Uptake of Task shifting strategy for blood pressure control in Community health planning services: A mixed method study

项目摘要/摘要 这项提议是由Kintampo Health的夸梅·恩克鲁马科技大学 加纳研究中心和纽约大学医学院。医生短缺是高血压的主要障碍 加纳(HTN)控制，2015年只有一名医生到10,000名患者，从而限制了其治疗HTN的能力 初级保健一级的控制，如社区卫生规划和服务(CHPS)化合物； 大多数加纳人都在那里接受护理。将初级保健职责从医生转移到非医生的任务 卫生工作者是缓解这一问题的一种具有成本效益的战略。在32个卫生中心的群集式随机对照试验中 加纳，我们展示了一种基于世卫组织心血管疾病控制的任务转移战略(TASSH) (CV)由社区卫生护士(CHN)提供的风险包导致收缩压下降34% BP超过了757名患者的医疗保险覆盖面。TASSH包括：1)心血管风险评估；2)患者 关于改变生活方式的咨询，以及3)开始抗高血压药物。尽管它很有效， 由于加纳缺乏资源，TASSH在CHPS大院中的实施情况仍未经过测试。 克服这一障碍的一个行之有效的战略是通过提供外部专业知识来促进实践(PF) 实践重新设计，以及实施符合指南的护理的量身定做的方法。CHPS化合物是 实施TASSH的独特设置，因为在CHPS中，社区卫生官员(CHO)提供初级 护理服务。在实施研究和REACH有效性综合框架的指导下 采用实施和维护(RE-AIM)框架，我们将在混合临床中进行评估 有效性-实施设计，PF在70种CHPS化合物中对TASSH吸收的作用。这个 拟议的爱国阵线战略将包括a)一个顾问委员会，它将为执行 TASSH；以及b)训练有素的实践外展促进员(CHN)，他们将担任实践教练并提供 向将在CHPS提供TASSH的CHO提供支持、知识交流和绩效反馈 化合物。具体目标是：(1)确定在CHPS采用TASSH的实践能力 使用定性方法，制定文化上量身定做的PF战略；(2a)分步骤地评估 楔形簇RCT，PF与常规护理(UC)对TASSH(主要结果)摄取的影响 12个月时的CHPS化合物；(2b)比较梯形楔形簇RCT的临床疗效 在12个月时，PF与UC在成人失控HTN患者中的收缩压降低(次要结果)； (3)评价调解人(执行环境、领导支持、组织能力和提供者-- 水平特征)在12个月时TASSH在CHPS化合物中的吸收；以及(4)评估 在CHPS化合物中实施TASSH的可持续性在24个月(完成后一年) 审判的结果)。所有组的结果将在12个月和24个月时进行衡量。

PROJECT SUMMARY / ABSTRACT 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.