Evaluation of a community-based hypertension improvement program (ComHIP) in Ghana: data from a baseline survey

Ghana’s national NCD Control Programme (NCDCP), under the Disease Control Prevention Department, was established in 1992. The Ghana Health Service (GHS) has developed various guidelines for NCDs and prioritized hypertension. The guidelines recommend that all patients with hypertension be referred for further assessment.

The capacity of the GHS workforce to diagnose and manage hypertension is low. For instance, while training on NCD management is incorporated in the basic nurse education curricula, there is no follow-up in-service training or specialist training on NCD management for nurses. Nurses are currently also not expected to manage hypertension and have to learn on-the-job while assisting specialists.

In partnership with the GHS and the Ghana Police Service, FHI 360 developed a facility- and community-based prevention and screening pilot program for cardiovascular diseases (CVD) in 2009. The program included two sites – the Police Hospital, an urban tertiary hospital located in Ghana’s capital city, Accra, and its surrounding community, and Atua Hospital, a district hospital serving a semi-urban community. A population-based Assessment of Biological and Behavioral NCD risk factors within the pilot communities and a Baseline Health Facility Assessment were completed. CVD screening started in mid-August 2011 and included 14,000 patients by May 2012. Counseling and education on healthy eating and lifestyle were provided alongside screening, which was supported through mHealth lifestyle messages, appointment reminders, and treatment adherence support. Baseline findings of this pilot indicate that hypertension was an important health problem in the areas with prevalence of 31.9% among females and 34.1% among males [18].

The current paper presents baseline data from a 2-year hypertension control project, the Community-based Hypertension Improvement Project (ComHIP), which has been introduced in the peri-urban Lower Maya-Krobo district in the Eastern Region of Ghana. ComHIP is a community-based program for hypertension control, based on a public-private partnership, and consisting of three parts: implementation, impact evaluation and a cost-effectiveness evaluation. The private sector is engaged through licensed chemical sellers (LCSs), who are community pharmacists. The program utilizes ICTs and task shifting to enhance the capacity of the Ghana Health Service to improve management and control of hypertension. The various components of ComHIP are presented in Fig. 1.

ComHIP is also a public-private partnership between the Ghana Health services, FHI360 and the Novartis Foundation, supported by the Ghana School of Public Health and the London School of Hygiene & Tropical Medicine. While the overaching goal of ComHIP is to address the huge burden of hypertension through the deployment of a community-based model that engages the private sector public sector, and utilizes information and communication technologies (ICTs). Such a partnership plus the deployment of innovative technology increases the odds of the project’s success. The current baseline study presents hypertension prevalence, awareness, treatment, as well as knowledge and the risk factors associated with hypertension in two Ghanaian health districts.

To evaluate the project, a quasi-experimental study consisting of two parts (cross-sectional surveys, and a cohort study) were employed. The cross-sectional surveys constitute a before and after evaluation at baseline and endline in the intervention and control districts. The cohort study is currently being implemented in the intervention district.

Blood pressure was measured a minimum of three times by survey interviewers, using as fully automated, digital devices, the OMRON digital sphygmomanometer. Interviewers were trained to use the device according to the manufacturer’s recommended protocol, using recommended methods and categories from standard guidelines the World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension [21].

The anthropometric measurements of weight, height, mid-upper arm circumference, waist and hip circumference were measured according to standard procedures [22].

We interviewed 1200 respondents each from the comparison and intervention districts. However, after cleaning, 1170 and 1167 surveys respectively from the comparison district and the intervention district had complete data for analysis. Demographic data are presented in Table 2. Other than ethnicity, baseline characteristics were similar between districts. Participants were overwhelmingly Christian (96.0%), had a mean age of 49 years; 66.0% being between 30 and 54 years. Only 10.0% had never been married, and 25.0% had no formal education.

Tables 2 3, and 4 present knowledge and prevalence of risk factors for hypertension, prevalence of selected behavioral and biological risk factors of hypertension, as well as other variables. Only 5.7% of the participants from the comparison district, and 8.6% in the intervention district knew three or more of the eight known risk factors. The proportion of people who were aware of one risk factor was 19% in the comparison district, and 16% in the intervention district, while 63% in the comparison and 58% in the intervention district unfortunately knew none of the risk factors (Table 3). Participants’ knowledge of alcohol consumption, lack of exercise, and insufficient fruit and vegetables as risk factors for hypertension are presented in Table 3. Participants from both intervention and comparison districts demonstrated similarly low knowledge of the behavioural risk factors for hypertension.

