|Year : 2022 | Volume
| Issue : 3 | Page : 68-75
Noncommunicable disease program for blood pressure ontrol in Tamil Nadu, India: Bridging care gaps among patients with hypertension in public health facilities
Kamaraj Pattabhi1, Jerard Selvam2, Azhagendran Sivalingam1, Piyalee Pal1, Savitha Kasivishwanathan1, Suresh Arunachalam1, TS Selvavinayagam2, Prabhdeep Kaur1
1 Department of Noncommunicable Diseases, National Institute of Epidemiology (Indian Council of Medical Research), # R-127, 3rd Avenue, Tamil Nadu Housing Board, Chennai, Tamil Nadu, India
2 State NCD Cell, Government of Tamil Nadu, Tamil Nadu, India
|Date of Submission||09-Jan-2022|
|Date of Decision||27-Feb-2022|
|Date of Acceptance||05-Mar-2022|
|Date of Web Publication||14-Sep-2022|
Dr. Prabhdeep Kaur
Department of Noncommunicable Diseases, National Institute of Epidemiology (Indian Council of Medical Research), # R-127, 3rd Avenue, Tamil Nadu Housing Board, Chennai - 600 077, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Despite advances in hypertension care, developing countries have a high burden of uncontrolled blood pressure (BP). The Government of Tamil Nadu, India, initiated a noncommunicable disease program to improve hypertension management in public facilities. Method: We conducted cross-sectional surveys at baseline and follow-up to evaluate BP control after a multipronged intervention among patients with hypertension visiting public health facilities in Tamil Nadu. The intervention included protocol-based hypertension treatment, lifestyle counseling and monitoring by trained nurses, alongside monthly free drug refills. Descriptive statistics and adjusted odds ratio (AOR) for BP control were analyzed. Results: We surveyed 923 patients at baseline and 941 at follow-up. Most patients were over 60 years of age, with female predominance. Proportion of patients dispensed drugs for 30 days increased at follow-up (84.5%) compared to baseline (11.4%) (P < 0.01). Proportion of patients with BP control was 32.4% at baseline and 40.5% at follow-up (P < 0.001). AOR for BP control at follow-up was 1.4 (95% confidence interval 1.1–1.7, P < 0.05) after adjusting for age, sex, type of facility, and the number of drugs. Conclusion: Focussing on accessibility, availability, and affordability, the program facilitated the provision of free drugs and counseling, resulting in optimal BP control. Encouraging physician adherence to protocols and task sharing with nurses can help streamline sustainable hypertension management.
Keywords: Blood pressure control, hypertension, public care facility, Tamil Nadu, task sharing
|How to cite this article:|
Pattabhi K, Selvam J, Sivalingam A, Pal P, Kasivishwanathan S, Arunachalam S, Selvavinayagam T S, Kaur P. Noncommunicable disease program for blood pressure ontrol in Tamil Nadu, India: Bridging care gaps among patients with hypertension in public health facilities. J Public Health Prim Care 2022;3:68-75
|How to cite this URL:|
Pattabhi K, Selvam J, Sivalingam A, Pal P, Kasivishwanathan S, Arunachalam S, Selvavinayagam T S, Kaur P. Noncommunicable disease program for blood pressure ontrol in Tamil Nadu, India: Bridging care gaps among patients with hypertension in public health facilities. J Public Health Prim Care [serial online] 2022 [cited 2022 Oct 1];3:68-75. Available from: http://www.jphpc.org/text.asp?2022/3/3/68/354820
| Introduction|| |
High blood pressure (BP) is the leading cause for global mortality, accounting for 10·8 million deaths in 2019. With a substantial burden in high-, middle-, low-income countries alike, hypertension is the predominant risk factor for cardiovascular diseases (CVD) such as stroke and ischemic heart disease (population-attributable fraction 22.3%);, In low- and middle-income (LMIC) countries such as India, the burden of hypertension (prevalence: 30.7%, 95% confidence interval [CI]: 30.5, 30.9) is further compounded by poor awareness, gaps in treatment, and suboptimal control rates;, a nationally representative survey in India estimated hypertension prevalence of 41.9%, with 54.4%, 50.8%, and 28.8% being aware, treated, and controlled, respectively. Regional estimates reveal a high burden of hypertension in South India, the prevalence being 31.5% and 26.2% in urban and rural Tamil Nadu, respectively.
