Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

BACKGROUND: Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS: This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION: SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Retention of patient-held medical records for chronic diseases in Mozambique.

INTRODUCTION: Non-Communicable Diseases (NCD) are becoming a public health problem in Mozambique and wider sub-Saharan Africa, and are driving changes to guaranty lifelong follow up of patients within the health systems. Patient-Held Medical Records (PHMR) are an option for this follow-up in under-resourced health systems. We designed a study to assess the rate of retention and quality of conservation of the PHMR. METHODS: we conducted a prospective observational study from November 2016 to October 2018 in a peri-urban hospital from in Mozambique. Consecutive newly diagnosed patients with cardiovascular disease were given PHMR. Data was collected after their first consultation and one year after. The retention and quality of conservation were assessed after 12 months. RESULTS: overall 134 PHMR were given to patients (24;17.9% children and 77;57.5% female), of which 121 (90.3%) retained at 12 months (90.9% in good conservation state). Most patients had on average four visits to health facilities during the study, all registered in the PHMR. Retention could not be confirmed in 13 patients who did not return the PHMR. CONCLUSION: PHMR retention rates were high in an urban low-income setting in Africa, with high quality of conservation, thus supporting its use to replace hospital paper-based medical files. Specific research is recommended on acceptability, quality of information registered and patient´s perception.

Differential patterns of disease and injury in Mozambique: New perspectives from a pragmatic, multicenter, surveillance study of 7809 emergency presentations.

BACKGROUND: There is a paucity of primary data to understand the overall pattern of disease and injuries as well as related health-service utilization in resource-poor countries in Africa. OBJECTIVE: To generate reliable and robust data describing the pattern of emergency presentations attributable to communicable disease (CD), non-communicable disease (NCD) and injuries in three different regions of Mozambique. METHODS: We undertook a pragmatic, prospective, multicentre surveillance study of individuals (all ages) presenting to the emergency departments of three hospitals in Southern (Maputo), Central (Beira) and Northern (Nampula) Mozambique. During 24-hour surveillance in the seasonally distinct months of April and October 2016/2017, we recorded data on 7,809 participants randomly selected from 39,124 emergency presentations to the three participating hospitals. Applying a pragmatic surveillance protocol, data were prospectively collected on the demography, clinical history, medical profile and treatment of study participants. FINDINGS: A total of 4,021 males and 3,788 (48.5%) females comprising 630 infants (8.1%), 2,070 children (26.5%), 1,009 adolescents (12.9%) and, 4,100 adults (52.5%) were studied. CD was the most common presentation (3,914 cases/50.1%) followed by NCD (1,963/25.1%) and injuries (1,932/24.7%). On an adjusted basis, CD was more prevalent in younger individuals (17.9±17.7 versus 26.6±19.2 years;p<0.001), females (51.7% versus 48.7%-OR 1.137, 95%CI 1.036-1.247;p = 0.007), the capital city of Maputo (59.6%) versus the more remote cities of Beira (42.8%-OR 0.532, 95%CI 0.476-0.594) and Nampula (45.8%-OR 0.538, 95%CI 0.480-0.603) and, during April (51.1% versus 49.3% for October-OR 1.142, 95%CI 1.041-1.253;p = 0.005). Conversely, NCD was progressively more prevalent in older individuals, females and in the regional city of Beira, whilst injuries were more prevalent in males (particularly adolescent/young men) and the northern city of Nampula. On a 24-hour basis, presentation patterns were unique to each hospital. INTERPRETATION: Applying highly pragmatic surveillance methods suited to the low-resource setting of Mozambique, these unique data provide critical insights into the differential pattern of CD, NCD and injury. Consequently, they highlight specific health priorities across different regions and seasons in Southern Africa.