BACKGROUND: Hypertension, the leading global risk factor for mortality, is characterized by low treatment and control rates in low-and middle-income countries. Poor linkage to hypertension care contributes to poor outcomes for patients. However, specific factors influencing linkage to hypertension care are not well known. OBJECTIVE: To evaluate factors influencing linkage to hypertension care in rural western Kenya. DESIGN: Qualitative research study using a modified Health Belief Model that incorporates the impact of emotional and environmental factors on behavior. PARTICIPANTS: Mabaraza (traditional community assembly) participants (n=242) responded to an open invitation to residents in their respective communities. Focus groups, formed by purposive sampling, consisted of hypertensive individuals, at-large community members, and community health workers (n=169). APPROACH: We performed content analysis of the transcripts with NVivo 10 software, using both deductive and inductive codes. We used a two-round Delphi method to rank the barriers identified in the content analysis. We selected factors using triangulation of frequency of codes and themes from the transcripts, in addition to the results of the Delphi exercise. Sociodemographic characteristics of participants were summarized using descriptive statistics. KEY RESULTS: We identified 27 barriers to linkage to hypertension care, grouped into individual (cognitive and emotional) and environmental factors. Cognitive factors included the asymptomatic nature of hypertension and limited information. Emotional factors included fear of being a burden to the family and fear of being screened for stigmatized diseases such as HIV. Environmental factors were divided into physical (e.g. distance), socioeconomic (e.g. poverty), and health system factors (e.g. popularity of alternative therapies). The Delphi results were generally consistent with the findings from the content analysis. CONCLUSIONS: Individual and environmental factors are barriers to linkage to hypertension care in rural western Kenya. Our analysis provides new insights and methodological approaches that may be relevant to other lowresource settings worldwide. INTRODUCTIONCardiovascular disease is the leading cause of mortality worldwide, with 80 % of cardiovascular deaths occurring in lowand middle-income countries (LMICs). 1 Hypertension, a major risk factor for cardiovascular disease, 2 is the leading global risk for mortality. 3 Over the next decade, the global cost of suboptimal blood pressure may approach $1 trillion. 4 Unless it is adequately controlled, hypertension will continue to be responsible for significant morbidity and mortality worldwide. 5 In many LMICs, however, the rates of hypertension treatment and control are low. 6 In Kenya, hypertension treatment and control rates have been reported at 9 % and 3 %, respectively. 7 Poor linkage to hypertension care, manifested as delays in seeking care after screening and referral, has been shown to be associated with increased mortality among pre...

<p><strong>Background: </strong>Hypertension is the leading global risk for mortality. Poor treatment and control of hypertension in low- and middle-income countries is due to several reasons, including insufficient human resources. Nurse management of hypertension is a novel approach to address the human resource challenge. However, specific barriers and facilitators to this strategy are not known. </p><p><strong>Objective: </strong>To evaluate barriers and facilitators to nurse management of hypertensive patients in rural western Kenya, using a qualitative research approach. </p><p><strong>Methods: </strong>Six key informant interviews (five men, one woman) and seven focus group discussions (24 men, 33 women) were conducted among physicians, clinical officers, nurses, support staff, patients, and community leaders. Content analysis was performed using Atlas.ti 7.0, using deductive and inductive codes that were then grouped into themes representing barriers and facilitators. Ranking of barriers and facilitators was performed using triangulation of density of participant responses from the focus group discussions and key informant interviews, as well as investigator assessments using a two-round Delphi exercise. <strong></strong></p><p><strong>Results: </strong>We identified a total of 23 barriers and nine facilitators to nurse management of hypertension, spanning the following categories of factors: health systems, environmental, nurse-specific, patient-specific, emotional, and community. The Delphi resultswere generally consistent with the findings from the content analysis. <strong></strong></p><p><strong>Conclusion: </strong>Nurse management of hypertension is a potentially feasible strategy to address the human resource challenge of hypertension control in low-resource settings. However, successful implementation will be contingent upon addressing barriers such as access to medications, quality of care, training of nurses, health education, and stigma. <em>Ethn Dis. </em>2016;26(3):315-322; doi:10.18865/ed.26.3.315. </p>

