Enhancing hypertension education of community health extension workers in Nigeria's federal capital territory: the impact of the extension for community healthcare outcomes model on primary care, a quasi-experimental study

Abstract

Background: Healthcare workers (HCWs) including community health extension workers (CHEWs) in the Federal Capital Territory, Nigeria participated in a hypertension training series following the Extension for Community Healthcare Outcomes (ECHO) model which leverages technology and a practical peer-to-peer learning framework to virtually train healthcare practitioners. We sought to evaluate the patient-level effects of the hypertension ECHO series.

Methods: HCWs from 12 of 33 eligible primary healthcare centers (PHCs) in the Hypertension Treatment in Nigeria Program (NCT04158154) were selected to participate in a seven-part hypertension ECHO series from August 2022 to April 2023. Concurrent Hypertension Treatment in Nigeria Program patient data were used to evaluate changes in hypertension treatment and control rates, and adherence to Nigeria's hypertension treatment protocol. Outcomes were compared between the 12 PHCs in the ECHO program and the 21 which were not.

Results: Between July 2022 and June 2023, 16,691 PHC visits were documented among 4340 individuals (ECHO: n = 1428 [33%], non-ECHO: n = 2912 [67%]). Patients were on average (SD) 51.5 (12.0) years old, and one-third were male (n = 1372, 32%) with no differences between cohorts in either characteristic (p ≥ 0.05 for both). Blood pressures at enrollment were higher in the ECHO cohort compared to the non-ECHO cohort (systolic p < 0.0001 and diastolic p = 0.0001), and patients were less likely to be treated with multiple medications (p < 0.0001). Treatment rates were similar at baseline (ECHO: 94.0% and Non-ECHO: 94.7%) and increased at a higher rate (interaction p = 0.045) in the ECHO cohort over time. After adjustment for baseline and within site variation, the difference was attenuated (interaction p = 0.37). Over time, control rates increased and medication protocol adherence decreased, with no differences between cohorts. Staffing levels, adult patient visits, and rates of hypertension screening and empanelment were similar between ECHO and non-ECHO cohorts (p ≥ 0.05 for all).

Conclusions: The ECHO series was associated with moderately increased hypertension treatment rates and did not adversely affect staffing or clinical capacity among PHCs in the Federal Capital Territory, Nigeria. These results may be used to inform strategies to support scaling hypertension education among frontline HCWs throughout Nigeria, and use of the ECHO model for CHEWs.

Trial registration: The Hypertension Treatment in Nigeria Program was prospectively registered on November 8, 2019 at www.

Clinicaltrials: gov (NCT04158154; https://clinicaltrials.gov/ct2/show/NCT04158154 ).

Keywords: Education; Hypertension; Implementation; Primary care; Qualitative.

Fig. 1

Observed Treatment (A), Control (B), and Medication Protocol Adherence (C) Rates and 95% Confidence Intervals Over Time by Extension for Community Healthcare Outcomes Group. The proportion of empaneled patients who were treated, controlled, and prescribed medications following the Nigeria hypertension protocol are shown based on the timing of their visits to 12 primary healthcare centers which were selected to participate in the Extension for Community Healthcare Outcomes program and 21 which were not. Results are shown as a proportion and accompanying 95% confidence interval using patient level data from the Nigeria Hypertension Treatment Program registry

Fig. 2

Clinic Caseload (A) and Cascade of Hypertension Evaluation (B), Diagnosis (C), and Empanelment (D) based on Quarterly Supportive Supervision Visits. Site supervision data from the Nigeria Hypertension Treatment Program were used to summarize clinic caseload and hypertension services. Data are from the immediate prior quarter (Q2 2022) and each quarter during (Q3 2022 to Q2 2023) the hypertension Extension for Community Healthcare Outcomes program. The site supervision protocol included visiting each site once per quarter, and all visits occurred as planned except for one. During the visit, site registry information was used to calculate the number of adult patients visiting the clinic per day. The number of those adults who had their blood pressure checked was documented, along with the number of adults who had high blood pressure and the number who were newly registered in the Nigeria Hypertension Treatment Program