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Ravindranath R, Sarma PS, Sivasankaran S, Thankappan KR, Jeemon P. Voices of care: unveiling patient journeys in primary care for hypertension and diabetes management in Kerala, India. Front Public Health 2024; 12:1375227. [PMID: 38846619 PMCID: PMC11155455 DOI: 10.3389/fpubh.2024.1375227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/06/2024] [Indexed: 06/09/2024] Open
Abstract
Background Diabetes and hypertension are leading public health problems, particularly affecting low- and middle-income countries, with considerable variations in the care continuum between different age, socio-economic, and rural and urban groups. In this qualitative study, examining the factors affecting access to healthcare in Kerala, we aim to explore the healthcare-seeking pathways of people living with diabetes and hypertension. Methods We conducted 20 semi-structured interviews and one focus group discussion (FGD) on a purposive sample of people living with diabetes and hypertension. Participants were recruited at four primary care facilities in Malappuram district of Kerala. Interviews were transcribed and analyzed deductively and inductively using thematic analysis underpinned by Levesque et al.'s framework. Results The patient journey in managing diabetes and hypertension is complex, involving multiple entry and exit points within the healthcare system. Patients did not perceive Primary Health Centres (PHCs) as their initial points of access to healthcare, despite recognizing their value for specific services. Numerous social, cultural, economic, and health system determinants underpinned access to healthcare. These included limited patient knowledge of their condition, self-medication practices, lack of trust/support, high out-of-pocket expenditure, unavailability of medicines, physical distance to health facilities, and attitude of healthcare providers. Conclusion The study underscores the need to improve access to timely diagnosis, treatment, and ongoing care for diabetes and hypertension at the lower level of the healthcare system. Currently, primary healthcare services do not align with the "felt needs" of the community. Practical recommendations to address the social, cultural, economic, and health system determinants include enabling and empowering people with diabetes and hypertension and their families to engage in self-management, improving existing health information systems, ensuring the availability of diagnostics and first-line drug therapy for diabetes and hypertension, and encouraging the use of single-pill combination (SPC) medications to reduce pill burden. Ensuring equitable access to drugs may improve hypertension and diabetes control in most disadvantaged groups. Furthermore, a more comprehensive approach to healthcare policy that recognizes the interconnectedness of non-communicable diseases (NCDs) and their social determinants is essential.
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Affiliation(s)
- Ranjana Ravindranath
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - P. Sankara Sarma
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | | | | | - Panniyammakal Jeemon
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Rivera-Lozada O, Rivera-Lozada IC, Bonilla-Asalde CA. Access to health services and its influence on adherence to treatment of arterial hypertension during the COVID-19 pandemic in a Hospital in Callao, Peru: A cross-sectional study. F1000Res 2024; 12:1215. [PMID: 38666264 PMCID: PMC11043659 DOI: 10.12688/f1000research.141856.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Background Access to health services compromises therapeutic adherence in patients with arterial hypertension (HTN), which is a risk factor for cardiovascular disease and premature death. The aim of the research is to determine the influence of access to health services on adherence to antihypertensive treatment during the COVID-19 pandemic. Methods We included a cross-sectional analytical study. A survey was applied to 241 hypertensive patients at the Daniel Alcides Carrión Hospital, Callao-Peru. Data were analyzed using SPSS software. Absolute and relative frequencies were reported and the chi-square test was applied with a statistical significance level of p<0.05. In addition, multiple logistic regression analysis was performed using the Stepwise method. Results Our results show that non-adherence to treatment is associated with health expenses (ORa: 1.9 CI 95% 1.7-2.2), considers the environment clean (ORa: 1.4 IC 95% 1.2-1.8), not receiving care due to lack of a doctor (ORa: 2.8 CI 95% 1.5-3.2), difficult with procedures (ORa: 2.8 IC 95% 1.2-2.8), having difficulty with schedules (ORa: 3.7 CI 95% 2. 3-5.5), fear of receiving care at the hospital (ORa: 4.5 CI 95 % 2.7-6.8), trust in health staff (ORa: 7.5 CI 95% 2.3-10.5) and considering that the physician does not have enough knowledge (ORa: 3.1 CI 95% 2.4-7.8). Conclusion Therapeutic adherence was associated with expenses in the consultation considers the environment clean, not receiving care due to lack of a doctor, difficult with procedures, having difficulty with schedules, fear of receiving care at the hospital, trust in health staff and considering that the physician does not have enough knowledge.
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Affiliation(s)
- Oriana Rivera-Lozada
- South American Center for Education and Research in Public Health, Universidad Norbert Wiener, Lima, 15046, Peru
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Wang J, Tan F, Wang Z, Yu Y, Yang J, Wang Y, Shao R, Yin X. Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review. JMIR Public Health Surveill 2024; 10:e51802. [PMID: 38149840 PMCID: PMC10907944 DOI: 10.2196/51802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/22/2023] [Accepted: 12/27/2023] [Indexed: 12/28/2023] Open
Abstract
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.
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Affiliation(s)
- Jie Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fangqin Tan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenzhong Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yiwen Yu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jingsong Yang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yueqing Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruitai Shao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xuejun Yin
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Karmakar R, Reddy US, Bhagat RB. Understanding patients' mobility for treatment seeking in India. Sci Rep 2024; 14:1887. [PMID: 38253646 PMCID: PMC10803797 DOI: 10.1038/s41598-023-50184-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 12/16/2023] [Indexed: 01/24/2024] Open
Abstract
Healthcare systems worldwide are grappling with the challenge of providing high-quality healthcare in the face of evolving disease patterns. India, like many other countries, faces a significant treatment gap for various curable impairments, non-communicable diseases (NCDs), and cardiovascular diseases (CVDs). To address their healthcare needs, individuals often relocate in search of better treatment options. However, no studies were conducted to understand the spatial mobility. This paper explores the determinants of spatial mobility for treatment in India using data from NSS 75th round (2017-2018). A total of 64,779 individual medical cases of different diseases were taken into consideration for our analysis. Fixed effect and multinomial regression models were used to understand diseases specific mobility for treatment. It was found that those with CVDs, NCDs, and disabilities are more prone to travel outside their district for medical care. Rural and economically disadvantaged individuals also tend to travel further for treatment. The key factors impacting treatment-seeking mobility include insurance coverage, hospital quality, cost of medicine, and cost of X-rays/surgeries. The study highlights the need for improved policies to address the gap between healthcare needs and infrastructure in India, with a focus on prioritizing the development of local healthcare facilities for disabilities, NCDs, and CVDs.
