Community-based medication delivery program for antihypertensive medications improves adherence and reduces blood pressure

Scoping review protocol of central chronic medicines dispensing and distribution programme for widening access to medications in South Africa

INTRODUCTION

The Central Chronic Medicines Dispensing and Distribution (CCMDD) programme, a differentiated alternative service delivery programme, initiated by the Department of Health, South Africa, allows clinically stable patients to receive chronic medication refills at the clinic-based or community-based pick-up points, offering stable patients suffering from non-communicable diseases an easy way to collect their medication. This facilitates the achievement of positive therapeutic outcomes and underscores the importance of this programme, which has resulted in decreased stigma concerns and optimising the workload for public health facilities and health workers. Therefore, this scoping review aims to explore and describe how the improved CCMDD programme has widened access to medications in South Africa in readiness for the implementation of the National Health Insurance.

METHODS AND ANALYSIS

This scoping review will be conducted using the Arksey and O'Malley framework and further refined by the Levac framework. The review will follow a six-step approach: (1) identifying the research question, (2) identifying relevant studies, (3) studying selection eligibility, (4) charting the data, (5) collating, summarising and reporting the results and (6) consultation. A comprehensive search strategy will be developed by searching studies published between 2014 and 2024 using the following electronic databases; PubMed, Web of Science and Google Scholar. Grey literature including conference abstracts and reports will also be searched. The Preferred Reporting Items for Systematic Reviews and the Meta-Analysis for Scoping Reviews (PRISMA-ScR) will be used as a guide for this scoping review protocol. Two independent reviewers will screen identified studies' titles, abstracts and full texts. Discrepancies will be handled by consensus or consulting a third reviewer author. Data extraction will be conducted using a standardised form. The selection of studies for the review is anticipated to be completed within 10 weeks, from 15 March to 30 May 2025, with strict adherence to the guidelines of the PRISMA-ScR checklist.

ETHICS AND DISSEMINATION

This review, not requiring ethical approval, will inform policymakers, researchers and healthcare professionals to improve the deliverables of the CCMDD programme for all chronic conditions and ailments with a high prevalence in South Africa and identify any research gaps. We plan to disseminate our findings via a peer-reviewed journal, policy briefs, conference presentations and stakeholder engagement.

Promoting self-care and improving quality of life in cardiovascular disease patients: The role of pharmacist-led interventions in community pharmacies

BACKGROUND

Community pharmacists are underutilized in assisting patients with cardiovascular diseases within pharmacy settings. Monitoring and controlling cardiovascular risks could prevent deaths globally and save public health expenses. The aim of this study is to verify how self-care can impact the quality of life of patients with cardiovascular diseases.

METHODS

A quasi-experimental study lasting 12 months was designed, involving pharmacist intervention. The intervention provided to patients involved personalized guidance tailored to their activation level. This included recommendations for lifestyle changes aimed at improving their quality of life, as assessed using research tools. Key biochemical variables, such as cholesterol levels, cardiovascular risk scores, blood pressure, and patient activation, were measured alongside the patients' perceived quality of life.

RESULTS

Activation level increased significantly after 12 months (from 2.81 ± 1.02 to 3.25 ± 0.78; p = 0.09), and quality of life by 9.9 points out of 100 (p = 0.02). In terms of total cholesterol levels, a decrease was observed between the beginning and the end of the study of 18.7 mg/dL (p = 0.04) and in diastolic pressure by 21.1 mm Hg (p = 0.02). In addition, there is a protective factor against cholesterol increase in those patients with a high activation level (PAM level above 3; RR = 0.273; 95%CI = 0.104-0.716), and with an improvement in quality of life (β = 0.761; p = 0.011); and a lower diastolic pressure when activation was higher (β = -0.351; p = 0.025).

CONCLUSION

Community pharmacists have an impact on improving self-care behaviors among patients with cardiovascular diseases. Community pharmacists, through their proactive involvement and tailored care approaches, are identified as key agents in chronic disease management, empowering patients towards healthier outcomes in the face of ongoing health challenges.

Rethinking chronic care: how blended patient-centered care delivery and innovative financing models can contribute to achieving universal health coverage-a case study of an integrated approach in Kenya

Universal Health Coverage (UHC) aims to ensure all individuals have access to essential health services without financial hardship. Chronic diseases, like hypertension and diabetes, play a critical role in achieving UHC due to their lifelong management needs. This paper examines the implementation of a digital and mobile-based, patient-centered care model aimed at improving care for hypertensive and diabetic patients in Kenya. Between 2018 and 2019, 1626 patients from nine clinics in Nairobi, Kiambu, Nyeri and Vihiga counties were enrolled in an integrated non-communicable disease (NCD) care model including self-management devices for home monitoring, a digital health wallet (M-TIBA) for co-payment and facility-based peer support groups. Follow-up data was collected November-December 2020. Results indicated significantly improved patient outcomes, with 50% of hypertensive and 74% of diabetic patients achieving disease control, compared to 42% and 52% at baseline. Additionally, peer group participation increased adherence to self-monitoring and lifestyle modifications, contributing to better health outcomes. Despite these successes, challenges such as accessing medications and technical issues with digital tools were identified. Financial sustainability and scalability remain critical concerns, particularly in under-resourced settings. The case study highlights the potential of digital health solutions to enhance chronic care and support UHC by improving accessibility and reducing costs. A multifaceted approach, combining digital tools with face-to-face support and addressing structural barriers in healthcare systems, is essential for long-term success. The findings contribute to the broader discourse on integrated care models for NCDs in low-resource settings, underscoring the importance of sustainable financing and innovative care delivery mechanisms.