A 20 mmHg reduction in systolic BP or ten mmHg in diastolic BP is associated with a two-fold decline in death rates due to stroke and ischemic heart diseases. However, a multitude of patient-related barriers such as poor awareness of risk factors, disbelief about treatment consequences and side effects, lead to nonadherence. Provider challenges such as lack of resources, high workload, and disagreement with guidelines widen the gulf for adequate BP management. In addition, health system issues such as fragmented governance and service delivery, low awareness among policymakers, and limited health budget for affordable drugs, act as major challenges. Despite the burden of traditional cardiovascular risk factors, the incidence of CVD events is lowest in high-income countries, suggesting better access to treatment and a stronger health system. The prospective urban rural epidemiological study showed that control of hypertension was substantially lower in LMICs, with disparities in use of proven medications, 69% of patients in LMIC received no medical treatment, compared with 45% in upper-middle-income countries. Only 25% rural and 38% of urban Indians are being treated for hypertension. Longitudinal Aging Study in India (LASI) determined that the highest absolute losses care for hypertensive individuals occurred at the awareness and treatment stage, highlighting an urgent need for interventions focussing on awareness and treatment. LMICs often lack access to more than one BP-lowering medicine and are often not affordable. A wide array of strategies and care models such as stringent BP monitoring and standardized algorithms are being evaluated for hypertension control;,, lack of drug availability and affordability are crucial concerns for elevated BP in India. Hence, it is imperative to assess their real-world implications across the management pathway.
To create a highly accessible, equitable, and effective health system, the Tamil Nadu Health Systems Project (TNHSP) was implemented in partnership with the World Bank, with support from the Government of Health and Family Welfare in Tamil Nadu. The program implemented a clinic-based noncommunicable disease intervention program across primary and secondary care public sector health facilities over 32 districts in 2012. We present the evaluation of the clinic-based hypertension component of the TNHSP program, evaluating the pre- and postintervention BP control, availability of treatment, counseling services, and compliance to drugs and lifestyle modification.
| Methods|| |
Study design and population
Pre- (2011) and post- (2014–15) intervention cross-sectional surveys were conducted in public primary health centers (PHCs) and secondary care hospitals (SCH) in Tamil Nadu. Villupuram, a northern district (population: 3.4 million, PHCs: 44 and SCH: 11) and Theni, a southern district (population: 1.2 million, PHCs: 33 and SCH: Seven) were selected ensuring geographical representation;, We included patients with hypertension above 30 years of age on treatment for at least 1 month.
Sample size and sampling strategy
Primary health centres
Assuming BP control 20% at baseline and 30% at follow-up, the one-tailed significance of 5%, power 80%, design effect 1.5 for cluster sampling (PHC as a cluster) and nonresponse rate of 10%, the calculated sample size was 360 at baseline and 360 at follow-up. We used simple random sampling to select 30 PHCs (among 77 PHCs in the districts) and selected 12 hypertension patients consecutively from each PHC during an exit interview [Figure 1].
|Figure 1: Flowchart illustrating patient recruitment in the pre and postintervention surveys, Tamil Nadu|
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Secondary care hospitals
We expected a higher nonresponse in SCH in urban areas and used a higher design effect, considering variation in treatment practices due to doctors' rotation and overcrowding. Assuming 10% difference (20% vs. 30%) with a one-tailed significance of 5% (expected increase), power of 80%, design effect of 2 for cluster sampling (SCH as a cluster) and nonresponse as 15%, calculated sample size was 540 at baseline and 540 at follow-up. We included all 18 SCH and selected 30 hypertension patients consecutively from each SCH [Figure 1].
Description of the intervention
Under the flagship of the Government of Tamil Nadu, the program incorporated a five-pronged clinic-based intervention strategy including: (1) infrastructure strengthening through the establishment of Noncommunicable Diseases (NCD) clinic in existing health facilities (2) development of the standard protocol for opportunistic screening, diagnosis, and treatment of hypertension by an expert group, (3) focussed involvement of nurses (appointment of one staff nurse in PHCs and two in SCH), (4) lifestyle counseling regarding healthy diet and physical exercises, (5) prescription of drugs for 30 days free of cost at every health-care level, through an uninterrupted supply of drugs by a state-level agency, Tamil Nadu Medical Services Corporation. In addition, protocol-based training of project medical officers and staff nurses was conducted for competency building. The nurses were responsible for measuring BP, completing the documentation, and providing counseling, whereas the doctors prescribed 30-day drugs as per protocols.