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Affiliation(s)
- Ranjan Karmakar
- Department of Migration and Urban Studies, International Institute for Population Sciences (IIPS), Mumbai, India
| | | | - Ram Babu Bhagat
- Department of Migration and Urban Studies, International Institute for Population Sciences (IIPS), Mumbai, India
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Ramani S, Bahuguna M, Spencer J, Pathak S, Shende S, Pantvaidya S, D’Souza V, Jayaraman A. Many hops, many stops: care-seeking "loops" for diabetes and hypertension in three urban informal settlements in the Mumbai Metropolitan Region. Front Public Health 2024; 11:1257226. [PMID: 38264249 PMCID: PMC10803512 DOI: 10.3389/fpubh.2023.1257226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
Background The burden of Non-Communicable Diseases (NCDs) in urban informal settlements across Lower and Middle Income Countries is increasing. In recognition, there has been interest in fine-tuning policies on NCDs to meet the unique needs of people living in these settlements. To inform such policy efforts, we studied the care-seeking journeys of people living in urban informal settlements for two NCDs-diabetes and hypertension. The study was done in the Mumbai Metropolitan Region, India. Methods This qualitative study was based on interviews with patients having diabetes and hypertension, supplemented by interactions with the general community, private doctors, and public sector staff. We conducted a total of 47 interviews and 6 Focus Group Discussions. We synthesized data thematically and used the qualitative software NVivo Version 10.3 to aid the process. In this paper, we report on themes that we, as a team, interpreted as striking and policy-relevant features of peoples' journeys. Results People recounted having long and convoluted care-seeking journeys for the two NCDs we studied. There were several delays in diagnosis and treatment initiation. Most people's first point of contact for medical care were local physicians with a non-allopathic degree, who were not always able to diagnose the two NCDs. People reported seeking care from a multitude of healthcare providers (public and private), and repeatedly switched providers. Their stories often comprised multiple points of diagnosis, re-diagnosis, treatment initiation, and treatment adjustments. Advice from neighbors, friends, and family played an essential role in shaping the care-seeking process. Trade-offs between saving costs and obtaining relief from symptoms were made constantly. Conclusion Our paper attempts to bring the voices of people to the forefront of policies on NCDs. People's convoluted journeys with numerous switches between providers indicate the need for trusted "first-contact" points for NCD care. Integrating care across providers-public and private-in urban informal settlements-can go a long way in streamlining the NCD care-seeking process and making care more affordable for people. Educating the community on NCD prevention, screening, and treatment adherence; and establishing local support mechanisms (such as patient groups) may also help optimize people's care-seeking pathways.
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Affiliation(s)
| | | | | | | | | | | | | | - Anuja Jayaraman
- Society for Nutrition, Education and Health Action, Mumbai, India
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Kumar SM, Anandraj J, Sivanatham P, Essakky S, Nain J, Talukdar R, Loganathan V, Kar SS. Control status of hypertension in India: systematic review and meta-analysis. J Hypertens 2023; 41:687-698. [PMID: 36883453 DOI: 10.1097/hjh.0000000000003381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND AND AIMS Uncontrolled hypertension is a major risk factor for cardiovascular diseases (CVDs). The present study aimed to conduct a systematic review and meta-analysis to estimate the pooled prevalence of control status of hypertension in India. METHODS AND RESULTS We carried out systematic search (PROSPERO No.: CRD42021239800) in PubMed and Embase published between April 2013 and March 2021 followed by meta-analysis with random-effects model. The pooled prevalence of controlled hypertension was estimated across geographic regions. The quality, publication bias and heterogeneity of the included studies were also assessed. We included 19 studies with 44 994 hypertensive population, among which 17 studies had low risk of bias. We found statistically significant heterogeneity ( P ≤ 0.05) and absence of publication bias among the included studies. The pooled prevalence of control status among patients with hypertension was 15% (95% CI: 12-19%) and among those under treatment was 46% (95% CI: 40-52%). The control status among patients with hypertension was significantly higher in Southern India 23% (95% CI: 16-31%) followed by Western 13% (95% CI: 4-16%), Northern 12% (95% CI: 8-16%), and Eastern India 5% (95% CI: 4-5%). Except for Southern India, the control status was lower among the rural areas compared with urban areas. CONCLUSION We report high prevalence of uncontrolled hypertension in India irrespective of treatment status, geographic regions and urban and rural settings. There is urgent need to improve control status of hypertension in the country.
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Affiliation(s)
- S Mathan Kumar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Akhtar MH, Ramkumar J. Primary Health Center: Can it be made mobile for efficient healthcare services for hard to reach population? A state-of-the-art review. DISCOVER HEALTH SYSTEMS 2023; 2:3. [PMID: 37520517 PMCID: PMC9870199 DOI: 10.1007/s44250-023-00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/04/2023] [Indexed: 08/01/2023]
Abstract
Indian healthcare system is in immediate need of a new healthcare delivery model to increase healthcare accessibility and improve the health outcomes of the marginalized. Inaccessibility and underutilization of Primary Health Centers (PHCs) disproportionately affect people living in remote areas. It is thus imperative for the designers, engineers, health professionals, and policymakers to come together with a collaborative mindset to develop innovative interventions that sustainably manage the accessibility of PHCs at large, promote preventive health, and thus improve the health outcomes of hard-to-reach communities. This article examines the available literature on barriers to primary healthcare in Indian context, the reason of failure of PHCs and the way forward. The article further analysis literature on existing Mobile Medical Units (MMUs) as an alternate solution to conventional PHCs and attempt to extract the major lessons to propose a mobile Primary Health Center (mPHC) in contrast to the existing conventional static PHCs. The intention is to find out the research gaps in the existing literature and try to address the same for future researchers, designers, engineers, health professionals and policy makers to think forward to make this idea of a mobile Primary Health Center (mPHC), as the main delivery model to cater basic healthcare services to the underserved communities.
