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Li SJ, Miles T, Vasisht I, Dere H, Agyekum C, Massoud R. Breaking barriers: assessing the impact of clinical quality improvements on reducing health disparities in hypertension care among Mumbai's urban slums. BMJ Open Qual 2024; 13:e002716. [PMID: 38806206 PMCID: PMC11138264 DOI: 10.1136/bmjoq-2023-002716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/13/2024] [Indexed: 05/30/2024] Open
Abstract
The clinical quality improvement initiatives, led by the organisation's Health Equity Working Group (HEWG), aim to support healthcare providers to provide equitable, quality hypertension care worldwide. After coordinating with the India team, we started monitoring the deidentified patient data collected through electronic health records between January and May 2021. After stratifying data by age, sex and residence location, the team found an average of 55.94% of our hypertensive patients control their blood pressure, with an inequity of 11.91% between male and female patients.The objective of this study was to assess the effectiveness of using clinical quality improvement to improve hypertension care in the limited-resourced, mobile healthcare setting in Mumbai slums. We used the model for improvement, developed by Associates in Process Improvement. After 9-month Plan-Do-Study-Act (PDSA) cycles, the average hypertensive patients with controlled blood pressure improved from 55.94% to 89.86% at the endpoint of the initiative. The gender gap reduced significantly from 11.91% to 2.19%. We continued to monitor the blood pressure and found that the average hypertensive patients with controlled blood pressure remained stable at 89.23% and the gender gap slightly increased to 3.14%. Hypertensive patients have 6.43 times higher chance of having controlled blood pressure compared with the preintervention after the 9-month intervention (p<0.001).This paper discusses the efforts to improve hypertension care and reduce health inequities in Mumbai's urban slums. We highlighted the methods used to identify and bridge health inequity gaps and the testing of PDSA cycles to improve care quality and reduce disparities. Our findings have shown that clinical quality improvement initiatives and the PDSA cycle can successfully improve health outcomes and decrease gender disparity in the limited-resource setting.
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Affiliation(s)
- Shang Ju Li
- Monitoring and Evaluation, AmeriCares Foundation Inc, Stamford, Connecticut, USA
| | - Thomas Miles
- Monitoring and Evaluation, AmeriCares Foundation Inc, Stamford, Connecticut, USA
| | - Itisha Vasisht
- Programs, Americares India Foundation, Mumbai, Maharaṣṭra, India
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Witter S, Zou G, Cheedella K, Walley J, Wurie H. Learning from implementation of a COVID case management desk guide and training: a pilot study in Sierra Leone. BMC Health Serv Res 2023; 23:1026. [PMID: 37743494 PMCID: PMC10518973 DOI: 10.1186/s12913-023-10024-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND When the COVID pandemic hit the world, there was need for applied guides and training materials to support frontline health care staff to manage patients effectively and safely and to educate themselves and communities. This article reports on the development and piloting of such a set of materials in Sierra Leone, which were based on international evidence but adapted to the local context. Reflecting on this experience, including community and health system barriers and enablers, is important to prepare for future regional shocks. METHODS This study, in Bombali district in 2020, piloted user-friendly COVID guides for frontline health workers (the intervention), which was evaluated using facility checklists (pre and post training), routine data analysis and 32 key informant interviews. RESULTS Key informants at district, hospital and community health centre levels identified gains from the training and desk guides, including improved diagnosis, triaging, infection prevention and management of patients. They also reported greater confidence to share messages on protection with colleagues and community members, which was needed to encourage continued use of essential services during the pandemic. However, important barriers were also revealed, including the lack of testing facilities, which reduced the sense of urgency, as few cases were identified. Actions based on the Ebola experience, such as setting up testing and isolation centres, which the community avoided, were not appropriate to COVID. Stigma and fear were important factors, although these were reduced with outreach activities. Supplies of essential medicines and personal protective equipment were also lacking. CONCLUSION This pilot study demonstrated the relevance and importance of guides adapted to the context, which were able to improve the confidence of health staff to manage their own and the community's fears in the face of a new pandemic and improve their skills. Previous epidemics, particularly Ebola, complicated this by both creating structures that could be revitalised but also assumptions and behaviours that were not adapted to the new disease. Our study documents positive adaptations and resilience by health staff but also chronic system weaknesses (particularly for medicines, supplies and equipment) which must be urgently addressed before the next shock arrives.
