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

项目总结/摘要 这项建议是由Kwame Nkrumah科技大学，Kintampo健康 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 (HTN)2015年，加纳的HTN控制只有一名医生对10，000名患者，因此限制了其HTN的能力 在初级保健一级进行控制，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治疗初级保健职责从医生到非医生的任务转移 卫生工作者是缓解这一问题的一项具有成本效益的战略。在32个健康中心的一项随机对照试验中， 加纳，我们表明，基于WHO心血管疾病控制策略的HTN控制任务转移策略（TASSH） (CV)由社区卫生护士（CHN）提供的风险包导致收缩压降低34% 英国石油公司比健康保险覆盖757名患者。TASSH包括：1）CV风险评估; 2）患者 生活方式改变的咨询，和3）开始抗高血压药物治疗。尽管它很有效， 由于加纳缺乏资源，在卫生和公众服务部大院实施TASH尚未得到检验。 克服这一障碍的一个行之有效的战略是通过提供以下方面的外部专门知识来促进实践 实践重新设计，并采取量身定制的方法来实施指南一致的护理。CHPS化合物是 实施TASSH的独特设置，因为在CHPS社区卫生官员（CHO）中， 护理服务。以实施研究的统一框架和有效性为指导 采用实施和维护（RE-AIM）框架，我们将在混合临床 有效性实施设计，PF对70种CHPS化合物中TASSH摄取的作用。的 拟议的方案基金战略将包括：a）一个咨询委员会，将为实施 TASSH;以及B）经过培训的实践推广促进者（CHN），他们将担任实践教练， 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CHPS采用TASSH的实践能力 （2a）采用定性方法，逐步评估- 楔形簇RCT，PF与泌尿系护理（UC）对TASSH摄取的影响（主要结局）， CHPS化合物在12个月时;（2b）在阶梯楔形簇RCT中比较CHPS化合物的临床有效性， 在12个月时，PF与UC对不受控制的HTN成人的收缩压降低（次要结局）的影响; (3)评估调解人（执行气候、领导支持、组织能力和提供者） 水平特征）;以及（4）评估12个月时CHPS化合物对TASSH的吸收 在24个月内（完成后一年），在CHPS大院内实施TASSH的可持续性 审判）。将在12个月和24个月时测量所有群组的结局。

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.