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Hernández-Galdamez D, Mansilla K, Peralta AL, Rodríguez-Szaszdi J, Ramírez JM, Roche D, Gulayin P, Ramirez-Zea M, He J, Irazola V, Fort MP. Monitoring Study Participants and Implementation with Phone Calls to Support Hypertension Control During the COVID-19 Pandemic: The Case of a Multicomponent Intervention Trial in Guatemala. Glob Heart 2021; 16:77. [PMID: 34900568 PMCID: PMC8622336 DOI: 10.5334/gh.954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 10/30/2021] [Indexed: 11/20/2022] Open
Abstract
Background The COVID-19 pandemic presents a challenge to health care for patients with chronic diseases, especially hypertension, because of the important association and increased risk of these patients with a severe presentation of COVID-19 disease. The Guatemalan Ministry of Health has been implementing a multi-component program aimed at improving hypertension control in rural communities since 2019 as a part of an intervention research cluster randomized trial. When the first cases of COVID-19 were reported (March 13, 2020) in Guatemala, our study paused all study field activities, and began monitoring participants through phone calls. The objective of this paper is to describe the approach used to monitor study participants during the COVID-19 pandemic and compare data obtained during phone calls for intervention and control group participants. Methods We developed a cross-sectional study within the HyTREC (Hypertension Outcomes for T4 Research within Lower Middle-Income Countries) project 'Multicomponent Intervention to Improve Hypertension Control in Central America: Guatemala' in which phone calls were made to participants from both intervention and control groups to monitor measures important to the study: delivery of antihypertensive medications in both groups, receipt of coaching sessions and use of a home blood pressure monitor by intervention group participants, as well as reasons that they were not implemented. Results Regarding the delivery of antihypertensive drugs by the MoH to participants, those in the intervention group had a higher level of medication delivery (73%) than the control group (51%), p<0.001. Of the total participants in the intervention group, 62% had received at least one health coaching session in the previous three months and 81% used a digital home blood pressure monitor at least twice a week. Intervention activities were lower than expected due to restricted public transportation on top of decreased availability of health providers. Conclusion In Guatemala, specifically in rural settings, access to antihypertensive medications and health services during pandemic times was impaired and less than expected, even after accounting for the program's implementation activities and actions.
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Affiliation(s)
- Diego Hernández-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Kristyne Mansilla
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Ana Lucía Peralta
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Javier Rodríguez-Szaszdi
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Juan Manuel Ramírez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Dina Roche
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Pablo Gulayin
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, AR
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, GT
| | - Jiang He
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, US
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, AR
| | - Meredith P. Fort
- Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, US
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Fort MP, Mundo W, Paniagua-Avila A, Cardona S, Figueroa JC, Hernández-Galdamez D, Mansilla K, Peralta-García A, Roche D, Palacios EA, Glasgow RE, Gulayin P, Irazola V, He J, Ramirez-Zea M. Hypertension in Guatemala's Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework. BMC Health Serv Res 2021; 21:908. [PMID: 34479559 PMCID: PMC8414027 DOI: 10.1186/s12913-021-06889-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 08/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. Methods We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. Results Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. Conclusions This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06889-0.
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Affiliation(s)
- Meredith P Fort
- Department of Health Systems, Management and Policy, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA. .,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA. .,INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.
| | - William Mundo
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Alejandra Paniagua-Avila
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Sayra Cardona
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Juan Carlos Figueroa
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Diego Hernández-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Kristyne Mansilla
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Ana Peralta-García
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Dina Roche
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | | | - Russell E Glasgow
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Pablo Gulayin
- South American Center of Excellence for Cardiovascular Health, Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Vilma Irazola
- South American Center of Excellence for Cardiovascular Health, Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Jiang He
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.,Tulane University Translation Science Institute, New Orleans, LA, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
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Paniagua-Avila A, Fort MP, Glasgow RE, Gulayin P, Hernández-Galdamez D, Mansilla K, Palacios E, Peralta AL, Roche D, Rubinstein A, He J, Ramirez-Zea M, Irazola V. Evaluating a multicomponent program to improve hypertension control in Guatemala: study protocol for an effectiveness-implementation cluster randomized trial. Trials 2020; 21:509. [PMID: 32517806 PMCID: PMC7281695 DOI: 10.1186/s13063-020-04345-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypertension is a major risk factor for cardiovascular disease (CVD). Despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (LMICs). We will evaluate an adapted version of a multilevel and multicomponent hypertension control program in Guatemala, previously proven effective and feasible in Argentina. The program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback. METHODS Using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in Guatemala over an 18-month period. Through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 to enhanced usual care across five departments, enrolling 44 participants per health district and 1584 participants in total. The clinical outcomes are (1) the difference in the proportion of patients with controlled hypertension (< 130/80 mmHg) between the intervention and control groups at 18 months and (2) the net change in systolic and diastolic blood pressure from baseline to 18 months. The context-enhanced Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM)/Practical Robust Implementation and Sustainability Model (PRISM) framework will guide the evaluation of the implementation at the level of the patient, provider, and health system. Using a mixed-methods approach, we will evaluate the following implementation outcomes: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost-effectiveness. DISCUSSION We will disseminate the study findings, and promote scale up and scale out of the program, if proven effective. This study will generate urgently needed data on effective, adoptable, and sustainable interventions and implementation strategies to improve hypertension control in Guatemala and other LMICs. TRIAL REGISTRATION ClinicalTrials.gov: NCT03504124. Registered on 20 April 2018.
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Affiliation(s)
- Alejandra Paniagua-Avila
- Mailman School of Public Health, Columbia University, New York, NY, USA.,INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Meredith P Fort
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala.,Colorado School of Public Health, Aurora, CO, USA
| | - Russell E Glasgow
- Department of Family Medicine, and Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, USA
| | - Pablo Gulayin
- Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Diego Hernández-Galdamez
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Kristyne Mansilla
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Eduardo Palacios
- Programa Nacional de Enfermedades Crónicas, Ministerio de Salud y Asistencia Social (MSPAS), Guatemala City, Guatemala
| | - Ana Lucia Peralta
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Dina Roche
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala
| | - Adolfo Rubinstein
- Programa Nacional de Enfermedades Crónicas, Ministerio de Salud y Asistencia Social (MSPAS), Guatemala City, Guatemala
| | - Jiang He
- Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, LA, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama - INCAP, Calzada Roosevelt 6-25 zona 11, INCAP III, Guatemala City, Guatemala.
| | - Vilma Irazola
- Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, LA, USA
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