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

Abstract

BackgroundHypertension, 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.MethodsOur 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.ResultsWe 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.ConclusionsTranslating 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.

High prevalence of undiagnosed hypertension among men in North Central Nigeria: Results from the Healthy Beginning Initiative

“…In their meta-analysis, Adeloye et al also estimated that 17% of hypertensives in Nigeria were aware of their diagnosis [7]. Our finding is similar to the 5%-10% awareness rate reported in some regions of Tajikistan [36], and the 7.4% awareness rate reported among the urban poor in Ghana [37], although much lower than the 17.5% reported in a pooled study of 44 LMICs in four regions of the world [38], the 44.7% in China [39], and the 63.8% in the United States [40]. Globally, undiagnosed hypertension remains a problem [39][40][41][42][43], with some patients "hiding in plain sight" even in high income countries like the United States [40].…”

Evaluation and pilot implementation of essential interventions for the management of hypertension and prevention of cardiovascular diseases in primary health care in the Republic of Tajikistan

“…sphygmomanometers), high case load of primary health care workers, and lack of awareness among health administrators. [ 15 ] However, according to this evaluation study the detection rate of hypertension seems to have improved in intervention clinics in Shahrinav as both the number of patients recorded having hypertension as well as newly diagnosed patients increased.…”

“…Previous research examining the quality of hypertension care in the Khatlon and Sogd oblasts of Tajikistan found persistent gaps in the detection, diagnosis, and outcomes of patients with hypertension. [ 15 ] In particular, it was estimated that only 5 to 10 % of hypertensive patients actually receive a diagnosis. This is consistent with our findings in that the number of registered hypertensive patients in the Shahrinav oblast was far below the expected, which contributed to our lower than expected sample size.…”

Evidence for an Expanded Hypertension Care Cascade in Low- and Middle-Income Countries: A Scoping Review

“…Mixed methods studies that incorporated qualitative data from patients described structural quality issues such long wait times, lack of drugs, and poor adherence, and outcome quality issues related to patient satisfaction (e.g. poor perceived quality of services) (39)(40)(41). Providers described a lack of appropriate equipment, stockouts of medicines, and insu cient time to counsel patients on lifestyle advice (42,43).…”

“…Although ve studies did not explicitly de ne a care cascade and four studies used steps from the standard hypertension care cascade, three recently published studies proposed alternative hypertension care cascades. One study separated treatment into service initiation and continued treatment (40). Another included supply-side considerations, namely contact with the health system (service availability) and the receipt of continuous, high-quality treatment (qualityadjusted treatment) (38).…”