Hypertension is a leading cause of disability and premature deaths worldwide. Like any other low and middle-income country, the burden of hypertension has increased significantly in the last decade in Ghana. Hypertension tops all adult hospital admissions and is associated with a significant proportion of overall adult deaths in hospitals in Ghana1. Of particular concern is the hike in hypertension cases among younger adults who constitute majority of the working population in Ghana. Currently, the prevalence of hypertension is reported between 27% and 34%2. On average, one in four adults in Ghana has hypertension. Nearly, less than 35% are aware of their status with only 22% on treatment. The high incidence of stroke accompanying hypertension cases in Ghana calls for urgent policy re-direction to position health systems to respond to the epidemics of hypertension. While the limited number of primary care physicians poses a challenge, there is a need to leverage the existing human resource strength to provide coordinated patient-centered hypertension care to improve the quality of life of people living with hypertension.
Overcoming the challenges; insights from the ADHINCRA Study
The ADHINCRA (Addressing Hypertension Care in Africa) Study, which seeks to address gaps in the management of hypertension in Africa through a multi-level intervention, provides potential directions for health systems in Africa to meet the healthcare needs of the hypertension populations. The study adopts a team-based care strategy and utilizes mobile health, and home blood pressure monitoring approaches to improve hypertension management. The ADHINCRA Study was conducted at four community hospitals in the Ashanti region in Ghana. The intervention aims to enhance the capacity of healthcare workers to deliver evidence-based and culturally tailored interventions to improve blood pressure control. Preliminary findings from the ADHINCRA Study showed improved capacity and clinical skills of healthcare workers including nurses in managing hypertension. In addition, patients also reported satisfaction with care and better care experiences with the intervention. The provision of culturally nuanced messages and reminders about clinic appointments and medications contributed to the success of the intervention, as it fostered a sense of cultural adaptation and increased compliance among patients.
The feasibility assessment visit
To contribute to Ghana’s efforts in addressing gaps in hypertension management, Dr. Yvonne Commodore-Mensah, the CO-PI of the ADHINCRA study, and her Ph.D. advisee, Thomas Hinneh visited selected tertiary and primary health facilities in the Northern and Bono Regions of Ghana to explore the possibility of expanding the ADHINCRA study to these regions. The team engaged with stakeholders, management teams, and healthcare providers at the Tamale Teaching Hospital, Sunyani Regional Hospital, Sunyani Municipal Hospital, and Holy Family Hospital in Berekum.
Health systems-level challenges hampering hypertension control efforts
During interactions with stakeholders and healthcare leaders, the high number of hypertension cases and the chronic shortage of resources and space were cited as major challenges healthcare workers face in hypertension management. Notably, most of the hypertension cases were reported at later stages where complications had already started. This can partly be attributed to low community-based hypertension interventions, delays in seeking healthcare, and misconceptions about antihypertensive medications. Erratic shortage of antihypertensive medications and late reimbursement of claims by the National Health Insurance Scheme further hampers hypertension control efforts in these health facilities. In Ghana, the physician-to-patient ratio is 0.2:1000 compared to 2.6:1000 in the US (World Bank OECD data, 2020). The high physician-patient ratio was also cited as one of the key challenges to quality hypertension care across all the health facilities visited. Other barriers reported by healthcare providers included poor road networks, the low socio-economic status of patients, and the rise in the patronage of uncertified herbal preparations as an alternative for hypertension treatment among patients.
Despite these systemic and patient-level challenges, there are potential opportunities to leverage local resources to improve hypertension care in Ghana. Providing opportunities for training and capacity building for other cadres of healthcare providers, particularly nurses, are proven strategies to bridge the provider-patient gap in access to hypertension care. The preliminary evidence from the ADHINCRA study highlights the benefit of team–based care strategy which allows the involvement of two or more healthcare workers to provide more coordinated and cost-effective hypertension care across healthcare settings (World Health Organization, 2018). Additionally, with the emerging adoption of digital health, there is a need to embrace home blood pressure monitoring which is an evidence-based strategy to improve blood pressure control and reduce the strain on the overburdened health systems.
The Way Forward
Addressing the burden of hypertension and preventing heart disease in Ghana requires a multi-level approach that leverages implementation science and enhances the capacity of primary-level healthcare providers, particularly nurses through team-based care and mobile health-enhanced interventions. The ADHINCRA study is a promising model, and the visits to various health facilities in the country demonstrate opportunities to improve hypertension management in Ghana by replicating the intervention in different settings.
Bosu, W. K., & Bosu, D. K. (2021). Prevalence, awareness and control of hypertension in Ghana: A systematic review and meta-analysis. PloS one, 16(3), e0248137. https://doi.org/10.1371/journal.pone.0248137
World Health Organization’s Global Health Workforce Statistics, OECD, supplemented by country data, 2020 https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=US
Owusu, A. Y., Kushitor, S. B., Ofosu, A. A., Kushitor, M. K., Ayi, A., & Awoonor-Williams, J. K. (2021). Institutional mortality rate and cause of death at health facilities in Ghana between 2014 and 2018. PLoS ONE, 16(9 September). https://doi.org/10.1371/journal.pone.0256515
World Heart Federation, Ghanaian Society of Cardiology (GSC), the Stroke Association Support Network – Ghana, 2002 Roundtable hypertension discussion 2022, https://world-heart-federation.org/news/whf-roundtables-on-hypertension-in-accra-ghana/
World Health Organization. HEARTS Technical package for cardiovascular disease management in primary health care: Team-based care. Geneva WHO; 2018.
About the Author: Thomas Hinneh, MScIH, BScN, RN
Thomas Hinneh is a current Hopkins school of Nursing PhD student working with Dr. Yvonne Commodore-Mensah as his advisor.