The Long and Winding Road: A Systematic Literature Review Conceptualising Pathways for Hypertension Care and Control in Low- and Middle-Income Countries

Abstract

Background: Hypertension control is poor everywhere, especially in low- and middle-income countries (LMICs). An effective response requires understanding factors acting at each stage on the patients’ pathway through the health system from entry or first contact with the health system, through to treatment initiation and follow up. This systematic review aimed to identify barriers to and facilitators of hypertension control along this pathway and, respectively, ways to overcome or strengthen them. Methods: MEDLINE, EMBASE, Global Health, CINAHL Plus, and Africa-Wide Information (1980-April 2019) were searched for studies of hypertensive adults in LMICs reporting details of at least 2 adequately described health system contacts. Data were extracted and analysed by 2 reviewers. Themes were developed using NVivo in patient-related (sociodemographic, knowledge and health beliefs, health status and co-morbidities, trade-offs), social (social relationships and traditions) and health system domains (resources and processes). Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: From 2584 identified records, 30 were included in the narrative synthesis. At entry, ‘health systems resources and processes’ and ‘knowledge and beliefs about hypertension’ dominated while ‘social relations and traditions’ and ‘comorbidities’ assume greater importance subsequently, with patients making ‘trade-offs’ with family priorities during follow up. Socio-demographic factors play a role, but to a lesser extent than other factors. Context matters. Conclusion: Understanding the changing barriers to hypertension control along the patient journey is necessary to develop a comprehensive and efficient response to this persisting problem.

World Heart Federation Roadmap for Hypertension – A 2021 Update

“…Table 3 provides an up-to-date overview of roadblocks and possible solutions based on both WHF members’ feedback and a review of the literature [ 1 77 ]. Some of the solutions highlighted in Table 3 are discussed more in-depth in ‘prioritised solutions along the continuum of care for hypertension’ (page 13).…”

“…Effective hypertension control involves the whole continuum of care and addressing different roadblocks and enablers at each of the three major stages of the pathway, requiring different approaches: pre-diagnosis/diagnosis, start of treatment, and follow-up/retention in the system. Roadblocks and enablers to hypertension care fall into a range of interlinked domains both at the demand side (e.g., socio-demographic characteristics, health status and co-morbidity, knowledge, and beliefs of hypertension, social relations, and traditions) and supply-side (health system resources and processes) [ 77 ]. There are roadblocks and enablers both within and outside the health system – both influence the pathway and retention.…”

“…There are roadblocks and enablers both within and outside the health system – both influence the pathway and retention. These are individual, community- and health system-related, and assume different importance at the major stages of care in the patient pathway [ 77 ] (see Figure 3 ). Contextual relevance and resource availability are two critical elements influencing the sustainability and scalability of hypertension control initiatives in any given setting.…”

Enablers of Patient Knowledge Empowerment for Self-Management of Chronic Disease: An Integrative Review

“…The concept of the health system is inseparable from the concept of patient empowerment. The health system includes all organizations, people, resources, and actions whose primary goal is to promote, restore, and maintain health at the individual or population levels [ 41 ]. Both the structures and processes of the health system (as supply factors) and patient choices (as demand factors) determine the progress of patient health.…”

“…The patient’s movement through the health system is identified with a pathway that describes the patient’s progress through the health system to avoid side effects and complications in the context of chronic disease. According to Brathwaite et al (2020), the patient uses a variety of enablers on their path through the health system to achieve health behavior [ 41 ]. From the perspective of conceptualizing patient knowledge, patient knowledge enablers create context and provide stimulating preconditions for patients to use knowledge through empowerment levels in the knowledge to action framework action cycle to make a specific decision.…”