstracts of located sources, and to screen full-text articles. A table was used to extract data and synthesize results.

RESULTS

Eighty-one articles were included. An acceleration of patient journey mapping research was observed, with 76.5% (n = 62) of articles published since 2015. Diverse mapping approaches were identified. Reporting of studies was inconsistent and largely non-adherent with relevant, established reporting guidelines.

CONCLUSION

Patient journey mapping is a relatively novel approach for understanding patient experiences and is increasingly being adopted. There is variation in process details reported. Considerations for improving reporting standards are provided.

IMPACT

Patient journey mapping is a rapidly growing approach for better understanding how people enter, experience and exit health services. This type of methodology has significant potential to inform new, patient centred models of care and facilitate clinicians, patients and health professionals to better understand gaps and strategies in health services. The synthesised results of this review alert researchers to options available for journey mapping research and provide preliminary guidance for elevating reporting quality.

Optimizing Hypertension Control Globally: WHF Roadmap

PURPOSE OF REVIEW

Hypertension represents the most important cardiovascular risk factor, affecting over 4.06 billion adults worldwide. In this review, we will discuss potential barriers and their solutions to improve prevention, detection, and management of hypertension.

RECENT FINDINGS

The prevalence of hypertension has been increasing in low- and middle-income countries, requiring new strategies to improve its recognition and proper management. The World Heart Federation (WHF) developed a roadmap for hypertension, advising health system policies and clinical practices as part of its commitment to improving global cardiovascular health. The World Health Organization (WHO) has published in 2021 practical guidelines for the pharmacological treatment of hypertension in adults. Identifying potential roadblocks and solutions deserves high priority to improve the detection, management, and control of hypertension.

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.

(De)constructing 'therapeutic itineraries' of hypertension care: A qualitative study in the Philippines

Hypertension, a major risk factor for non-communicable diseases, remains poorly controlled in many countries. In the Philippines, it is still one of the leading causes of preventable deaths despite the accessibility and availability of essential technologies and medicine to detect and treat hypertension. This paper characterizes the 'therapeutic itineraries' of people with hypertension from poor communities in rural and urban settings in the Philippines. We employ longitudinal qualitative methodology comprised of repeat interviews and digital diaries using mobile phones from 40 recruited participants in 12 months. Our findings demonstrate that therapeutic itineraries, rather than being organized according to categories that stem from the structure of the health system (i.e., diagnosis, treatment, follow-up, adherence), diverge from clinical pathways. Therapeutic itineraries begin at a stage we label as 'pre-diagnosis' (PD). Following this, itineraries diverge according to two possible entry points into the healthcare system: via incidental diagnosis (ID) whereby participants were diagnosed with hypertension without deliberately seeking care for hypertension-related symptoms and symptom-driven diagnosis (SD) whereby their diagnosis was obtained during a clinical encounter specifically prompted by hypertension-related symptoms. Participants whose itineraries follow the SD route typically oscillated between periods of regular and intermittent medical treatment, while participants who were diagnosed incidentally (ID) typically opted for self-care As we follow our participants' therapeutic itineraries, we explore the confluence of factors informing their care journey, namely, their conceptions of hypertension, their social relationships, as well the choices and trade-offs they make. We conclude with policy implications from our findings, chief of which is our proposition that models of care based on mere access and availability of clinical interventions fail to reflect the complexity of people's lay understanding and their lived experiences of hypertension and are thus ultimately unhelpful in improving its control.

Protocol for integrating mental health services into primary healthcare facilities: a qualitative study of the perspectives of patients, family members and healthcare providers in rural Bangladesh

INTRODUCTION

In Bangladesh, Non-communicable diseases (NCDs) account for 67% of all deaths. Mental health services are not available in routine healthcare at the primary facilities in Bangladesh. The protocol is for a qualitative study that seeks to understand the perceptions, beliefs and norms regarding common mental disorders (CMDs) among patients with NCD with and without CMDs to identify barriers to accessing mental health services in rural communities in Bangladesh. We also aim to explore the feasibility of integrating mental healthcare into routine NCD services at primary health facilities in rural Bangladesh.

METHODS AND ANALYSIS

This study will be conducted at the outpatient departments in two subdistrict hospitals and one district hospital in Munshiganj district in Bangladesh. We will purposefully select patients with hypertension and diabetes from the patient inventory generated from a recently completed randomised control trial titled 'Control of Blood Pressure and Risk Attenuation Bangladesh, Pakistan, Sri Lanka' in two subdistricts in Munshiganj district in Bangladesh. The selected participants will be screened for CMD using the Depression, Anxiety and Stress Scale - 21 Items (DASS-21) over the telephone. Sixty in-depth interviews with patients and family members, 8-10 key informant interviews with healthcare providers and 2 focus group discussions with community health workers will be held following consent.The study is conceptualised under Levesque et al's framework. Thematic analysis will be applied following the study objectives and key issues, and commonly emerging topics generated by the data. The findings will be presented anonymously to corroborate the interpretation.

