scholarly journals Challenges and opportunities in the continuity of care for hypertension: a mixed-methods study embedded in the Tajikistan Health Services Improvement Project

2019 ◽  
Author(s):  
Adanna Chukwuma ◽  
Estelle Gong ◽  
Mutriba Latypova ◽  
Nicole Fraser-Hurt
Keyword(s):  
Mixed Methods ◽  
Health Services ◽  
Service Delivery ◽  
Significant Risk ◽  
Mixed Methods Study ◽  
Primary Health Care System ◽  
Case Detection ◽  
Core Element ◽  
Improvement Project ◽  
Cascade Of Care

Abstract Background: Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of hypertension case detection and retention in care within Tajikistan’s primary health care system, and to identify challenges and appropriate solutions. Methods: Our mixed-methods study drew on the cascade of care framework to examine patient progression through the recommended stages of hypertension care. We triangulated data from household surveys and facility registries within Tajikistan’s Health Services Improvement Project (HSIP) to describe the cascade. Focus group discussions with local HSIP stakeholders identified the barriers to and facilitators for care. Drawing on global empirical evidence on effective interventions and stakeholder judgments on the feasibility of implementation, we developed recommendations to improve hypertension service delivery that were informed by our quantitative and qualitative findings. Results: We review the results for the case detection stage of the cascade of care, which had the most significant gaps. Of the half a million people with hypertension in Khatlon and Sogd Oblasts (administrative regions), about 10 percent have been diagnosed in Khatlon and only 5 percent in Sogd. Barriers to case detection include misinformation about hypertension, ambiguous protocols, and limited delivery capacity. Solutions identified to these challenges were mobilizing faith-based organizations, scaling up screening through health caravans, task-shifting to increase provider supply, and introducing job aids for providers. Conclusions: Translating findings on discontinuities in care for hypertension and other chronic diseases to actionable policy insights can be facilitated by collaboration with local stakeholders, triangulation of data sources, and identifying the intersection between the feasible and the effective in defining solutions to service delivery challenges.

scholarly journals Challenges and opportunities in the continuity of care for hypertension: a mixed-methods study embedded in a primary health care intervention in Tajikistan

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Adanna Chukwuma ◽  
Estelle Gong ◽  
Mutriba Latypova ◽  
Nicole Fraser-Hurt
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Mixed Methods ◽  
Service Delivery ◽  
Mixed Methods Study ◽  
Primary Health Care System ◽  
Case Detection ◽  
Improvement Project ◽  
Primary Health ◽  
Cascade Of Care

Abstract Background Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of hypertension case detection and retention in care within Tajikistan’s primary health care system, and to identify challenges and appropriate solutions. Methods Our mixed methods study drew on the cascade of care framework to examine patient progression through the recommended stages of hypertension care. We triangulated data from household surveys and facility registries within Tajikistan’s Health Services Improvement Project (HSIP) to describe the cascade. Focus group discussions with local HSIP stakeholders identified the barriers to and facilitators for care. Drawing on global empirical evidence on effective interventions and stakeholder judgments on the feasibility of implementation, we developed recommendations to improve hypertension service delivery that were informed by our quantitative and qualitative findings. Results We review the results for the case detection stage of the cascade of care, which had the most significant gaps. Of the half a million people with hypertension in Khatlon and Sogd Oblasts (administrative regions), about 10% have been diagnosed in Khatlon and only 5% in Sogd. Barriers to case detection include misinformation about hypertension, ambiguous protocols, and limited delivery capacity. Solutions identified to these challenges were mobilizing faith-based organizations, scaling up screening through health caravans, task-shifting to increase provider supply, and introducing job aids for providers. Conclusions Translating findings on discontinuities in care for hypertension and other chronic diseases to actionable policy insights can be facilitated by collaboration with local stakeholders, triangulation of data sources, and identifying the intersection between the feasible and the effective in defining solutions to service delivery challenges.

scholarly journals Identifying solutions to bottlenecks in hypertension service delivery: Insights for improving case detection in Tajikistan

2019 ◽  
Author(s):  
Adanna Chukwuma ◽  
Estelle Gong ◽  
Mutriba Latypova ◽  
Nicole Fraser-Hurt
Keyword(s):  
Service Delivery ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Case Detection ◽  
Core Element ◽  
Systematic Assessment ◽  
Effective Interventions ◽  
Local Stakeholders ◽  
Cascade Of Care ◽  
Feasible Solutions

Abstract Background Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of bottlenecks in service delivery for hypertension within primary health care in Tajikistan and define appropriate solutions.Methods Our study drew on the cascade of care framework to examine patient progression through the recommended stages of care. We triangulated data from household surveys and facility registries to describe the cascade. Focus group discussions with local stakeholders identified the determinants of discontinuities in care. Drawing on global empirical evidence on effective interventions and stakeholder judgments on the feasibility of implementation, we developed recommendations to improve hypertension service delivery.Results We review the results for the case detection stage of the cascade of care, which had the most significant gaps. Of the half a million people with hypertension in either Oblast, about 10 percent have been diagnosed in Khatlon and only 5 percent in Sogd. Bottlenecks in case detection include misinformation about hypertension, ambiguous protocols, and limited delivery capacity. Solutions identified to these challenges were mobilizing faith-based organizations, scaling up screening through health caravans, job aids for providers, and task-shifting to increase provider supply.Conclusions Translating findings on discontinuities in care for hypertension and other chronic diseases to actionable policy insights can be facilitated by collaboration with local stakeholders, triangulation of data sources, and identifying the intersection between the feasible and the effective in defining solutions to service delivery bottlenecks.

scholarly journals Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

2020 ◽  
Vol 8 (15) ◽  
pp. 1-256
Author(s):  
Alicia O’Cathain ◽  
Emma Knowles ◽  
Jaqui Long ◽  
Janice Connell ◽  
Lindsey Bishop-Edwards ◽  
...  
Keyword(s):  
General Practice ◽  
Mixed Methods ◽  
General Practitioner ◽  
Health Service ◽  
Health Services ◽  
Focus Groups ◽  
Emergency Departments ◽  
Help Seeking ◽  
Mixed Methods Study ◽  
Coping Capacity

Background There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use. Objectives To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives. Design This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking. Results From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice. Limitations Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service. Conclusions Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered. Future work There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions. Study registration This study is registered as PROSPERO CRD42017056273. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

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