Global estimates suggest that sub-Saharan Africa (SSA) now has the highest incidence and prevalence of stroke. However, limited system resources, meager patient resources, uncoordinated care, and shortage of clinicians, greatly hamper the capacity of countries in SSA to implement effective measures aimed at controlling key vascular risk factors such as hypertension (HTN) to thwart stroke recurrence in routine clinical practice. In particular, SSA has the highest estimated effect size of HTN for stroke causation worldwide. HTN is often unrecognized, undertreated and uncontrolled in a significant proportion of the adult population in this region due to a clustering of factors including cultural beliefs and misconceptions about hypertension, low self-efficacy, non- adherence to treatment, unavailability of health facilities, health personnel, lack of access to of antihypertensive medications, therapeutic inertia by physicians, and other factors. With the anticipated continued transition from primarily infectious conditions to chronic non-communicable diseases, the burden of stroke in SSA is likely to increase even further over the next several decades. Given all of the aforementioned factors, it is an urgent priority for countries in SSA to develop and test self-management interventions to control hypertension among those at highest risk of adverse outcomes. The overall objective of Phone-based Intervention under Nurse Guidance after Stroke II (PINGS-2) is to deploy a hybrid study design to firstly, demonstrate the efficacy in a randomized controlled trial of a theoretical-model-based, mHealth technology-centered, nurse-led, multi-level integrated approach to substantially improve longer term BP control among 500 recent stroke patients encountered at 10 hospitals in Ghana. Secondly, PINGS II seeks to develop an implementation strategy for routine integration and policy adoption of mhealth for post-stroke BP control in a LMIC setting. We will leverage experience gained from the NIH Global Brain Disorders funded R21 pilot study (NS094033) to test efficacy of a refined, culturally-tailored, and potentially implementable intervention aimed at addressing the premier modifiable risk for stroke & other key variables in an under-resourced system burdened by suboptimal care & outcomes. The primary outcome is blood pressure control at month 12 alongside a host of secondary outcome measures such as medication adherence, self-efficacy, cardiovascular emergency department encounters, quality of life, and mediator outcomes. While it is important to establish the efficacy of a nurse-led, m-health-centered self- management intervention for blood pressure control in LMICs, it equally crucial to simultaneously begin crafting an implementation plan. Hence we will seek to identify context-specific implementation facilitators and barriers, to understand the implementation context, and craft evidence-based implementation strategies for routine use & policy adoption of the PINGS intervention in Ghana through multiple stakeholder engagements.
This research seeks to develop and test the efficacy and implementation of a multi- level, culturally-tailored self-management, nurse-guided intervention comprising of domiciliary self-monitoring of blood pressure, medication reminders and health education information on hypertension, stroke and unhealthy lifestyles delivered via mobile phones for 12 months among recent Ghanaian stroke survivors encountered at 10 hospitals across all the cadres of healthcare. Specifically, this study will test efficacy of a culturally-refined, and potentially scalable intervention aimed at addressing hypertension, the premier modifiable risk for stroke & other key variables in an under- resourced system in Ghana burdened by suboptimal care & outcomes. A secondary objective is to develop an implementation strategy for routine integration and policy adoption of mHealth as a component of a self-management strategy for post-stroke management of hypertension and other cardiovascular risk factors associated with unhealthy lifestyles in resource-limited settings.