In Table 2, prevalence of behavioral and biological risk factors for hypertension are summarized. The majority of the participants was identified as non- alcohol users (88.7% in the intervention district and 90.1% in the control district). BMI was normal in 45.2% of the participants in the intervention district and 46.3% in the comparison district, while 7.3% of the respondents from both sites was underweight and 19.0% obese.

Figures 3, 4 and 5 represent the different factors associated with hypertension. Bivariate/unadjusted regression estimates are presented together with measures adjusted for age, gender and district. Age was a predictor of having hypertension; similarly, the odds of being hypertensive tended to increase with increasing BMI and waist- and hip circumference. Those with a family history of hypertension or NCD and participants who smoked also had higher odds of being hypertensive. The multiple logistic regression model examined predictors of hypertension after adjusting for a number of covariates. When adjusted for age, risk factors with the greatest association with hypertension were being overweight (aOR = 2.30; 95% CI 1.53–3.46) or obese (aOR = 3.61; 95% CI 2.37–5.51), although significant associations were also observed with increased waist/hip ratio (aOR = 1.43; 95% CI 1.30–157), MUAC (aOR = 1.47; 95%CI 1.34–1.62), high waist circumference (aOR = 1.47; 95% CI 1.34–1.61), and having some sort of sleep disturbance (aOR = 1.51; 95% CI 1.21–1.87) (Fig. 3).

Figure 4 presents factors associated with hypertension awareness, adjusted for age. In unadjusted models, older individuals were more likely to be aware of their hypertension status than younger people. When adjusted for age, sex, and district people with a family history of hypertension (aOR = 2.98; 95% CI 1.20–7.40), or CVD (aOR = 1.71; 95% CI 1.17–2.52), or with a high waist hip ratio (aOR = 1.94; 95% CI 1.44–2.63), were more likely to be aware of their hypertension status. Figure 5 compares the primary outcome of hypertension awareness, adjusted by age. There were no significant differences for the primary outcome hypertension awareness by study site.

Overall the findings in our two study sites were very similar. Descriptive analysis suggested that individuals in the intervention district may have had more exposure to educational information about heart health, and an overall greater awareness of risk factors. This may be because of FHI 360 s previous efforts in the area as in 2009 a facility- and community-based CVD prevention and screening project was implemented in the district hospital aiming to strengthen the capacity of facilities to manage CVD. The project also implemented facility and community-based primary and secondary prevention activities, and engaged policy makers in the prevention of CVD and NCDs in general. mHealth technology provided patients with information on healthy lifestyles and adherence to NCD treatment [18].

The largest demographic difference between the comparison and intervention sites was ethnic group, with the majority in the comparison district defining themselves as Akan, and of the majority in the intervention group as Krobo/Ga/Dangbe. Although belonging to two distinct ethnic groups, both are located within the same ecological zone and do not differ significantly in their health seeking behaviour or practices [23, 24].

In line with the Ghana National Strategy for the Management, Prevention and Control of Chronic Non-Communicable Diseases 2012–2016, this study focused on adults aged 30 years or more. The PURE study included a comparable age group between 35 and 70 years [15] coming from both high and low-and middle income countries. Other previous studies [10‐12] all involved Ghanaian men and women aged between 25 and 102 years. The 2014 Ghana Demographic and Health Survey (DHS) was a representative survey looking at hypertension [13]: although the survey is focusing on 15–49 year olds, the age band 30–49 years permits comparisons with our study. Our prevalence findings of 20.1/19.6% males/females with hypertension is similar to that found in the DHS of 23.5/20.1% males/females. The estimated hypertension prevalence in our baseline survey is comparable with that of previous local and international studies. The PURE study [15] reported an overall prevalence of 40.8% (40.7% for HICs, 49.7% for UMICs, 39.9% for LMICs, and 32.2% for LICs), while hypertension prevalence from local studies involving men and women in similar age groups were comparable with our findings (Table 3). Our prevalence estimates are substantially higher than the most recent DHS (2014) survey and lower than those found by Lloyd-Sherlock [17]. This is, however, not surprising given that the DHS survey included individuals for 15–49 and the Lloyd-Sherlock [17] only included adults over 50. Our data compare with those of a 2009 facility- and community-based CVD prevention and screening project implemented in the intervention district: about one-in-five (22%) of those screened were pre-hypertensive (systolic 120–139, diastolic 80–89) and 33% were hypertensive (systolic ≥140, diastolic ≥90) [18]). Our estimated prevalence of hypertension is consistent with reported prevalence in other parts of Africa [8, 25], such as in the neighboring cities of Abidjan in 2005 and Cotonou in 2007, the prevalence was 21.7% and 27.3% respectively [26]. Higher prevalence was however reported in semi-urban Nigeria (37%) [25], Burkina Faso (40%) [27] and Niger (42%) [26].