Effectiveness of team-based care interventions in improving blood pressure outcomes among adults with hypertension in Africa: a systematic review and meta-analysis

OBJECTIVE

We evaluated the effectiveness of team-based care interventions in improving blood pressure (BP) outcomes among adults with hypertension in Africa.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed, CINAHL, EMBASE, Cochrane Library, HINARI and African Index Medicus databases were searched from inception to March 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomised controlled trials (RCTs) and pre-post study designs published in English language focusing on (1) Adults diagnosed with hypertension, (2) Team-based care hypertension interventions led by non-physician healthcare providers (HCPs) and (3) Studies conducted in Africa.

DATA EXTRACTION AND SYNTHESIS

We extracted study characteristics, the nature of team-based care interventions, team members involved and other reported secondary outcomes. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs and the National Heart, Lung, and Blood Institute assessment tool for pre-post studies. Findings were summarised and presented narratively including data from pre-post studies. Meta-analysis was conducted using a random effects model for only RCT studies. Overall certainty of evidence was determined using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool for only the primary outcome (systolic BP).

RESULTS

Of the 3375 records screened, 33 studies (16 RCTs and 17 pre-post studies) were included and 11 RCTs were in the meta-analysis. The overall mean effect of team-based care interventions on systolic BP reduction was -3.91 mm Hg (95% CI -5.68 to -2.15, I² = 0.0%). Systolic BP reduction in team-based care interventions involving community health workers was -4.43 mm Hg (95% CI -5.69 to -3.17, I² = 0.00%) and nurses -3.75 mm Hg (95% CI -10.62 to 3.12, I² = 42.0%). Based on the GRADE assessment, we judged the overall certainty of evidence low for systolic BP reduction suggesting that team-based care intervention may result in a small reduction in systolic BP.

CONCLUSION

Evidence from this review supports the implementation of team-based care interventions across the continuum of care to improve awareness, prevention, diagnosis, treatment and control of hypertension in Africa. PROSPERO registration number CRD42023398900.

Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV

BACKGROUND

People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers.

METHODS

We conducted a qualitative investigation of barriers to CMD care among 25 couples in Malawi. Couples were eligible if at least one partner was living with HIV and had hypertension or diabetes (i.e., the index patient). Index patients were recruited from HIV care clinics in the Zomba district, and their partners were enrolled thereafter. Interviews were conducted separately with both partners to determine barriers to CMD care access and how partners were involved in care.

RESULTS

Participants framed their experiences with CMD care by making comparisons to HIV treatment, which was free and consistently available. The main barriers to accessing CMD care included shortage of medications, cost of tests and treatments, high cost of transportation to health facilities, lengthy wait times at health facilities, faulty or unavailable medical equipment and supplies, inadequate monitoring of patients' health conditions, some cultural beliefs about causes of illness, use of herbal therapies as an alternative to prescribed medicine, and inadequate knowledge about CMD treatments. Partners provided support through decision-making on accessing medical care, assisting partners in navigating the healthcare system, and providing financial assistance with transportation and treatment expenses. Partners also helped manage care for CMD, including communicating health information to their partners, providing appointment reminders, supporting medication adherence, and supporting recommended lifestyle behaviors.

CONCLUSIONS

Couples identified many barriers to CMD care access, which were perceived as greater challenges than HIV care. Partners provided critical forms of support in navigating these barriers. With the rise of CMD among PLWH, improving access to CMD care should be prioritized, using lessons learned from HIV and integrated care approaches. Partner involvement in CMD care may help mitigate most barriers to CMD care.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Cross-sectional analysis of factors associated with medication adherence in western Kenya

OBJECTIVES

Poor medication adherence in low-income and middle-income countries is a major cause of suboptimal hypertension and diabetes control. We aimed to identify key factors associated with medication adherence in western Kenya, with a focus on cost-related and economic wealth factors.

SETTING

We conducted a cross-sectional analysis of baseline data of participants enrolled in the Bridging Income Generation with Group Integrated Care study in western Kenya.

PARTICIPANTS

All participants were ≥35 years old with either diabetes or hypertension who had been prescribed medications in the past 3 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Baseline data included sociodemographic characteristics, wealth and economic status and medication adherence information. Predictors of medication adherence were separated into the five WHO dimensions of medication adherence: condition-related factors (comorbidities), patient-related factors (psychological factors, alcohol use), therapy-related factors (number of prescription medications), economic-related factors (monthly income, cost of transportation, monthly cost of medications) and health system-related factors (health insurance, time to travel to the health facility). A multivariable analysis, controlling for age and sex, was conducted to determine drivers of suboptimal medication adherence in each overarching category.

RESULTS

The analysis included 1496 participants (73.7% women) with a mean age of 60 years (range 35-97). The majority of participants had hypertension (69.2%), 8.8% had diabetes and 22.1% had both hypertension and diabetes. Suboptimal medication adherence was reported by 71.2% of participants. Economic factors were associated with medication adherence. In multivariable analysis that investigated specific subtypes of costs, transportation costs were found to be associated with worse medication adherence. In contrast, we found no evidence of association between monthly medication costs and medication adherence.

CONCLUSION

Suboptimal medication adherence is highly prevalent in Kenya, and primary-associated factors include costs, particularly indirect costs of transportation. Addressing all economic factors associated with medication adherence will be important to improve outcomes for non-communicable diseases.

TRIAL REGISTRATION NUMBER

NCT02501746.