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Affiliation(s)
- Sophie Witter
- NIHR Research Unit on Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Kiran Cheedella
- NIHR Research Unit on Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - John Walley
- Nuffield Centre for International Health and Development, Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Cheedella K, Conteh P, Zou G, Walley J, Kamara A, Wurie H, Witter S. Developing a social mobilisation intervention for salt reduction: participatory action research in Bombali district, Sierra Leone. BMC Public Health 2023; 23:1774. [PMID: 37700274 PMCID: PMC10496325 DOI: 10.1186/s12889-023-16693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND High salt intake is a major risk factor for hypertension, which in turn contributes to cardiovascular diseases, the major cause of death from non communicable diseases (NCDs). Research is limited on social mobilisation interventions to tackle NCDs, including in fragile health settings such as Sierra Leone. METHODS Participatory action research methods were used to develop a social mobilisation intervention for salt reduction in Bombali District, Sierra Leone. A team of 20 local stakeholders were recruited to develop and deliver the intervention. Stakeholder workshop reports and interviews were used to record outcomes, enablers, and barriers to the intervention. Focus group discussions were used to observe knowledge, attitudes, and behaviours of community members pre- and post- the intervention. RESULTS Stakeholders showed enthusiasm and were well engaged in the social mobilisation process around salt reduction. They developed radio jingles, radio show talks, organised community awareness raising meetings, school sensitisation outreaches, and door to door engagements. Stakeholders reported benefiting personally through developing their own skills and confidence in communication and felt positive about their role in educating their community. The interventions led to reported increased awareness of risks of high salt intake and NCDs, resulting in a reduction of salt use in the community, leading to perceived health gains. However, salt reduction was also met with some resistance due to social factors. Local community structures were also reactivated to work on the interventions and connect the community to the local health facility, which saw an increase in patients having their blood pressure checked. The comparison villages also experienced an increase in awareness and perceived reductions in salt intake behaviours. This was as messages had cascaded via the radio and initial focus group discussions. The social mobilisation stakeholders also agreed on future activities that could continue at no or low cost. CONCLUSION Social mobilisation interventions can provide low-cost strategies to tackle NCDs in fragile settings such as Sierra Leone through the utilisation of community structures. However, more research is required to ascertain the key enablers for replicability and if such successes can be sustained over a longer follow up period.
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Affiliation(s)
- Kiran Cheedella
- NIHR Research Unit On Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Peter Conteh
- NIHR Research Unit On Health in Situations of Fragility and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - John Walley
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ajaratu Kamara
- NIHR Research Unit On Health in Situations of Fragility and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Haja Wurie
- NIHR Research Unit On Health in Situations of Fragility and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sophie Witter
- NIHR Research Unit On Health in Situations of Fragility, Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Byiringiro S, Ogungbe O, Commodore-Mensah Y, Adeleye K, Sarfo FS, Himmelfarb CR. Health systems interventions for hypertension management and associated outcomes in Sub-Saharan Africa: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001794. [PMID: 37289741 DOI: 10.1371/journal.pgph.0001794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/21/2023] [Indexed: 06/10/2023]
Abstract
Hypertension is a significant global health problem, particularly in Sub-Saharan Africa (SSA). Despite the effectiveness of medications and lifestyle interventions in reducing blood pressure, shortfalls across health systems continue to impede progress in achieving optimal hypertension control rates. The current review explores the health system interventions on hypertension management and associated outcomes in SSA. The World Health Organization health systems framework guided the literature search and discussion of findings. We searched PubMed, CINAHL, and Embase databases for studies published between January 2010 and October 2022 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We assessed studies for the risk of bias using the tools from the Joanna Briggs Institute. Twelve studies clustered in 8 SSA countries met the inclusion criteria. Two thirds (8/12) of the included studies had low risk of bias. Most interventions focused on health workforce factors such as providers' knowledge and task shifting of hypertension care to unconventional health professionals (n = 10). Other health systems interventions addressed the supply and availability of medical products and technology (n = 5) and health information systems (n = 5); while fewer interventions sought to improve financing (n = 3), service delivery (n = 1), and leadership and governance (n = 1) aspects of the health systems. Health systems interventions showed varied effects on blood pressure outcomes but interventions targeting multiple aspects of health systems were likely associated with improved blood pressure outcomes. The general limitations of the overall body of literature was that studies were likely small, with short duration, and underpowered. In conclusion, the literature on health systems internventions addressing hypertension care are limited in quantity and quality. Future studies that are adequately powered should test the effect of multi-faceted health system interventions on hypertension outcomes with a special focus on financing, leadership and governance, and service delivery interventions since these aspects were least explored.
