Setting up a nurse-led model of care for management of hypertension and diabetes mellitus in a high HIV prevalence context in rural Zimbabwe: A descriptive study

Background: In the light of the increasing burden of non-communicable diseases (NCDs) on health systems in low- and middle-income countries, particularly in Sub-Saharan Africa, context-adapted, cost-effective service delivery models are now required as a matter of urgency. We describe the experience of setting up and organising a nurse-led Diabetes Mellitus (DM) and Hypertension (HTN) model of care in rural Zimbabwe, a low-income country with unique socio-economic challenges and a dual disease burden of HIV and NCDs. Methods: Mirroring the HIV experience, we designed a conceptual framework with 9 key enablers: decentralization of services, integration of care, simplification of management guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system. We selected 9 primary health care clinics (PHC) and two hospitals in Chipinge district and integrated DM and HTN either into the general out-patient department, pre-existing HIV clinics, or an integrated chronic care clinic (ICCC). We provided structured intensive mentoring for staff, using simplified protocols, and disease-specific education for patients. Free medication with differentiated periodic refills and regular monitoring with point of care (POC) glycosylated haemoglobin (HbA1c) were provided. Results: Nurses in 7 PHC facilities and one hospital developed sufficient knowledge and skills to diagnose, initiate treatment and monitor DM and HTN patients, and 3094 patients were registered in the programme (188 with DM only, 2473 with HTN only, 433 with both DM and HTN). Major lessons learned from our experience include: the value of POC devices in the management of diabetes; the pressure on services of the added caseload, exacerbated by the availability of free medications in supported health facilities; and the importance of leadership in the successful implementation of care in health facilities. Conclusion: Our experience demonstrates a model for nurse-led decentralized integrated DM and HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted efficient model of care is a dynamic process. We present our lessons learned with the intention of sharing experience which may be of value to other public health programme managers. This is a programmatic description of a model of care for DM and HTN services. The study took place in Chipinge rural district, one of the seven districts of Manicaland in Zimbabwe. The economy is based on subsistence and commercial farming, with low incomes per household [10] . It has a population of over 300,000 [11] served by 51 health facilities. The dirt road network makes some health facilities hard to reach, especially during the rainy season. Chipinge District Hospital (CDH) is the major referral hospital for the North and St Peter’s Mission Hospital (SPMH) for the South. Reliable figures on DM and HTN prevalence in Chipinge district have not been documented. MOH/MSF began activities in July 2016 in 11 health facilities, offering care for patients with DM and HTN. An MSF mentoring team provided structured teaching sessions and hands-on clinical training to MOH staff, who performed consultations. No NCD-specific guidelines were available in Zimbabwe, therefore MOH/MSF developed simplified context-adapted clinical protocols, training materials and patient literacy tools. MSF supported MoH to meet the cost of medications and laboratory consumables. Patients who attended health facilities for DM and HTN care were registered in the programme. Our programme design was based on a conceptual framework (Fig. 1) developed by the authors by drawing from MSF’s experience on HIV care in SSA including Zimbabwe. We were also inspired by various publications describing successful strategies used in delivering HIV care across the entire health pyramid [12–14]. The mid-section of the framework illustrates the health system. Patients within the community can access their PHC facility for acute or chronic care, and maternal and child health services, where they are attended to by qualified nurses. Where the condition requires expertise, patients are referred to secondary or tertiary levels. Once patients are stable, they are then referred back through the various levels down to PHC level. The left-hand column highlights the 9 strategic key-enablers of a successful ART programme while the right-hand column mirrors the same strategies for the NCD programme. Conceptual framework We used automated sphygmomanometers to measure blood pressure (BP) and diagnosed HTN if two out of three readings were ≥ 140/90 mmHg on 3 separate visits (or 2 separate occasions if BP ≥ 180/110 mmHg). Any adult presenting to a health facility in Zimbabwe receives a blood pressure check, and among HIV patients annual screening for HTN is recommended [15]. For DM we adopted a health facility-based opportunistic screening approach according to risk factors such as family history, presence of HTN, HIV, active TB, obesity, CVD or Chronic Kidney Disease (CKD). Diagnosis of DM was based upon a combination of two tests: glycosylated haemoglobin (HbA1c) ≥6.5% and a random blood sugar (RBS) ≥11.1 mmol/L, or a fasting blood sugar (FBS) ≥7 mmol/L. In the presence of severe symptoms of hyperglycaemia, a single high reading of blood glucose confirmed diagnosis (see Table 1). Diagnosis of DM: test combinations required FBS ≥ 7.0 mmol/L OR RBS ≥ 11.1 mmol/L AND symptoms of hyperglycaemia Not applicable No second test required Those with self-reported conditions were rescreened to confirm the diagnosis, if there was insufficient clinical or documentary evidence to support the accuracy of the initial diagnosis. For both conditions, active screening in the community was avoided as this has been shown not to be cost-effective [8, 16], and due to concerns that it might overload health facilities with patients. The treatment initiation threshold for patients with HTN-only was set at BP ≥160/100 mmHg in line with the WHO/ISH risk stratification [17] and standard MSF protocols. For patients with additional risk factors such as diabetes, known CVD or CKD, a lower threshold was chosen (BP ≥140/90 mmHg). The initial treatment target was defined as BP < 140/90 mmHg for patients < 65 years, and BP < 150/90 for patients ≥65 years. Subsequently we simplified protocols, and set a single target of 140/90 for all age-groups. HbA1c targets for diabetes were initially defined as < 8% for < 65 years, and < 9% for ≥65 years. A single target of < 7% for low risk patients independently of age was subsequently chosen within a rationale of simplification. A target of < 8% was set for high risk patients (elderly, history of severe hypoglycaemia, multiple comorbidities, long-standing diabetes, limited life expectancy or advanced chronic diabetic complications).