ETHICS AND DISSEMINATION

Approval has been obtained from the Institutional Review Board at icddr,b (PR-19108) and the University of York (HSRGC/2020/382/F). Written informed consent or audio recording consent form in Bangla will be obtained. For dissemination, we will invite representatives of the collaborating institutions to share the findings in national or international conferences and peer-reviewed journals.

World Heart Federation Roadmap for Hypertension - A 2021 Update

The World Heart Federation (WHF) Roadmap series covers a large range of cardiovascular conditions. These Roadmaps identify potential roadblocks and their solutions to improve the prevention, detection and management of cardiovascular diseases and provide a generic global framework available for local adaptation. A first Roadmap on raised blood pressure was published in 2015. Since then, advances in hypertension have included the publication of new clinical guidelines (AHA/ACC; ESC; ESH/ISH); the launch of the WHO Global HEARTS Initiative in 2016 and the associated Resolve to Save Lives (RTSL) initiative in 2017; the inclusion of single-pill combinations on the WHO Essential Medicines' list as well as various advances in technology, in particular telemedicine and mobile health. Given the substantial benefit accrued from effective interventions in the management of hypertension and their potential for scalability in low and middle-income countries (LMICs), the WHF has now revisited and updated the 'Roadmap for raised BP' as 'Roadmap for hypertension' by incorporating new developments in science and policy. Even though cost-effective lifestyle and medical interventions to prevent and manage hypertension exist, uptake is still low, particularly in resource-poor areas. This Roadmap examined the roadblocks pertaining to both the demand side (demographic and socio-economic factors, knowledge and beliefs, social relations, norms, and traditions) and the supply side (health systems resources and processes) along the patient pathway to propose a range of possible solutions to overcoming them. Those include the development of population-wide prevention and control programmes; the implementation of opportunistic screening and of out-of-office blood pressure measurements; the strengthening of primary care and a greater focus on task sharing and team-based care; the delivery of people-centred care and stronger patient and carer education; and the facilitation of adherence to treatment. All of the above are dependent upon the availability and effective distribution of good quality, evidence-based, inexpensive BP-lowering agents.

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.

Invitations and incentives: a qualitative study of behavioral nudges for primary care screenings in Armenia

BACKGROUND

Non-communicable diseases account for a growing proportion of deaths in Armenia, which require early detection to achieve disease control and prevent complications. To increase rates of screening, demand-side interventions of personalized invitations, descriptive social norms, labeled cash transfers, and conditional cash transfers were tested in a field experiment. Our complementary qualitative study explores factors leading to the decision to attend screening and following through with that decision, and experiences with different intervention components.

METHODS

Informed by the Health Belief Model as our conceptual framework, we collected eighty in-depth interviews with service users and twenty service providers and analyzed them using open coding and thematic analysis.

RESULTS

An individual's decision to screen depends on 1) the perceived need for screening based on how they value their own health and perceive hypertension and diabetes as a harmful but manageable condition, and 2) the perceived utility of a facility-based screening, and whether screening will provide useful information on disease status or care management and is socially acceptable. Following through with the decision to screen depends on their knowledge of and ability to attend screenings, as well as any external motivators such as an invitation or financial incentive.

CONCLUSIONS

Personalized invitations from physicians can prompt individuals to reconsider their need for screening and can, along with financial incentives, motivate individuals to follow through with the decision to screen. The effect of descriptive social norms in invitations should be further studied. Efforts to increase preventive screenings as an entry point into primary care in Armenia may benefit from implementation of tailored messages and financial incentives.

TRIAL REGISTRATION

The protocol was approved on January 11, 2019 by the Institutional Review Board of the Center of Medical Genetics and Primary Health Care in Armenia (02570094). https://www.socialscienceregistry.org/trials/3776 .

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.

Patient Compliance: Fact or Fiction?

The word ‘compliance' comes from the Latin word complire, meaning to fill up and hence to complete an action, transaction, or process and to fulfil a promise. In the Oxford English Dictionary, the relevant definition is ‘The acting in accordance with, or the yielding to a desire, request, condition, direction, etc.; a consenting to act in conformity with; an acceding to; practical assent”. Compliance with therapy is simply patients understanding of medication, motivation toward having this medication is a prescribed manner with the belief that the prescriber and prescribed medicine will be beneficial for his well-being. Although this is often the case, in a number of situations, the physician and pharmacist have not provided the patient with adequate instructions or have not presented the instructions in such a manner that the patient understands them. Nothing should be taken for granted regarding the patient's understanding of how to use medication, and appropriate steps must be taken to provide patients with the information and counseling necessary to use their medications as effectively and as safely as possible. 20% to 30% of new prescriptions are never filled at the pharmacy. Medication is not taken as prescribed 50% of the time. For patients prescribed medications for chronic diseases, after six months, the majority take less medication than prescribed or stop the medication altogether. There are both federal and state laws that make using or sharing prescription drugs illegal. If someone take a pill that was prescribed to someone else or give that pill to another person, not only is it against the law, it's extremely dangerous.