Perceptions of inhibitors and facilitators for adhering to hypertension treatment among insured patients in rural Nigeria: a qualitative study.

BACKGROUND: Universal health care coverage has been identified as a promising strategy for improving hypertension treatment and control rates in sub Saharan Africa (SSA). Yet, even when quality care is accessible, poor adherence can compromise treatment outcomes. To provide information for adherence support interventions, this study explored what low income patients who received hypertension care in the context of a community based health insurance program in Nigeria perceive as inhibitors and facilitators for adhering to pharmacotherapy and healthy behaviors. METHODS: We conducted a qualitative interview study with 40 insured hypertensive patients who had received hypertension care for > 1 year in a rural primary care hospital in Kwara state, Nigeria. Supported by MAXQDA software, interview transcripts were inductively coded. Codes were then grouped into concepts and thematic categories, leading to matrices for inhibitors and facilitators of treatment adherence. RESULTS: Important patient-identified facilitators of medication adherence included: affordability of care (through health insurance); trust in orthodox "western" medicines; trust in Doctor; dreaded dangers of hypertension; and use of prayer to support efficacy of pills. Inhibitors of medication adherence included: inconvenient clinic operating hours; long waiting times; under-dispensing of prescriptions; side-effects of pills; faith motivated changes of medication regimen; herbal supplementation/substitution of pills; and ignorance that regular use is needed. Local practices and norms were identified as important inhibitors to the uptake of healthier behaviors (e.g. use of salt for food preservation; negative cultural images associated with decreased body size and physical activity). Important factors facilitating such behaviors were the awareness that salt substitutes and products for composing healthier meals were cheaply available at local markets and that exercise could be integrated in people's daily activities (e.g. farming, yam pounding, and household chores). CONCLUSIONS: With a better understanding of patient perceived inhibitors and facilitators of adherence to hypertension treatment, this study provides information for patient education and health system level interventions that can be designed to improve compliance. TRIAL REGISTRATION: ISRCTN47894401 .

Cardiovascular disease prevention in rural Nigeria in the context of a community based health insurance scheme: QUality Improvement Cardiovascular care Kwara-I (QUICK-I).

BACKGROUND: Cardiovascular diseases (CVD) are a leading contributor to the burden of disease in low- and middle-income countries. Guidelines for CVD prevention care in low resource settings have been developed but little information is available on strategies to implement this care. A community health insurance program might be used to improve patients' access to care. The operational research project "QUality Improvement Cardiovascular care Kwara - I (QUICK-I)" aims to assess the feasibility of CVD prevention care in rural Nigeria, according to international guidelines, in the context of a community based health insurance scheme. DESIGN: prospective observational hospital based cohort study. SETTING: a primary health care centre in rural Nigeria. STUDY POPULATION: 300 patients at risk for development of CVD (patients with hypertension, diabetes, renal disease or established CVD) who are enrolled in the Hygeia Community Health Plan. MEASUREMENTS: demographic and socio- economic data, physical and laboratory examination, CVD risk profile including screening for target organ damage. MEASUREMENTS will be done at 3 month intervals during 1 year. Direct and indirect costs of CVD prevention care will be estimated. OUTCOMES: 1) The adjusted cardiovascular quality of care indicator scores based on the "United Kingdom National Health Services Quality and Outcome Framework". 2) The average costs of CVD prevention and treatment per patient per year for patients, the clinic and the insurance company. 3) The estimated net health care costs of standard CVD prevention care per quality-adjusted life year gained. ANALYSIS: The primary outcomes, the score on CVD quality indicators and cost data will be descriptive. The quality scores and cost data will be used to describe the feasibility of CVD prevention care according to international guidelines. A cost-effectiveness analysis will be done using a Markov model. DISCUSSION: Results of QUICK-I can be used by policy makers and professionals who aim to implement CVD prevention programs in settings with limited resources. The context of the insurance program will provide insight in the opportunities community health insurance may offer to attain sustainable chronic disease management programs in low resource settings. TRIAL REGISTRATION: This protocol has been registered at ISRCTN, ID number: ISRCTN47894401.

Development and evaluation of a patient centered cardiovascular health education program for insured patients in rural Nigeria (QUICK - II).

BACKGROUND: In Sub Saharan Africa, the incidence of hypertension and other modifiable cardiovascular risk factors is growing rapidly. Poor adherence to prescribed prevention and treatment regimens by patients can compromise treatment outcomes. Patient-centered cardiovascular health education is likely to improve shortcomings in adherence. This paper describes a study that aims to develop a cardiovascular health education program for patients participating in a subsidized insurance plan in Nigeria and to evaluate the applicability and effectiveness in patients at increased risk for cardiovascular disease. DESIGN: The study has two parts. Part 1 will develop a cardiovascular health education program, using qualitative interviews with stakeholders. Part 2 will evaluate the effectiveness of the program in patients, using a prospective (pre-post) observational design. SETTING: A rural primary health center in Kwara State, Nigeria. POPULATION: For part 1: 40 patients, 10 healthcare professionals, and 5 insurance managers. For part 2: 150 patients with uncontrolled hypertension or other cardiovascular risk factors after one year of treatment. INTERVENTION: Part 2: patient-centered cardiovascular health education program. MEASUREMENTS: Part 1: Semi-structured interviews to identify stakeholder perspectives. Part 2: Pre- and post-intervention assessments including patients' demographic and socioeconomic data, blood pressure, body mass index and self-reporting measures on medication adherence and perception of care. Feasibility of the intervention will be measured using process data. OUTCOMES: For program development (part 1): overview of healthcare professionals' perceptions on barriers and facilitators to care, protocol for patient education, and protocol implementation plan.For program evaluation (part 2): changes in patients' scores on adherence to medication and life style changes, blood pressure, and other physiological and self-reporting measures at six months past baseline. ANALYSIS: Part 1: content analytic technique utilizing MAXQDA software. Part 2: univariate and multilevel analysis to assess outcomes of intervention. DISCUSSION: Diligent implementation of patient-centered education should enhance adherence to cardiovascular disease prevention and management programs in low income countries. TRIAL REGISTRATION: ISRCTN47894401.

