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Chavan TA, Kaviprawin M, Sakthivel M, Kishore N, Jogewar P, Gill SS, Kunwar A, Durgad K, Wankhede AB, Bharadwaj V, Khedkar SN, Sarode L, Das B, Bangar SD, Venkatasamy V, Gupta A, Kriina M, Krishna A, Pathni AK, Sahoo SK, Parasuraman G, Shivashankar R, Pragya P, Sharma M, Kaur P. India Hypertension Control Initiative: decentralization of hypertension care to health wellness centres in Punjab and Maharashtra, India, 2018-2022. BMC Health Serv Res 2024; 24:884. [PMID: 39095821 PMCID: PMC11297667 DOI: 10.1186/s12913-024-11354-9] [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: 04/25/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
INTRODUCTION The India Hypertension Control Initiative (IHCI) emphasizes decentralized patient-centric care to boost hypertension control in public healthcare facilities. We documented the decentralization process, enrolment pattern by facility type, and treatment outcomes in nine districts of Punjab and Maharashtra states, India, from 2018-2022. METHODS We detailed the shift in hypertension care from higher facilities to Health and Wellness Centres (HWCs) using the World Health Organization (WHO) health system pillar framework. We reviewed hypertension treatment records in 4,045 public facilities from nine districts in the two states, focusing on indicators including registration numbers, the proportion of controlled, uncontrolled blood pressure (BP), and missed visits among those under care. RESULTS The decentralization process involved training, treatment protocol provision, supervision, and monitoring. Among 394,038 individuals registered with hypertension from 2018-2021, 69% were under care in 2022. Nearly half of those under care (129,720/273,355) received treatment from HWCs in 2022. Care of hypertensive individuals from district hospitals (14%), community health centres (20%), and primary health centres (24%) were decentralized to HWCs. Overall BP control rose from 20% (4,004/20,347) in 2019 to 58% (157,595/273,355) in 2022, while missed visits decreased from 61% (12,394/20,347) in 2019 to 26% (70,894/273,355) in 2022. This trend was consistent in both states. HWCs exhibited the highest BP control and the lowest missed visits throughout the study period compared to other facility types. CONCLUSION We documented an increase in decentralized access to hypertension treatment and improved treatment outcomes over four years. We recommend operationalizing hypertension care at HWCs to other districts in India to improve BP control.
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Affiliation(s)
- Tejpalsinh A Chavan
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India.
- India Hypertension Control Initiative (IHCI) Project, District NCD Cell, World Health Organization (WHO), Pune, India.
| | - Mogan Kaviprawin
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
| | - Manikandanesan Sakthivel
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
| | - Navneet Kishore
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
- IHCI Project, State NCD Cell, WHO, Chandigarh, Punjab, India
| | - Padmaja Jogewar
- State NCD Cell, Directorate of Health Services, Government of Maharashtra, Mumbai, India
| | - Sandeep Singh Gill
- State NCD Cell, Department of Health and Family Welfare, Government of Punjab, Chandigarh, India
| | - Abhishek Kunwar
- Department of Noncommunicable Diseases, WHO Country Office, New Delhi, India
| | - Kiran Durgad
- Department of Noncommunicable Diseases, WHO Country Office, New Delhi, India
| | - Amol B Wankhede
- IHCI Project, State NCD Cell, WHO, Mumbai, Maharashtra, India
| | | | - Suhas N Khedkar
- IHCI Project, District NCD Cell, WHO, Satara, Maharashtra, India
| | - Lalit Sarode
- IHCI Project, District NCD Cell, WHO, Wardha, Maharashtra, India
| | - Bidisha Das
- IHCI Project, District NCD Cell, WHO, Bhatinda, Punjab, India
| | | | - Vettrichelvan Venkatasamy
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
| | - Ashu Gupta
- State NCD Cell, Department of Health and Family Welfare, Government of Punjab, Chandigarh, India
