Evaluating the cascade of care for hypertension in Sierra Leone

Tropical Medicine and International Health, Volume 26, No. 11, Year 2021

Interpretação

Objective: To assess the care for hypertension in Sierra Leone, by the use of a cascade-of-care approach, to identify where the need for healthcare system interventions is greatest. Methods: Using data from a nationwide household survey on surgical conditions undertaken in 1956 participants ≥18 years from October 2019 to March 2020, a cascade of care for hypertension consisting of four categories – hypertensive population, those diagnosed, those treated and those controlled – was constructed. Hypertension was defined as having a blood pressure ≥140/90 mmHg, or self-reported use of antihypertensive medication. Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension. Results: The prevalence of hypertension was 22%. Among those with hypertension, 23% were diagnosed, 11% were treated and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Male sex, age and living in a rural location, were significantly associated with the odds of undiagnosed hypertension. There was no significant difference between men and women in the number of patients with controlled blood pressure. Adults aged 40 or older were observed to be better retained in care compared with those younger than 40 years of age. Conclusion: There is a significant loss to care in the care cascade for hypertension in Sierra Leone. Our results suggest that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis might have a large impact on hypertension care. This study used data from a national household‐based survey to estimate surgical and maternal health conditions (PREvalence Study on Surgical COnditions (PRESSCO 2020) study) in Sierra Leone. Data were collected via individual face‐to‐face interviews at the homes of the respondents. Standardised data collection was undertaken by trained nurses and medical staff. Tablets with mobile internet access were used to collect data during field work. Data were subsequently uploaded to and stored in REDCap©, a secure, web‐based software platform hosted at the University Medical Center Utrecht [18, 19]. Data collection took place October to November 2019 and February to March 2020. Sampling was done through a weighted random cluster design, where the probability of cluster choice is proportional to the population size. Clusters in this context referred to enumeration areas, the smallest administrative units in Sierra Leone as per Statistics Sierra Leone. 1.875 households from 75 nationwide clusters were visited. Information on demographic, socio‐economic status (SES), medical history and physical condition was collected by questionnaire. In participants ≥18 years, systolic and diastolic BP was measured three times, preferably on the upper left arm (if this was not possible, the right arm was used), with a 3‐min interval between measurements with OMRON M6 comfort machines (OMRON Healthcare, the Netherlands). The average of the second and third BP measurements was used for analysis. Hypertension was defined as having a mean systolic blood pressure (SBP) ≥140 mmHg and/or a mean diastolic blood pressure (DBP) ≥90 mmHg or self‐reported use of antihypertensive drugs [13, 20, 21]. In order to identify gaps in the care cascade, study participants with hypertension were divided into four categories: total number of participants with hypertension based on BP measurements during the survey (Category 1); number of study participants diagnosed with hypertension (Category 2); number of participants treated (Category 3); and the number that had controlled BP (Category 4). Being diagnosed with hypertension was defined as having received a previous diagnosis by a healthcare worker or health professional. Being treated for hypertension was defined as having a diagnosis and self‐reported current use of antihypertensive drugs. Being controlled for hypertension was defined as currently using antihypertensives and a mean SBP <140 mmHg [20, 21]. The proportion of study participants who reached each stage of the cascade of care was determined using the number of participants in the previous step as the denominator. Age was categorised as 18–34 years, 35–44 years, 45–54 years, 55–64 years, 65+ years, respectively, as 18–39 years and 40+ years. Residential location was divided as urban and rural, following the definition of the 2015 EA census frame of Sierra Leone [22]; ethnicity differentiated between Creole, Limba, Mende, Temne and other ethnicities (including Fullah, Kissi, Kono, Koranko, Loko, Mandingo, Sherbro, Susu, Vai and Yalunka), other African and non‐African. SES encompassed information on education (none, primary school, secondary school and tertiary/higher education) and occupation (employed and unemployed). Lifestyle factors included tobacco use (smoking and non‐smoking) and alcohol consumption (regularly and not regularly). Medical history information included time since diagnosis of hypertension (past year or before); diabetes screening (screened or never been screened); mobility (no problems, some and confined to bed); medical history (heart problems and/or cerebral vascular accident (CVA), other (including leprosy, tuberculosis, Wuchereria bancrofti filariasis), none and unknown). Frequencies and percentages were used to estimate the prevalence of hypertension. To calculate the proportions of study participants diagnosed with hypertension, treated and controlled, we obtained frequencies and percentages of study participants at each step compared with the preceding step. Multivariable logistic regression using backward elimination, with a p‐value of 0.2 for variable selection, was used to investigate demographic, SES and lifestyle predictors of falling out of the care cascade. Logistic regression was conducted on the cascade step with the biggest loss to care. To extrapolate our results to the entire population, we accounted for the weighted random cluster design consisting of 16 clusters and 75 strata. Analyses were done using STATA/IC 15.1 [23]. The study was endorsed by the Masanga Medical Research Unit's Scientific Review Committee (MMRU‐SRC‐009–2019). Ethical approval was obtained from the Sierra Leone National Ethics Committee and The Norwegian National Committee for Research Ethics (Ref‐No 31932). Study approval was obtained from the formal head of each enumerator area, following community engagement activities contributing to the development of the study protocol. District medical officers were informed to expect referrals in case of medical diagnoses, such as undiagnosed high BP in participants of this study, depending on severity referral was within 24 hours or a week. As part of the larger PRESSCO 2020 study, referrals were arranged for patients who had serious medical problems identified during the physical examination. All participants or their guardian signed informed consent forms prior to study enrolment. Privacy and confidentiality were assured through the use of password‐protected tablets, secure internet data transfer and use of anonymised data for analyses.

