Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review

Abstract Background: The challenge of achieving effective treatment and control of blood pressure is linked to various barriers to hypertension care at different layers of health system (HS). Evidence is emerging globally on the effectiveness of multi-pronged hypertension control strategies. However, no systematic review of strategies of and factors associated with hypertension treatment and control in Nepal is available. Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. This study aimed to systematically review published literature and synthesise the findings on barriers, enablers and strategies for hypertension treatment and control in Nepal. Methods: Six databases namely Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, Nepali journals and Nepal government websites were systematically searched for qualitative, quantitative and mixed-methods studies investigating the factors or strategies in relation to hypertension treatment and control in Nepal. The methodological quality of selected articles was assessed using Mixed Methods Appraisal Tool. Themes on barriers and enablers were generated and framed under “health system” , “provider” and “patient” domains, according to the framework synthesis approach. Findings on hypertension strategies were narratively synthesised. Results: We identified 14 published studies; one with mixed, three with qualitative and 10 with quantitative methods. Eight were related to barriers and enablers and six of hypertension strategies. The identified barriers associated with the HS were: lack of affordable services and lack of resources. The barriers at the provider’s level were: communication gaps and long waiting hours for appointments. Poor help-seeking behaviour, non-adherence to medication, perceived side-effects of drugs, financial hardship and lack of family support were barriers identified at patient level. The following enablers were identified: positive illness perception, free essential healthcare services and family support. Strategies implemented across the HS, provider and patient were: establishing digital health records at health centres, health worker’s capacity development, health education and yoga practice. Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the HS, providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.Registration: The protocol is registered in PROSPERO (registration number: CRD42020145823)

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Barriers, enablers and strategies for the treatment and control of hypertension in Nepal: a systematic review

10.21203/rs.2.20936/v1 ◽

2020 ◽

Author(s):

Raja Ram Dhungana ◽

Achyut Raj Pandey ◽

Nipun Shrestha ◽

Zeljko Pedisic ◽

Maximilian de Courten

Keyword(s):

Systematic Review ◽

Health System ◽

Family Support ◽

Quantitative Methods ◽

Illness Perception ◽

Health System Strengthening ◽

Hypertension Treatment ◽

Barriers And Enablers ◽

Adherence To Medication ◽

And Control

Abstract Background Untreated and uncontrolled hypertension are major challenges in the cascade of care of hypertension in Nepal. The challenge of achieving effective treatment and control of blood pressure is linked to various barriers to hypertension care at different layers of health system. Evidence is emerging globally on the effectiveness of multi-pronged hypertension control strategies, including health system strengthening and population-based interventions. However, no systematic review of the strategies of and factors associated with hypertension treatment and control in Nepal is available. Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. This study, therefore, aimed to systematically review published literature and synthesise the findings on barriers, enablers and strategies for hypertension treatment and control in Nepal. Methods Six databases namely Embase, PubMed, Web of Science, CINAHL (through EBSCOHost), ProQuest and WorldCat were systematically searched for studies investigating the factors or strategies in relation to hypertension treatment and control in Nepal. The methodological quality of selected articles was assessed using Mixed Methods Appraisal Tool (MMAT). Themes on barriers and enablers were generated and framed under “health system excluding provider and patient (HS)”, “provider” and “patient” domains, according to the framework synthesis approach. Findings on hypertension strategies were narratively synthesised. Results We identified 14 published studies; one with mixed, three with qualitative and 10 with quantitative methods, eight relating to barriers and enablers and six of hypertension strategies. The identified barriers associated with the health system (HS) were: lack of affordable services and lack of resources. The commonly reported barriers at the provider’s level were: lack of clear instructions from the providers for medication use, follow-up visits and lifestyle modifications, and long waiting hours for appointments. Poor help-seeking behaviour, non-adherence to medication, perceived side-effects of drugs, financial hardship and lack of family support were barriers identified at patient level. The following enablers were identified: positive illness perception, free essential healthcare services and family support. Strategies implemented across the HS, provider and patient were: establishing digital health records at health centres, health worker’s capacity development, health education and yoga practice. Conclusion There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

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Barriers, enablers and strategies for the treatment and control of hypertension in Nepal: a mixed-methods systematic review

10.21203/rs.2.20936/v2 ◽

2020 ◽

Author(s):