| | - Mosoniro Kriina
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
| | | | | | | | - Ganeshkumar Parasuraman
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
| | | | | | | | - Prabhdeep Kaur
- Division of Noncommunicable Diseases (NCD), Indian Council of Medical Research (ICMR) - National Institute of Epidemiology (NIE), Chennai, India
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Hinneh T, Boakye H, Metlock F, Ogungbe O, Kruahong S, Byiringiro S, Dennison Himmelfarb C, Commodore-Mensah Y. Effectiveness of team-based care interventions in improving blood pressure outcomes among adults with hypertension in Africa: a systematic review and meta-analysis. BMJ Open 2024; 14:e080987. [PMID: 39019631 DOI: 10.1136/bmjopen-2023-080987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVE We evaluated the effectiveness of team-based care interventions in improving blood pressure (BP) outcomes among adults with hypertension in Africa. DESIGN Systematic review and meta-analysis. DATA SOURCE PubMed, CINAHL, EMBASE, Cochrane Library, HINARI and African Index Medicus databases were searched from inception to March 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included randomised controlled trials (RCTs) and pre-post study designs published in English language focusing on (1) Adults diagnosed with hypertension, (2) Team-based care hypertension interventions led by non-physician healthcare providers (HCPs) and (3) Studies conducted in Africa. DATA EXTRACTION AND SYNTHESIS We extracted study characteristics, the nature of team-based care interventions, team members involved and other reported secondary outcomes. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs and the National Heart, Lung, and Blood Institute assessment tool for pre-post studies. Findings were summarised and presented narratively including data from pre-post studies. Meta-analysis was conducted using a random effects model for only RCT studies. Overall certainty of evidence was determined using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool for only the primary outcome (systolic BP). RESULTS Of the 3375 records screened, 33 studies (16 RCTs and 17 pre-post studies) were included and 11 RCTs were in the meta-analysis. The overall mean effect of team-based care interventions on systolic BP reduction was -3.91 mm Hg (95% CI -5.68 to -2.15, I² = 0.0%). Systolic BP reduction in team-based care interventions involving community health workers was -4.43 mm Hg (95% CI -5.69 to -3.17, I² = 0.00%) and nurses -3.75 mm Hg (95% CI -10.62 to 3.12, I² = 42.0%). Based on the GRADE assessment, we judged the overall certainty of evidence low for systolic BP reduction suggesting that team-based care intervention may result in a small reduction in systolic BP. CONCLUSION Evidence from this review supports the implementation of team-based care interventions across the continuum of care to improve awareness, prevention, diagnosis, treatment and control of hypertension in Africa. PROSPERO registration number CRD42023398900.
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Affiliation(s)
- Thomas Hinneh
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hosea Boakye
- Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Massachusetts, USA
| | - Faith Metlock
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Suratsawadee Kruahong
- Faculty of Nursing, Department of Nursing, Department of Surgical Nursing, Mahidol University, Bangkok, Thailand
| | - Samuel Byiringiro
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
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Byiringiro S, Hinneh T, Commodore-Mensah Y, Masteller J, Sarfo FS, Perrin N, Assibey S, Himmelfarb CR. Exploring patient-, provider-, and health facility-level determinants of blood pressure among patients with hypertension: A multicenter study in Ghana. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002121. [PMID: 39008513 PMCID: PMC11249229 DOI: 10.1371/journal.pgph.0002121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/19/2024] [Indexed: 07/17/2024]