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Perseh L, Peimani M, Ghasemi E, Nasli-Esfahani E, Rezaei N, Farzadfar F, Larijani B. Inequalities in the prevalence, diagnosis awareness, treatment coverage and effective control of diabetes: a small area estimation analysis in Iran. BMC Endocr Disord 2023; 23:17. [PMID: 36650506 PMCID: PMC9847158 DOI: 10.1186/s12902-023-01271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE This study aims to assess geographic inequalities in the prevalence, awareness of diagnosis, treatment coverage and effective control of diabetes in 429 districts of Iran. METHODS A modelling study by the small area estimation method, based on a nationwide cross-sectional survey, Iran STEPwise approach to surveillance (STEPS) 2016, was performed. The modelling estimated the prevalence, awareness of diagnosis, treatment coverage, and effective control of diabetes in all 429 districts of Iran based on data from available districts. The modelling results were provided in different geographical and socio-economic scales to make the comparison possible across the country. RESULTS In 2016, the prevalence of diabetes ranged from 3.2 to 19.8% for women and 2.4 to 19.1% for men. The awareness of diagnosis ranged from 51.9 to 95.7% for women and 35.7 to 100% for men. The rate of treatment coverage ranged from 37.2 to 85.6% for women and 24.4 to 80.5% for men. The rate of effective control ranged from 12.1 to 63.6% for women and 12 to 73% for men. The highest treatment coverage rates belonged to Ardebil for women and Shahr-e-kord for men. The highest effective control rates belonged to Sanandaj for women and Nehbandan for men. Across Iran districts, there were considerable differences between the highest and lowest rates of prevalence, diagnosis awareness, treatment coverage, and effective control of diabetes. The concentration indices of diabetes prevalence, awareness of diagnosis, and treatment coverage were positive and significant for both sexes. CONCLUSION Findings of this study highlight the existence of inequalities in diagnosis awareness, treatment coverage, and effective control of diabetes in all Iran regions. More suitable population-wide strategies and policies are warranted to handle these inequalities in Iran.
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Affiliation(s)
- Lida Perseh
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Peimani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Ghasemi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ensieh Nasli-Esfahani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Negar Rezaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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P Suseela R, Ambika RB, Mohandas S, Menon JC, Numpelil M, K Vasudevan B, Ved R, Danaei G, Spiegelman D. Effectiveness of a community-based education and peer support led by women's self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial. BMJ Glob Health 2022; 7:bmjgh-2022-010296. [PMID: 36384950 PMCID: PMC9670931 DOI: 10.1136/bmjgh-2022-010296] [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: 08/01/2022] [Accepted: 10/23/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND With less than 20% of people with hypertension achieving their target blood pressure (BP) goals, uncontrolled hypertension remains a major public health problem in India. We conducted a study to assess the effectiveness of a community-based education and peer support programme led by women's self-help group (SHG) members in reducing the mean systolic BP among people with hypertension in urban slums of Kochi city, Kerala, India. METHODS A cluster randomised controlled pragmatic trial was conducted where 20 slums were randomised to either the intervention or the control arms. In each slum, participants who had elevated BP (>140/90) or were on antihypertensive medications were recruited. The intervention was delivered through women's SHG members (1 per 20-30 households) who provided (1) assistance in daily hypertension management, (2) social and emotional support to encourage healthy behaviours and (3) referral to the primary healthcare system. Those in the control arm received standard of care. The primary outcome was change in mean systolic BP (SBP) after 6 months. RESULTS A total of 1952 participants were recruited-968 in the intervention arm and 984 in the control arm. Mean SBP was reduced by 6.26 mm Hg (SE 0.69) in the intervention arm compared with 2.16 mm Hg (SE 0.70) in the control arm; the net difference being 4.09 (95% CI 2.15 to 4.09), p<0.001. CONCLUSION This women's SHG members led community intervention was effective in reducing SBP among people with hypertension compared with those who received usual care, over 6 months in urban slums of Kerala, India. TRIAL REGISTRATION NUMBER CTRI/2019/12/022252.
