Opportunities to Leverage Telehealth Approaches Along the Hypertension Control Cascade in Sub-Saharan Africa

Community health worker-facilitated telehealth for moderate-severe hypertension care in Kenya and Uganda: A randomized controlled trial

BACKGROUND

Hypertension is underdiagnosed and undertreated in sub-Saharan Africa. Improving hypertension treatment within primary health centers can improve cardiovascular disease outcomes; however, individuals with moderate-severe hypertension face additional barriers to care, including the need for frequent clinic visits to titrate medications. We conducted a pilot study to test whether a clinician-driven, community health worker (CHW)-facilitated telehealth intervention would improve hypertension control among adults with severe hypertension in rural Uganda and Kenya.

METHODS AND FINDINGS

We conducted a pilot randomized controlled trial (RCT) of hypertension treatment delivered via telehealth by a clinician (adherence assessment, counseling, decision-making) and facilitated by a CHW in the participant's home, compared to clinic-based hypertension care (NCT04810650). We recruited adults ≥40 years with BP ≥ 160/100 mmHg at household screening by CHWs, with no restrictions by HIV status. After initial evaluation at the clinic, participants were randomized to telehealth or clinic-based hypertension follow-up. Randomization assignment was not blinded, except for the study statistician. All participants were treated using standard country guideline-based antihypertensive drugs. The primary outcome was hypertension control at 24 weeks (BP < 140/90 mmHg). We also assessed hypertension control at 48 weeks. In intention-to-treat analyses, we compared outcomes between randomized arms with targeted minimum loss-based estimation using sample-splitting to select optimal adjustment covariates (candidates: age, sex, baseline hypertension severity, and country). We screened 2,965 adults ≥40 years, identifying 266 (9%) with severe hypertension and enrolling 200 (98 telehealth arms, 102 clinic arms). Participants were 67% women, median age of 62 years (Q1-Q3 51-72); 14% with HIV. Week 24 blood pressure was measured in 96/99 intervention and 99/102 control participants; week 24 hypertension control was 77% in telehealth and 51% in clinic arms (risk difference (RD) 26%, 95% confidence interval (CI) [14%, 38%], p < 0.001). Week 48 hypertension control was 86% in telehealth and 44% in clinic arms (RD 42%, 95% CI [30%, 53%], p < 0.001). Three participants died (telehealth: 2, clinic: 1); all deaths were unrelated to the study interventions. Our study was limited by its small sample size, although findings are strengthened by being conducted in three primary health centers across two countries.

CONCLUSION

In this pilot, RCT, clinician-driven, CHW-facilitated telehealth for hypertension management improved hypertension control and reduced severe hypertension compared to clinic-based care. Telehealth focused on individuals with moderate-severe hypertension is a promising approach to improve outcomes among those with the highest risk for CVD.

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

BACKGROUND

Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

OBJECTIVE

This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

METHODS

The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

RESULTS

A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

CONCLUSIONS

This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

Using Technology to Deliver Cardiovascular Care in African Countries

PURPOSE OF REVIEW

This review aims to explore the applications of digital technology in cardiovascular care across African countries. It highlights the opportunities and challenges associated with leveraging technology to enhance patient self-monitoring, remote patient-clinician interactions, telemedicine, clinician and patient education, and research facilitation. The purpose is to highlight how technology can transform cardiovascular care in Africa.