Abstract
Optimal blood pressure (BP) control is essential in averting cardiovascular disease and associated complications, yet multiple factors influence the achievement of BP targets. We explored patient-, provider-, and health facility-level factors of systolic and diastolic BP and controlled BP status among patients with hypertension in Ghana. Using a cross-sectional design, we recruited 15 health facilities, and from each facility, we recruited four healthcare providers involved in managing hypertension and 15 patients diagnosed with hypertension. The primary outcome of interest was systolic and diastolic BP; the secondary outcome was BP control (<140/90 mmHg) in compliance with Ghana's national standard treatment guidelines. We used mixed-effects regression models to explore the patient- and facility-level predictors of the outcomes. Two hundred twenty-four patients and 67 healthcare providers were sampled across 15 health facilities. The mean (SD) age of providers and patients was 32 (7) and 61 (13) years, respectively. Most (182 [81%]) of the patient participants were female, and almost half (109 [49%]) had controlled BP. At the patient level, traveling for 30 minutes to one hour to the health facility was associated with higher diastolic BP (Coeff.:3.75, 95% CI: 0.12, 7.38) and lower odds of BP control (OR: 0.51, 95% CI: 0.28, 0.92) compared to traveling for less than 30 minutes. Receiving hypertension care at government health facilities than at private health facilities was associated with lower systolic BP (Coeff.: -13.89; 95% CI: -23.99, -3.79). A higher patient-to-physician or physician-assistant ratio was associated with elevated systolic BP (Coeff.: 21.34; 95% CI: 8.94, 33.74) and lower odds of controlled BP (OR: 0.19, 95% CI: 0.05, 0.72). Along with addressing the patient-level factors influencing BP outcomes in Ghana, there is a need for public health and policy interventions addressing the inaccessibility of hypertension services, the shortage of clinical care providers, and the underperformance of private health facilities.
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Affiliation(s)
- Samuel Byiringiro
- Johns Hopkins University, School of Nursing, Baltimore, Maryland, United States of America
| | - Thomas Hinneh
- Johns Hopkins University, School of Nursing, Baltimore, Maryland, United States of America
| | - Yvonne Commodore-Mensah
- Johns Hopkins University, School of Nursing, Baltimore, Maryland, United States of America
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jill Masteller
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ashanti Region, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ashanti Region, Ghana
| | - Nancy Perrin
- Johns Hopkins University, School of Nursing, Baltimore, Maryland, United States of America
| | | | - Cheryl R Himmelfarb
- Johns Hopkins University, School of Nursing, Baltimore, Maryland, United States of America
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States of America
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Okpechi IG, Chukwuonye II, Ekrikpo U, Noubiap JJ, Raji YR, Adeshina Y, Ajayi S, Barday Z, Chetty M, Davidson B, Effa E, Fagbemi S, George C, Kengne AP, Jones ESW, Liman H, Makusidi M, Muhammad H, Mbah I, Ndlovu K, Ngaruiya G, Okwuonu C, Samuel-Okpechi U, Tannor EK, Ulasi I, Umar Z, Wearne N, Bello AK. Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review. BMC Health Serv Res 2023; 23:446. [PMID: 37147670 PMCID: PMC10163711 DOI: 10.1186/s12913-023-09416-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 04/18/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations. METHODS We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively. RESULTS Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively. CONCLUSION Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.
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Affiliation(s)
- Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Canada.
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.