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Affiliation(s)
- Rakesh P Suseela
- Department of Community Medicine & Center for Public Health, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Renjini Balakrishnan Ambika
- Department of Community Medicine & Center for Public Health, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sreelakshmi Mohandas
- Department of Community Medicine & Center for Public Health, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Jaideep C Menon
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- Department of Preventive Cardiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidhyapeetham, Kochi, Kerala, India
| | | | - Beena K Vasudevan
- Department of Community Medicine & Center for Public Health, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Rajani Ved
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- National Health Systems Resource Centre, New Delhi, India
| | - Goodarz Danaei
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Donna Spiegelman
- Department of Epidemiology, Biostatistics, Nutrition and Global Health, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- Centre for Methods in Implementation and Prevention Science, Yale School of Public Health, Yale University, New Haven, Connecticut, USA
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Chham S, Buffel V, Van Olmen J, Chhim S, Ir P, Wouters E. The cascade of hypertension care in Cambodia: evidence from a cross-sectional population-based survey. BMC Health Serv Res 2022; 22:838. [PMID: 35768805 PMCID: PMC9241312 DOI: 10.1186/s12913-022-08232-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background Hypertension (HTN) is a leading cause of cardiovascular diseases and deaths globally. To respond to the high HTN prevalence (23.5% among adults aged 40–69 years in 2016) in Cambodia, the government (and donors) established innovative interventions to improve access to screening, care, and treatment at different public health system and community levels. We assessed the effectiveness of these interventions and resulting health outcomes through a cascade of HTN care and explored key determinants. Methods We performed a population-based survey among 5070 individuals aged ≥ 40 years to generate a cascade of HTN care in Cambodia. The cascade, built with conditional approach, shows the patients’ flow in the health system and where they are lost (dropped out) along the steps: (i) prevalence, (ii) screening, (iii) diagnosis, (iv) treatment in the last twelve months, (v) treatment in the last three months, and (vi) HTN being under control. The profile of people dropping out from each bar of the cascade was determined by multivariate logistic regression. Results The prevalence of HTN (i) among study participants was 35.2%, of which 81.91% had their blood pressure (BP) measured in the last three years (ii). Over 63.72% of those screened were diagnosed by healthcare professionals as hypertensive patients (iii). Among these, 56.19% received treatment in the last twelve months (iv) and 54.26% received follow-up treatment in the last three months (v). Only 35.8% of treated people had their BP under control (vi). Males, those aged ≥ 40 years, and from poorer households had lower odds to receive screening, diagnosis, and treatment. Lower odds to have their BP under-control were found in males, those from poor and rich quintiles, having HTN < five years, and receiving treatment at a private facility. Conclusions Overall, people with HTN are lost along the cascade, suggesting limited access to appropriate screening, diagnosis, and treatment and resulting poor health outcomes, especially among those who are male, aged 40–49 years, from poorer households, and visiting a private facility. Efforts to improve the quality of facility-based and community-based interventions are needed to prevent inequitable drops along the cascade of care.
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Affiliation(s)
- Savina Chham
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia. .,Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium.
| | - Veerle Buffel
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Josefien Van Olmen
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Srean Chhim
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia
| | - Por Ir
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia
| | - Edwin Wouters
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium.,Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
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Peters MA, Noonan CM, Rao KD, Edward A, Alonge OO. Evidence for an expanded hypertension care cascade in low- and middle-income countries: a scoping review. BMC Health Serv Res 2022; 22:827. [PMID: 35761254 PMCID: PMC9235242 DOI: 10.1186/s12913-022-08190-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance. Methods A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage. Results The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment. Conclusion There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08190-0.
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Affiliation(s)
- Michael A Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Caitlin M Noonan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Anbrasi Edward
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Olakunle O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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12
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Ortiz P, Vásquez Y, Arévalo E, Van der Stuyft P, Londoño Agudelo E. Gaps in Hypertension Management in a Middle-Income Community of Quito-Ecuador: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19105832. [PMID: 35627369 PMCID: PMC9141875 DOI: 10.3390/ijerph19105832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 11/18/2022]
Abstract
Optimal hypertension care and control at population level significantly reduces cardiovascular morbidity and mortality. The study objective was to measure the gaps in the diagnosis, care, and control of hypertension in residents of an urban community in Quito, Ecuador. A cross-sectional population-based study with a sample of 2160 persons was performed using a survey and direct blood pressure measurement. Logistical regression models were used for analyzing factors associated with the gaps, expressed as percentages. The prevalence of hypertension was 17.6% [CI 95% 17.3–17.9%]. The diagnosis gap was 6.1% [CI 95% 5.9–6.2%] among the entire population and 34.5% [CI 95% 33.7–35.3%] among persons with hypertension. No access gaps were detected; whereas the follow-up gap was 22.7% [CI 95% 21.8–23.6%] and control gap reached 43.5% [CI 95% 42.6–44.2%]. Results indicated that being male, older than 64 years, an employee, without health insurance, and not perceiving a need for healthcare, increased the risk of experiencing these gaps. Data showed appropriate access to health services and high coverage in the diagnosis was due to the application of a community and family healthcare model. Notwithstanding, we found significant gaps in the follow-up and control of hypertensive patients, especially among older males, which should warrant the attention of the Ministry of Health.
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Affiliation(s)
- Patricia Ortiz
- Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito 170143, Ecuador; (Y.V.); (E.A.)
- Consortium Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, Medellin 050010, Colombia; (P.V.d.S.); (E.L.A.)
- Departamento de Pediatría, Obstetricia y Ginecología y de Medicina Preventiva, Universidad Autónoma de Barcelona, 08193 Barcelona, Spain
- Correspondence:
| | - Yajaira Vásquez
- Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito 170143, Ecuador; (Y.V.); (E.A.)
- Consortium Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, Medellin 050010, Colombia; (P.V.d.S.); (E.L.A.)
| | - Esperanza Arévalo
- Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito 170143, Ecuador; (Y.V.); (E.A.)
- Consortium Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, Medellin 050010, Colombia; (P.V.d.S.); (E.L.A.)
| | - Patrick Van der Stuyft
- Consortium Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, Medellin 050010, Colombia; (P.V.d.S.); (E.L.A.)
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Esteban Londoño Agudelo
- Consortium Latin-American Network for Multidisciplinary Research on Chronic Non-Communicable Diseases, Medellin 050010, Colombia; (P.V.d.S.); (E.L.A.)
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
- Department of Public Health, Institute of Tropical Medicine, 2000 Antwerp, Belgium
- Grupo de Epidemiología, Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín 50010, Colombia
- Facultad de Medicina, Universidad CES, Medellín 0510, Colombia
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13
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Quaresma FRP, Maciel EDS, Barasuol AM, Pontes-Silva A, Fonseca FLA, Adami F. Quality of primary health care for quilombolas’ Afro-descendant in Brazil: A cross-sectional study. REVISTA DA ASSOCIAÇÃO MÉDICA BRASILEIRA 2022; 68:482-489. [DOI: 10.1590/1806-9282.20210994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/22/2022] [Indexed: 05/31/2023]
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14
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Chowdhury HA, Paromita P, Mayaboti CA, Rakhshanda S, Rahman FN, Abedin M, Rahman AKMF, Mashreky SR. Assessing service availability and readiness of healthcare facilities to manage diabetes mellitus in Bangladesh: Findings from a nationwide survey. PLoS One 2022; 17:e0263259. [PMID: 35171912 PMCID: PMC8849622 DOI: 10.1371/journal.pone.0263259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 01/14/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction
Diabetes Mellitus (DM) is one of the most prevalent non-communicable diseases (NCDs)as well as a major cause of morbidity and mortality worldwide. Around 80% diabetic patients live in low- and middle-income countries. In Bangladesh, there is a scarcity of data on the quality of DM management within health facilities. This study aims to describe service availability and readiness for DM at all tiers of health facilities using the World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA) standard tool.
