| Hypertension: Adults ≥18 years with systolic blood pressure ≥140/90 mmHg and/or currently on hypertension medication. | Diabetes: Adults ≥18 years with a random blood glucose ≥200 mg/dl and/or currently on diabetes medication or insulin. |
Management approaches:
| Management approaches:
|
| Clinical care |
| Clinical training of clinical officers in diagnosis and case management. A French-language curriculum based on Primary Care International, WHO, and Ministry of Health guidelines were developed. The Ministry of Health and IRC clinical advisors delivered the training over a week. Theoretical topics included the physiology of diabetes and hypertension and practical topics included diagnosis, fundoscopy, clinical and home-based management, complications including diabetic foot, gestational diabetes, cardiovascular risk assessment, cardiac emergencies, and management among displaced populations. |
| Drugs, consumables, and equipment supply. Hypertensive and oral diabetes medications, insulin, and equipment (sphygmomanometers, glucometers, glucose strips, weighing scales) and laboratory supplies (blood glucose, urine protein/ketone strips) were provided. |
| Referral costs to secondary care. Given that primary care facilities are not expected to manage complications of hypertension and diabetes (e.g., diabetic foot), referral costs to the district hospital were covered by the IRC. |
| Health facility assessment. Using the WHO Package of Essential Noncommunicable Disease Interventions health facility assessment tool, a baseline assessment of readiness for NCD management was undertaken [23]. |
| Adherence and monitoring of care |
| Training and monitoring tools for CHWs. CHWs were trained to provide community education sessions to describe available NCD services, symptoms and complications, danger signs, and dietary advice for patients. They were also trained to provide monthly household visits to known patients to monitor availability of medications, adherence to medications and clinic visits, and provide referrals if necessary. |
| Cohort monitoring system. Condensed essential NCD reporting to monitor programmatic outcomes of continuous care was implemented using a data entry and visualization program (EpiInfo7, CDC, Atlanta, GA, USA) on the research nurse’s laptop to perform cohort monitoring. Information was extracted from the patient register to the program on blood pressure (BP, mmHg), random blood sugar (RBS, mg/dL) for diabetics, patient outcome (remaining in care, died of and cause, transferred out, no monthly attendance, lost to follow up/defaulted after 90 days) and complications (defined as blindness, end-stage renal failure, myocardial infarction, congestive heart failure, stroke and/or above-ankle amputation) on a monthly basis. A dashboard self-populated with these program metrics. On a monthly basis, a report was produced for each health facility detailing the proportion of patients continuing care or absent, and under disease control. This report was discussed during a monthly meeting in each health facility. |
| This was paired with patient-held cards which were provided to the patient information on their diagnoses, medications, and date of next visit. |
Figure 1
Counts and predicted means of hypertension and diabetes consultations, Aug 2017 to May 2019.
Table 1
Characteristics of patients at registration (up to October 2018), N = 833.
| CHARA CTERISTICS | ALL (N, %) | HYPERTENSION (N, %) | DIABETES (N, %) | BOTH CONDITIONS (N, %) |
|---|---|---|---|---|
| Cases (%, of all conditions) | 833 (100) | 739 (88.7) | 59 (7.1) | 35 (4.2) |
| Age*, median, IQR | 56 (44–66) | 56 (44–66) | 55 (41–65) | 60 (50–64) |
| Age group* | ||||
| <20 | 14 (1.7) | 13 (1.8) | 1 (1.7) | 0 |
| 20–39 | 117 (14.2) | 104 (14) | 12 (20.3) | 1 (2.9) |
| 40–59 | 328 (39.9) | 290 (39.2) | 22 (37.3) | 16 (45.7) |
| 60 and above | 374 (44.2) | 321 (43.4) | 24 (40.7) | 18 (51.4) |
| Sex (female) | 556 (66.8) | 505 (68.3) | 27 (45.8) | 24 (68.6) |
| Displaced | 364 (43.7) | 342 (46.3) | 11 (18.6) | 11 (31.4) |
| Body mass index (BMI), median, IQR | 22.6 (20.8–24.1) | 22.6 (20.8–24.1) | 22.2 (21–23.4) | 22.6 (21.3–26.8) |
| Body mass index (BMI) | ||||
| Underweight | 42 (5) | 32 (4.3) | 7 (11.9) | 3 (8.6) |
| Normal | 657 (78.9) | 590 (79.8) | 44 (74.6) | 23 (65.7) |
| Overweight | 118 (14.2) | 103 (13.9) | 7 (11.9) | 8 (22.9) |
| Obese | 16 (1.9) | 14 (1.9) | 1(1.7) | 1 (2.9) |
| Newly-diagnosed | 798 (95.9) | 719 (97.3) | 48 (82.8) | 31 (88.6) |
| Systolic blood pressure* (SBP, mmHg), mean, SD | 160, 25 | 161.1, 22.4 | 131.8, 53.3 | 159.9, 30.2 |
| Random blood sugar* (RBS, mg/dl), mean, SD | – | – | 290.5, 121.7 | – |
[i] * Missing 11 ages, 36 SBP measures, 38 RBS measures (diabetes or both conditions).
Table 2
Attendance if registered by September 2018 (n = 788) and early outcomes if attended in September or October 2018 (n = 254).
| OUTCOME | HYPERTENSION n/N (%) | DIABETES n/N (%) | BOTH CONDITIONS n/N (%) |
|---|---|---|---|
| Attended at least two visits1 (n = 373/788 or 47.3%) | 324/713 (45.4) | 26/47 (55.3) | 23/28 (82.1) |
| Remained in care2 (n = 254/833 or 30.5%) | 220/649 (33.9) | 20/40 (50) | 14/25 (56) |
| Outcome at last visit (remained in care only, N = 254) | |||
| N = 220 | N = 20 | N = 14 | |
| SBP* (mmHg) (mean, SD) | 133, 12.7 | – | 136.8, 18.9 |
| SBP* <140 mmHg | 157 (71.4) | – | 8 (57.1) |
| RBS* (mg/dL) (mean, SD) | – | 219.4, 79.6 | 187.1, 63.2 |
| RBS* ≤200 mg/dL | – | 12 (60) | 7 (50) |
| Complications3 | 11 (5) | 1 (5) | 1 (7) |
| Died | 1 (<1) | 1 (5) | – |
[i] 1 Patients eligible for at least two visits during the time period (registered by September 2018); 2 Patients attended the September or October visit (registered by August 2018); 3 Complications included diabetic foot, gestational diabetes, cardiovascular risk assessment, cardiac emergencies; SBP, systolic blood pressure; RBS, random blood sugar; SD, standard deviation. * Missing 16 SBP values, 5 RBS values.
| PANEL 1: CHALLENGES TO NCD CARE (BASELINE). |
|
| PANEL 2: IMPROVEMENTS TO NCD CARE (ENDLINE). |
|
| PANEL 3: ENDURING CHALLENGES (ENDLINE). |
CHW, community health worker; HCW, health care worker. |