Patient, clinician and logistic barriers to blood pressure control among adult hypertensives in rural district hospitals in Rwanda: a cross-sectional study

J P Sibomana,R L Mcnamara,T D Walker

doi:10.1186/s12872-019-1203-3

Abstract

BackgroundHypertension management in rural, resource-poor settings is difficult. Detailed understanding of patient, clinician and logistic factors which pose barriers to effective blood pressure control could enable strategies to improve control to be implemented.MethodsThis cross-sectional, multifactorial, observational study was conducted at four rural Rwandan district hospitals, examining patient, clinician and logistic factors. Questionnaires were administered to consenting adult outpatient hypertensive patients, obtaining information on sociodemographic factors, past management for hypertension, and adherence (by Morisky Medication Adherence 8-item Scale (MMAS-8). Treating clinicians identified local difficulties in providing hypertension management from a standard World Health Organisation list and nominated their preferred treatment regimens. Blood pressure measurements and other clinical data were collected during the study visit and used to determine blood pressure control, according to goals from JNC-8 guidelines. Medication availability and cost at each hospital’s pharmacy were reviewed as logistic barriers to treatment.ResultsThe 112 participating patients were 80% female, with only 41% having completed primary education. Self-reported adherence by the MMAS-8 was high in 77% (86/112) and significantly associated) with literacy, lack of medication side effects and the particular hospital and pharmacy attended (all p < 0.05). However, of 89 patients with blood pressure data, only 26 (29%) had achieved goal blood pressure. No patient factor were statistically associated with poor blood pressure control. Among 30 participating clinicians, deficiencies in knowledge were evident; 43% (13/30) and 37% (11/30) chose a loop diuretic as their prescribed medication and as an ideal medication, respectively, for a newly diagnosed hypertensive patient without comorbidities, counter to JNC 8 recommendations, and 50% (15/30) identified clinician non-adherence to hypertension guidelines as a barrier. In the pharmacies, common anti-hypertensive medications were affordably available (> 6 out of 8 examined medications available in all pharmacies, cost <US$0.50 per month); however, clinicians perceived medication cost and availability to be barriers to care.ConclusionsClinician-based factors are a major barrier to blood pressure control in rural district hospitals in Rwanda, and blood pressure control overall was poor. Patient and logistic barriers to blood pressure were not evident in this study.

Highlights

Hypertension management in rural, resource-poor settings is difficult
While these features are currently atypical in Sub-Saharan Africa, other countries in the region are already following Rwanda’s blueprint for health system strengthening, and it is likely that such processes will become more widespread
Patients reported features of their clinical consultation with their treating doctor on the day; they reported that 75/112 (67%) of them were not given feedback about their current blood pressure control by their doctor, 17/110 (16%) were asked about adherence and 2/ 110 (2%) were asked about medication side effects

Summary

Introduction

Hypertension management in rural, resource-poor settings is difficult. Detailed understanding of patient, clinician and logistic factors which pose barriers to effective blood pressure control could enable strategies to improve control to be implemented. Poor control of hypertension in rural healthcare settings is likely to be multifactorial, with contributions from factors related to patient knowledge and behaviour (e.g. non adherence), physician knowledge and skills (e.g. rural-urban health professional disparities), and the logistic supply chain (e.g. medication cost and availability) [4, 6, 10,11,12]. Rwanda has a process for central allocation of newly graduated doctors to rural district hospitals, possibly reducing urban-rural disparities seen elsewhere [8, 10,11,12] While these features are currently atypical in Sub-Saharan Africa, other countries in the region are already following Rwanda’s blueprint for health system strengthening, and it is likely that such processes will become more widespread. No published data on the relative importance of patient, clinician and logistic factors in hypertension control in Rwanda were available previously, but data from under-served rural populations in North America suggest both patient and clinician factors are important [13]

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Discussion

Conclusion