Hypertension Research Programme - HT12

Task shifting and blood pressure control in Ghana - a cluster-randomized trial

Project location: Ghana

Project duration: 2012 - 2017

Funding organisation

• National Institutes of Health, USA (NIH)
• National Heart, Lung, and Blood Institute, USA (NHLBI)

Primary research aim

Countries in sub-Saharan Africa (SSA) are experiencing an epidemic of cardiovascular disease (CVD) propelled by rapidly increasing rates of hypertension. Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs. Although SSA bears 24% of the global disease burden, it has only 3% of the global health workforce. Given such limited resources, cost-effective strategies, such as task shifting, are needed to mitigate the rising CVD epidemic in SSA. Ghana, a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization (WHO) task-shifting strategy. This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage, on blood pressure (BP) reduction.

Research objectives and methodology

Using a cluster randomized design, 32 community health centers (CHCs) and district hospitals in Ghana will be randomized to either the intervention group (16 sites) or the control group (16 sites). A total of 640 patients with uncomplicated hypertension (BP 140-179/90-99 mmHg and absence of target organ damage) will be enrolled in this study (20 patients per site). The intervention consists of WHO Package of CV risk assessment, patient education, initiation and titration of antihypertensive medications, behavioral counselling on lifestyle behaviours, and medication adherence every three months for 12 months. The primary outcome is the mean change in systolic BP from baseline to 12 months. The secondary outcomes are rates of BP control at 12 months; levels of physical activity, percent change in weight, and dietary intake of fruits and vegetables at 12 months; and sustainability of intervention effects at 24 months. All outcomes will be assessed at baseline, six months and 12 months. Trained community health nurses will deliver the intervention as part of Ghana’s community-based health planning and services (CHPS) program. Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in resource-poor settings.

Current status

We have recruited and randomized all 32 health facilities (16 district hospitals, 16 health centers) into four cohorts. We have completed baseline recruitment with a total of 757 patients. Final patient recruitment was ~18% more than the estimated recruitment target of 640. Follow-up is almost completed for the first cohort of eight sites with a total of 198 patients. We are currently working on patient follow-up for all four cohorts.

Project contact: Joyce Gyamfi - joyce.gyamfi@nyumc.org

Investigators

• Olugbenga Ogedegbe, New York University Medical Center, New York, USA
• Joyce Gyamfi, New York University Medical Center, New York, USA
• Jacob Plange-Rhule, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
• Michael Ntim, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
• Kingsley Apusiga, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
• Richard Cooper, Loyola University Health System, USA

Publications

1. Airhihenbuwa CO, Ogedegbe G, Iwelunmor J, Jean-Louis G, Williams N, Zizi F, Okuyemi K. Claim Your Space: Leadership Development as a Research Capacity Building Goal in Global Health. Health Educ Behav. 2016 Apr; 43(1 Suppl):17S-24S. doi: 10.1177/1090198116633455.
2. Iwelunmor J, Blackstone S, Veira D, Nwaozuru U, Airhihenbuwa C, Munodawafa D, Kalipeni E, Jutal A, Shelley D, Ogedegbe G. Toward the sustainability of health interventions implemented in sub-Saharan Africa: a systematic review and conceptual framework. Implement Sci. 2016 Apr 18; 11(1):53.
3. W Tobe S; Global Alliance for Chronic Diseases Hypertension Research Teams With the World Hypertension League. The Global Alliance for Chronic Diseases Supports 15 Major Studies in Hypertension Prevention and Control in Low- and Middle-Income Countries. J Clin Hypertens (Greenwich). 2016 Jul; 18(7):600-5. doi: 10.1111/jch.12835. Epub 2016 Jun 1.
4. GACD Hypertension Research Programme, Writing Group, Peiris D, Thompson SR, Beratarrechea A, Cárdenas MK, Diez-Canseco F, Goudge J, Gyamfi J, Kamano JH, Irazola V, Johnson C1, Kengne AP, Keat NK, Miranda JJ, Mohan S, Mukasa B, Ng E, Nieuwlaat R, Ogedegbe O, Ovbiagele B, Plange-Rhule J, Praveen D, Salam A, Thorogood M, Thrift AG, Vedanthan R, Waddy SP, Webster J, Webster R, Yeates K, Yusoff K; Hypertension Research Programme members. Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme. Implement Sci. 2015 Nov 9; 10:158. doi: 10.1186/s13012-015-0331-0.
5. Iwelunmor J, Plange-Rhule J, Airhihenbuwa CO, Ezepue C, Ogedegbe O. A Narrative Synthesis of the Health Systems Factors Influencing Optimal Hypertension Control in Sub-Saharan Africa. PLOS ONE. 2015 Jul 15; 10(7):e0130193. doi: 10.1371/journal.pone.0130193.
6. Iwelunmor J, Blackstone S, Gyamfi J, Airhihenbuwa C, Plange-Rhule J, Tayo B, Adanu R, , Ogedegbe G. A concept mapping study of physicians’ perceptions of factors influencing management and control of hypertension in Sub-Saharan Africa. Int J Hypertens. 2015;2015:412804. doi: 10.1155/2015/412804. Epub 2015 Oct 13.
7. Iwelunmor J, Airhihenbuwa CO, Cooper R, Tayo B, Plange-Rhule J, Adanu R, et al. Prevalence, determinants and systems-thinking approaches to optimal hypertension control in West Africa. Global Health. 2014;10:42. doi:10.1186/1744-8603-10-42.
8. Ogedegbe G, Gyamfi J, Plange-Rhule J, Surkis A, Rosenthal DM, Airhihenbuwa C, Iwelunmor J, Cooper R. Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials. BMJ open. 2014; 4(10):e005983. doi: 10.1136/bmjopen-2014-005983.
9. Ogedegbe G, Plange-Rhule J, Gyamfi J, Chaplin W, Ntim M, Apusiga K, Khurshid K, Cooper R. A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol. Implement Sci. 2014; 9:73. doi: 10.1186/1748-5908-9-73.