Raja Ram Dhungana ◽

Zeljko Pedisic ◽

Achyut Raj Pandey ◽

Nipun Shrestha ◽

Maximilian de Courten

Keyword(s):

Systematic Review ◽

Mixed Methods ◽

Health System ◽

Family Support ◽

Quantitative Methods ◽

Illness Perception ◽

Hypertension Treatment ◽

Barriers And Enablers ◽

Adherence To Medication ◽

And Control

Abstract Background Untreated and uncontrolled hypertension are major challenges in the cascade of care of hypertension in Nepal. The challenge of achieving effective treatment and control of blood pressure is linked to various barriers to hypertension care at different layers of health system. Evidence is emerging globally on the effectiveness of multi-pronged hypertension control strategies. However, no systematic review of strategies of and factors associated with hypertension treatment and control in Nepal is available. Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. This study aimed to systematically review published literature and synthesise the findings on barriers, enablers and strategies for hypertension treatment and control in Nepal. Methods Six databases namely Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat were systematically searched for studies investigating the factors or strategies in relation to hypertension treatment and control in Nepal. The methodological quality of selected articles was assessed using Mixed Methods Appraisal Tool. Themes on barriers and enablers were generated and framed under “health system” (HS), “provider” and “patient” domains, according to the framework synthesis approach. Findings on hypertension strategies were narratively synthesised. Results We identified 14 published studies; one with mixed, three with qualitative and 10 with quantitative methods. Eight were related to barriers and enablers and six of hypertension strategies. The identified barriers associated with the HS were: lack of affordable services and lack of resources. The barriers at the provider’s level were: communication gaps and long waiting hours for appointments. Poor help-seeking behaviour, non-adherence to medication, perceived side-effects of drugs, financial hardship and lack of family support were barriers identified at patient level. The following enablers were identified: positive illness perception, free essential healthcare services and family support. Strategies implemented across the HS, provider and patient were: establishing digital health records at health centres, health worker’s capacity development, health education and yoga practice. Conclusion There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.Registration: The protocol is registered in PROSPERO (registration number: CRD42020145823)

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Insight into Blood Pressure Targets for Universal Coverage of Hypertension Services in Iran: The 2017 ACC/AHA versus JNC 8 Hypertension Guidelines

10.21203/rs.2.12895/v3 ◽

2020 ◽

Author(s):

Mahdi Mahdavi ◽

Mahboubeh Parsaeian ◽

Bahram Mohajer ◽

Mitra Modirian ◽

Naser Ahmadi ◽

...

Keyword(s):

Blood Pressure ◽

Survey Design ◽

Age Groups ◽

Universal Coverage ◽

Blood Pressure Target ◽

Lifestyle Modifications ◽

Treatment Rate ◽

Blood Pressure Targets ◽

Hypertension Guidelines ◽

And Control

Abstract Background: We assessed and compared the prevalence, awareness, treatment, and control of hypertension in Iran under two hypertension guidelines; the 2017 ACC/AHA with an aggressive blood pressure target 130/80 mm Hg and commonly used guideline JNC8 with 140/90 mm Hg. We shed light on the implications of 2017 ACC/AHA for population subgroups and high-risk individuals eligible for non-pharmacologic and pharmacologic therapies. Methods: Data were obtained from the Iran national STEPS 2016 study. Participants included 27 738 adults ≥25 years as a representative sample of Iranians. The logistic regression models with a survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension. Results: The prevalence of hypertension based on JNC8 was 29.9% (95% CI: 29.2-30.6), which soared to 53.7% (52.9-54.4) by 2017 ACC/AHA. Awareness, treatment, and control were 59.2% (58.0-60.3), 80.2% (78.9-81.4), and 39.1% (37.4-40.7) based on JNC8, which dropped to 37.1% (36.2-38.0), 71.3% (69.9-72.7), and 19.6% (18.3-21.0) respectively by 2017 ACC/AHA. By new guideline, adults 25-34 years had the largest increase in prevalence (from 7.3% to 30.7%). They also had the lowest awareness and treatment rate but the highest control rate (36.5%) among age groups. Compared with JNC8, under 2017 ACC/AHA, 24%, 15%, 17%, and 11% more individuals with dyslipidaemia, high triglyceride, diabetes, and cardiovascular disease (CVD) events respectively fell into the hypertensive category. Yet, based on 2017 ACC/AHA, 68.2% of individuals falling into a hypertensive group were supposed to receive medications (versus 95.7% in JNC8). LDL cholesterol, physical activity, and one unit of Body Mass Index were found to change blood pressure by -3.56 (-4.38, -2.74), -2.04 (-2.58, -1.50), and 0.48 (0.42, 0.53) mm Hg respectively. Conclusions: Switching from JNC8 to 2017 ACC/AHA highlighted sharp increases in prevalence and drastic declines in awareness, treatment, and control in Iran. By the 2017 ACC/AHA, more young adults and those with chronic comorbidities fell into the hypertensive category, thus might benefit from earlier interventions such as lifestyle modifications. The low control rate among treated individuals calls for a critical review of hypertension services in Iran.

