This proposal is between the Kwame Nkrumah University of Science and Technology, Kintampo Health Research Center in Ghana and NYU School of Medicine. Physician shortage is a major barrier to hypertension (HTN) control in Ghana, with ONLY one physician to 10,000 patients in 2015, thus limiting its capacity for HTN control at the primary care level such as the Community Health Planning and Services (CHPS) compounds, where most Ghanaians receive care. Task shifting of primary care duties from physicians to non-physician health workers is a cost-effective strategy for mitigating this problem. In a cluster RCT in 32 health centers in Ghana, we showed that a Task-Shifting Strategy for HTN Control (TASSH) based on the WHO Cardiovascular (CV) Risk Package, delivered by community health nurses (CHNs), led to 34% greater reduction in systolic BP than health insurance coverage among 757 patients. TASSH comprised: 1) CV risk assessment; 2) patient counseling on lifestyle modification, and 3) initiation of antihypertensive medications. Despite its effectiveness, implementation of TASSH across CHPS compounds remains untested because of lack of resources in Ghana. A well-proven strategy to overcome this barrier is practice facilitation (PF) via provision of external expertise on practice redesign, and a tailored approach to implementing guideline-concordant care. CHPS compounds are unique settings to implement TASSH because in CHPS Community Health Officers (CHOs) deliver primary care services. Guided by Consolidated Framework for Implementation Research and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework, we will evaluate, in a hybrid clinical effectiveness-implementation design, the role of PF on the uptake of TASSH in 70 CHPS compounds. The proposed PF strategy will include a) an advisory board that will provide leadership support for implementing TASSH; and b) trained Practice Outreach Facilitators (CHNs) who will serve as practice coaches and provide support, knowledge exchange and performance feedback to the CHOs who will deliver TASSH at the CHPS compounds.
The specific aims are to: (1) Identify practice capacity for the adoption of TASSH at CHPS compounds and develop a culturally tailored PF strategy using qualitative methods; (2a) Evaluate in a stepped- wedge cluster RCT, the effect of PF vs. Usual Care (UC), on the uptake of TASSH (primary outcome) across the CHPS compounds at 12 months;(2b) Compare in a stepped-wedge cluster RCT, the clinical effectiveness of PF vs. UC on systolic BP reduction (secondary outcome) among adults with uncontrolled HTN at 12 months; (3) Evaluate the mediators (implementation climate, leadership support, organizational capacity and provider- level characteristics) of the uptake of TASSH across the CHPS compounds at 12 months; and (4) Evaluate the sustainability of TASSH implementation across the CHPS compounds at 24 months (one year after completion of the trial). Outcomes will be measured at 12 and 24 months in all clusters.
STATEMENT Uptake of community-based evidence-supported interventions for hypertension control in Ghana are urgently needed to address the CVD epidemic and its associated morbidity, mortality, and societal costs. Using a mixed methods (quantitative-qualitative) design, we will evaluate practice facilitation (PF) in 70 CHPS compounds utilizing the task-shifting strategies for hypertension control (TASSH) program. The goal of this project is to improve the uptake of evidence-based TASSH in CHPS compounds in Ghana. We will employ a cluster randomized step-wedge design and the CFIR and RE-AIM frameworks to understand systems, organizational, and provider level factors, which may influence TASSH adoption and sustainability. Findings from this study will provide policy makers and other stakeholders the ?how to do it? empirical literature on the uptake of evidence-based interventions in Ghana, which may be applicable to other low-income countries.