AI Digest

Study Justification:

The study aimed to evaluate the cascade of care for hypertension in Sierra Leone. This is important because hypertension is a significant public health issue in the country, and understanding the gaps in the care cascade can help identify areas where healthcare system interventions are needed the most. By assessing the prevalence of hypertension, diagnosis rates, treatment rates, and control rates, the study provides valuable insights into the current state of hypertension care in Sierra Leone.

Highlights:

– The prevalence of hypertension in Sierra Leone was found to be 22%.
– Among individuals with hypertension, only 23% were diagnosed, 11% were treated, and 5% had controlled blood pressure.
– The largest loss to care (77%) occurred between being hypertensive and receiving a diagnosis.
– Factors associated with undiagnosed hypertension included male sex, age, and living in a rural location.
– There was no significant difference between men and women in the number of patients with controlled blood pressure.
– Adults aged 40 or older were observed to be better retained in care compared to those younger than 40 years of age.

Recommendations:

Based on the study findings, the following recommendations can be made:

1. Increase awareness of cardiovascular risk and promote risk factor screening for early diagnosis of hypertension.
2. Improve access to healthcare services, particularly in rural areas, to ensure timely diagnosis and treatment of hypertension.
3. Strengthen healthcare provider training on hypertension management and control.
4. Implement strategies to improve patient adherence to antihypertensive medication and lifestyle modifications.
5. Enhance monitoring and evaluation systems to track progress in hypertension care and control.

Key Role Players:

To address the recommendations, the involvement of the following key role players is crucial:

1. Ministry of Health: Responsible for policy development, resource allocation, and coordination of healthcare services.
2. Healthcare Providers: Including doctors, nurses, and community health workers who play a vital role in diagnosing, treating, and managing hypertension.
3. Community Leaders: Engaging community leaders can help raise awareness, promote screenings, and encourage adherence to treatment.
4. Non-Governmental Organizations (NGOs): NGOs can support healthcare initiatives, provide training, and facilitate community outreach programs.
5. Pharmaceutical Companies: Collaboration with pharmaceutical companies can ensure the availability and affordability of antihypertensive medications.