Methods
This cross-sectional survey was conducted in 266 health facilities all across Bangladesh using the WHO SARA standard tool. Descriptive analyses for the availability of DM services was carried out. Composite scores for facility readiness index (RI) were calculated in four domains: staff and guideline, basic equipment, diagnostic capacity, and essential medicines. Indices were stratified by facility level and a cut off value of 70% was considered as ‘ready’ to manage diabetes at each facility level.
Results
The mean RI score of tertiary and specialized hospitals was above the cutoff value of 70% (RI: 79%), whereas for District Hospitals (DHs), Upazila Health Complexes (UHCs) and NGO and Private hospitals the RI scores were other levels of 65%, 51% and 62% respectively. This indicating that only the tertiary level of health facilities was ready to manage DM. However, it has been observed that the RI scores of the essential medicine domain was low at all levels of health facilities including tertiary-level.
Conclusions
The study revealed only tertiary level facilities were ready to manage DM. However, like other facilities, they require an adequate supply of essential medicines. Alongside the inadequate supply of medicines, shortage of trained staff and unavailability of guidelines on the diagnosis and treatment of DM also contributed to the low RI score for rest of the facilities.
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Affiliation(s)
- Hasina Akhter Chowdhury
- Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- * E-mail:
| | - Progga Paromita
- Kirtipasha Health and Family Welfare Centre, Jhalokathi Sadar Upazila, Barishal, Bangladesh
| | | | - Shagoofa Rakhshanda
- Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh
| | - Farah Naz Rahman
- Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh
| | - Minhazul Abedin
- Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh
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15
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Lall D, Engel N, Devadasan N, Horstman K, Criel B. Team-based primary health care for non-communicable diseases: complexities in South India. Health Policy Plan 2021; 35:ii22-ii34. [PMID: 33156934 PMCID: PMC7646724 DOI: 10.1093/heapol/czaa121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/26/2022] Open
Abstract
Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.
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Affiliation(s)
- Dorothy Lall
- Institute of Public Health, 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka, 560070 India
| | - Nora Engel
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Narayanan Devadasan
- Institute of Public Health, 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka, 560070 India
| | - Klasien Horstman
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Bart Criel
- Institute of Tropical Medicine, Nationalestraat 155, Antwerpen 2000, Belgium
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16
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Raikwar AA, Dogra V, Giri A, Rathnam N, Hegde SK. Cost analysis of a mobile medical unit programme in Andhra Pradesh: a microcosting study protocol. BMJ Open 2021; 11:e038191. [PMID: 33542036 PMCID: PMC7871218 DOI: 10.1136/bmjopen-2020-038191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Offering primary healthcare through mobile medical units is an innovative way to reach the rural and the vulnerable population. With 292 mobile medical units, the Andhra Pradesh mobile medical unit (APMMU) programme is one of the largest health outreach programmes in rural India. However, India lacks reliable cost estimates for the health services delivered through mobile medical platforms. This study aims to estimate the unit cost of providing primary care services through mobile medical units in rural and tribal areas of Andhra Pradesh. METHOD AND ANALYSIS Cost analysis of 12 mobile medical units will be undertaken. We will use the activity-based microcosting technique from the providers' perspective. A bottom-up approach will be used for cost estimation. Standardised tools will be used to collect data on activities and resources, and on the costs. Capital investments and recurrent costs will be measured and evaluated. Average unit costs, along with 95% CIs, will be reported. Sensitivity analysis will assess the cost estimate uncertainties and other cost assumptions. ETHICS AND DISSEMINATION Piramal Swasthya Management Research Institute's ethics committee approved the study. The findings of the study will be disseminated through conference presentations, publications in peer-reviewed journals and advocacy with the national and state governments. This study will provide first-hand comprehensive cost estimates of provisioning primary healthcare services using mobile medical units in India.
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Affiliation(s)
- Aakash Ashok Raikwar
- Research and Analytics, Piramal Swasthya Management and Research Institute, Hyderabad, India
| | - Vishal Dogra
- Research and Analytics, Piramal Swasthya Management and Research Institute, Hyderabad, India
| | | | - Ashish Giri
- Research and Analytics, Piramal Swasthya Management and Research Institute, Hyderabad, India
| | - Nitin Rathnam
- Public Private Partnerships and CSR Operations, Piramal Swasthya Management and Research Institute, Hyderabad, India
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17
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Sudharsanan N, Ali MK, McConnell M. Hypertension knowledge and treatment initiation, adherence, and discontinuation among adults in Chennai, India: a cross-sectional study. BMJ Open 2021; 11:e040252. [PMID: 33472779 PMCID: PMC7818807 DOI: 10.1136/bmjopen-2020-040252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION A substantial share of urban Indians with diagnosed hypertension do not take regular treatment, potentially due to poor knowledge of hypertension consequences and treatment options. We describe hypertension knowledge and beliefs, treatment patterns, and reported reasons for treatment non-use among adults with diagnosed hypertension in Chennai, India. METHODS We collected data on 833 adults ages 30+ with physician diagnosed hypertension using a door-to-door household survey within randomly selected wards of Chennai. We described the proportion of individuals who were not taking daily medications and their reported reasons for not doing so. Next, we described individuals' knowledge of hypertension consequences and how to control blood pressure (BP) and assessed the association between knowledge and daily treatment use. RESULTS Over one quarter (28% (95% CI 25% to 31%)) of diagnosed individuals reported not taking daily treatment. The largest proportion (18% (95% CI 16% to 21%)) were individuals who had discontinued prior treatment use. The primary reason individuals reported for non-daily use was that their BP had returned to normal. Just 23% (95% CI 20% to 26%) of individuals listed BP medications as the most effective way to reduce BP; however, these individuals were 11% points (95% CI 4% to 19%) more likely to take daily medications. Conversely, 43% (95% CI 40% to 47%) of individuals believed that BP medications should be stopped from time to time and these individuals were 15% points (95% CI -0.21 to -0.09) less likely to take daily treatment. While awareness of the consequences of hypertension was poor, we found no evidence that it was associated with taking daily medications. CONCLUSIONS There were large gaps in consistency of BP medication use which were strongly associated with knowledge about BP medications. Further research is needed to identify whether addressing beliefs can improve daily treatment use among individuals with diagnosed hypertension.