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Insight into Blood Pressure Targets for Universal Coverage of Hypertension Services in Iran: The 2017 ACC/AHA versus JNC 8 Hypertension Guidelines

10.21203/rs.2.12895/v2 ◽

2019 ◽

Author(s):

Mahdi Mahdavi ◽

Mahboubeh Parsaeian ◽

Bahram Mohajer ◽

Mitra Modirian ◽

Naser Ahmadi ◽

...

Keyword(s):

Blood Pressure ◽

Survey Design ◽

Age Groups ◽

Universal Coverage ◽

Blood Pressure Target ◽

Lifestyle Modifications ◽

Treatment Rate ◽

Blood Pressure Targets ◽

Hypertension Guidelines ◽

And Control

Abstract Background: We assessed and compared the prevalence, awareness, treatment, and control of hypertension in Iran under two hypertension guidelines; the 2017 ACC/AHA with an aggressive blood pressure target 130/80 mm Hg and commonly used guideline JNC8 with 140/90 mm Hg. We shed light on the implications of 2017 ACC/AHA for population subgroups and high-risk individuals eligible for non-pharmacologic and pharmacologic therapies. Methods: Data were obtained from the Iran national STEPS 2016 study. Participants included 27 738 adults ≥25 years as a representative sample of Iranians. The logistic regression models with a survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension. Results: The prevalence of hypertension based on JNC8 was 29.9% (95% CI: 29.2-30.6), which soared to 53.7% (52.9-54.4) by 2017 ACC/AHA. Awareness, treatment, and control were 59.2% (58.0-60.3), 80.2% (78.9-81.4), and 39.1% (37.4-40.7) based on JNC8, which dropped to 37.1% (36.2-38.0), 71.3% (69.9-72.7), and 19.6% (18.3-21.0) respectively by 2017 ACC/AHA. By new guideline, adults 25-34 years had the largest increase in prevalence (from 7.3% to 30.7%). They also had the lowest awareness and treatment rate but the highest control rate (36.5%) among age groups. Compared with JNC8, under 2017 ACC/AHA, 24%, 15%, 17%, and 11% more individuals with dyslipidaemia, high triglyceride, diabetes, and cardiovascular disease (CVD) events respectively fell into the hypertensive category. Yet, based on 2017 ACC/AHA, 68.2% of individuals falling into a hypertensive group were supposed to receive medications (versus 95.7% in JNC8). LDL cholesterol, physical activity, and one unit of Body Mass Index were found to change blood pressure by -3.56 (-4.38, -2.74), -2.04 (-2.58, -1.50), and 0.48 (0.42, 0.53) mm Hg respectively. Conclusions: Switching from JNC8 to 2017 ACC/AHA highlighted sharp increases in prevalence and drastic declines in awareness, treatment, and control in Iran. By the 2017 ACC/AHA, more young adults and those with chronic comorbidities fell into the hypertensive category, thus might benefit from earlier interventions such as lifestyle modifications. The low control rate among treated individuals calls for a critical review of hypertension services in Iran.

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Forty-Year Shifting Distribution of Systolic Blood Pressure With Population Hypertension Treatment and Control

Circulation ◽

10.1161/circulationaha.120.048063 ◽

2020 ◽

Vol 142 (16) ◽

pp. 1524-1531 ◽

Cited By ~ 1

Author(s):

Daniel T. Lackland ◽

Virginia J. Howard ◽

Mary Cushman ◽

Suzanne Oparil ◽

Brett Kissela ◽

...