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Background: Hypertension is a major risk factor for cardiovascular disease, and the leading risk factor for mortality in sub-Saharan Africa. Yet hypertension treatment and control rates are low. One strategy to address inadequate hypertension treatment in Kenya is task redistribution of care from physicians to nurses. However, the workforce requirements for comprehensive hypertension treatment are not well known. Objective: To develop a needs-based workforce estimation model in order to estimate the health workforce requirements for stable, long-term hypertension management in Kenya. Methods: A mixed-methods approach was used to assess a nurse-based hypertension program in western Kenya. We conducted 7 key informant interviews and 6 focus group discussions among program managers, nurses, community health workers, community leaders, and patients. Qualitative transcripts were analyzed using content analysis with deductive and inductive codes. We also conducted time-motion studies of 118 patient encounters over 7 clinical days in 7 rural health facilities. Finally, we conducted a two-round Delphi exercise, involving anonymous surveys of 8 experts in hypertension and chronic disease care. Results of the time-motion studies and Delphi exercise were summarized using descriptive statistics. The results were inputted into a needs-based health workforce estimation model using Microsoft Excel. Sensitivity analyses were performed, using alternate input values for disease complexity, follow-up interval, and nurse productivity. Results: For a total of 5000 patients, with 60%, 32%, and 8% requiring follow-up visits in 1, 2, and 3 months, respectively, we estimated that 3928 patient encounters are required per month. Our data yielded an estimated clinical capacity of each nurse full-time equivalent (FTE) at 81 patient encounters/month. Thus, 49 nurse FTEs would be required to treat 5000 hypertension patients. Conclusions: A simple needs-based workforce estimation model for hypertension management is able to provide workforce projections that are useful for program planning, human resource allocation, and policy formulation. This approach can serve as a benchmark for future studies to manage chronic diseases in low- and middle-income countries.

Introduction: Hypertension is the leading risk factor for global mortality. Hypertension treatment rates are low, partly due to inadequate linkage and retention to care. The LARK Study evaluates the use of community health workers (CHWs), equipped with a behavioral assessment and a tailored behavioral change strategy, to improve linkage and retention to hypertension care in Kenya. Here we describe the development and validation of the assessment tool used by CHWs to identify patients’ barriers to care, facilitating behavioral change communication. Methods: We derived behavioral assessment items from prior research on barriers to hypertension care in Kenya. Patients, CHWs, and clinicians scored each item for clarity and representativeness, and provided qualitative feedback during focus groups. A content validity index (CVI), representing inter-rater agreement of scores, was calculated for each item. Multivariable linear mixed-effects models were used to compare CVIs and level of modification (none, minor, major, or deleted) by participant category. Results: We tested 70 items in 9 focus groups. Mean CVIs were greater than 0.9 in all study groups (Table). Multivariable adjustment revealed that patients and CHWs had significantly higher CVIs than clinicians. Despite this, qualitative feedback from patients and CHWsled to higher item modification rates. 37 items were retained in the linkage assessment and 57 items in the retention assessment. Conclusions: The mean CVI was greater than 0.9 in all study populations, indicating excellent inter-rater agreement of the overall clarity and representativeness of assessment items. However, CVI alone could not account for modifications suggested during qualitative discussions. A combination of quantitative and qualitative methods yielded the most informative evaluation of assessment items. These findings may be relevant to the validation of similar assessment tools in other low-resource settings.

Objective: The Harlem area of New York City has among the highest obesity and diabetes prevalence rates in the city. Nearly half of the children in the Head Start program and about 94% of adults are overweight or obese. We sought to identify factors that may impact the implementation of an integrated family-based health promotion program for children aged 3-5 years and their caregivers in Harlem. Methods: We conducted a qualitative study consisting of 5 focus group discussions (FGD) at two Head Start preschool centers in Harlem, NY. The FGDs included the following participants: parents, teachers, directors, educational directors, nutritionists, cooks, health, mental health and social service professionals. Content analysis of the transcript and notes was performed to identify salient themes. Relationships between and among themes were formulated. Findings: Twenty-five individuals participated in the FGDs. Seven themes emerged as potential barriers to program implementation. Program implications and specific strategies to address them were generated (Table). Conclusions: Formative work prior to program implementation has revealed important, actionable issues that will be addressed during the intervention period. This type of approach may be useful for other health promotion programs in similar settings.