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Table 4 Studies reported outcomes and key findings

From: Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services

 

Author and publication year

Country

Described outcomes

Timeline of outcomes

Reported outcomes

(Study comparations if available)

Key findings reported by authors

     

Reported benefits

Reported challenges

1

Steyn 1993 [62]

South Africa

•BP control (< 160/95 mmHg)

•Engagement in care

4 years

BP control:

-In men: SBP decreased by 4,5 mmHg in both intervention towns compared with 1,8 mmHg in the control town

-DBP decreased by 1,5 and 2,3 mmHg in control towns, while it increased by 2,2 mmHg in the control town

-In women: SBP, mean SBP decreased by 6,3 and 8,0 mmHg in the intervention towns, compared with a decrease of 4,9 mmHg in the control town

-DBP decreased by 3,4 and 3,8 mmHg against 0,7 in the control town

•Positive impact on prevention of CVDRFs and BP treatment management

•Limited generalisability due to only inclusion of white population during the Apartheid years

•Unclear impact on stand-alone BP intervention, as the program was part of an extensive multifactorial risk factor intervention

•Historical BP control targets

2

Oparah 2006 [60]

Nigeria

•Acceptability

•BP control (< 140/90 mmHg)

•Engagement in care

6 months

Patient satisfaction: significantly higher rating than baseline P < 0.0001

BP control:

-Significant difference (P < 0.0001) in mean SBP from baseline (187.67 ± 29.46 mmHg) to the end of the study (137.22 ± 21.65 mmHg)

-Significant difference (P < 0.0001) in mean DBP from baseline (117.56 ± 21.65) to the end of study (89 ± 17.23)

-75% reached SBP goals, while 69% attained DBP goals

Adherence to treatment:

-Improvement on compliance-rated scores at the end of the study compared to baseline (< 0.006)

•Increased access and acceptability of the BP intervention with the involvement of community pharmacists

•Community pharmacists involved in early diagnosis of BP and potential role in CVRFs screening

•Practices in Nigeria do not conform to international standards for community pharmacies

•Limited long-term impact due to short follow-up and small sample size

•Need to provide remuneration for the community pharmacists

3

Ndou 2013 [51]

South Africa

•BP control (< 130/85 mmHg)

8 (2–18) months

BP control:

-21.4% of patients in the community were controlled at > 40% of health checks in comparison to 13.1% of clinic patients

-In diabetic patients: hypertension was controlled in higher proportion of community-based patients (27.3%) at > 40% of health checks in comparison with 4.8% of clinic patients

•Increased accessibility of services, especially among elder groups

•Reduced patient load at the clinics

•Service delivery frequently compromised by lack of doctors, poor drug supply, centralized services, and poor stakeholders coordination

•Quality of care compromised by poor management of side effects, lack of CHWs supervision, poor referrals of patients to higher levels, inability to address other determinants of health

4

Khabala 2015 [58]

Kenya

•BP control (BP threshold in MACs < 150/100 mmHg)

•Engagement in care

12 months

BP control:

-A total of 12/2208 consultations were referred back to regular care due to failure to control diabetes/hypertension

Engagement in care:

-Overall loss to follow-up: 3.5%

-LTFU occurred only between the 1st and 2nd MAC attendees

-There were no known deaths of MAC patients during the study period

End-organ damage:

-followed up 211 group participants with creatinine (outcomes not reported)

•Reduced patient burden at clinics

•Reduced waiting times and increased appointment flexibility

•Free services, leading to increased retention in care

•Unclear impact in long-term outcomes

•Very selected population: “Stable”: HIV ≥ 25y on treatment > 6 months (in HIV +  > 1y). Criteria of stability: BP < 150/200, HbA1C < 8%, CD4 > 200, undetectable viral load, not WHO stage 3 or 4, or other active disease

5

Marfo 2017 [55]

Ghana

•BP control (< 140/90 mmHg/ < 130/80 mmHg in diabetic hypertensive patients)

•Engagement in care

6 months

BP control:

-Mean SBP difference between the intervention and the control

group was statistically significant (p = 0.001)

-Mean adherence difference between the two groups was

statistically significant (p = 0.001)

Adherence:

-The intervention group increased in mean adherence scores and the control group showed a decrease in adherence scores at the end of the study. The difference in the mean adherence scores between the two groups was statistically significant

• Increased users satisfaction due to reductions in waiting time and increased access to health education

•Lack of national policies concerning services at community pharmacies

•Time consuming intervention for pharmacists (preparing appointments and the preparation of patients reminders)

•Remuneration of community pharmacists could increase cost for the patients

•Quality of services compromised by lack of assessment of adherence to medicines and poor telecommunication coverage, leading to increased LFU

6

Nelissen 2018 [61]

Nigeria

•Acceptability

•BP control (SBP < 140/ 90 mmHg in patients < 60y< 150/ 90 mmHg in diabetic and > 60 years)

•Engagement in care

6–8 months

Acceptability:

-Cardiologists, pharmacists, and patients where content with model of care, however, expressed difficulties with management of mHealth digital platform

BP control:

-Mean SBP decreased 9.9 mmHg (SD: 18)

-BP on target increased from 24 to 56% and an additional 10% had an improved blood pressure. However, this was not associated with duration of mHealth activity

Engagement in care:

-mHealth activity was present ranging from 38 to 83% across pharmacies

- Median mHealth activity duration was 3.3 months. However, patients self-reported more visits than recorded in the mHealth data

-52% self-reported low adherence, 24% moderate adherence and 24% high adherence to antihypertensive medication. This distribution

did not significantly differ across the pharmacies

•Increased access and quality of care for users

•Increased self-care practice and reduction in waiting times

•mHealth app bridged the gap between clinicians and pharmacies

•Financial savings: costs reductions and ability to negotiate different payment methods with the pharmacists

•Limited representability of population as very selected participants

•Patients perspectives: user fees. Sense of being monitored too closely. Unclear links with the cardiologists through the app

•Health care workers perspectives: Understaffing. Users fees. Difficulties with connectivity to the mHealth application and usability. Fear of clinicians/cardiologists to have their role been taken over by the pharmacists. Increased workload for clinicians and pharmacies

•Overall long-term financial sustainability of the model of care

7

Kuria 2018 [54]

Kenya

•Engagement in care

20 months

Engagement in care:

-Of the 4960 scheduled follow-up visits, the health facility group were more compliant (64%) than either

walkway (60%) or weekend clinic attenders (55%) (P 0.006)

-Self-reported adherence of those

who complied with scheduled clinic visits was 94%, with walkway at 96%, facility at 94% and weekend at 88%, (P 0.001)

-Patients who received hypertension services through the

weekend clinic were 76% less likely to adhere to the treatment than those treated

at the facility (AOR 0.24, 95% CI 0.10–0.57)

-The association between the model of hypertension service delivery and self-reported adherence to medication remained significant even after adjusting for sex and age at enrolment

•Placing full-service clinics in strategic locations to account for travel to work may be effective

•Offering services for men outside working hours may increase their participation

•Using a simple pill regimen likely increases adherence

•Health passports with medical information facilitate long-term care in transient populations

•Services did not provide comprehensive services at a convenient location for patients

•Adherence to medication was self-reported and hence could have introduced bias in care

•Lack of quality data increased LFU

•Compliance with the health facility model was better than in walkway and weekend clinics

8

Adler 2019 [52]

Ghana

•BP control (< 140/90 mm Hg)

•Engagement in care

6–12 months

Blood pressure control:

- 72% (95% CI: 67% to 77%) of participants had their BP under control. SBP was reduced by 12.2 mm Hg (95% CI: 14.4 to 10.1) and diastolic BP by 7.5 mm Hg (95% CI: 9.9 to 6.1)

Engagement in care:

552/1339 (41%) patients were in care at 6 m and 338/1339 (25%) were retained in care at 12 months