| | - Ijezie I Chukwuonye
- Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
| | - Udeme Ekrikpo
- Division of Nephrology, University of Uyo, Akwa Ibo State, Uyo, Nigeria
| | - Jean Jacques Noubiap
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Yemi R Raji
- Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Yusuf Adeshina
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Samuel Ajayi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Zunaid Barday
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Malini Chetty
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Bianca Davidson
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Emmanuel Effa
- Department of Medicine, University of Calabar, Calabar, Nigeria
- Department of Internal Medicine, Edward Francis Small Teaching Hospital, Banjul, The Gambia
| | - Stephen Fagbemi
- Department of Epidemiology, Ondo State Ministry of Health, Ondo, Nigeria
| | - Cindy George
- Non-Communicable Disease Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Andre P Kengne
- Non-Communicable Disease Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Erika S W Jones
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Hamidu Liman
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Mohammad Makusidi
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Hadiza Muhammad
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Ikechukwu Mbah
- Dept of Medicine College of Med and Health Sciences, Bingham University, Jos, Nigeria
| | - Kwazi Ndlovu
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | | | - Chimezie Okwuonu
- Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
| | | | - Elliot K Tannor
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ifeoma Ulasi
- Department of Medicine, University of Nigeria, Ituku Ozalla, Enugu State, Nigeria
| | - Zulkifilu Umar
- Department of Epidemiology, Ondo State Ministry of Health, Ondo, Nigeria
| | - Nicola Wearne
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
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Olickal JJ, Chinnakali P, Suryanarayana BS, Rajanarayanan S, Vivekanandhan T, Saya GK, Ganapathy K, Subrahmanyam DKS. Down referral and assessing comprehensive diabetes care in primary care settings: An operational research from India. Diabetes Metab Syndr 2023; 17:102694. [PMID: 36563492 DOI: 10.1016/j.dsx.2022.102694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/04/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS In this study, we aimed to refer eligible (patients with stable blood sugar and without any history of cardiovascular events or proliferative retinopathy) and willing persons with diabetes (PwDs) to primary healthcare centers (PHCs) from tertiary care and to compare the care indicators. METHODS This before-after interventional study was conducted among PwDs aged ≥18 years at a tertiary care hospital in South India. Care indicators (regularity to the clinic, waiting time, and blood sugar control status) were assessed before down referral and after three months of follow-ups at PHCs. RESULTS Of 204 PwDs referred to PHCs. Among them, 88% (n = 180) registered at PHCs for care and 46% (n = 94, 95% CI 39.1-53.2%) were lost to follow-ups at PHCs. The main reason for loss to follow-ups was the unavailability of medicines at PHCs(n = 41, 44%). Among those who were on regular follow-ups at PHCs, there was no significant difference in fasting blood glucose (FBG) control status compared to tertiary (52%-64.6%, p = 0.083). However, there was a significant improvement in the regularity of clinic visits (75% vs. 100%, p < 0.001), consultation waiting time (90 vs. 60 min, p = 0.028), and waiting time at pharmacy queues (120 vs. 30 min, p < 0.001) between tertiary care and PHCs. However, among those registered at PHCs, only 40.6% (n = 73, 95% CI 33.3-48.1) were willing to continue care at PHCs for their diabetes management. CONCLUSION Primary care was better than tertiary care in terms of PwD's regularity of clinic visits and waiting time for care.
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Affiliation(s)
- Jeby Jose Olickal
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India; Department of Public Health, KS Hegde Medical Academy, NITTE (Deemed to be University), Mangaluru, Karnataka, India
| | - Palanivel Chinnakali
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
| | - B S Suryanarayana
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - S Rajanarayanan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - T Vivekanandhan
- District Programme Office for NCD, Villupuram, Tamil Nadu, India
| | - Ganesh Kumar Saya
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalaiselvan Ganapathy
- Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - D K S Subrahmanyam
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Mousavi SF, Peimani M, Moghaddam SS, Tabatabaei-Malazy O, Ghasemi E, Shobeiri P, Rezaei N, Nasli-Esfahani E, Larijani B. National and subnational survey on diabetes burden and quality of care index in Iran: a systematic analysis of the global burden of disease study 1990-2019. J Diabetes Metab Disord 2022; 21:1599-1608. [PMID: 36404869 PMCID: PMC9672253 DOI: 10.1007/s40200-022-01108-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/08/2022] [Indexed: 10/10/2022]
Abstract
Purpose Diabetes care is one of the major healthcare problems . This study aimed to introduce a recently-developed Quality of Care Index (QCI) for type 2 diabetes and utilized it to compare different genders, age groups, and Iranian provinces. Methods From the Global Burden of Disease 1990-2019 database, we obtained primary epidemiologic measures and combined them to build four secondary indices, all indicating the quality of care provided to patients. We utilized the principal component analysis (PCA) method to calculate the substantial component named QCI (with a scale of 0-100). Gender inequality was shown by the gender disparity ratio (GDR), defining female to male QCI. Results National QCI ranged from 43.0 in 1990 to 38.6 in 2019. By excluding the more frequent outlier province; Tehran as the Capital of Iran, the QCI score reached 50.27 in 2019. The GDR decreased from 1.04 to 0.95. QCI indicated rather more favorable conditions in Iranian provinces with a higher socio-demographic index (SDI). Conversely, provinces with a lower SDI had worse QCI. In 2019, Tehran, the capital of Iran, with the highest (58.5), and South Khorasan with the lowest QCIs (0.4) were the two Iranian provinces' extremes. Moreover, the elderly QCI improved in 2019. Conclusion During 1990-2019, there are remarkable disparities between Iran's provinces, genders and age groups. The equitable and widespread provision of facilities should be considered along with the decentralization of healthcare resources. Supplementary Information The online version contains supplementary material available at 10.1007/s40200-022-01108-x.
