Implementation of a Combination Intervention for Sustainable Blood Pressure Control in Rural KwaZulu-Natal, South Africa (IMPACT-BP)

摘要 失控的高血压是中风和高血压性心脏病的主要危险因素，这两种疾病 南非非传染性疾病死亡和残疾调整后寿命年全球损失的主要原因。临床试验 在血压适度下降的情况下，发病率和死亡率都有相当大的下降。 然而，关于高血压控制的有效性文献之间存在着很大的知识和实施差距。 以及卫生系统提供高血压护理的有效性。这在资源方面尤其如此- 有限的环境，其中受限的公共卫生基础设施将需要创新的可扩展性和成本- 有效的干预措施。在南非，25%的人口在15岁以上患有高血压，但 只有33%的高血压患者正在接受治疗。在夸祖鲁-纳塔尔农村，我们最近发现，16%的人 18岁的成年人患有高血压，其中只有不到25%的人得到了控制。 该项目的科学目标是提供实施干预措施的最佳做法，以 促进撒哈拉以南非洲农村地区的高血压护理。我们已经开展了混合方法的组建工作，以 确定参与高血压护理的重大结构性障碍。与患者的定性访谈 医护人员还透露，缺乏患者自我效能感、结构性障碍和护理 培训不足是卫生系统的额外障碍。最后，我们回顾了 高血压护理，并让当地利益攸关方提出与农村有关的一揽子干预措施 南非环境，并可能适用于其他中低资源环境。 我们将对两级干预方案进行实施评估：1)和 通过阶梯式楔形群组随机化增强临床水平的干预，以及2)单独 随机入户血压监测系统，促进自我效能。我们将评估 使用实施研究和监管者综合框架实施 执行成果框架，重点是可接受性和忠诚度(目标1)、有效性(目标1) 2)和成本效益和可持续性(目标3)。为此，我们将利用一个多学科团队 专家，以及一项外部资助的高血压筛查和转诊计划，该计划在 2018-2019年的集水区。 这项提议是对PAR-18-007中所述的多个优先事项的回应，包括1)实施 临床环境中的循证实践，2)与现有护理系统的伙伴关系，3)纵向 观察以评估可持续性，以及4)侧重于缩小健康差距。也许最重要的是， 由于我们与卫生署建立了伙伴关系，我们已做好充分准备，以推进实施 科学阐明在资源有限的情况下高血压护理的最佳做法，具有全球影响。 好了！

ABSTRACT Uncontrolled hypertension is the primary risk factor for stroke and hypertensive heart disease, which are the leading causes of NCD deaths in South Africa, and of disability adjusted-life years lost globally. Clinical trials have demonstrated sizeable reductions in morbidity and mortality with modest reductions in blood pressure. Yet, there is a large knowledge-implementation gap between efficacy literature on hypertension control and effectiveness of health systems to provide hypertension care. This is particularly true in resource- limited settings, where the constrained public health infrastructure will require innovative scalable and cost- effective interventions. In South Africa, 25% of the population over 15 years have elevated blood pressure, yet only 33% of those with hypertension are on treatment. In rural KwaZulu-Natal, we recently found that 16% of adults > 18 years old have hypertension, and fewer than 25% of them are controlled. The scientific goals of this project are to inform best practices for implementation of interventions to promote hypertension care in rural sub-Saharan Africa. We have undertaken mixed-methods formative work to identify significant structural barriers to engagement in hypertension care. Qualitative interviews with patients and healthcare professionals also revealed that lack of patient self-efficacy, structural barriers, and nursing training deficiencies were additional health systems barriers. Finally, we reviewed best practices for hypertension care and engaged local stakeholders to propose a package of interventions relevant to the rural South African setting, and potentially applicable to other low-medium resource settings. We will conduct an implementation evaluation of a two-level intervention package: 1) an enhanced clinic-level intervention, through stepped-wedge cluster randomization, and 2) an individually randomized home blood pressure monitoring system to promote self-efficacy. We will evaluate the implementation using the Consolidated Framework for Implementation Research and the Proctor Implementation outcomes framework, with a focus on Acceptability & Fidelity (Aim 1), Effectiveness (Aim 2) and Cost-effectiveness and Sustainability (Aim 3). To do so, we will leverage a multidisciplinary team of experts, and an externally-funded hypertension screening and referral program for 30,000 individuals in the catchment area during 2018-2019. This proposal is responsive to multiple priorities stated in PAR-18-007, including 1) implementation of evidence-based practices within clinical settings, 2) partnership with existing care systems, 3) longitudinal observation to assess sustainability, and 4) focus on reduction of health disparities. Perhaps most importantly, due to our partnership with the Department of Health, we are well-poised to advance the implementation science to elucidate best practices for hypertension care in resource-limited settings, with global implications. !