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Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic

The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to...

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Autores principales: Stephens, Joseph H., Alizadeh, Faraz, Bamwine, John Bosco, Baganizi, Michael, Chaw, Gloria Fung, Yao Cohen, Morgen, Patel, Amit, Schaefle, K. J., Mangat, Jasdeep Singh, Mukiza, Joel, Paccione, Gerald A.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274420/
https://www.ncbi.nlm.nih.gov/pubmed/32502169
http://dx.doi.org/10.1371/journal.pone.0234049
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author Stephens, Joseph H.
Alizadeh, Faraz
Bamwine, John Bosco
Baganizi, Michael
Chaw, Gloria Fung
Yao Cohen, Morgen
Patel, Amit
Schaefle, K. J.
Mangat, Jasdeep Singh
Mukiza, Joel
Paccione, Gerald A.
author_facet Stephens, Joseph H.
Alizadeh, Faraz
Bamwine, John Bosco
Baganizi, Michael
Chaw, Gloria Fung
Yao Cohen, Morgen
Patel, Amit
Schaefle, K. J.
Mangat, Jasdeep Singh
Mukiza, Joel
Paccione, Gerald A.
author_sort Stephens, Joseph H.
collection PubMed
description The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of “stockouts” and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.
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spelling pubmed-72744202020-06-09 Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic Stephens, Joseph H. Alizadeh, Faraz Bamwine, John Bosco Baganizi, Michael Chaw, Gloria Fung Yao Cohen, Morgen Patel, Amit Schaefle, K. J. Mangat, Jasdeep Singh Mukiza, Joel Paccione, Gerald A. PLoS One Research Article The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of “stockouts” and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities. Public Library of Science 2020-06-05 /pmc/articles/PMC7274420/ /pubmed/32502169 http://dx.doi.org/10.1371/journal.pone.0234049 Text en © 2020 Stephens et al http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Research Article
Stephens, Joseph H.
Alizadeh, Faraz
Bamwine, John Bosco
Baganizi, Michael
Chaw, Gloria Fung
Yao Cohen, Morgen
Patel, Amit
Schaefle, K. J.
Mangat, Jasdeep Singh
Mukiza, Joel
Paccione, Gerald A.
Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic
title Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic
title_full Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic
title_fullStr Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic
title_full_unstemmed Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic
title_short Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic
title_sort managing hypertension in rural uganda: realities and strategies 10 years of experience at a district hospital chronic disease clinic
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274420/
https://www.ncbi.nlm.nih.gov/pubmed/32502169
http://dx.doi.org/10.1371/journal.pone.0234049
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