Setting up a nurse-led model of care for management of hypertension and diabetes mellitus in a high HIV prevalence context in rural Zimbabwe: a descriptive study

Frieden, Marthe Marie; Zamba, Blessing; Mukumbi, Nisbert; Mafaune, Patron Titsha; Makumbe, Brian; Irungu, Elizabeth; Moneti, Virgínia; Isaakidis, Petros; Garone, Daniela; Prasai, Madhu Janina

doi:10.1186/s12913-020-05351-x

Cited by 16 publications

(58 citation statements)

References 35 publications

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“…The WHO supported Package of NCDs (PEN) program has led to significant improvement in access to care for hypertension, type 2 diabetes, chronic respiratory disease and basic breast and cervical cancer screening. To provide decentralized access to PEN services, many LICs and LMICs are empowering mid-level providers, either nurses or clinical officers, to provide this care [14,15,25,26,27,28]. Subsequently, most of the literature around task shifting of NCD care to mid-level providers focuses on primary prevention and PEN services.…”

Section: Discussionmentioning

confidence: 99%

“…To combat the lack of physicians, many lowerincome countries are task shifting treatment of hypertension, diabetes, and asthma to nurses or clinical officers (often referred to collectively as mid-level providers). This strategy has been found to be successful in bridging this human resources gap [14,15]. In 2018, Partners In Health, a non-governmental organization, began working with the Malawi Ministry of Health to train clinical officers in Neno, Malawi to provide chronic care for patients with severe and chronic NCDs at the district and community hospitals.…”

Section: Introductionmentioning

confidence: 99%

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Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Ruderman

Chibwe

Boudreaux

et al. 2022

Annals of Global Health

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Background: Non-communicable diseases (NCDs) are a leading cause of worldwide morbidity and mortality, yet access to care in lower-income countries is limited. Rural communities, where poverty levels are high, feel the greatest burden. In Malawi, as elsewhere in the African region, it is particularly challenging for patients in rural districts to obtain care for locally endemic and severe NCDs such as type 1 diabetes, rheumatic heart disease, and sickle cell disease. The Package of Essential NCD Interventions -Plus (PEN-Plus) is a strategy to decentralize care for these severe conditions by enabling local clinicians at intermediate-care facilities to provide services otherwise available only through specialty clinics at central hospitals. Objectives:The primary objective of this study was to evaluate the impact of training mid-level providers to treat severe and chronic NCDs in newly established PEN-Plus clinics in Neno, Malawi. Methods:Our team developed a logic model to describe the anticipated impacts of the intervention on provider knowledge, patient recruitment, and care provision. We applied a retrospective review of routinely collected clinical and administrative data to assess changes along these hypothesized pathways.Findings: Didactic trainings improved provider test scores immediately following training (25-point improvement; p < 0.01), with demonstrated retention of knowledge after 6 months (21-point improvement, p < 0.01). Over 350 patients were enrolled in the first 18 months of program initiation. The PEN-Plus clinic led to significant improvement in the provision of medications and testing across a range of services. Conclusion:Mid-level providers can be successfully trained to treat severe NCDs with physician-guided education, mentorship, and supervision. The PEN-Plus clinic improved patient enrollment, the quality of clinical care and access to essential medications and laboratory supplies. These lessons learned can guide decentralization of NCD care to district hospitals in Malawi and expansion of PEN-Plus services in the African region.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Ruderman

Chibwe

Boudreaux

et al. 2022

Annals of Global Health

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“…The person-centred framing allows clear linkage of the model components to their outcomes for patients and therefore the reasons for implementing the service delivery strategies to achieve the component goal. If an understanding of the model of care is included within healthcare worker training, this may help with buy-in and motivation for integrated care activities, a problem which was identified in several primary studies as compromising implementation of integrated care 37 42…”

Section: Discussionmentioning

confidence: 99%

Integrated chronic disease care delivery at a primary care level in sub-Saharan Africa: A systematic review, ‘best fit’ framework synthesis, and new conceptual model

Harrison

Jordan

2021

Preprint

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BackgroundExisting chronic care conceptual models were not designed for sub-Saharan Africa, where there is a growing burden of chronic disease. This review provides a qualitative synthesis and new conceptual model for primary care approaches to the integration of chronic communicable and non-communicable disease care in a sub-Saharan African context.MethodsA ‘best fit’ framework synthesis comprising two systematic reviews, with information retrieved from PubMed, Embase, CINAHL plus, Global Health, and Global Index Medicus databases between 1st – 30th April 2020. Articles on chronic care conceptual models were included if they were developed for application in a primary care context and described a framework for long-term management of chronic disease care, and themes extracted to construct an a priori framework. A second systematic review included articles focussing on integrated HIV and diabetes care at a primary care level in sub-Saharan Africa, with thematic analysis carried out against the a priori framework. A new conceptual model was constructed from a priori themes and new themes. Risk of bias of included studies was assessed using CASP and MMAT.ResultsTwo conceptual models of chronic disease care, comprising 6 themes, were used to build the a priori framework. The systematic review of primary research identified 12 articles, with all 6 of the a priori framework themes, and 5 new themes identified. A new patient-centred conceptual model for integrated HIV and diabetes care was constructed, specific to a sub-Saharan African context.DiscussionImproving patient access to chronic disease care through implementing decentralised, integrated, affordable and efficient primary care services should be prioritised in sub-Saharan Africa. Services must be acceptable to patients, viewing them as partners, addressing their concerns, and seeking to safeguard confidentiality. Limitations of this study include potential publication bias, and impact of policy environment and economic factors in sub-Saharan Africa.SUMMARY BOXWhat is already known?The health transition taking place in sub-Saharan Africa (SSA) towards chronic communicable and non-communicable diseases such as HIV and diabetes as the main causes of morbidity and mortality means that health systems currently orientated towards acute, episodic care, must be re-orientated towards meeting the long-term needs of patients with chronic diseases.Existing chronic care conceptual models were designed for use in high income countries rather than a SSA context.What are the new findings?All 6 of the a priori framework themes derived from the Chronic Care Model and the ICCCF were identified within the primary research studies and therefore have relevance to the provision of chronic care in a primary care context in SSA.An additional 5 new themes were identified from the primary research studies; improving patient access, task-shifting, clinical mentoring, stigma and confidentiality, and patient-provider partnerships.What do the new findings imply?These findings imply that there are additional themes and delivery strategies specific to an SSA context that need to be considered in the implementation of primary care level integrated chronic disease care provision in SSA.The new themes identified from the primary research highlight the importance of health services being accessible and acceptable to patients, of partnering with patients to improve health outcomes, and of patient confidentiality and imply a need to reconceptualise chronic care from a patient-centred viewpoint.

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“…facilities. Policy changes to enable nurse-led HTN treatment in SSA have been considered [51], and several pilot studies have explored the feasibility of nurse-led delivery models with encouraging results [52][53][54][55]. Should nurse-led models find broad acceptance, steady attention to quality of care remains paramount [51,56].…”

Section: Plos Onementioning

confidence: 99%

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

et al. 2022

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Background Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia. Methods Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions. Results Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges. Conclusions Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions—such as task sharing and supply chain strengthening—should be pursued to further improve delivery of HTN care among PWH beyond initial screening.

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Setting up a nurse-led model of care for management of hypertension and diabetes mellitus in a high HIV prevalence context in rural Zimbabwe: a descriptive study

Cited by 16 publications

References 35 publications

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Integrated chronic disease care delivery at a primary care level in sub-Saharan Africa: A systematic review, ‘best fit’ framework synthesis, and new conceptual model

Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach

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