Sustained effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: A population-based study.

BACKGROUND: Hypertension is a leading risk factor for death in sub-Saharan Africa. Quality treatment is often not available nor affordable. We assessed the effect of a voluntary health insurance program, including quality improvement of healthcare facilities, on blood pressure (BP) in hypertensive adults in rural Nigeria. METHODS: We compared changes in outcomes from baseline (2009) to midline (2011) and endline (2013) between non-pregnant hypertensive adults in the insurance program area (PA) and a control area (CA), through household surveys. The primary outcome was the difference between the PA and CA in change in BP, using difference-in-differences analysis. RESULTS: Of 1500 eligible households, 1450 (96.7%) participated, including 559 (20.8%) hypertensive individuals, of which 332 (59.4%) had follow-up data. Insurance coverage increased from 0% at baseline to 41.8% at endline in the PA and remained under 1% in the CA. The PA showed a 4.97 mm Hg (95% CI: -0.76 to +10.71 mm Hg) greater decrease in systolic BP and a 1.81 mm Hg (-1.06 to +4.68 mm Hg) greater decrease in diastolic BP from baseline to endline compared to the CA. Respondents with stage 2 hypertension showed an 11.43 mm Hg (95% CI: 1.62 to 21.23 mm Hg) greater reduction in systolic BP and 3.15 mm Hg (-1.22 to +7.53 mm Hg) greater reduction in diastolic BP in the PA compared to the CA. Attrition did not affect the results. CONCLUSION: Access to improved quality healthcare through an insurance program in rural Nigeria was associated with a significant longer-term reduction in systolic BP in subjects with moderate or severe hypertension.

Costs and Cost-Effectiveness of Hypertension Screening and Treatment in Adults with Hypertension in Rural Nigeria in the Context of a Health Insurance Program.

BACKGROUND: High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria. METHODS: A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario. RESULTS: Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment. CONCLUSIONS: Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.

Costs of cardiovascular disease prevention care and scenarios for cost saving: a micro-costing study from rural Nigeria.

OBJECTIVE: To assess the costs of cardiovascular disease (CVD) prevention care according to international guidelines, in a primary healthcare clinic in rural Nigeria, participating in a health insurance programme. METHODS: A micro-costing study was conducted from a healthcare provider perspective. Activities per patient per year (e.g., consultations, diagnostic tests) were based on clinical practice in the study clinic. Direct (e.g., staff, drugs) and indirect cost items (overheads) for each activity were measured. A cohort study, patient and staff observations, and interviews in the study clinic provided patient resource utilization data. Univariate sensitivity analyses were performed. Scenario analyses evaluated cost-saving options. The main outcome was the costs of CVD prevention care per patient per year. RESULTS: The costs of CVD prevention care were United States dollars (USD) 144 (range 130-158) per patient per year. Direct costs were USD 82 and indirect costs were USD 62. The main cost drivers were drugs (USD 39) and diagnostic tests (USD 36). The costs of hypertension care were USD 118 (107-132) and that of diabetes care USD 263 (236-289) per patient per year. A combination of task-shifting from doctors to nurses, reduction of appointment frequencies, and minimal organ damage screening would result in a direct cost reduction of 42%. CONCLUSION: This is the first study to report the costs of CVD prevention care in sub-Saharan Africa, based on prospectively collected operational data. The costs observed in our study are unaffordable in many countries in sub-Saharan Africa, highlighting the need for innovative financing mechanisms to fund CVD prevention care.

Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria.

BACKGROUND: While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria. METHODS AND FINDINGS: We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program's scale up within the State's healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9-152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program's scale up by the State is dependent on further investments in healthcare. CONCLUSIONS: This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care.

Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria: an operational cohort study.

OBJECTIVE: To assess the feasibility of providing guideline-based cardiovascular disease (CVD) prevention care within the context of a community-based health insurance program (CBHI) in rural Nigeria. METHODS: A prospective operational cohort study was conducted in a primary healthcare clinic in rural Nigeria, participating in a CBHI program. The insurance program provided access to care and improved the quality of the clinics participating in the program, including CVD prevention guideline implementation. Insured adults at risk of CVD were consecutively included upon clinic attendance. The primary outcome was quality of care determined by scoring of quality indicators on patient files of the cohort, 1.5 year after guideline implementation. RESULTS: Of the 368 screened patients, 349 were included and 323 (93%) completed 1 year of follow-up. The majority of patients (331, 95%) had hypertension. Process indicators showed that 114/115 (99%) new hypertension cases had a record of CVD risk assessment and 249/333 (75%) eligible cases a record of lifestyle advice. Outcome indicators showed that in 292/328 (64%) hypertension cases, blood pressure was on target. Barriers to care included limited human resources, limited affordability of diagnostic tests and multidrug regimes for the healthcare provider, frequent doctor's appointments, and inefficient drug supplies. CONCLUSION: Implementation of CVD prevention care within the context of a CBHI program resulted in high-quality care in rural sub-Saharan Africa, comparable to high-income countries. However, guideline implementation was resource-intense and specific recommendations were not feasible. Simple models of care delivery are needed for rapid scale-up of CVD prevention services in sub-Saharan Africa.