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Affiliation(s)
- Nikkil Sudharsanan
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- LEAD at Krea University, Chennai, India
| | - Mohammed K Ali
- Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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18
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Seiglie JA, Serván-Mori E, Begum T, Meigs JB, Wexler DJ, Wirtz VJ. Predictors of health facility readiness for diabetes service delivery in low- and middle-income countries: The case of Bangladesh. Diabetes Res Clin Pract 2020; 169:108417. [PMID: 32891691 PMCID: PMC8092080 DOI: 10.1016/j.diabres.2020.108417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 11/30/2022]
Abstract
AIMS We aimed to evaluate the readiness and predictors of diabetes service capability at the level of primary care in Bangladesh as an illustrative instance of readiness for diabetes care in low- and middle-income countries (LMICs). METHODS We used data from the 2014 Bangladesh Health Facility Survey (BHFS), a cross-sectional, nationally representative survey (n = 1596 health facilities). We constructed a diabetes-specific readiness index to assess diabetes service readiness in facilities with outpatient capability and used multivariable regression analysis to evaluate contextual predictors of diabetes service readiness. RESULTS Three-hundred and forty-five facilities with outpatient and diabetes service capability were included. Mean readiness for diabetes service capability on a scale of 0-100 was 24.9 (95%CI: 20.8-28.9) and was lowest in rural settings, districts with high social deprivation, and public facilities, where diabetes diagnostic equipment and medications were largely unavailable. Facility type was the strongest, independent predictor of diabetes service readiness. CONCLUSIONS Diabetes service readiness in outpatient facilities in Bangladesh was low, particularly in public facilities, rural settings, and districts with high social deprivation. .These findings could inform policies aimed at improving diabetes care in areas of high unmet need and may serve as a model to assess diabetes service readiness in other LMICs.
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Affiliation(s)
- Jacqueline A Seiglie
- Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - James B Meigs
- Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Deborah J Wexler
- Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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19
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Szlyk H, Tan J. The Role of Technology and the Continuum of Care for Youth Suicidality: Systematic Review. J Med Internet Res 2020; 22:e18672. [PMID: 33034568 PMCID: PMC7584980 DOI: 10.2196/18672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/26/2020] [Accepted: 06/25/2020] [Indexed: 12/13/2022] Open
Abstract
Background Youth suicide is a global public health issue, and using technology is one strategy to increase participation in preventive interventions. However, there is minimal knowledge on how technology-enhanced interventions for youth correspond to the stages of care, from illness or risk recognition to treatment follow-up. Objective This systematic review aims to examine the efficacy of technology-enhanced youth suicide prevention and interventions across the continuum of care. Methods Four electronic databases were searched up to spring 2019 for youth suicide preventive interventions that used technology. The review was not restricted by study design and eligible studies could report outcomes on suicidality or related behaviors, such as formal treatment initiation. An adapted version of the Methodological Quality Ratings Scale was used to assess study quality. Results A total of 26 studies were identified. The findings support the emerging efficacy of technology-enhanced interventions, including a decline in suicidality and an increase in proactive behaviors. However, evidence suggests that there are gaps in the continuum of care and recent study samples do not represent the diverse identities of vulnerable youth. Conclusions The majority of identified studies were conducted in school settings and were universal interventions that aligned with the illness and risk recognition and help-seeking stages of the continuum of care. This field could be strengthened by having future studies target the stages of assessment and treatment initiation, include diverse youth demographics, and examine the varying roles of providers and technological components in emerging interventions.
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Affiliation(s)
- Hannah Szlyk
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Jia Tan
- The Brown School, Washington University in St Louis, Saint Louis, MO, United States
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20
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Flor LS, Wilson S, Bhatt P, Bryant M, Burnett A, Camarda JN, Chakravarthy V, Chandrashekhar C, Chaudhury N, Cimini C, Colombara DV, Narayanan HC, Cortes ML, Cowling K, Daly J, Duber H, Ellath Kavinkare V, Endlich P, Fullman N, Gabert R, Glucksman T, Harris KP, Loguercio Bouskela MA, Maia J, Mandile C, Marcolino MS, Marshall S, McNellan CR, Medeiros DSD, Mistro S, Mulakaluri V, Murphree J, Ng M, Oliveira JAQ, Oliveira MG, Phillips B, Pinto V, Polzer Ngwato T, Radant T, Reitsma MB, Ribeiro AL, Roth G, Rumel D, Sethi G, Soares DA, Tamene T, Thomson B, Tomar H, Ugliara Barone MT, Valsangkar S, Wollum A, Gakidou E. Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA. BMJ Glob Health 2020; 5:e001959. [PMID: 32503887 PMCID: PMC7279660 DOI: 10.1136/bmjgh-2019-001959] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation. METHODS The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time. RESULTS Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges. CONCLUSIONS Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.