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Affiliation(s)
- Samuel Byiringiro
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - Oluwabunmi Ogungbe
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - Yvonne Commodore-Mensah
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Khadijat Adeleye
- University of Massachusetts, Amherst, MA, United States of America
| | - Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ashanti Region, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ashanti Region, Ghana
| | - Cheryl R Himmelfarb
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Werner K, Kak M, Herbst CH, Lin TK. The role of community health worker-based care in post-conflict settings: a systematic review. Health Policy Plan 2022; 38:261-274. [PMID: 36124928 PMCID: PMC9923383 DOI: 10.1093/heapol/czac072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/28/2022] [Accepted: 09/18/2022] [Indexed: 11/15/2022] Open
Abstract
Countries affected by conflict often experience the deterioration of health system infrastructure and weaken service delivery. Evidence suggests that healthcare services that leverage local community dynamics may ameliorate health system-related challenges; however, little is known about implementing these interventions in contexts where formal delivery of care is hampered subsequent to conflict. We reviewed the evidence on community health worker (CHW)-delivered healthcare in conflict-affected settings and synthesized reported information on the effectiveness of interventions and characteristics of care delivery. We conducted a systematic review of studies in OVID MedLine, Web of Science, Embase, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINHAL) and Google Scholar databases. Included studies (1) described a context that is post-conflict, conflict-affected or impacted by war or crisis; (2) examined the delivery of healthcare by CHWs in the community; (3) reported a specific outcome connected to CHWs or community-based healthcare; (4) were available in English, Spanish or French and (5) were published between 1 January 2000 and 6 May 2021. We identified 1976 articles, of which 55 met the inclusion criteria. Nineteen countries were represented, and five categories of disease were assessed. Evidence suggests that CHW interventions not only may be effective but also efficient in circumventing the barriers associated with access to care in conflict-affected areas. CHWs may leverage their physical proximity and social connection to the community they serve to improve care by facilitating access to care, strengthening disease detection and improving adherence to care. Specifically, case management (e.g. integrated community case management) was documented to be effective in improving a wide range of health outcomes and should be considered as a strategy to reduce barrier to access in hard-to-reach areas. Furthermore, task-sharing strategies have been emphasized as a common mechanism for incorporating CHWs into health systems.
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Affiliation(s)
- Kalin Werner
- *Corresponding author. Institute for Health and Aging, Department of Social and Behavioral Sciences, University of California, 490 Illinois Street, 12th Floor, Box 0646, San Francisco, CA 94158, USA. E-mail:
| | - Mohini Kak
- Health, Nutrition and Population Global Practice, The World Bank, 1818 H Street, N.W., Washington, DC 20433, USA
| | - Christopher H Herbst
- Health, Nutrition and Population Global Practice, The World Bank, 1818 H Street, N.W., Washington, DC 20433, USA
| | - Tracy Kuo Lin
- Institute for Health and Aging, Department of Social and Behavioral Sciences, University of California, 490 Illinois Street, 12th Floor, Box 0646, San Francisco, CA 94158, USA
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Jackson-Morris AM, Mutungi G, Maree E, Waqanivalu T, Marten R, Nugent R. 'Implementability' matters: using implementation research steps to guide and support non-communicable disease national planning in low-income and middle-income countries. BMJ Glob Health 2022; 7:bmjgh-2021-008275. [PMID: 35418410 PMCID: PMC9014004 DOI: 10.1136/bmjgh-2021-008275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/20/2022] [Indexed: 11/03/2022] Open
Abstract
The 'implementation gap' between national plans and successful implementation is a central theme in addressing non-communicable diseases (NCDs). It is a factor that has undermined Sustainable Development Goal 3.4, which aims to achieve a one-third reduction in premature mortality from four major NCDs by 2030. Responding to the potential of implementation research to support low-income and middle-income countries to effectively advance their strategies, we describe ways to make NCD plans more robust by including implementation steps. These steps are (1) choosing some (but not all) effective and cost-effective options; (2) tailoring interventions and their scale-up to national capacity; and (3) making the priorities implementable. We illustrate with examples from several countries.