RECENT FINDINGS

Recent findings indicate that the increasing penetration of mobile phones and internet connectivity in Africa offers a unique opportunity to improve cardiovascular care. Smartphone-based applications and text messaging services have been employed to promote self-monitoring and lifestyle management, although challenges related to smartphone ownership and digital literacy persist. Remote monitoring of patients by clinicians using home-based devices and wearables shows promise but requires greater accessibility and validation studies in African populations. Telemedicine diagnosis and management of cardiovascular conditions demonstrates significant potential but faces adoption challenges. Investing in targeted clinician and patient education on novel digital technology and devices as well as promoting technology-assisted research for participant recruitment and data collection can facilitate cardiovascular care advancements in Africa. Technology has the potential to revolutionize cardiovascular care in Africa by improving access, efficiency, and patient outcomes. However, barriers related to limited resources, supportive infrastructure, digital literacy, and access to devices must be addressed. Strategic actions, including investment in digital infrastructure, training programs, community collaboration, and policy advocacy, are crucial to ensuring equitable integration of digital health solutions.

mHealth in Sub-Saharan Africa and Europe: Context of current health, healthcare status, and demographic structure

Introduction

The advent of digital systems and global mobile phone availability presents an opportunity for better healthcare access and equity. However, the disparity in the usage and availability of mHealth systems between Europe and Sub-Saharan Africa (SSA) has not been explored in relation to current health, healthcare status, and demographics.

Objective

This study aimed to compare mHealth system availability and use in SSA and Europe in the above-mentioned context.

Methods

The study analyzed health, healthcare status, and demographics in both regions. It assessed mortality, disease burden, and universal health coverage. A systematic narrative review was conducted to thoroughly assess available data on mHealth availability and use, guiding future research in the field.

Results

SSA is on the verge of stages 2 and 3 in the demographic transition with a youthful population and high birth rate. Communicable, maternal, neonatal, and nutritional diseases contribute to high mortality and disease burden, including child mortality. Europe is on the verge of stages 4 and 5 in the demographic transition with low birth and death rates. Europe's population is old, and non-communicable diseases (NCDs) pose major health challenges. The mHealth literature adequately covers cardiovascular disease/heart failure, and cancer. However, it lacks approaches for respiratory/enteric infections, malaria, and NCDs.

Conclusions

mHealth systems in SSA are underutilized than in Europe, despite alignment with the region's demographics and major health issues. Most initiatives in SSA lack implementation depth, with only pilot tests or small-scale implementations. Europe's reported cases highlight actual implementation and acceptability, indicating a strong implementation depth of mHealth systems.

Use of technology to prevent, detect, manage and control hypertension in sub-Saharan Africa: a systematic review

OBJECTIVE

To identify and assess the use of technologies, including mobile health technology, internet of things (IoT) devices and artificial intelligence (AI) in hypertension healthcare in sub-Saharan Africa (SSA).

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, Scopus and Web of Science.

ELIGIBILITY CRITERIA

Studies addressing outcomes related to the use of technologies for hypertension healthcare (all points in the healthcare cascade) in SSA.

METHODS

Databases were searched from inception to 2 August 2021. Screening, data extraction and risk of bias assessment were done in duplicate. Data were extracted on study design, setting, technology(s) employed and outcomes. Blood pressure (BP) reduction due to intervention was extracted from a subset of randomised controlled trials. Methodological quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

1717 hits were retrieved, 1206 deduplicated studies were screened and 67 full texts were assessed for eligibility. 22 studies were included, all reported on clinical investigations. Two studies were observational, and 20 evaluated technology-based interventions. Outcomes included BP reduction/control, treatment adherence, retention in care, awareness/knowledge of hypertension and completeness of medical records. All studies used mobile technology, three linked with IoT devices. Short Message Service (SMS) was the most popular method of targeting patients (n=6). Moderate BP reduction was achieved in three randomised controlled trials. Patients and healthcare providers reported positive perceptions towards the technologies. No studies using AI were identified.

CONCLUSIONS

There are a range of successful applications of key enabling technologies in SSA, including BP reduction, increased health knowledge and treatment adherence following targeted mobile technology interventions. There is evidence to support use of mobile technology for hypertension management in SSA. However, current application of technologies is highly heterogeneous and key barriers exist, limiting efficacy and uptake in SSA. More research is needed, addressing objective measures such as BP reduction in robust randomised studies.

PROSPERO REGISTRATION NUMBER

CRD42020223043.

