There is a high prevalence of hypertension in South Africa, with up to 60% of adults affected, most of whom do not have their blood pressure controlled adequately. The South African Department of Health has recently introduced a new initiative, the provision of integrated management of chronic disease, which focuses on the management of chronic disease including HIV and hypertension.
The Nkateko ('blessing') trial aims to support improvement in chronic diseases care in primary care clinics. With the integrated care initiative, there were many new tasks for the nurses, including setting up an appointments system, managing a separate queuing system and pre-packing medication for patients. The hypothesis was that the LHWs would help with the new tasks, thus ensuring the system ran smoothly and releasing nurses to focus on providing good quality care. It is a cluster randomised controlled trial. Four clinics have been randomised to have lay health workers, and four clinics will continue as normal The trial is nested in the Agincourt Health and Demographic Surveillance System (HDSS).
Implementation of the project ran for 18 months (ending in Sept 2015), with four clinics randomised to have lay health workers, and four clinics continued as normal. The principal outcome was changes in population level prevalence of uncontrolled hypertension. We measured this in two surveys; at baseline and at the end of the intervention. As part of the process evaluation of the trial, detailed information has been collected on clinic users, on systems and practices in the clinics and on the views of the communities served by the clinics.
The three year trial is a collaboration of the Wits School of Public Health and University of Warwick (UK) with financial support from MRC (UK). Other collaborators include the MRC/Wits Rural Public Health and Health Transitions Research Unit, South African National Department of Health, Mpumalanga Provincial Department of Health and Bushbuckridge Health District.
The project was coordinated by CHP Fellow and PhD student, Felix Limbani, with board nine years of managing public health and research programmes.
The analysis plan can be found here.
The trial is now complete. The results showed no effect on population prevalence of poorly managed hypertension, although patients in both intervention and control clinics showed an improvement in management. The process evaluation showed that intervention clinics had higher numbers of patients with hypertension attending regularly, and higher numbers coming on their appointed day. However, clinics were overwhelmed by rapidly increasing numbers of patients, partly due to the roll-out of anti-retrovirals and there were problems with the poor condition of the blood pressure machines and cuffs, drug outages for anti-hypertensives, an influx of inexperienced nurses and the challenging physical conditions of the clinic buildings. Because the care of patients with HIV is funded generously and vertically managed as a separate service, there was a tendency for management of hypertension to be regarded as a lesser priority.
Thorogood M, Goudge J, Bertram M, Chirwa T, Eldridge S, Gomez-Olive F, Limbani F, Musenge E, Myakayaka N, Tollman S, Twine R. (2014) The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial. Trials;15 (1):435.