The Long and Winding Road: A Systematic Literature Review Conceptualising Pathways for Hypertension Care and Control in Low- and Middle-Income Countries

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

INTRODUCTION

The burden of non-communicable diseases (NCDs) has increased substantially in low- and middle-income countries (LMICs), and adapting health service delivery models to address this remains a challenge. Many patients with NCD seek private care at different points in their encounters with the health system, but the determinants and outcomes of these choices are insufficiently understood. The proposed systematic review will help inform the governance of mixed health systems towards achieving the goal of universal health coverage. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

METHODS AND ANALYSIS

Following the PRISMA approach, this systematic review will develop a descriptive synthesis of the determinants and outcomes of private healthcare utilisation for NCDs in LMICs. The databases Embase, Medline, Web of Science Core Collection, EconLit, Global Index Medicus and Google Scholar will be searched for relevant studies published in English between period 1 January 2010 and 30 June 2022 with additional searching of reference lists. The study selection process will involve a title-abstract and full-text review, guided by clearly defined inclusion and exclusion criteria. A quality and risk of bias assessment will be done for each study using the Mixed Methods Appraisal Tool.

ETHICS AND DISSEMINATION

Ethical approval is not required because this review is based on data collected from publicly available materials. The results will be published in a peer-reviewed journal and presented at related scientific events.

PROSPERO REGISTRATION NUMBER

CRD42022340059.

A village doctor-led multifaceted intervention for blood pressure control in rural China: an open, cluster randomised trial

BACKGROUND

The prevalence of uncontrolled hypertension is high and increasing in low-income and middle-income countries. We tested the effectiveness of a multifaceted intervention for blood pressure control in rural China led by village doctors (community health workers on the front line of primary health care).

METHODS

In this open, cluster randomised trial (China Rural Hypertension Control Project), 326 villages that had a regular village doctor and participated in the China New Rural Cooperative Medical Scheme were randomly assigned (1:1) to either village doctor-led multifaceted intervention or enhanced usual care (control), with stratification by provinces, counties, and townships. We recruited individuals aged 40 years or older with an untreated blood pressure of 140/90 mm Hg or higher (≥130/80 mm Hg among those with a history of cardiovascular disease, diabetes, or chronic kidney disease) or a treated blood pressure of 130/80 mm Hg or higher. In the intervention group, trained village doctors initiated and titrated antihypertensive medications according to a standard protocol with supervision from primary care physicians. Village doctors also conducted health coaching on home blood pressure monitoring, lifestyle changes, and medication adherence. The primary outcome (reported here) was the proportion of patients with a blood pressure of less than 130/80 mm Hg at 18 months. The analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03527719, and is ongoing.

FINDINGS

Between May 8 and November 28, 2018, we enrolled 33 995 individuals from 163 intervention and 163 control villages. At 18 months, 8865 (57·0%) of 15 414 patients in the intervention group and 2895 (19·9%) of 14 500 patients in the control group had a blood pressure of less than 130/80 mm Hg, with a group difference of 37·0% (95% CI 34·9 to 39·1%; p<0·0001). Mean systolic blood pressure decreased by -26·3 mm Hg (95% CI -27·1 to -25·4) from baseline to 18 months in the intervention group and by -11·8 mm Hg (-12·6 to -11·0) in the control group, with a group difference of -14·5 mm Hg (95% CI -15·7 to -13·3 mm Hg; p<0·0001). Mean diastolic blood pressure decreased by -14·6 mm Hg (-15·1 to -14·2) from baseline to 18 months in the intervention group and by -7·5 mm Hg (-7·9 to -7·2) in the control group, with a group difference of -7·1 mm Hg (-7·7 to -6·5 mm Hg; p<0·0001). No treatment-related serious adverse events were reported in either group.

INTERPRETATION

Compared with enhanced usual care, village doctor-led intervention resulted in statistically significant improvements in blood pressure control among rural residents in China. This feasible, effective, and sustainable implementation strategy could be scaled up in rural China and other low-income and middle-income countries for hypertension control.

FUNDING

Ministry of Science and Technology of China.

(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.

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.

Enablers of Patient Knowledge Empowerment for Self-Management of Chronic Disease: An Integrative Review

The non-development of the concept of patient knowledge empowerment for disease self-management and the non-development of the theory of patient knowledge empowerment in patients with chronic diseases, cause methodological inconsistency of patient empowerment theory and does not provide a methodological basis to present patient knowledge empowerment preconditions. Therefore, the aim of the present integrative review was to synthesize and critically analyze the patient knowledge enablers distinguished in the public health management theory, the knowledge sharing enablers presented in the knowledge management theory and to integrate them by providing a comprehensive framework of patient knowledge enablers. To implement the purpose of the study, in answering the study question of what patient knowledge empowerments are and across which levels of patient knowledge empowerment they operate, an integrative review approach was applied as proposed by Cronin and George. A screening process resulted in a final sample of 78 papers published in open access, peer-review journals in the fields of public health management and knowledge management theories. Based on the results of the study, the Enablers of Patient Knowledge Empowerment for Self-Management of Chronic Disease Framework was created. It revealed that it is important to look at patient knowledge empowerment as a pathway across the empowerment levels through which both knowledge enablers identified in public health management theory and knowledge sharing enablers singled out in knowledge management theory operate. The integration of these two perspectives across patient empowerment levels uncovers a holistic framework for patient knowledge empowerment.