abstract: 'Background: Improved primary health care is needed in developing

  countries to effectively manage the growing burden of hypertension. Our

  objective was to evaluate hypertension management in Zambian rural

  primary care clinics using process and outcome indicators to assess the

  screening, monitoring, treatment and control of high blood pressure.

  Methods: Better Health Outcomes through Mentoring and Assessment (BHOMA)

  is a 5-year, randomized steppedwedge trial of improved clinical service

  delivery underway in 46 rural Zambian clinics. Clinical data were

  collected as part of routine patient care from an electronic medical

  record system, and reviewed for site performance over time according to

  hypertension related indicators: screening (blood pressure measurement),

  management (recorded diagnosis, physical exam or urinalysis), treatment

  (on medication), and control. Quantitative data was used to develop

  guides for qualitative in-depth interviews, conducted with health care

  providers at a proportional sample of half (20) of clinics. Qualitative

  data was iteratively analyzed for thematic content.

  Results: From January 2011 to December 2014, 318,380 visits to 46

  primary care clinics by adults aged >= 25 years with blood pressure

  measurements were included. Blood pressure measurement at vital sign

  screening was initially high at 89. 1\% overall (range: 70.1-100\%), but

  decreased to 62.1\% (range: 0-100\%) by 48 months after intervention

  start. The majority of hypertensive patients made only one visit to the

  clinics (57.8\%). Out of 9022 patients with at least two visits with an

  elevated blood pressure, only 49.3\% had a chart recorded hypertension

  diagnosis. Process indicators for monitoring hypertension were < 10\%

  and did not improve with time. In in-depth interviews, antihypertensive

  medication shortages were common, with 15/20 clinics reporting

  hydrochlorothiazide-amiloride stockouts. Principal challenges in

  hypertension management included 1) equipment and personnel shortages,

  2) provider belief that multiple visits were needed before official

  management, 3) medication stock-outs, leading to improper prescriptions

  and 4) poor patient visit attendance.

  Conclusions: Our findings suggest that numerous barriers stand in the

  way of hypertension diagnosis and management in Zambian primary health

  facilities. Future work should focus on performance indicator

  development and validation in low resource contexts, to facilitate

  regular and systematic data review to improve patient outcomes.'
affiliation: 'Yan, LD (Corresponding Author), Ctr Infect Dis Res Zambia, Primary Care
  \& Hlth Syst Dept, Lusaka, Zambia.

  Yan, LD (Corresponding Author), Stanford Univ, Sch Med, Stanford, CA 94305 USA.

  Yan, Lily D.; Chirwa, Cindy; Chi, Benjamin H.; Bosomprah, Samuel; Sindano, Ntazana;
  Mwanza, Moses; Musatwe, Dennis; Mulenga, Mary; Chilengi, Roma, Ctr Infect Dis Res
  Zambia, Primary Care \& Hlth Syst Dept, Lusaka, Zambia.

  Yan, Lily D., Stanford Univ, Sch Med, Stanford, CA 94305 USA.

  Chi, Benjamin H.; Chilengi, Roma, Univ N Carolina, Dept Obstet \& Gynecol, Sch Med,
  Chapel Hill, NC USA.

  Bosomprah, Samuel, Univ Ghana, Sch Publ Hlth, Dept Biostat, Accra, Ghana.'
article-number: '111'
author: Yan, Lily D. and Chirwa, Cindy and Chi, Benjamin H. and Bosomprah, Samuel
  and Sindano, Ntazana and Mwanza, Moses and Musatwe, Dennis and Mulenga, Mary and
  Chilengi, Roma
author-email: lilyyan@alumni.stanford.edu
author_list:
- family: Yan
  given: Lily D.
- family: Chirwa
  given: Cindy
- family: Chi
  given: Benjamin H.
- family: Bosomprah
  given: Samuel
- family: Sindano
  given: Ntazana
- family: Mwanza
  given: Moses
- family: Musatwe
  given: Dennis
- family: Mulenga
  given: Mary
- family: Chilengi
  given: Roma
da: '2023-09-28'
doi: 10.1186/s12913-017-2063-0
files: []
issn: 1472-6963
journal: BMC HEALTH SERVICES RESEARCH
keywords: 'Hypertension; Zambia; Mixed methods; Antihypertensive medication;

  Performance indicators; Quality improvement'
keywords-plus: 'MIDDLE-INCOME COUNTRIES; PRIMARY-HEALTH-CARE; QUALITY INDICATORS;

  ALMA-ATA; PERFORMANCE; PREVENTION; DISEASE; REBIRTH; AFRICA; NEEDS'
language: English
month: FEB 3
number-of-cited-references: '30'
orcid-numbers: 'Yan, Lily/0000-0001-6363-7920

  Bosomprah, PhD, Prof. Samuel/0000-0002-2826-3887'
papis_id: 113c0ab858c7fbc675c75a282954ed20
ref: Yan2017hypertensionmanageme
researcherid-numbers: 'Yan, Lily/AAR-6163-2021

  '
times-cited: '14'
title: 'Hypertension management in rural primary care facilities in Zambia: a mixed
  methods study'
type: Article
unique-id: WOS:000393277500002
usage-count-last-180-days: '0'
usage-count-since-2013: '11'
volume: '17'
web-of-science-categories: Health Care Sciences \& Services
year: '2017'