MATTERS OF THE HEART
HEALTHY HEART AFRICA (HHA) PROGRAM INTERVENTION
Author: Anteneh Getachew, Market Research Manager & Kidus Desalegn, Senior Communication and PR Manager, PSI Ethiopia
Cardiovascular disease accounts for the largest share of the global health burden of noncommunicable diseases (NCDs). People in low- and middle-income countries, where more than three-quarters of global NCD deaths — 31.4 million — occur, are disproportionately affected by NCDs. These diseases are often associated with older people, but evidence shows that more than 15 million of all deaths attributable to NCDs occur between the ages of 30 and 69. Of these “premature” deaths, an estimated 85% occur in low- and middle-income countries like Ethiopia.
In Ethiopia, cardiovascular disease accounts for 16% of all annual deaths. The odds of dying prematurely due to an NCD are nearly One in five, and despite high adult blood pressure rates (24%), only 12% of people at high risk of stroke or heart attack receive preventive drug treatment and counseling. According to the 2015 Ethiopian report STEPS, the prevalence of elevated blood pressure in adults 18 years and older is 16%. Prevalence increases with age, from 10.8% in the youngest age group to 24.3% (45–59 years) and 38.8% (60–69 years). Despite these staggering figures, 77% of participants in STEPS had never had their blood pressure measured. In addition, 94% of study participants were found to have 1–2 NCD risk factors. Despite the high prevalence of NCDs and associated risk factors, treatment of chronic NCDs in Ethiopia is largely limited to the hospital setting. These data indicate a large gap between the need for and uptake of interventions to prevent hypertension and other diseases.
Population Services International Ethiopia (PSI /E) has been working with the Ministry of Health since 2016 under the AstraZenecafunded Healthy Heart Africa program to reduce the prevalence of hypertension and improve the quality of hypertension care in selected public health facilities in different regions of the country, including Harar and Dire Dawa. Harar Regional State and Dire Dawa Municipality are in eastern Ethiopia and were identified as areas with a high prevalence of elevated blood pressure (BP). These regions are associated with a high prevalence of khat chewing and smoking, and studies have shown that these are important risk factors for elevated blood pressure. According to the 2015 Ethiopian report STEPS, 83.3% and 91.7% of study participants in Dire Dawa and Harar, respectively, have never measured their BP. The proportion of elevated BP was 14% in Harar and 20% in Dire Dawa.Risk factors such as unhealthy lifestyle including lack of regular exercise, use of mild drugs such as khat and cigarettes, and environmental factors have been identified and associated with the prevalence of elevated BP.
HEALTHY HEART AFRICA (HHA) INTERVENTIONS
To reduce the prevalence of hypertension, the HHA program works to raise awareness of the importance of routine blood pressure screening for the early diagnosis and management of hypertension in the adult population, leading to optimal management of the patient pathway. The program uses an integrated approach to:
- Raise awareness of and demand for hypertension screening services at selected sites and health centers.
- Strengthen the capacity of health workers to perform hypertension screening, early diagnosis, and referral to treatment, leading to optimal patient management.
This integrated approach is implemented through intensive training and mentoring at health centers and sites. It also includes technical support for on-site management by ensuring that all patients are screened at triage before being referred to the appropriate treatment areas.
FACILITY BASED INTERVENTION
The facility-based intervention is implemented to improve the screening, treatment, and management of hypertension through task sharing and task shifting between providers and facilities through standardization in the management of hypertension. The program emphasizes capacity building and the generation and use of evidence through routine monitoring and evaluation of key program indicators.
The team strengthens providers’ capacity to implement, monitor, evaluate, and support the management of hypertension at the facility level. The team takes a learning approach and encourages feedback and ideas to identify challenges and develop solutions regularly. This is done through monthly site-level multidisciplinary team (MDT) meetings and regional TWG team meetings. Lessons learned are shared with the Federal Ministry of Health and AstraZeneca. The program conducts training for healthcare providers at supported health facilities and equips facilities with necessary equipment and supplies, such as automated BP machines with accessories, weight and size scales, job aids, protocols, and data collection and reporting tools. Sharing experiences among health facilities through performance review meetings and site visits is another important component of the intervention.
COMMUNITY-BASED INTERVENTION
A community-based program involves the development of a targeted campaign with messages to raise awareness and prompt screening for BP, followed by community-based BP screening services conducted either in community households, marketplaces, workplaces, etc., with referral to a nearby health facility for diagnosis and treatment.
TRANSFORMING HYPERTENSION SERVICES: THE IMPACT OF HEALTHY HEART AFRICA’S INTERVENTION AT JUGOL HOSPITAL.
Jugol is a historic hospital in the walled city of Harar and one of seven health facilities supported by the HHA program in the city. Since the inception of the HHA program, the hospital has established a separate triage room for blood pressure screening, where every patient who visits the hospital is screened before being referred to other service areas. This has allowed the hospital to identify people with high BP who are referred to the chronic disease department for further evaluation, diagnosis, and treatment. Management of treatment is regularly monitored by trained healthcare providers.
The HHA program, in collaboration with the Federal Ministry of Health and Regional Health Bureau, is supporting these seven health facilities in documenting and managing hypertensive patients for treatment and follow-up. The program provides technical assistance, capacity-building training, and consistent follow-up with hospitals and health centers such as Jugol in Dire Dawa and Harar.
“HHA’s support and intervention have helped our staff provide quality screening and follow-up for hypertension patients who would otherwise be very difficult to identify. Thank you for the equipment, documentation tools, and support from the project; we can provide high-quality services. The training and ongoing mentorship support have also helped us deliver services according to Ministry of Health guidelines and protocols. And from the patient’s perspective, long wait times have been kept to a minimum as they are cared for in a separate unit for chronic conditions. “ -Nurse, Jugol Hospital.
CLIENT PROFILE, HARAR JUGOL HOSPITAL
Meet: Munira Mahdi is a 52-year-old woman and mother of five children. Munira lives with her husband and children in the city of Harar. Five years ago, she was diagnosed with hypertension during a mass screening organized by the HHA team in Harar. At first, she was stunned and could not accept the diagnosis, but after six months she began to experience headaches and neck pain. Faced with these recurring signs, she decided to visit Jugol Hospital to have her blood pressure measured.
The doctor measured Munira’s BP and found it to be elevated. She was again diagnosed with hypertension, and the doctor educated Munira about her diagnosis and prognosis. At this point, Munira realized the severity of her condition. The doctor gave her an appointment for a follow-up after educating her about a healthy lifestyle and the need for regular follow-up visits to the hospital. Munira decided to change her lifestyle by reducing salt consumption, eating more fruits and vegetables, and exercising. She currently takes medication and regularly goes to Jugol Hospital for routine checkups.
“I appreciate the service provided by the health care staff. Their support and care have saved my life.”- Munira Mahdi
CONCLUSION
The program has improved hypertension services and cares in the 12 implementation sites, starting with routine triaging for early detection of hypertension, referral to health care practitioners for correct diagnosis, and treatment of hypertension through medication and/or lifestyle modification interventions. To date, PSI has been successful in screening 577,335 individuals and identifying 65,718 individuals with elevated blood pressure. 16.208 individuals have been enrolled in treatment in the two regions.
The HHA program focuses on building capacity and generating and using evidence through training, routine monitoring, and evaluation of key program indicators. The program strengthens providers’ capacity to implement, monitor, evaluate, and sustain quality management of hypertension at the facility level. Routine data quality assessments contributed to improved quality of documentation and reporting and service delivery.