Optimizing Linkage and Retention to Hypertension Care in Rural Kenya

描述(由申请者提供)：优化肯尼亚农村高血压护理的联系和保留。心血管疾病是撒哈拉以南非洲30岁以上成年人的主要死亡原因。高血压是心血管疾病的一个主要风险因素，在撒哈拉以南非洲，高血压的患病率随着时间的推移正在增加，给该地区造成了重大的流行病学和经济负担。如果不对高血压进行适当的控制，它的健康和经济负担将在未来几十年急剧增加。已有完善的循证干预措施来管理高血压；然而，治疗率和控制率都很低。高血压管理的一个关键组成部分是促进受影响的个人持续获得有效的临床服务。与肯尼亚政府合作，美国国际开发署-提供获得医疗保健伙伴关系的学术模式(AMPATH)正在扩大其在肯尼亚西部农村地区的临床工作范围，将高血压和其他慢性病包括在内。然而，将高血压患者与临床护理计划联系起来并留住他们一直是一件困难的事情。因此，这项申请的总体目标是利用多学科实施研究方法来解决将高血压患者与高血压管理计划联系起来并留住他们的挑战。具体地说，我们建议测试一种假设，即配备了定制的行为沟通策略和基于智能手机的工具链接到电子健康记录的社区卫生工作者(CHWS)可以增加高血压患者与高血压护理计划的联系和保持，从而显著降低这些患者的血压。我们进一步假设，这些干预措施将是具有成本效益的。目标1是利用创新和新颖的定性研究技术，确定将高血压患者与高血压护理服务计划联系起来并留住他们的促进者和障碍。我们将利用从这项调查中获得的信息来设计一种量身定制的行为沟通策略和一种基于智能手机的工具，供CHW使用，以优化高血压患者的联系和保留。目的2是评估配备这些干预措施的CHW在改善高血压患者之间的联系和降低血压方面的有效性，方法是进行一项三臂整群随机试验，比较：1)常规护理(CHW接受招募个人的标准培训)；2)额外定制的行为沟通策略；3)配备定制行为沟通策略的CHW，他们也配备了连接电子健康记录的智能手机。目的3是评估集群随机试验中每个干预分支的增量成本效益，包括单位降压成本和每次降低心血管风险的成本。这项研究将由一个具有不同和互补专业知识的多学科调查小组完成。我们的目标是增加关于可扩展和可持续的战略的现有知识，以优化低收入和中等收入国家的高血压和其他慢性病的控制。 相关性：优化与肯尼亚农村高血压护理的联系和保持。高血压是导致死亡的主要全球风险因素，在接下来的十年里，全球因次优血压而付出的代价估计接近1万亿美元。因此，该项目旨在解决低收入和中等收入国家的一个特别关键的健康和发展问题。这项工作的成果将增加在低收入和中等收入国家以及美国和其他高收入国家资源匮乏的情况下有效管理高血压和相关慢性病的可扩展和可持续战略的新兴知识体系。

DESCRIPTION (provided by applicant): Optimizing Linkage and Retention to Hypertension Care in Rural Kenya. Cardiovascular disease (CVD) is the leading cause of death in sub-Saharan Africa among adults above age 30. The prevalence of hypertension, a major risk factor for CVD, is increasing over time in sub-Saharan Africa, exerting a significant epidemiologic and economic burden on the region. Without adequate control of hypertension, its health and economic burden will increase drastically in the decades ahead. Well established and evidence-based interventions to manage hypertension exist; however, treatment and control rates are low. A critical component of hypertension management is to facilitate sustained access of affected individuals to effective clinical services. In partnership with the Government of Kenya, the United States Agency for International Development-Academic Model Providing Access to Healthcare Partnership (AMPATH) is expanding its clinical scope of work in rural western Kenya to include hypertension and other chronic diseases. However, linking and retaining individuals with elevated blood pressure to the clinical care program has been difficult. Thus, the overall objective of this application is to utilize a multi-disciplinary implementation research approach t address the challenge of linking and retaining hypertensive individuals to a hypertension management program. Specifically, we propose to test the hypothesis that community health workers (CHWs), equipped with a tailored behavioral communication strategy and a smartphone-based tool linked to an electronic health record, can increase linkage and retention of hypertensive individuals to a hypertension care program and thereby significantly reduce blood pressure among these patients. We further hypothesize that these interventions will be cost-effective. Aim 1 is to identify facilitators and barriers to linking and retaining individualswith high blood pressure to a hypertension care delivery program, using innovative and novel qualitative research techniques. We will use the information derived from this investigation to design a tailored behavioral communication strategy and a smartphone-based tool to be used by CHWs to optimize linkage and retention of hypertensive patients. Aim 2 is to evaluate the effectiveness of CHWs equipped with these interventions in improving linkage and reducing blood pressure among hypertensive patients, by conducting a three-arm cluster randomized trial comparing: 1) usual care (CHWs with standard training on recruitment of individuals); 2) CHWs with an additional tailored behavioral communication strategy; and 3) CHWs with a tailored behavioral communication strategy who are also equipped with smartphones linked to the electronic health record. Aim 3 is to evaluate the incremental cost-effectiveness of each intervention arm of the cluster randomized trial, presented both in terms of costs per unit decrease in blood pressure and costs per reductions in CVD risk. The research will be accomplished by a multidisciplinary team of investigators with diverse and complementary expertise. We aim to add to existing knowledge on scalable and sustainable strategies for optimizing control of hypertension and other chronic diseases in low- and middle-income countries. RELEVANCE: Optimizing Linkage and Retention to Hypertension Care in Rural Kenya. Hypertension is the leading global risk factor for mortality and the global cost of suboptimal blood pressure is estimated to be nearly $1 trillion over the next decade. This project therefore aims to address a singularly critical health and development issue for low- and middle-income countries. The results of this work will add to the emerging body of knowledge on scalable and sustainable strategies for effectively managing hypertension and related chronic diseases in low- and middle-income countries, as well as resource-poor settings in the USA and other high-income countries.