Primary health center
The first contact point between medical officer and community in rural areas, catering to 30,000 people in plains and 20,000 in hilly areas. PHCs function as a referral unit for approximately six subcenters, refereeing complicated cases to SCH.
Secondary care hospitals
Referral centers that provide specialist services, including subdistrict, subdivisional, and district hospitals.,
Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg or history of the previously diagnosed disease, or prior treatment with antihypertensive medications.
Blood pressure control
Systolic BP <140 mmHg and diastolic BP <90 mmHg.
Pre- and post-intervention data on socio-demographic characteristics, access to health facilities, availability of drugs and counseling, compliance for drugs, and lifestyle modification were collected using a pretested structured interviewer-administered questionnaire. BP was measured using a digital monitor (Omron) based on a standard protocol.
Data were entered and analyzed in Epi Info™ version 7. We compared pre- and post-intervention patient characteristics, prescription of drugs, and counseling using Chi-square test. BP control at baseline and follow-up was stratified by age, sex, type of facility, and drugs. We computed adjusted odds ratio (AOR) with a 95% CI for change in BP control at baseline and follow-up.
Human subject protection
The institutional ethics committee of the Indian Council of Medical Research-National Institute of Epidemiology, Chennai, approved the study. We obtained written informed consent from the study participants and ensured privacy during the data collection.
| Results|| |
Socio-demographic characteristics during the pre- and postintervention surveys
We surveyed 923 (360 at PHC and 563 at SCH) participants at baseline and 941 (371 at PHC and 570 at SCH) at follow-up. More than half of the patients were aged above 60 years, with a female predominance. Overall, the distribution of patients for age, gender, and occupation was comparable at baseline and follow-up. Type 2 diabetes was the most common comorbidity, reported by one-third of participants in both surveys. The proportion of participants with at least one comorbidity such as heart attack, stroke, diabetes, kidney disease, and asthma, was 39.1% at baseline and 42.1% at follow-up [Table 1]. During baseline survey, 334 (36.2%) patients reported undergoing treatment from private sector compared to 134 (14.2%) at follow-up (P < 0.001).
|Table 1: Characteristics of the study participants during pre and post intervention surveys in the public sector health facilities in two districts, Tamil Nadu, India|
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Elements of intervention for hypertension treatment
In terms of accessibility, the proportion of patients reporting a higher time to reach the health facility (median time >20 min) was 38.2% at baseline and 57.7% in resurvey. Waiting time of 30–60 min was reported by 50.6% of patients at baseline and 63.9% at follow-up. Proportion of participants prescribed two or more drugs were similar at baseline (322 [34.9%]) and follow-up (309 [32.8%]). However, the proportion of patients dispensed drugs for 28 days and more, remarkably increased at follow-up 795 (84.5%), compared to baseline 105 (11.4%) (P < 0.01). Majority of participants (79.0%) reported being counseled by an NCD nurse or doctor for salt reduction at follow-up, however, only 49.4% reported the same for physical activity. The self-reported compliance (in the previous 30 days) for drugs was similar at baseline and follow-up. Though the compliance for physical activity didn't change, self-reported compliance for salt reduction was higher at follow-up 785 (83.4%) than baseline 674 (73%) (P < 0.01) [Table 2].
|Table 2: Hypertension treatment services provided in the public sector facilities and compliance to treatment among people with hypertension during the pre and post-intervention surveys, Tamil Nadu, India|
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Blood pressure control during pre- and postintervention
Proportion of participants with BP control was 32.4% at baseline compared to 40.5% at follow-up, (P < 0.001). A similar increase was demonstrated during follow-up across the different age categories and genders, particularly a statistically significant increase in BP control was reported in the age group of 60–74 and among the females [Table 3]. Proportion of patients with BP control during follow-up increased in both primary and secondary tiers of healthcare (PHCs baseline: 33.6%, follow-up: 45.3%, P = 0.002 and SCH baseline: 31.6%, follow-up: 37.4%, P < 0.048).
