Transforming Hypertension Management in Nigeria

Elevated blood pressure (BP) is a leading modifiable risk factor for global cardiovascular disease morbidity and mortality. In Nigeria, the most populous country in sub-Saharan Africa, the prevalence of hypertension based on a BP threshold >140/90 mmHg in adults (>40 years) has been estimated to be 45%.1 Despite this very high burden, hypertension awareness (14-30%), treatment (<20%), and control (9%) rates are very low in Nigeria.2 A 2018 systematic review of 119 trials (n=55,641 participants) evaluating implementation strategies for improving BP control demonstrated that multi-level team-based care with non-physician health worker titration of BP lowering medicines was the most effective approach for lowering systolic BP (-7.1 mmHg [95% CI: -8.9, -5.2], 10 trials).3 The most effective patient-centered interventions for lowering systolic BP were health coaching (-3.9 mmHg [95% CI: -5.4, -2.3], 38 trials) and home BP monitoring (-2.7 mmHg [95% CI: -3.6, -1.7], 26 trials). Importantly, <20% of the studies in this systematic review were from low- and middle-income countries, and none were from sub-Saharan Africa. Translating these findings into routine clinical practice requires systems to track patients, performance review, algorithms, physicians to cede control to non-physicians, and non-physicians to cede control to and to support patients, much like how HIV care is structured throughout sub-Saharan Africa. Our pilot data (n=60) from Abuja, Nigeria already demonstrate feasibility and short-term efficacy in lowering systolic BP at 1 month with community health worker-led care (-10.5 mmHg [95% CI: -15.4, -5.5]) and home BP monitoring (-7.3 mmHg [95% CI: -11.7, -2.8]) compared with usual care. In this proposal, we will utilize implementation science methodologies including the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to adapt, implement, and evaluate an evidence-based, multi-level intervention that includes: (1) system-level hypertension program adapted from Kaiser Permanente Northern California’s model in public, primary health care facilities in Federal Capital Territory [Abuja], Nigeria, and (2) patient-level health coaching with home BP monitoring in a sample of high-risk patients with uncontrolled hypertension. We will study the effectiveness and implementation of these adapted interventions through an interrupted time series design on hypertension treatment and control rates, as well as patient-centered outcomes. We will also evaluate the implementation outcomes using the RE-AIM framework, as well as acceptability and cost, at system and patient levels for both interventions. This proposal directly addresses critical challenge #11 of the NHLBI’s Strategic Vision: “Multidisciplinary, multinational partnerships are needed to develop effective and sustainable strategies for combating chronic HLBS disorders in developing nations, which take into account the highly variable local epidemiology of HLBS disorders, the need for novel approaches to reducing disease burden, and the challenges of implementation.”4