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Affiliation(s)
| | - Gerald Mutungi
- Noncommunicable Diseases, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Ephantus Maree
- Noncommunicable Diseases, Kenya Ministry of Health, Nairobi, Kenya
| | - Temo Waqanivalu
- Department of Non-communicable Diseases, World Health Organisation, Suva, Fiji
| | - Robert Marten
- WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland
| | - Rachel Nugent
- Center for Global Noncommunicable Diseases, RTI International, Durham, North Carolina, USA
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Geraedts TJM, Boateng D, Lindenbergh KC, van Delft D, Mathéron HM, Mönnink GLE, Martens JPJ, van Leerdam D, Vas Nunes J, Bu-Buakei Jabbi SM, Kpaka MS, Westendorp J, van Duinen AJ, Sankoh O, Grobusch MP, Bolkan HA, Klipstein-Grobusch K. Evaluating the cascade of care for hypertension in Sierra Leone. Trop Med Int Health 2021; 26:1470-1480. [PMID: 34350675 PMCID: PMC9290521 DOI: 10.1111/tmi.13664] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the care for hypertension in Sierra Leone, by the use of a cascade-of-care approach, to identify where the need for healthcare system interventions is greatest. METHODS Using data from a nationwide household survey on surgical conditions undertaken in 1956 participants ≥18 years from October 2019 to March 2020, a cascade of care for hypertension consisting of four categories - hypertensive population, those diagnosed, those treated and those controlled - was constructed. Hypertension was defined as having a blood pressure ≥140/90 mmHg, or self-reported use of antihypertensive medication. Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension. RESULTS The prevalence of hypertension was 22%. Among those with hypertension, 23% were diagnosed, 11% were treated and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Male sex, age and living in a rural location, were significantly associated with the odds of undiagnosed hypertension. There was no significant difference between men and women in the number of patients with controlled blood pressure. Adults aged 40 or older were observed to be better retained in care compared with those younger than 40 years of age. CONCLUSION There is a significant loss to care in the care cascade for hypertension in Sierra Leone. Our results suggest that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis might have a large impact on hypertension care.
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Affiliation(s)
- Tessa J M Geraedts
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karel C Lindenbergh
- Faculty of Medicine, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Hanna M Mathéron
- Masanga Medical Research Unit, Masanga, Sierra Leone.,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Gulia L E Mönnink
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Janine P J Martens
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Daniel van Leerdam
- CapaCare, Trondheim, Norway.,Royal Tropical Institute, Amsterdam, The Netherlands
| | - Jonathan Vas Nunes
- Masanga Medical Research Unit, Masanga, Sierra Leone.,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mohamed S Kpaka
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Josien Westendorp
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,CapaCare, Trondheim, Norway
| | - Alex J van Duinen
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,CapaCare, Trondheim, Norway
| | - Osman Sankoh
- Statistics Sierra Leone, Freetown, Sierra Leone.,Njala University, Njala, Sierra Leone
| | - Martin P Grobusch
- Masanga Medical Research Unit, Masanga, Sierra Leone.,Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Håkon A Bolkan
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Surgery, St. Olavs Hospital HF, Trondheim, Norway
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Kachimanga C, Dibba Y, Patiño M, Gassimu JS, Lavallie D, Sesay S, Lado M, Kulinkina AV. Implementation of a non-communicable disease clinic in rural Sierra Leone: early experiences and lessons learned. J Public Health Policy 2021; 42:422-438. [PMID: 34497378 PMCID: PMC8452567 DOI: 10.1057/s41271-021-00304-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2021] [Indexed: 02/04/2023]
Abstract
This study is an evaluation of the first cohort of patients enrolled in an outpatient non-communicable disease clinic in Kono, Sierra Leone. In the first year, the clinic enrolled 916 patients. Eight months after the enrollment of the last patient, 53% were still active in care, 43% had been lost to follow-up (LTFU) and 4% had defaulted. Of the LTFU patients, 47% only came for the initial enrollment visit and never returned. Treatment outcomes of three patient groups [HTN only (n = 720), DM only (n = 51), and HTN/DM (n = 96)] were analyzed through a retrospective chart review. On average, all groups experienced reductions in blood pressure and/or blood glucose of approximately 10% and 20%, respectively. The proportions of patients with their condition controlled also increased. As NCDs remain underfunded and under-prioritized in low-income countries, the integrated program in Kono demonstrates the possibility of improving outpatient NCD care in Sierra Leone and similar settings.