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Affiliation(s)
- Luisa S Flor
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Shelley Wilson
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Paurvi Bhatt
- Medtronic Foundation, Minneapolis, Minnesota, USA
| | - Miranda Bryant
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Aaron Burnett
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Regions Hospital, Saint Paul, Minnesota, USA
| | - Joseph N Camarda
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | | | | | | | - Christiane Cimini
- School of Medicine, Federal University of Jequitinhonha and Mucuri Valleys, Teofilo Otoni, MG, Brazil
| | | | | | - Matheus Lopes Cortes
- Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil
| | - Krycia Cowling
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Jessica Daly
- Medtronic Foundation, Minneapolis, Minnesota, USA
| | - Herbert Duber
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | | | - Patrick Endlich
- School of Medicine, Federal University of Jequitinhonha and Mucuri Valleys, Teofilo Otoni, MG, Brazil
| | - Nancy Fullman
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Rose Gabert
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Thomas Glucksman
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Katie Panhorst Harris
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | | | - Junia Maia
- Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Milena S Marcolino
- Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Claire R McNellan
- National CASA/GAL Association for Children, Seattle, Washington, USA
| | - Danielle Souto de Medeiros
- Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil
| | - Sóstenes Mistro
- Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil
| | - Vasudha Mulakaluri
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | | | - Marie Ng
- IBM Watson Health, San Jose, California, USA
| | - J A Q Oliveira
- Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Márcio Galvão Oliveira
- Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil
| | - Bryan Phillips
- Health Policy and Management, University of California Los Angeles, Los Angeles, California, USA
| | - Vânia Pinto
- School of Medicine, Federal University of Jequitinhonha and Mucuri Valleys, Teofilo Otoni, MG, Brazil
| | | | - Tia Radant
- Regions Hospital, Saint Paul, Minnesota, USA
| | - Marissa B Reitsma
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Antonio Luiz Ribeiro
- Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Gregory Roth
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Davi Rumel
- Research and Teaching Institute, Hospital Sirio-Libanes, Sao Paulo, São Paulo, Brazil
- School of Medicine, Municipal University Sao Caetano do Sul, Sao Caetano do Sul, Sao Paulo, Brazil
| | - Gaurav Sethi
- MAMTA Health Institute for Mother and Child, New Delhi, Delhi, India
| | - Daniela Arruda Soares
- Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil
| | - Tsega Tamene
- Pillsbury United Communities, Minneapolis, Minnesota, USA
| | - Blake Thomson
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Harsha Tomar
- MAMTA Health Institute for Mother and Child, New Delhi, Delhi, India
| | - Mark Thomaz Ugliara Barone
- Medtronic Foundation, Minneapolis, Minnesota, USA
- Global Health Leaders, Public Health Institute, Sao Paulo, Sao Paulo, Brazil
| | - Sameer Valsangkar
- Research and Monitoring Systems, The Catholic Health Association of India, Hyderabad, Telangana, India
| | | | - Emmanuela Gakidou
- Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
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21
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Pati MK, Swaroop N, Kar A, Aggarwal P, Jayanna K, Van Damme W. A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India. Public Health Rev 2020; 41:8. [PMID: 32435518 PMCID: PMC7222468 DOI: 10.1186/s40985-020-00128-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist. METHOD The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC). RESULT The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level. CONCLUSION This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings.
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Affiliation(s)
- Manoj Kumar Pati
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
| | - N. Swaroop
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
| | - Arin Kar
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
| | | | - Krishnamurthy Jayanna
- Karnataka Health Promotion Trust, IT Park, 5th floor, 1-4, Rajajinagar Industrial Area behind KSSIDC Admin Office, Rajajinagar, Bangalore, Karnataka 560044 India
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Wim Van Damme
- Health Policy Department, Institute of Tropical Medicine, Antwerp, Belgium
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22
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Sukartini T, Theresia Dee TM, Probowati R, Arifin H. Behaviour model for diabetic ulcer prevention. J Diabetes Metab Disord 2020; 19:135-143. [PMID: 32550163 DOI: 10.1007/s40200-019-00484-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/27/2019] [Indexed: 01/27/2023]
Abstract
Purpose Diabetic ulcers are one of the complications that often occur in patients with DM. The aim is to develop a behaviour model for diabetic ulcer prevention by integrating Lawrance Green Theory and the Theory of Planned Behaviour. Methods An explanative observational design was used with a cross-sectional approach. The population consisted of DM patients who had underwent treatment at the internal medicine clinic of Sidoarjo District Hospital. The sample size of 133 respondents was obtained through purposive sampling. The data analysis used Partial Least Square. Results Predisposing factors (knowledge), supporting factors (availability of health facilities and accessibility of health resources) and driving factors (the role of health workers and family support) significantly influence the main factors (attitudes toward behaviour, subjective norms and perceptions of self-control) with a statistical T value>1.96. The main factor influences intention (T = 48.650) and intention influences behaviour (T = 4.891). Conclusion Intention is influenced by the attitudes toward behaviour, subjective norms and self-control perceptions. Good intentions can increase the preventive behaviour related to diabetic ulcers. Increasing the diabetic ulcer prevention behaviour can be done by providing regular education to both the patients and their families about diabetic ulcers and their prevention through the appropriate management of DM, lifestyle modification and regular foot care that requires active involvement from the family and health care workers.
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Affiliation(s)
- Tintin Sukartini
- Department of Fundamental, Medical-Surgical and Critical Nursing, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
| | | | - Ririn Probowati
- Sekolah Tinggi Ilmu Kesehatan Pemkab Jombang, Jombang, Indonesia
| | - Hidayat Arifin
- Master's of Nursing Study Program, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
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23
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Moucheraud C. Service Readiness For Noncommunicable Diseases Was Low In Five Countries In 2013-15. Health Aff (Millwood) 2019; 37:1321-1330. [PMID: 30080459 DOI: 10.1377/hlthaff.2018.0151] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The growing burden of noncommunicable diseases (NCDs) may pose challenges for resource-limited health systems. This study used standardized, nationally representative data from Service Provision Assessments conducted in 2013-15 and the Service Availability and Readiness Assessment methodology to examine NCD service availability and readiness in Bangladesh, Haiti, Malawi, Nepal, and Tanzania. Both service availability and readiness were found to be very low: Very few facilities were fully "ready" to provide any one NCD service. Shortages of trained health workers and essential medicines were critical limitations to readiness. Rural and free facilities had lower availability and readiness, which may present access barriers. Policy makers should draw on decades of experience with global health initiatives to close these service gaps through the training of health workers on NCD screening and treatment, engaging the private sector on NCDs, and ensuring access to NCD medicines. Such efforts must be attentive to distributional equity and the multiple dimensions of care quality.