|Table 3: Proportion of people with hypertension who had blood pressure control during the pre- and post- intervention surveys stratified by age, sex, drugs prescribed, and type of facility, Tamil Nadu, India|
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Step-wise regression analysis for BP control post-intervention survey as compared to pre-intervention survey revealed an AOR of 1.4 (95% CI 1.1–1.7; P < 0.05), after adjusting for age, sex, type of facility, and number of drugs [Table 4]. Thus, the post-intervention survey demonstrated higher odds for BP control compared to pre-intervention survey.
|Table 4: Adjusted odds ratio for blood pressure control during post-intervention survey (n=941) as compared to pre-intervention survey (n=923) in the public sector health facilities in two districts, Tamil Nadu, India|
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| Discussion|| |
This report presents the effectiveness of a clinic-based hypertension intervention strategy, part of a state-wide program pioneered by the Government of Tamil Nadu across public sector health facilities. The comprehensive intervention strengthened the health system, particularly at the primary care level, through a dedicated cader of nurses, protocol-based treatment, and reliable drug supply through monthly refills at no cost. This led to a significant improvement in BP control at follow-up across all the health facilities, irrespective of age, sex, or type of facility. Using patient-centric approaches for overcoming barriers, the Tamil Nadu program highlighted that political commitment and investments in the public sector health system can reduce reliance on the private sector, thus paving the way for better patient outcomes.
The program demonstrated the feasibility of rendering patient-centric treatment and achievement of BP control in PHCs of low resource settings, based on the robust foundation of primary care infrastructure and high investment in the health sector in Tamil Nadu. A study from rural South Asia showed that counseling, care coordination in the public sector, and regular monitoring by home visits, led to a reduction in BP at 24 months. The India Hypertension Control Initiative demonstrated that simplified treatment protocol, uninterrupted availability of drug refills at no cost, alongside counseling and monitoring systems, can enhance BP control in patients (proportion with BP control: 26.3% at registration and 59.8% at follow-up, P < 0.001). Going forward, digital technology and mHealth apps can be leveraged for improving hypertension self-assessment, treatment, and control in LMICs.
The program appointed dedicated staff nurses in the health facilities to enable screening, BP monitoring, counseling, and documentation. A study in Chennai showed that 28% of diagnosed individuals reported not taking daily treatment due to knowledge gaps. WHO suggests that pharmacological treatment of hypertension can be provided by nonphysician professionals such as nurses with proper training, prescribing authority, specific management protocols, and physician oversight. Task-sharing of interventions between health-care workers is an effective approach for reducing BP; the mean difference in systolic BP was-5·34 mm Hg, while diastolic BP was −3.18 for task-sharing with nurses. The dedicated nurses in our program can be critical in enhancing patient knowledge and supporting primary care physicians to render guideline-based treatment — thus maintaining the continuum of care for hypertension, especially in PHCs with the heavy workload of patients. Although nurses were not authorized to prescribe or modify drugs due to legal constraints in our setting, the presence of a reliable dedicated nurse improved patient experience and built trust in the public sector. We documented increased waiting time, possibly due to higher patient load after the intervention. As the nurses were not allowed to prescribe or escalate the drugs using algorithms, patients had to wait to consult the doctor and subsequently collect the prescription during every visit. Qualified nonphysician health workers (NPHWs) embedded within the community; ongoing training and supervision; authorizing NPHWs to render autonomous care; equipping NPHWs with reliable systems to track patient data; supporting NPHWs with medications, and compensating NPHWs adequately, can be key for improving NCD care. Based on this premise, the program managers could consider escalation of the dose or addition of drugs by nurses, thus encouraging patient-friendly care while reducing the doctors' burden. The dedicated nurses were provisionally appointed in an ad hoc mode; however, sustaining them through government funding can be pivotal for scaling the program in the long term.
