Delivering integrated hypertension care at private health facilities in urban Pakistan: a process evaluation

Abstract

BackgroundIn Pakistan about 18% of all adults are affected by hypertension, and only one in eight of the prevalent cases have their hypertension controlled. As in many other low-middle income countries, a public–private partnership approach is being considered for delivering non-communicable disease care in urban areas.AimThis process evaluation was undertaken to understand how an integrated care intervention was experienced by the care providers and patients, and to inform modifications before possible scaling.Design & settingThe mixed-methods study was conducted as part of a cluster randomised trial on integrated hypertension care at 26 private clinics.MethodThe care practices were assessed by analysing the clinical records of 1138 registered patients with hypertension. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data.ResultsDistrict-led objective selection and context-sensitive staff training helped to get the clinics engaged in partnership working. About one-third of patients with hypertension had associated diabetes or renal compromise. The prescription of drugs is influenced by multiple non-clinical considerations of providers and patients. Many doctors allowed the use of home-based remedies as supplements to the prescribed allopathic drugs. Female patients faced more challenges in managing lifestyle changes. The intervention improved adherence to follow-up visits, but patient attrition remained a challenge.ConclusionThe integrated hypertension care intervention at private clinics is feasible, and leads to improved diagnosis and treatment in low-income country urban setting. The authors recommend continued implementation research and informed scaling of hypertension care at private clinics.

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“…8 The intervention was found to have improved the attendance for follow-up visits. However, high attrition (even in intervention arm) does indicate the need for improving treatment adherence through implementation research on various potential options, 18 such as reducing the frequency of follow-up visits (unless clinically indicated), 14 extending the timing of hospital outpatient, adding a treatment supporter, 19 and developing public–private partnership for expanded coverage and continued care. 20…”

“…About 20% of asthma and COPD patients being prescribed leukotriene modifier tablets seems in line with the generally reported 26 tendency of physicians to overprescribe, even when the drug is not made available for free dispensing. Another study 14 on non-communicable disease care in Pakistan reported the prescription of drugs to be a blend of doctor and patient preferences, with some doctors prescribing high-cost pharmaceutical products because of fancy packaging and active marketing.…”

“…After the authors' experience in other similar studies, 14,15 Skype call technology was used by a qualified female researcher to conduct staff and patient interviews, during April–July 2016, at respective facilities. After consent, the interviews were conducted in the national language (Urdu) and were audio-recorded.…”

Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial

“…A process evaluation of the trial, published in this journal, 20 indicated that offering programme-endorsed hypertension care at private clinics, during the first 9 months after registration, was feasible for the clinic staff and acceptable to the patients.…”

“…To keep the trial evidence relevant to the real-life programme implementation processes, any special measure for an enhanced staff adherence to the intervention protocol was deliberately avoided. Staff and patient adherence, and challenges to the intervention protocols, have been studied and published in this journal, 20 and the guides and tools are available at .…”