•Use of Ghana health system existing protocols and medications

•Incomplete picture of medical interventions as ComHIP was connected only with certain HCWs

•No control cohort

•High LFU rates and staff turnover

9

Bolarinwa 2019 [59]

Nigeria

•BP control (< 140/90 mm Hg)

•Engagement in care

6–12 months

Blood pressure control:

-Mean SBP ± SD (mmHg) was 139.39 ± 23.79 in the intervention group and 140.57 ± 21.90 in the control group (P = 0.658)

- Mean DBP ± SD (mmHg) was 86.58 ± 12.11 in the intervention group and 87.27 ± 11.63 in the control group (P = 0.616)

Engagement in care:

Adherence to treatment was increased in the intervention group (P =  < 0.001)

•Improvement of the physical component of quality of life after controlling for the baseline quality of life and age

•Possible improvement in adherence linked to improved counselling

•High attrition rates (lower than similar RCTs)

10

Stephens 21 [53]

Uganda

•BP control (SBP < 169 mm Hg)

•Engagement in care

24 months

Blood pressure control:

-Treatment targets: once treatment is initiated for uncomplicated aHT, the target SBP is < 159. If the SBP is 140–169, the patient is given lifestyle advice and followed up regularly by the VHW for a year. If the threshold of SBP > 169 is reached, the patient is enrolled in CDCom

-68% hypertensive patients enrolled in CDCom had their most recent blood pressure below the

treatment target

•Ability to integrate medical treatment within VHWs screening activities, improving the continuum of care

•Services are closer to patients home

•VHWs have better rapport with the communities

•Increased communication among the different levels of care (primary, secondary and tertiary)

•Inconsistency in measuring BP, leading to over/under measurement

•Increased cost if there is not a comprehensive package of care

•Rotation of clinical staff and lack of clear job descriptions

•Drug stock-outs

•Cost of drugs (user fees) likely rends the model unsuccessful

11

Otieno 21 [57]

Kenya and Ghana

•BP control (< 140/90 mm Hg)

7–16 months

Blood pressure control:

-SBP decreased significantly through 12 months

in both the overall cohort (− 9.4 mmHg, p < .001) and in the uncontrolled subgroup (− 17.6 mmHg, p < .001)

-Proportion of patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001)

•Co-created, locally appropriate model of care implemented to address formidable socioeconomic barriers

•The drops BP plateaued at about 4 months and were sustained over the 12-month follow-up period

•In-clinic patient visits were reduced 60% as compared to standard monthly visits

•Limited representability, as cohort may not represent correspond to the broader sub-population of undiagnosed or untreated patients outside an organized health care system

•The analysis did not include a control arm for comparison. However, the magnitude of the BP reduction and the sustainment of the large reduction through a year of follow-up provided evidence against the effect of a Hawthorne effect

12

Vedanthan 2021 [56]

Kenya

•BP control

(< 140/90 mm Hg)

•Engagement in care

12 months

Blood pressure control:

-Model-based estimates showed that, compared with the UC arm, the mean reduction in SBP was 3.9 mm Hg greater in the GMV-MF arm (98.3% CI: -8.5 to 0.7 mm Hg; p = 0.05), 3.3 mm Hg greater in the GMV arm (98.3% CI: -7.8 to 1.2 mm Hg; p = 0.09), and 2.3 mm Hg greater in the MF arm (98.3% CI: -7.0 to 2.4 mm Hg; p = 0.25)

Engagement in care:

- 12-moths retention: 661/708 (93%) UC, 673/709 (95%) MF, 704/740 (95%) GMVs, 672/763 GMV-MF (88%)

•Observed improvements in BP control were clinically meaningful and would yield substantial long-term cardiovascular and mortality benefit

•Model of care addressing social determinants of health

•Contingent upon enrolment led to differential exposure to the intervention across participants

•Follow-up duration was insufficient to demonstrate a significant benefit

•Unlikely, but possible cross-contamination across the trial arms

•Study population not fully representative of the general population. However, the economic challenges experienced by study participants were not dissimilar from a large proportion of the global population