108. Difference in difference analysis of task-shifting with community health extension workers to manage hypertensive disorders in pregnancy in Nigeria

Abstract

Introduction In Nigeria, though the task-shifting policy recognizes community health extension workers (CHEWs) to administer a loading dose of magnesium sulphate in severe pre-eclampsia/eclampsia prior to referral, it is silent on whether CHEWs should administer anti-hypertensive drugs for the associated hypertension. Objective This study tests the feasibility and acceptability of CHEWs managing hypertension in HDPs at Primary Care level. Methods A cross-sectional survey (baseline n = 72 and endline n = 73) carried out in 40 selected facilities, stratified into intervention and comparison arms (n = 20/ study arm). CHEWs in intervention arm received training, job aids and mentoring on how to identify and manage HDPs with alpha methyldopa and were monitored for one year. The comparison received no training. Structured interviews using pre-tested questionnaires were conducted before and after the intervention. A difference-in-difference (DID) analysis was conducted using SPSS version 20. Results There was significant increase in CHEWs’ ability to define hypertension correctly (DID = 33.3%, p = 0.009), describe how to manage blood pressure (DID = 13.8%, p = 0.000) and grade the hypertension as mild, moderate or severe (DID = 60%, p = 0.000). CHEWs in the intervention arm were more likely to know when to introduce and stop anti-hypertensives (DID = 69.3%, p = 0.000; DID = 48.9%, p = 0.000, respectively), and were more likely to classify HDPs into chronic hypertension (DID = 35%, p = 0.024), gestational hypertension (DID = 18.2%, p = 0.054), pre-eclampsia (DID = 10.2%, p = 0.073), severe pre-eclampsia (DID = 39.6%, p = 0.000) and eclampsia (DID = 20.1%, p = 0.804). CHEWs in the intervention arm were more likely to prescribe an antihypertensive (DID = 42.2%, p = -0.095) and mostly prescribed (DID = 20.6%, p = 0.03) methyldopa compared to their counterparts in the comparison arm. Antihypertensives were mainly procured through the open market. Incidence of anti-hypertensives stock-outs were frequent. Discussion CHEWs gained and retained knowledge and skills in the diagnosis and management of HDPs-associated hypertension. If this is combined with regular availability of commodities, care for women with HDPs at PHC level could improve remarkably.