Keyword(s):

United States ◽

Blood Pressure ◽

High Risk ◽

Racial Differences ◽

The United States ◽

Hypertension Treatment ◽

Heart Study ◽

Blacks And Whites ◽

The 1960S ◽

And Control

Background: Hypertension awareness, treatment, and control programs were initiated in the United States during the 1960s and 1970s. Whereas blood pressure (BP) control in the population and subsequent reduced hypertension-related disease risks have improved since the implementation of these interventions, it is unclear whether these BP changes can be generalized to diverse and high-risk populations. This report describes the 4-decade change in BP levels for the population in a high disease risk southeastern region of the United States. The objective is to determine the magnitude of the shift in systolic BP (SBP) among Blacks and Whites from the Southeast between 1960 and 2005 with the assessment of the unique population cohorts. Methods: A multicohort study design compared BPs from the CHS (Charleston Heart Study) and ECHS (Evans County Heart Study) in 1960 and the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) 4 decades later. The analyses included participants ≥45 years of age from CHS (n=1323), ECHS (n=1842), and REGARDS (n=6294) with the main outcome of SBP distribution. Results: Among Whites 45 to 54 years of age, the median SBP was 18 mm Hg (95% CI, 16–21 mm Hg) lower in 2005 than 1960. The median shift was a 45 mm Hg (95% CI, 37–51 mm Hg) decline for those ≥75 years of age. The shift was larger for Blacks, with median declines of 38 mm Hg (95% CI, 32–40 mm Hg) at 45 to 54 years of age and 50 mm Hg (95% CI, 33–60 mm Hg) for ages ≥75 years. The 95th percentile of SBP decreased 60 mm Hg for Whites and 70 mm Hg for Blacks. Conclusions: The results of the current analyses of the unique cohorts in the Southeast confirm the improvements in population SBP levels since 1960. This assessment provides new evidence of improvement in SBP, suggesting that strategies and programs implemented to improve hypertension treatment and control have been extraordinarily successful for both Blacks and Whites residing in a high-risk region of the United States. Severe BP elevations commonly observed in the 1960s have been nearly eliminated, with the current 75th percentile of BP generally less than the 25th percentile of BP in 1960.

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Factors influencing the performance of community health volunteers working within urban informal settlements in low- and middle-income countries: a qualitative meta-synthesis review

Human Resources for Health ◽

10.1186/s12960-021-00691-z ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Michael Ogutu ◽

Kui Muraya ◽

David Mockler ◽

Catherine Darker

Keyword(s):

Health System ◽

Family Support ◽

Contextual Factors ◽

Informal Settlements ◽

Supportive Supervision ◽

Personal Safety ◽

Middle Income ◽

Middle Income Countries ◽

Factors Influencing ◽

Urban Informal Settlements

Abstract Background There is limited information on community health volunteer (CHV) programmes in urban informal settlements in low- and middle-income countries (LMICs). This is despite such settings accounting for a high burden of disease. Many factors intersect to influence the performance of CHVs working in urban informal settlements in LMICs. This review was conducted to identify both the programme level and contextual factors influencing performance of CHVs working in urban informal settlements in LMICs. Methods Four databases were searched for qualitative and mixed method studies focusing on CHVs working in urban and peri-urban informal settlements in LMICs. We focused on CHV programme outcome measures at CHV individual level. A total of 13 studies met the inclusion criteria and were double read to extract relevant data. Thematic coding was conducted, and data synthesized across ten categories of both programme and contextual factors influencing CHV performance. Quality was assessed using both the Critical Appraisal Skills Programme (CASP) and the Mixed Methods Assessment Tool (MMAST); and certainty of evidence evaluated using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach. Results Key programme-level factors reported to enhance CHV performance in urban informal settlements in LMICs included both financial and non-financial incentives, training, the availability of supplies and resources, health system linkage, family support, and supportive supervision. At the broad contextual level, factors found to negatively influence the performance of CHVs included insecurity in terms of personal safety and the demand for financial and material support by households within the community. These factors interacted to shape CHV performance and impacted on implementation of CHV programmes in urban informal settlements. Conclusion This review identified the influence of both programme-level and contextual factors on CHVs working in both urban and peri-urban informal settlements in LMICs. The findings suggest that programmes working in such settings should consider adequate remuneration for CHVs, integrated and holistic training, adequate supplies and resources, adequate health system linkages, family support and supportive supervision. In addition, programmes should also consider CHV personal safety issues and the community expectations.