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Affiliation(s)
- Seyedeh Farzaneh Mousavi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Peimani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Saeedi Moghaddam
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ozra Tabatabaei-Malazy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Ghasemi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Parnian Shobeiri
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negar Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ensieh Nasli-Esfahani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Institute, Postal box: 1411713137, North Kargar Ave., Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Institute, Postal box: 1411713137, North Kargar Ave., Tehran, Iran
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Niyonsenga SP, Park PH, Ngoga G, Ntaganda E, Kateera F, Gupta N, Rwagasore E, Rwunganira S, Munyarugo A, Mutumbira C, Dusabayezu S, Eagan A, Boudreaux C, Noble C, Muhimpundu MA, Ndayisaba FG, Nsanzimana S, Bukhman G, Uwinkindi F. Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda. Trop Med Int Health 2021; 26:953-961. [PMID: 33892521 PMCID: PMC8453822 DOI: 10.1111/tmi.13593] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals. This study describes the facility-level implementation outcomes of this strategy. METHODS In 2014, the Ministry of Health trained two nurses in each of the country's 42 first-level hospitals to implement and deliver nurse-led, integrated, outpatient NCD clinics, which focused on severe NCDs. Post-intervention evaluation occurred via repeated cross-sectional surveys, informal interviews and routinely collected clinical data over two rounds of visits in 2015 and 2017. Implementation outcomes included fidelity, feasibility and penetration. RESULTS By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. Among the approximately 27 000 nationally enrolled patients, hypertension was the most common diagnosis (70%), followed by type 2 diabetes (19%), chronic respiratory disease (5%), type 1 diabetes (4%) and heart failure (2%). With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators. CONCLUSION The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs.
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Affiliation(s)
| | - Paul H. Park
- Partners In HealthBostonMAUSA
- Division of Global Health EquityBrigham and Women’s HospitalBostonMAUSA
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Gedeon Ngoga
- Partners In HealthBostonMAUSA
- Inshuti Mu BuzimaRwinkwavuRwanda
| | | | | | - Neil Gupta
- Partners In HealthBostonMAUSA
- Division of Global Health EquityBrigham and Women’s HospitalBostonMAUSA
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Edson Rwagasore
- Rwanda Biomedical CenterRwanda Ministry of HealthKigaliRwanda
| | | | | | - Cadet Mutumbira
- Rwanda Biomedical CenterRwanda Ministry of HealthKigaliRwanda
| | | | - Arielle Eagan
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Chantelle Boudreaux
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | - Christopher Noble
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
| | | | | | | | - Gene Bukhman
- Partners In HealthBostonMAUSA
- Division of Global Health EquityBrigham and Women’s HospitalBostonMAUSA
- Department of Global Health and Social MedicineProgram in Global Noncommunicable Diseases and Social ChangeHarvard Medical SchoolBostonMAUSA
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMAUSA
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