A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol

Abstract

BackgroundCountries in sub-Saharan Africa (SSA) are experiencing an epidemic of cardiovascular disease (CVD) propelled by rapidly increasing rates of hypertension. Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs. Although SSA bears 24% of the global disease burden, it has only 3% of the global health workforce. Given such limited resources, cost-effective strategies, such as task shifting, are needed to mitigate the rising CVD epidemic in SSA. Ghana, a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization (WHO) task-shifting strategy. This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage, on blood pressure (BP) reduction.MethodsUsing a cluster randomized design, 32 community health centers (CHCs) and district hospitals in Ghana will be randomized to either the intervention group (16 CHCs) or the control group (16 CHCs). A total of 640 patients with uncomplicated hypertension (BP 140–179/90–99 mm Hg and absence of target organ damage) will be enrolled in this study (20 patients per CHC). The intervention consists of WHO Package of CV risk assessment, patient education, initiation and titration of antihypertensive medications, behavioral counseling on lifestyle behaviors, and medication adherence every three months for 12 months. The primary outcome is the mean change in systolic BP from baseline to 12 months. The secondary outcomes are rates of BP control at 12 months; levels of physical activity, percent change in weight, and dietary intake of fruits and vegetables at 12 months; and sustainability of intervention effects at 24 months. All outcomes will be assessed at baseline, six months and 12 months. Trained community health nurses will deliver the intervention as part of Ghana’s community-based health planning and services (CHPS) program.DiscussionFindings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in resource-poor settings.Trial registrationNCT01802372.

Task-shifting training improves stroke knowledge among Nigerian non-neurologist health workers

“…Task-shifting is a novel strategy of proven efficacy to build relevant competences in NPHW to bridge the human resource gap in the provision of services for non-communicable diseases [7–9] and HIV/AIDS [10] in low and middle income countries. By restructuring the workforce in this way, task shifting enables more efficient use of the available human resources.…”

Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries

“…All the studies supported NPHWs by training them for two to six days, followed by re-training where required. 14, 54, 55 Some studies facilitated task redistribution by using mHealth technology, 14, 56 whereby NPHWs used electronic decision support tools to screen individuals in the community and link them to hypertension care. Process and interim evaluations have identified that the main barriers to task-redistribution include resistance from other health professionals; increasing NPHW workload due to additional tasks; complexity of training materials; health system-related issues such as non-availability or non-functioning BP machines, poor drug supply, lack of physician availability for referral; regulatory restrictions including the inability to prescribe medications; and low remuneration of NPHWs.…”

Ambulatory Blood Pressure Monitoring

“…44,45 Task shifting strategies have been implemented both in chronic communicable diseases such as HIV/AIDS as well as non-communicable disease conditions such as diabetes and hypertension. 46-51 However, few studies have examined the use of ABPM as part of task shifting strategies. In a recent study, James et al 52 demonstrated the feasibility of a pharmacist-led hypertension management strategy using ABPM in Ireland.…”