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Insight into Blood Pressure Targets for Universal Coverage of Hypertension Services in Iran: The 2017 ACC/AHA versus JNC 8 Hypertension Guidelines

10.21203/rs.2.12895/v4 ◽

2020 ◽

Author(s):

Mahdi Mahdavi ◽

Mahboubeh Parsaeian ◽

Bahram Mohajer ◽

Mitra Modirian ◽

Naser Ahmadi ◽

...

Keyword(s):

Blood Pressure ◽

Survey Design ◽

Age Groups ◽

Universal Coverage ◽

Blood Pressure Target ◽

Lifestyle Modifications ◽

Treatment Rate ◽

Blood Pressure Targets ◽

Hypertension Guidelines ◽

And Control

Abstract Background: We assessed and compared the prevalence, awareness, treatment, and control of hypertension in Iran under two hypertension guidelines; the 2017 ACC/AHA with an aggressive blood pressure target 130/80 mm Hg and commonly used guideline JNC8 with 140/90 mm Hg. We shed light on the implications of 2017 ACC/AHA for population subgroups and high-risk individuals eligible for non-pharmacologic and pharmacologic therapies. Methods: Data were obtained from the Iran national STEPS 2016 study. Participants included 27 738 adults ≥25 years as a representative sample of Iranians. The logistic regression models with a survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension. Results: The prevalence of hypertension based on JNC8 was 29.9% (95% CI: 29.2-30.6), which soared to 53.7% (52.9-54.4) by 2017 ACC/AHA. Awareness, treatment, and control were 59.2% (58.0-60.3), 80.2% (78.9-81.4), and 39.1% (37.4-40.7) based on JNC8, which dropped to 37.1% (36.2-38.0), 71.3% (69.9-72.7), and 19.6% (18.3-21.0) respectively by 2017 ACC/AHA. By new guideline, adults 25-34 years had the largest increase in prevalence (from 7.3% to 30.7%). They also had the lowest awareness and treatment rate but the highest control rate (36.5%) among age groups. Compared with JNC8, under 2017 ACC/AHA, 24%, 15%, 17%, and 11% more individuals with dyslipidaemia, high triglyceride, diabetes, and cardiovascular disease (CVD) events respectively fell into the hypertensive category. Yet, based on 2017 ACC/AHA, 68.2% of individuals falling into a hypertensive group were supposed to receive medications (versus 95.7% in JNC8). LDL cholesterol, physical activity, and one unit of Body Mass Index were found to change blood pressure by -3.56 (-4.38, -2.74), -2.04 (-2.58, -1.50), and 0.48 (0.42, 0.53) mm Hg respectively. Conclusions: Switching from JNC8 to 2017 ACC/AHA highlighted sharp increases in prevalence and drastic declines in awareness, treatment, and control in Iran. By the 2017 ACC/AHA, more young adults and those with chronic comorbidities fell into the hypertensive category, thus might benefit from earlier interventions such as lifestyle modifications. The low control rate among treated individuals calls for a critical review of hypertension services in Iran.

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Faculty Opinions recommendation of Forty-Year Shifting Distribution of Systolic Blood Pressure With Population Hypertension Treatment and Control.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.738855325.793579783 ◽

2020 ◽

Author(s):

Wilbert Aronow

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Hypertension Treatment ◽

And Control

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Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

Implementation Science ◽

10.1186/s13012-021-01123-1 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Kate Morton ◽

Laura Dennison ◽

Rebecca Band ◽

Beth Stuart ◽

Laura Wilde ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Decision Making ◽

Mixed Methods ◽

Process Evaluation ◽

Contextual Factors ◽

Clinical Inertia ◽

Adherence To Medication ◽

Factors Influencing ◽

Digital Intervention

Abstract Background A high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients’ home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation. Methods One hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients’ medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol. Results Mean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients. Conclusions This mixed-methods process evaluation provided novel insights into practitioners’ decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients’ readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response. Trial registration (ISRCTN13790648). Registered 14 May 2015.

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