Hypertension control is a global problem, despite us knowing what should be done, we have very poor hypertension control across the world, the worst still in Africa. So the lesson learned from the STRENGTHS study will be applicable in many other places.
Hypertension is a major risk factor for cardiovascular disease, the leading cause of death globally, and poorly controlled in lower-middle-income countries. This project aims to improve hypertension treatment and control by strengthening referral networks to ensure equitable access to hypertension care across the care continuum.
The results of this work will enrich the growing body of knowledge on innovative, scalable, and sustainable strategies for effectively reducing cardiovascular risk in hypertension and other non-communicable diseases among vulnerable populations in low-resource settings.
- To conduct baseline needs and contextual assessment, consisting of process mapping, referral network analysis, and qualitative methods.
- To evaluate the effectiveness of Health Information Technology (HIT) and peer support for hypertension control.
- To evaluate the incremental cost-effectiveness of the intervention, in terms of costs per unit decrease in SBP, per percent change in CVD risk score, and per disability-adjusted life year (DALY) saved.
We have completed protocol development and are currently conducting a context and baseline needs assessment for the intervention. So far, we completed piloting of the need assessment tools and data collection from focus group discussions with patients, providers, mabaraza (community gatherings), and key informant interviews. We also completed observational process mapping and gap assessment; baseline referral network analysis.
Transcription and analysis of the data are ongoing. The research team has just completed training on the human-centered design process and are assembling a design team which will develop the HIT and peer navigator interventions to be contextually and culturally appropriate for hypertension referral networks strengthening.
There are six levels in the Kenyan health system which can be functionally grouped into traditional health system levels: primary secondary and tertiary.
STRENGTHS is conducted within the AMPATH catchment area across six geographically separate referral networks, each centered around a secondary-level health facility staffed by medical officers (general practitioners) and clinical officers (mid-level providers): Kitale , Webuye, Kocholya, Turbo, Mosoriot, and Burnt Forest.
The six networks traverse 5 different counties in western Kenya and refer patients for specialist services to the Moi Teaching and Referral Hospital (MTRH) which is a level 6 facility that hosts the AMPATH research offices.
STRENGTHS project aims to utilize the PRECEDE-PROCEED framework to conduct transdisciplinary, translational implementation research focused on strengthening referral networks for hypertension control. We will conduct a baseline needs and contextual assessment for implementing and integrating HIT and peer support to strengthen referral networks for hypertension control, using a mixed-methods approach, including observational process mapping and gap assessment; baseline referral network analysis; and qualitative methods to identify facilitators, barriers, contextual factors, and readiness for change. This aligns with phases 1-4 of the PRECEDE-PROCEED framework.
We will use data from the baseline needs and contextual assessment to develop a contextually appropriate intervention to strengthen referral networks for hypertension control using a participatory, iterative design process. Conduct pilot acceptability and feasibility testing of the intervention, which aligns with phase 5 of the framework.
After which we will, evaluate the effectiveness of HIT and peer support for hypertension control by conducting a two-arm cluster randomized trial comparing: 1) usual care vs. 2) referral networks strengthened with the intervention. The primary outcome will be a one-year change in systolic blood pressure (SBP) and a key secondary outcome will be CVD risk reduction.
In addition to this, we will conduct mediation analysis to evaluate the influence of changes in referral network characteristics on intervention outcomes, and a moderation analysis to evaluate the influence of baseline referral network characteristics on the effectiveness of the intervention. A process evaluation will also be conducted using the Saunders framework, evaluating key implementation measures related to fidelity, dose delivered, dose received, recruitment, reach, and context.
Finally, we will evaluate the incremental cost-effectiveness of the intervention, in terms of costs per unit decrease in SBP, per percent change in CVD risk score, and per disability-adjusted life year (DALY) saved.
We have planned to build momentum on dissemination throughout our entire project life cycle. Dissemination will include publishing in peer-reviewed journal articles, poster presentations, videos, and conferences.
Feedback meetings with stakeholders including the community members through mabarazas, AMPATH research fraternity, the county health management teams, and the national NCD office will be done periodically throughout the grant implementation period to exchange knowledge, troubleshoot on arising challenges and raise awareness of our work.
We are pleased to partner with the following organisations:
Moi Teaching and Referral Hospital
Moi University School of Medicine
New York University School of Medicine
Indiana University School of Medicine
Duke University School of Medicine, Duke Clinical Research Institute and Duke Global Health Institute
Duke-NUS Medical School
The University of Texas at Austin Dell Medical School
Purdue University College of Pharmacy
Keck School of Medicine University of Southern California