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Affiliation(s)
- Corrina Moucheraud
- Corrina Moucheraud ( ) is an assistant professor in the Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, at the University of California Los Angeles
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24
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Kujawski SA, Leslie HH, Prabhakaran D, Singh K, Kruk ME. Reasons for low utilisation of public facilities among households with hypertension: analysis of a population-based survey in India. BMJ Glob Health 2018; 3:e001002. [PMID: 30622745 PMCID: PMC6307571 DOI: 10.1136/bmjgh-2018-001002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 11/14/2018] [Accepted: 12/03/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction In India, for most patients, primary healthcare remains the intended entry point for the management of non-communicable disease risk factors. The extent and determinants of non-utilisation of public primary care among households with hypertension are not well examined. We explored health facility utilisation patterns and reasons for non-utilisation of public facilities in 21 states and union territories in India, with a focus on hypertension. Methods We used data from the 2012-2013 District Level Household and Facility Survey. We examined the self-reported usual source of care for all households, households with hypertension and─to understand multimorbidity for those with hypertension─households with hypertension and diabetes. Hypertension was defined by self-reported diagnosis or measurement of systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Diabetes was defined by self-reported diagnosis or fasting blood glucose level ≥ 7.0 mmol/L or non-fasting blood glucose level ≥ 11.1 mmol/L. We assessed facility utilisation choice and reasons for non-utilisation of public facilities by household with the presence of hypertension alone and hypertension with diabetes. Results In 336 305 households, 37.6% (N=126 597) had at least one household member with hypertension, while 15.9% (N=53 385) had members with hypertension and diabetes. 20.0% of households sought care at public primary clinics, 29.9% at public hospitals and 48.3% at private facilities. Choice of private facilities increased with the burden of disease. Households with hypertension only and hypertension and diabetes cited quality reasons for non-utilisation of public facilities more than households without hypertension. Conclusion Households, particularly those with hypertension, chose private over public primary facilities for usual care. Quality of care was an important determinant of facility choice in households with hypertension and diabetes. With the increase in hypertension and cardiovascular disease in India, quality of public primary healthcare must be addressed for current policy to become reality.
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Affiliation(s)
- Stephanie A Kujawski
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India.,Public Health Foundation of India, Gurgaon, India.,London School of Hygiene and Tropical Medicine, London, UK
| | - Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India.,Public Health Foundation of India, Gurgaon, India
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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25
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The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990-2016. LANCET GLOBAL HEALTH 2018; 6:e1339-e1351. [PMID: 30219317 PMCID: PMC6227386 DOI: 10.1016/s2214-109x(18)30407-8] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/27/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The burden of cardiovascular diseases is increasing in India, but a systematic understanding of its distribution and time trends across all the states is not readily available. In this report, we present a detailed analysis of how the patterns of cardiovascular diseases and major risk factors have changed across the states of India between 1990 and 2016. METHODS We analysed the prevalence and disability-adjusted life-years (DALYs) due to cardiovascular diseases and the major component causes in the states of India from 1990 to 2016, using all accessible data sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016. We placed states into four groups based on epidemiological transition level (ETL), defined using the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed heterogeneity in the burden of major cardiovascular diseases across the states of India, and the contribution of risk factors to cardiovascular diseases. We calculated 95% uncertainty intervals (UIs) for the point estimates. FINDINGS Overall, cardiovascular diseases contributed 28·1% (95% UI 26·5-29·1) of the total deaths and 14·1% (12·9-15·3) of the total DALYs in India in 2016, compared with 15·2% (13·7-16·2) and 6·9% (6·3-7·4), respectively, in 1990. In 2016, there was a nine times difference between states in the DALY rate for ischaemic heart disease, a six times difference for stroke, and a four times difference for rheumatic heart disease. 23·8 million (95% UI 22·6-25·0) prevalent cases of ischaemic heart disease were estimated in India in 2016, and 6·5 million (6·3-6·8) prevalent cases of stroke, a 2·3 times increase in both disorders from 1990. The age-standardised prevalence of both ischaemic heart disease and stroke increased in all ETL state groups between 1990 and 2016, whereas that of rheumatic heart disease decreased; the increase for ischaemic heart disease was highest in the low ETL state group. 53·4% (95% UI 52·6-54·6) of crude deaths due to cardiovascular diseases in India in 2016 were among people younger than 70 years, with a higher proportion in the low ETL state group. The leading overlapping risk factors for cardiovascular diseases in 2016 included dietary risks (56·4% [95% CI 48·5-63·9] of cardiovascular disease DALYs), high systolic blood pressure (54·6% [49·0-59·8]), air pollution (31·1% [29·0-33·4]), high total cholesterol (29·4% [24·3-34·8]), tobacco use (18·9% [16·6-21·3]), high fasting plasma glucose (16·7% [11·4-23·5]), and high body-mass index (14·7% [8·3-22·0]). The prevalence of high systolic blood pressure, high total cholesterol, and high fasting plasma glucose increased generally across all ETL state groups from 1990 to 2016, but this increase was variable across the states; the prevalence of smoking decreased during this period in all ETL state groups. INTERPRETATION The burden from the leading cardiovascular diseases in India-ischaemic heart disease and stroke-varies widely between the states. Their increasing prevalence and that of several major risk factors in every part of India, especially the highest increase in the prevalence of ischaemic heart disease in the less developed low ETL states, indicates the need for urgent policy and health system response appropriate for the situation in each state. FUNDING Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.
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