Cost Items for Planning Recommendations:

While actual cost estimates are not provided, the following cost items should be considered in planning the recommendations:

1. Training and Capacity Building: Budget for training healthcare providers on hypertension management and control.
2. Healthcare Infrastructure: Allocate funds for improving healthcare facilities, especially in rural areas, to ensure access to diagnosis and treatment.
3. Medications and Supplies: Budget for the procurement and distribution of antihypertensive medications and necessary medical supplies.
4. Awareness Campaigns: Allocate funds for public awareness campaigns to promote cardiovascular risk screening and early diagnosis.
5. Monitoring and Evaluation: Set aside resources for establishing and maintaining monitoring and evaluation systems to track progress in hypertension care and control.
Please note that the provided information is based on the description and findings of the study and should be interpreted in that context.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study used data from a nationwide household survey, which provides a representative sample of the population. The cascade-of-care approach is a useful method for assessing the care for hypertension. The study identified a significant loss to care in the cascade, with only 23% of hypertensive individuals being diagnosed and 5% having controlled blood pressure. The study also identified factors associated with undiagnosed hypertension, such as male sex, age, and living in a rural location. However, the abstract does not provide information on the sample size or the statistical significance of the findings. Additionally, the abstract could benefit from providing more details on the methods used, such as the specific data collection procedures and the statistical analyses conducted. To improve the evidence, the authors could consider providing more information on the sample size, statistical significance, and the specific methods used. They could also include more details on the data collection procedures and the statistical analyses conducted.

Resumo

This study used data from a national household‐based survey to estimate surgical and maternal health conditions (PREvalence Study on Surgical COnditions (PRESSCO 2020) study) in Sierra Leone. Data were collected via individual face‐to‐face interviews at the homes of the respondents. Standardised data collection was undertaken by trained nurses and medical staff. Tablets with mobile internet access were used to collect data during field work. Data were subsequently uploaded to and stored in REDCap©, a secure, web‐based software platform hosted at the University Medical Center Utrecht [18, 19]. Data collection took place October to November 2019 and February to March 2020. Sampling was done through a weighted random cluster design, where the probability of cluster choice is proportional to the population size. Clusters in this context referred to enumeration areas, the smallest administrative units in Sierra Leone as per Statistics Sierra Leone. 1.875 households from 75 nationwide clusters were visited. Information on demographic, socio‐economic status (SES), medical history and physical condition was collected by questionnaire. In participants ≥18 years, systolic and diastolic BP was measured three times, preferably on the upper left arm (if this was not possible, the right arm was used), with a 3‐min interval between measurements with OMRON M6 comfort machines (OMRON Healthcare, the Netherlands). The average of the second and third BP measurements was used for analysis. Hypertension was defined as having a mean systolic blood pressure (SBP) ≥140 mmHg and/or a mean diastolic blood pressure (DBP) ≥90 mmHg or self‐reported use of antihypertensive drugs [13, 20, 21]. In order to identify gaps in the care cascade, study participants with hypertension were divided into four categories: total number of participants with hypertension based on BP measurements during the survey (Category 1); number of study participants diagnosed with hypertension (Category 2); number of participants treated (Category 3); and the number that had controlled BP (Category 4). Being diagnosed with hypertension was defined as having received a previous diagnosis by a healthcare worker or health professional. Being treated for hypertension was defined as having a diagnosis and self‐reported current use of antihypertensive drugs. Being controlled for hypertension was defined as currently using antihypertensives and a mean SBP <140 mmHg [20, 21]. The proportion of study participants who reached each stage of the cascade of care was determined using the number of participants in the previous step as the denominator. Age was categorised as 18–34 years, 35–44 years, 45–54 years, 55–64 years, 65+ years, respectively, as 18–39 years and 40+ years. Residential location was divided as urban and rural, following the definition of the 2015 EA census frame of Sierra Leone [22]; ethnicity differentiated between Creole, Limba, Mende, Temne and other ethnicities (including Fullah, Kissi, Kono, Koranko, Loko, Mandingo, Sherbro, Susu, Vai and Yalunka), other African and non‐African. SES encompassed information on education (none, primary school, secondary school and tertiary/higher education) and occupation (employed and unemployed). Lifestyle factors included tobacco use (smoking and non‐smoking) and alcohol consumption (regularly and not regularly). Medical history information included time since diagnosis of hypertension (past year or before); diabetes screening (screened or never been screened); mobility (no problems, some and confined to bed); medical history (heart problems and/or cerebral vascular accident (CVA), other (including leprosy, tuberculosis, Wuchereria bancrofti filariasis), none and unknown). Frequencies and percentages were used to estimate the prevalence of hypertension. To calculate the proportions of study participants diagnosed with hypertension, treated and controlled, we obtained frequencies and percentages of study participants at each step compared with the preceding step. Multivariable logistic regression using backward elimination, with a p‐value of 0.2 for variable selection, was used to investigate demographic, SES and lifestyle predictors of falling out of the care cascade. Logistic regression was conducted on the cascade step with the biggest loss to care. To extrapolate our results to the entire population, we accounted for the weighted random cluster design consisting of 16 clusters and 75 strata. Analyses were done using STATA/IC 15.1 [23]. The study was endorsed by the Masanga Medical Research Unit's Scientific Review Committee (MMRU‐SRC‐009–2019). Ethical approval was obtained from the Sierra Leone National Ethics Committee and The Norwegian National Committee for Research Ethics (Ref‐No 31932). Study approval was obtained from the formal head of each enumerator area, following community engagement activities contributing to the development of the study protocol. District medical officers were informed to expect referrals in case of medical diagnoses, such as undiagnosed high BP in participants of this study, depending on severity referral was within 24 hours or a week. As part of the larger PRESSCO 2020 study, referrals were arranged for patients who had serious medical problems identified during the physical examination. All participants or their guardian signed informed consent forms prior to study enrolment. Privacy and confidentiality were assured through the use of password‐protected tablets, secure internet data transfer and use of anonymised data for analyses.

