Hypertension management in rural primary care facilities in Zambia: a mixed methods study

Lily D Yan,Cindy Chirwa,Roma Chilengi,Benjamin H Chi,Moses Mwanza,Ntazana Sindano,Dennis Musatwe,Samuel Bosomprah,Mary Mulenga

doi:10.1186/s12913-017-2063-0

Abstract

BackgroundImproved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening, monitoring, treatment and control of high blood pressure.MethodsBetter Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content.ResultsFrom January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89.1% overall (range: 70.1–100%), but decreased to 62.1% (range: 0–100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were <10% and did not improve with time. In in-depth interviews, antihypertensive medication shortages were common, with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts. Principal challenges in hypertension management included 1) equipment and personnel shortages, 2) provider belief that multiple visits were needed before official management, 3) medication stock-outs, leading to improper prescriptions and 4) poor patient visit attendance.ConclusionsOur findings suggest that numerous barriers stand in the way of hypertension diagnosis and management in Zambian primary health facilities. Future work should focus on performance indicator development and validation in low resource contexts, to facilitate regular and systematic data review to improve patient outcomes.Trial registrationClinicalTrials.gov, Identifier NCT01942278. Date of Registration: September 2013.

Highlights

Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension
This paper presents data on novel retrospectively generated process and outcome indicators for hypertension management, informed by those from Western countries, but adapted to the Zambian primary care clinics enrolled in the Better Health outcomes through Mentoring and Assessment (BHOMA) study
Study setting and design Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural government clinics in Chongwe, Kafue and Luangwa districts of Zambia, which represent almost all publically run rural clinics in Lusaka province. They capture the full range of size, patient population and services available in rural Zambian government primary care clinics

Summary

Introduction

Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. There is increasing evidence that a robust primary care system can handle the growing NCD burden, and manage risk factors like hypertension for CVD, to prevent disease progression [3, 4]. In this context, performance monitoring is critical to develop, support and sustain effective delivery of proven therapies in primary care for NCDs. Quality improvement provides an iterative framework to monitor multilevel contributors to patient outcomes by using routine health program data to examine what system elements need to be changed [5, 6]. When linked with pay for performance, indicators accelerate improvements in quality in both developed and developing settings [9, 10]

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