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Affiliation(s)
| | - Yusupha Dibba
- Partners In Health, 25 Saquee Drive, Off Wilkinson Road, Freetown, Sierra Leone ,grid.38142.3c000000041936754XHarvard Medical School, 25 Shattuck Street, Boston, MA USA
| | - Marta Patiño
- Partners In Health, 25 Saquee Drive, Off Wilkinson Road, Freetown, Sierra Leone
| | - Joseph S. Gassimu
- Partners In Health, 25 Saquee Drive, Off Wilkinson Road, Freetown, Sierra Leone
| | - Daniel Lavallie
- grid.463455.5Ministry of Health and Sanitation, Wilkinson Road, Freetown, Sierra Leone
| | - Santigie Sesay
- grid.463455.5Ministry of Health and Sanitation, Wilkinson Road, Freetown, Sierra Leone
| | - Marta Lado
- Partners In Health, 25 Saquee Drive, Off Wilkinson Road, Freetown, Sierra Leone
| | - Alexandra V. Kulinkina
- Partners In Health, 25 Saquee Drive, Off Wilkinson Road, Freetown, Sierra Leone ,grid.416786.a0000 0004 0587 0574Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, Switzerland ,grid.6612.30000 0004 1937 0642University of Basel, Petersplatz 1, Basel, Switzerland
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9
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Witter S, Zou G, Diaconu K, Senesi RGB, Idriss A, Walley J, Wurie HR. Opportunities and challenges for delivering non-communicable disease management and services in fragile and post-conflict settings: perceptions of policy-makers and health providers in Sierra Leone. Confl Health 2020; 14:3. [PMID: 31921333 PMCID: PMC6945746 DOI: 10.1186/s13031-019-0248-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/24/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The growing burden of non-communicable diseases in low- and middle-income countries presents substantive challenges for health systems. This is also the case in fragile, post-conflict and post-Ebola Sierra Leone, where NCDs represent an increasingly significant disease burden (around 30% of adult men and women have raised blood pressure). To date, documentation of health system challenges and opportunities for NCD prevention and control is limited in such settings. This paper aims to identify opportunities and challenges in provision of NCD prevention and care and highlight lessons for Sierra Leone and other fragile states in the battle against the growing NCD epidemic. METHODS This paper focuses on the case of Sierra Leone and uses a combination of participatory group model building at national and district level, in rural and urban districts, interviews with 28 key informants and review of secondary data and documents. Data is analysed using the WHO's health system assessment guide for NCDs. RESULTS We highlight multiple challenges typical to those encountered in other fragile settings to the delivery of preventive and curative NCD services. There is limited government and donor commitment to financing and implementation of the national NCD policy and strategy, limited and poorly distributed health workforce and pharmaceuticals, high financial barriers for users, and lack of access to quality-assured medicines with consequent high recourse to private and informal care seeking. We identify how to strengthen the system within existing (low) resources, including through improved clinical guides and tools, more effective engagement with communities, and regulatory and fiscal measures. CONCLUSION Our study suggests that NCD prevention and control is of low but increasing priority in Sierra Leone; challenges to addressing this burden relate to huge numbers with NCDs (especially hypertension) requiring care, overall resource constraints and wider systemic issues, including poorly supported primary care services and access barriers. In addition to securing and strengthening political will and commitment and directing more resources and attention towards this area, there is a need for in-depth exploratory and implementation research to shape and test NCD interventions in fragile and post-conflict settings.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Guanyang Zou
- School of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Reynold G. B. Senesi
- Directorate of Non-Communicable Diseases and Mental Health, Ministry of Health and Sanitation of Sierra Leone, Freetown, Sierra Leone
| | - Ayesha Idriss
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Haja Ramatulai Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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