Materiais

https://efashare.b-cdn.net/materials/17ded20e843b9100d14ba23338a2815962bb8fc629c2e061eeabe68c493d1819/TMI-26-1470-s001.docx

Inovações

Based on the provided information, here are some potential innovations that could improve access to maternal health in Sierra Leone:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide information and resources related to maternal health, including prenatal care, nutrition, and postpartum care. These apps can also include features such as appointment reminders and access to telemedicine consultations.

2. Community Health Workers: Train and deploy community health workers to provide education, support, and basic healthcare services to pregnant women and new mothers in rural areas. These workers can help identify and refer high-risk pregnancies, provide prenatal and postnatal care, and promote healthy behaviors.

3. Telemedicine: Establish telemedicine services to connect pregnant women in remote areas with healthcare providers. This can enable remote consultations, monitoring of high-risk pregnancies, and timely access to medical advice and support.

4. Health Information Systems: Implement electronic health records and data management systems to improve the collection, analysis, and sharing of maternal health data. This can help identify gaps in care, track patient outcomes, and inform evidence-based decision-making.

5. Maternal Health Vouchers: Introduce voucher programs that provide financial assistance to pregnant women, particularly those from low-income backgrounds, to access essential maternal health services. These vouchers can cover costs such as prenatal care, delivery, and postpartum care.

6. Transportation Support: Develop transportation initiatives to address the challenge of accessing healthcare facilities in remote areas. This can include providing transportation vouchers, establishing community transportation networks, or partnering with local transportation providers to ensure pregnant women can reach healthcare facilities in a timely manner.

7. Maternal Health Education Campaigns: Launch targeted education campaigns to raise awareness about the importance of maternal health and promote healthy behaviors during pregnancy. These campaigns can utilize various channels such as radio, television, community meetings, and mobile messaging.

8. Collaborative Care Models: Foster collaboration between healthcare providers, community organizations, and government agencies to create integrated care models for maternal health. This can involve establishing referral networks, coordinating care across different healthcare settings, and ensuring continuity of care throughout the pregnancy and postpartum period.