The predominant roadblocks in the continuum of hypertension care at PHCs stem from patient-level issues such as inadequate access, poor awareness, low treatment adherence, and high out-of-pocket expenditure, alongside health system issues such as time constraints, inadequate counseling, lack of trained staff, gaps in drug procurement, distribution, and frequent stockouts.,,,,,, LASI showed a statistically significant effect of access to a public health center on hypertension treatment, underlining the need for accessible interventions and the importance of free medication in achieving BP control, especially for those with low economic status. The World Heart Federation proposed a roadmap for reducing cardiovascular mortality through: governmental and societal willingness to make hypertension control a priority, low-cost medications; patient awareness; lifestyle modifications; and education of health-care providers and patients regarding treatment adherence. Provision of free medication and consistent counseling in our program can be potential solutions to enhance access and adherence at the primary care level which forms the nucleus of care for CVD. The provision of uninterrupted supply of free drugs was the cornerstone of the TNHSP hypertension program. Adequate availability of drugs enabled dispensing medications for 30 days during follow-up, one of the program's critical achievements. The project implemented a treatment protocol agreed upon by state experts and program managers and allocated funds to procure drugs. The reliable supply of drugs was materialized by the Tamil Nadu Medical Services Corporation, a state-owned organization with a robust system for procurement and distribution per the rate contracts. Given the scale and volume of procurement, drugs were purchased at a low cost, for instance, the approximate cost for 100 tablets of amlodipine was six INR (0.08 USD), while that of enalapril was sixteen INR (0.22 USD), which translates into less than five USD per patient per year. LMICs have poor access to more than one BP-lowering medicine and when available, are often not affordable. The proportion of households unable to afford two BP-lowering medicines was 31% in low-income, 9% in middle-income, and <1% in high-income countries, emphasizing the need for access to affordable medicines. HOPE 4 trial demonstrated that free medications recommended by NPHWs (but supervised by physicians) using digital algorithms, counseling programs, and familial support for improving adherence to medications, led to change in BP control (69% in the intervention group versus 30% in the control group, P < 0·0001). Our program focuses on improving adherence to antihypertensive medications through patient counseling, and medication regimen management by eliminating out-of-pocket costs. Given the scarcity of physicians, especially in rural regions, our program can support primary care providers to fulfill three-fold objective of individualized counseling for lifestyle improvement and treatment adherence, while ensuring accessible and affordable quality medicines across the disease continuum, thus optimizing BP control in low resource settings.
We observed a higher proportion of patients with BP control at follow-up than baseline. However, control can be further enhanced by the identification of patient and provider-related barriers impeding standardized management. Although the patients reported a remarkable increase in compliance with drugs and salt reduction at follow-up, the proportion of patients with BP control remained relatively low. Soliciting support from family/friends for ensuring adherence to drugs and lifestyle modification can be crucial in this regard. Therapeutic inertia among doctors, including improper dose intensification or timely addition of combination drugs, may have led to gaps in BP control. Provider assumptions and beliefs on time required to attain full effect after starting a new drug, satisfaction with improvement of BP, or with BP nearing the goal, are a few reasons for therapeutic inertia. Hence, it is imperative to sensitize doctors for timely drug escalation through regular training and feedback.
This state-wide initiative was one of the largest programs for hypertension control across public sector facilities, ensuring accessibility and affordability of care in Tamil Nadu. We conducted the pre- and post-intervention cross-sectional surveys among consecutive patients receiving treatment at the health centers due to lack of documentation or line list for patients at baseline. Ideally, comparisons of patient cohorts pre- and post-intervention might have provided more accurate data on BP control. Drug compliance and salt reduction were self-reported and therefore outcomes related to lifestyle modifications might have been overestimated.
| Summary and Conclusion|| |
The Government of Tamil Nadu implemented an evidence-based successful hypertension intervention program in public sector health facilities. The program demonstrated a successful, scalable approach by strengthening the pillars of the health system through dedicated staff nurses, and the provision of standard treatment protocols. The program highlighted that improving accessibility to care and regular provision of free drugs can encourage patients to adopt healthy lifestyles and overcome nonadherence, leading to better BP control. However, it is pivotal to account for unique challenges in resource-constrained settings such as therapeutic inertia and increased patient load. We recommend scaling the hypertension interventions focussing on dedicated human resources, free drugs procured at low cost, capacity building of care providers, and task shifting to expand the role of paramedical staff for efficient service delivery. In addition, sustained public sector investment is necessary to ensure continuity of care and improved BP control in the long run.
Financial support and sponsorship
The program is a World Bank supported project implemented by Department of Health and Family Welfare of Tamil Nadu Government. The program was evaluated by the National Institute of Epidemiology, Chennai, Tamil Nadu.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]