Capacity and site readiness for hypertension control program implementation in the Federal Capital Territory of Nigeria: a cross-sectional study

Abstract

Background: Nigeria faces an increase in the burden of non-communicable diseases (NCDs), including cardiovascular diseases (CVDs), leading to an estimated 29% of all deaths in the country. Nigeria has an estimated hypertension prevalence ranging from 25 to 40% of her adult population. Despite this high burden, awareness (14-30%), treatment (< 20%), and control (9%) rates of hypertension are low in Nigeria. Against this backdrop, we sought to perform capacity and readiness assessments of public Primary Healthcare Centers (PHCs) to inform Nigeria's system-level hypertension control program's implementation and adaptation strategies.

Methods: The study employed a multi-stage sampling to select 60 from the 243 PHCs in the Federal Capital Territory (FCT) of Nigeria. The World Health Organization (WHO) Service Availability and Readiness Assessment was adapted to focus on hypertension diagnosis and treatment and was administered to PHC staff from May 2019 - October 2019. Indicator scores for general and cardiovascular service readiness were calculated based on the proportion of sites with available amenities, equipment, diagnostic tests, and medications.

Results: Median (interquartile range [IQR]) number of full-time staff was 5 (3-8), and were predominantly community health extension workers (median = 3 [IQR 2-5]). Few sites (n = 8; 15%) received cardiovascular disease diagnosis and management training within the previous 2 years, though most had sufficient capacity for screening (n = 58; 97%), diagnosis (n = 56; 93%), and confirmation (n = 50; 83%) of hypertension. Few PHCs had guidelines (n = 7; 13%), treatment algorithms (n = 3; 5%), or information materials (n = 1; 2%) for hypertension. Most sites (n = 55; 92%) had one or more functional blood pressure apparatus. All sites relied on paper records, and few had a functional computer (n = 10; 17%) or access to internet (n = 5; 8%). Despite inclusion on Nigeria's essential medicines list, 35 (59%) PHCs had zero 30-day treatment regimens of any blood pressure-lowering medications in stock.

Conclusions: This first systematic assessment of capacity and readiness for a system-level hypertension control program within the FCT of Nigeria demonstrated implementation feasibility based on the workforce, equipment, and paper-based information systems, but a critical need for essential medicine supply strengthening, health-worker training, and protocols for hypertension treatment and control in Nigeria.

Keywords: Capacity; Hypertension; Nigeria; Primary health care; Readiness.

Fig. 1

STROBE Site Flow Chart. Of 243 Primary Healthcare Centers within the Federal Capital Territory, Abuja, Nigeria, 90 were excluded based on having fewer than two full-time staff, security concerns, no or poor road access or lack of functionality by providing patient services at the time of the assessment. Of the remaining 153 Primary Healthcare Centers, multistage random selection was applied to select 60 for inclusion in the study

Fig. 2

Selected Primary Healthcare Centers within the Federal Capital Territory. The 60 Primary Healthcare Centers selected for the study represent broad geographic diversity within the Federal Capital Territory, depicted here with wards represented in black lines. Some of the selected sites (black) have a ward-level focal person based within the site, and some (blue) are sites of interest for the FCT Primary Health Care Board for Basic Health Care Provision Fund (BHCPF) project. Many sites (yellow) are both

Fig. 3

Hypertension Treatment Cascade by Council Area. Steps within the hypertension treatment cascade are shown along the x-axis, including screening, diagnosis, confirmation, treatment at initial diagnosis and at follow-up, monitoring and long-term continued care services. The proportion of primary healthcare centers within each area council who self-reported providing these services are shown by bars. Diagnosis: high blood pressure (> 140/90 mmHg) after measuring two or three times at 1–2 min intervals preceded by 3–5 min rest. Confirmation: defined as persistent high blood pressures (> 140/90 mmHg) after two or three clinic visits at 1–4 weeks intervals. Dispense initial treatment: occurs at the first visit, when a patient who has been confirmed as hypertensive is given the first 1-month course of treatment. Dispense follow-up treatment: occurs during routine monthly follow-up visit. Long term care: follow-up of patient’s treatment over several months to years

Fig. 4

Drugs Available for 30-Day Regimens by Drug Class among Selected PHCs (n = 59). The number of 30-day treatment regimens in stock of the day of assessment were tabulated by drug class. Most sites had no 30-day treatment regimens in stock. Of the drugs that were stocked, calcium channel blockers, central acting agents, diuretics and angiotensin converting enzymes inhibitors (ACE-I) were most common