We estimated that only between 42.6 and 50% of the people with hypertension were aware of their condition, while PURE reported an overall awareness of 46.5% (49.0% for HICs, 52.5% for UMICs, 43.6% for LMICs, and 40.8% for LICs). The level of awareness in our study was higher than in most previous studies in Ghana (Table 5), but disparity in age, as well as setting peculiarity may explain the differences.

Compared to PURE, the overall self-reported treatment and control rates in our study were only 31 of 757 hypertensive individuals (14 from the comparison district, and 17 from the intervention district). Among the treated hypertension patients, the control rate was 9% overall, with 14.3% in the control arm and 47.1% in the intervention. In the Ghana DHS only 11.5% of hypertensives under treatment were reported to have their hypertension under control [13].

Supportive of previous studies [10‐12, 28], our study showed that age, BMI, and biological factors were positively associated with both hypertension status and awareness of the condition. Older individuals, females, people with a family history of CVD and with unhealthy hip/waist ratios were more likely to be aware of their hypertension status. Age, increasing BMI and waist hip circumference were predictors of having hypertension.

This was a community-based study with a sample size of over 2000 individuals, one of the largest studies of its kind in the region. This study is part of a larger, mixed-methods evaluation of community based hypertension control project, and will be followed up with a second similar sized cross sectional survey. However, as with any survey there are some potential limitations of the data collected. Due to safety issues data collectors were only able to visit households during daylight hours, and as a result some adults were at work when they visited the house. To minimize this, collectors would come back to houses on multiple occasions. This issue seems however to be similar in both the comparison and intervention districts.

The results of this baseline survey have implications for the intervention being implemented and for future research. The high burden of hypertension among the studied population, coupled to the relatively high level of awareness yet very low levels of hypertension treatment and control requires in-depth investigation of the bottlenecks to treatment and control. Secondly, the low treatment and control rates despite current and previous general educational programs in the intervention district, are suggestive that such programs are not really impactful health service delivery strategies. The RODAM study reported hypertension prevalence among rural Ghanaian women/men to be 32.1% 25.5% respectively, and higher among urbanized populations (37.9% 38.2% respectively) [29]. The progressive rise of hypertension as Ghanaians become more urbanized in Berlin, London and Amsterdam, even in the presence of more sophisticated health care, show that Ghanaians continue to be at risk of uncontrolled hypertension. It may therefore be argued that attitude/behaviour is as important as access, if not more so.

These are important findings for the ongoing intervention. The lack of in-depth knowledge of hypertension risk factors and the high burden of biological risk factors of hypertension, particularly obesity, will be notable challenges for the intervention to have its desired impact.

The project’s next steps include an in-depth mapping of individuals with hypertension by census enumeration areas. The key findings of the survey have been shared with the program Technical and Steering Committees, to optimize targeting of interventions. The implementation of the program is currently being carried out. The endline survey will be conducted in 2017, to evaluate the change in hypertension prevalence, awareness, treatment and control between the two districts. Using individual patient data, we will apply logistic regressions for each of these outcomes including the district and survey period baseline / endline variables and look at their interaction; we will also adjust for age. Given that the observed awareness at baseline in either group was about 46%, a sample size of 1150 individuals in each group in the end line survey will provide about a 85% power to detect a difference of 10% between groups. It will also provide a more than 90% power to detect a difference of 7% in treatment coverage in people aware of hypertension (versus a baseline of about 9%), and a 87% power to detect a difference of 10% in the proportion of patients under treatment who have their BP under control (versus a baseline of about 32%).