Caregiver Acceptability of Mobile Phone Use for Pediatric Cancer Care in Tanzania: Cross-sectional Questionnaire Study

BACKGROUND

There is a 60% survival gap between children diagnosed with cancer in low- and middle-income countries (LMICs) and those in high-income countries. Low caregiver knowledge about childhood cancer and its treatment results in presentation delays and subsequent treatment abandonment in LMICs. However, in-person education to improve caregiver knowledge can be challenging due to health worker shortages and inadequate training. Due to the rapid expansion of mobile phone use worldwide, mobile health (mHealth) technologies offer an alternative to delivering in-person education.

OBJECTIVE

The aim of this study is to assess patterns of mobile phone ownership and use among Tanzanian caregivers of children diagnosed with cancer as well as their acceptability of an mHealth intervention for cancer education, patient communication, and care coordination.

METHODS

In July 2017, caregivers of children <18 years diagnosed with cancer and receiving treatment at Bugando Medical Centre (BMC) were surveyed to determine mobile phone ownership, use patterns, technology literacy, and acceptability of mobile phone use for cancer education, patient communication, and care coordination. Descriptive statistics were generated from the survey data by using mean and SD values for continuous variables and percentages for binary or categorical variables.

RESULTS

All eligible caregivers consented to participate and completed the survey. Of the 40 caregivers who enrolled in the study, most used a mobile phone (n=34, 85%) and expressed high acceptability in using these devices to communicate with a health care provider regarding treatment support (n=39, 98%), receiving laboratory results (n=37, 93%), receiving reminders for upcoming appointments (n=38, 95%), and receiving educational information on cancer (n=35, 88%). Although only 9% (3/34) of mobile phone owners owned phones with smartphone capabilities, about 74% (25/34) self-reported they could view and read SMS text messages.

CONCLUSIONS

To our knowledge, this is the first study to assess patterns of mobile phone ownership and use among caregivers of children with cancer in Tanzania. The high rate of mobile phone ownership and caregiver acceptability for a mobile phone-based education and communication strategy suggests that a mobile phone-based intervention, particularly one that utilizes SMS technology, could be feasible in this setting.

Telemedicine interventions for hypertension management in low- and middle-income countries: A scoping review

Hypertension remains the leading cause of cardiovascular disease worldwide and disproportionately impacts patients living in low- and middle-income countries (LMICs). Telemedicine offers a potential solution for improving access to health care for vulnerable patients in LMICs.

OBJECTIVES

The purpose of this scoping review was to summarize the evidence for telemedicine interventions for blood pressure management in LMICs and assess the relationships between the telemedicine intervention characteristics and clinical outcomes.

DESIGN

Published studies were identified from the following databases (from their inception to May 2020): PubMed, Scopus, and Embase. Search terms related to "Low and Middle Income Countries," "Telemedicine," and "Hypertension" were used, and clinical outcomes were extracted from the screened articles.

RESULTS

Our search resulted in 530 unique articles, and 14 studies were included in this review. Five studies assessed telemedicine interventions for patient-provider behavioral counseling, four assessed patient-provider medical management, and five assessed provider-provider consultation technologies. Out of fourteen individual studies, eleven demonstrated a significant improvement in systolic or diastolic blood pressure in the intervention group. Of the eight studies that reported difference-in-differences changes in systolic blood pressure, between-arm differences ranged from 13.2 mmHg to 0.4 mmHg.

CONCLUSIONS

The majority of the studies in this review demonstrated a significant reduction in blood pressure with use of the telemedicine intervention, though the magnitude of benefit was not consistently large. Limitations of the studies included small sample sizes, short duration, and intervention heterogeneity. Current evidence suggests that telemedicine may provide a promising approach to increase access to care and improve outcomes for hypertension in LMICs, especially during events that limit access to in-person care, such as the COVID-19 pandemic. However, high-quality clinical trials of sufficient size and duration are needed to establish the impact and role of telemedicine in hypertension care. The protocol for this review was not registered.