It is important to note that these recommendations are based on the general context of improving access to maternal health and may need to be tailored to the specific needs and challenges faced in Sierra Leone.

AI Innovations Description

The study mentioned in the description focuses on evaluating the cascade of care for hypertension in Sierra Leone. The goal of the study is to identify areas where healthcare system interventions are needed to improve the care for hypertension. The study used data from a nationwide household survey conducted between October 2019 and March 2020.

The study found that there is a significant loss to care in the care cascade for hypertension in Sierra Leone. Among those with hypertension, only 23% were diagnosed, 11% were treated, and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Factors associated with undiagnosed hypertension included male sex, age, and living in a rural location.

The study suggests that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis could have a large impact on hypertension care. By improving awareness and screening, more individuals with hypertension can be identified and receive appropriate care and treatment.

In summary, the recommendation to improve access to maternal health based on this study would be to focus on increasing awareness of cardiovascular risk and conducting regular risk factor screening for early diagnosis of hypertension. This can help identify individuals with hypertension and ensure they receive the necessary care and treatment.

AI Innovations Methodology

The study mentioned in the description focuses on evaluating the cascade of care for hypertension in Sierra Leone. It aims to identify areas where healthcare system interventions are needed the most. The methodology used in the study involves data collection through a nationwide household survey on surgical conditions. Here is a brief description of the methodology:

1. Data Collection: The data was collected through individual face-to-face interviews conducted at the homes of the respondents. Trained nurses and medical staff used tablets with mobile internet access to collect data during the fieldwork. The data collection took place from October to November 2019 and February to March 2020.

2. Sampling: The sampling was done using a weighted random cluster design, where the probability of cluster choice was proportional to the population size. Clusters referred to enumeration areas, which are the smallest administrative units in Sierra Leone. A total of 1,875 households from 75 nationwide clusters were visited.

3. Questionnaire: A standardized questionnaire was used to collect information on demographic factors, socio-economic status, medical history, and physical condition. The questionnaire included questions about hypertension, such as systolic and diastolic blood pressure measurements.

4. Blood Pressure Measurement: Systolic and diastolic blood pressure measurements were taken three times from participants aged 18 years and above. The measurements were preferably taken on the upper left arm, and the average of the second and third measurements was used for analysis. Hypertension was defined as having a mean systolic blood pressure (SBP) ≥140 mmHg and/or a mean diastolic blood pressure (DBP) ≥90 mmHg or self-reported use of antihypertensive drugs.

5. Cascade of Care: To identify gaps in the care cascade for hypertension, study participants with hypertension were divided into four categories: those with hypertension based on blood pressure measurements (Category 1), those diagnosed with hypertension (Category 2), those treated for hypertension (Category 3), and those with controlled blood pressure (Category 4). The proportions of participants in each category were calculated using the number of participants in the previous step as the denominator.

6. Statistical Analysis: Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension. Factors such as sex, age, and residential location were examined for their association with undiagnosed hypertension. Multivariable logistic regression with backward elimination was used to identify predictors of falling out of the care cascade.

7. Extrapolation: The results obtained from the study were extrapolated to the entire population by accounting for the weighted random cluster design. This involved considering the 16 clusters and 75 strata in the analysis.

8. Ethical Considerations: The study obtained ethical approval from the Sierra Leone National Ethics Committee and The Norwegian National Committee for Research Ethics. Informed consent was obtained from all participants or their guardians, and privacy and confidentiality were ensured through the use of password-protected tablets and anonymized data for analysis.

In summary, the methodology used in the study involved data collection through a nationwide household survey, blood pressure measurements, and the construction of a cascade of care for hypertension. Logistic regression analysis was used to identify factors associated with undiagnosed hypertension, and the results were extrapolated to the entire population. Ethical considerations were taken into account throughout the study.

Autores & Coautores

Statistics:

Citations: 2

Authors: 17

Identifiers:

DOI: 10.1111/tmi.13664

ISSN: 13602276

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Social Determinants, Substance Abuse

Study Countries:

Sierra Leone

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female

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