Tropical Medicine and International Health doi:10.1111/tmi.

13078

volume 23 no 7 pp 785–794 july 2018

Compliance with follow-up and adherence to medication in

hypertensive patients in an urban informal settlement in
Kenya: comparison of three models of care
Ng’endo Kuria1, Anthony Reid2, Philip Owiti3,4, Hannock Tweya5, Caleb Kipkurui Kibet6, Lilian Mbau1,
Marcel Manzi2, Victor Murunga1, Tecla Namusonge1 and Joseph Kibachio7,8

1 Amref Health Africa in Kenya, Nairobi, Kenya

2 Operational Research Unit, Operational Centre Brussels, Medecins Sans Frontieres, Luxembourg, Luxembourg
3 Academic Model Providing Access to Healthcare, Eldoret, Kenya
4 International Union against Tuberculosis and Lung Disease, Paris, France
5 Lighthouse Trust, Lilongwe, Malawi
6 Computer Science Department, Rhodes University, Rhodes, South Africa
7 Division of Noncommunicable Diseases, Ministry of Health, Nairobi, Kenya
8 The National Public Health Institute, Nairobi, Kenya

Abstract objective To determine and compare, among three models of care, compliance with scheduled
clinic appointments and adherence to antihypertensive medication of patients in an informal
settlement of Kibera, Kenya.
methods Routinely collected patient data were used from three health facilities, six walkway clinics
and one weekend/church clinic. Patients were eligible if they had received hypertension care for more
than 6 months. Compliance with clinic appointments and self-reported adherence to medication were
determined from clinic records and compared using the chi-square test. Univariate and multivariate
logistic regression models estimated the odds of overall adherence to medication.
results A total of 785 patients received hypertension treatment eligible for analysis, of whom two-
thirds were women. Between them, there were 5879 clinic visits with an overall compliance with
appointments of 63%. Compliance was high in the health facilities and walkway clinics, but men
were more likely to attend the weekend/church clinics. Self-reported adherence to medication by
those complying with scheduled clinic visits was 94%. Patients in the walkway clinics were two times
more likely to adhere to antihypertensive medication than patients at the health facility (OR 1.97,
95% CI 1.25–3.10).
conclusion Walkway clinics outperformed health facilities and weekend clinics. The use of
multiple sites for the management of hypertensive patients led to good compliance with scheduled
clinic visits and very good self-reported adherence to medication in a low-resource setting.

keywords hypertension, models of care, walkway clinics, weekend clinics, medical management,
operational research

often detected when it presents with complications result-

Introduction
ing from long-term uncontrolled blood pressure (BP) [5].
Hypertension is a leading cause of morbidity and mortal- A 25% relative reduction in raised BP and premature
ity in adults aged 25 years and older causing an esti- mortality from cardiovascular diseases is possible if risk
mated 7.5 million deaths globally [1]. Much of this factor targets for reduced salt intake, diabetes, obesity,
burden is borne by low- and middle-income countries alcohol and tobacco use are achieved [6, 7]. The conse-
which have seen a steady increase in newly reported quences of uncontrolled blood pressure can be fatal; and
cases, in contrast to high-income countries, which have many lives could be saved if medication adherence was
experienced a decrease [2, 3]. The burden of hypertension reinforced as BP control can reduce the frequency of
in Africa is very high at 46% in adults aged 25 years and complications such as stroke, myocardial infarction and
older [1, 4]. In developing countries, hypertension is cardiac failure [8].

© 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 785
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distribution and reproduction in any medium, provided the original work is properly cited.
Tropical Medicine and International Health volume 23 no 7 pp 785–794 july 2018

N. Kuria et al. Effective hypertension management models

WHO reports that poor adherence to treatment is a settlements. Many people in Kibera are casual labourers
worldwide concern [9]. Even in developed countries, working either in industries or wealthy homes outside the
adherence is difficult (approximately 50% at best), and it settlement. In the morning, many of these people leave
is much lower in developing countries [9, 10]. Adherence the slum in search of work and in the evening return
is defined as ‘the extent to which a person’s behaviour – home through defined routes used daily. The walkway
taking medication, following a diet and/or executing life- clinics are strategically placed at points of entry into Kib-
style changes, corresponds with agreed recommendations era to capture as much of the human traffic as possible.
from a health care provider’ [11]. Adherence to lifestyle Comprehensive screening, counselling, diagnosis and
modification advice, treatment regimens and regular fol- treatment are offered to this population that would have
low-up is important in BP control, as shown by a study otherwise not been able to receive these services during
in Cameroon [8]. normal working hours (0800–1700 hours) at the clinic.
Two of the most important factors that influence medi- This population cannot afford to sacrifice a day of work
cation adherence in hypertension are the asymptomatic to treat an asymptomatic disease, as shown by a study in
and lifelong nature of the disease as patients must regu- Korogocho slums, Nairobi [19].
larly attend clinics and take medication for a condition Thus, the aim of this study was to determine and com-
they cannot feel [12]. Proper management of hyperten- pare, among the three models, compliance with scheduled
sion requires time commitment and a willingness to take clinic appointments of patients and self-reported adher-
medication, both of which may present a financial burden ence to antihypertensive medication in the informal settle-
[13, 14]. Any measures that would reduce the cost of ment of Kibera, Kenya.
treatment and medication, increase the convenience of
monitoring and renewal of medications would likely
improve hypertension management [15]. Methods
In Kenya, according to a 2015 WHO STEPwise survey,
Design and setting
the overall hypertension prevalence was 23.8%, slightly
higher in men (25.1%) than in women (23.8%) [16]. This was a retrospective analysis of routinely collected
About 90% of people living with hypertension were not project data. Healthy Heart Africa (HHA) is an innova-
on treatment; 22% of those diagnosed with hypertension tive programme created to tackle the rising burden of
were on medication prescribed by a physician, but only hypertension and cardiovascular diseases (CVD) in Africa
3% of these were controlled [16]. A population-based [20]. The programme aims to reach 10 million patients
survey in 2010 found the hypertension prevalence in Kib- with hypertension in Africa by 2025. This will be
era, an informal settlement in Nairobi, to be 12.6%; it achieved by awareness creation on symptoms and risk
was slightly higher in females (13.7%) than in males factors, supporting local health systems, and by offering
(11.7%) and increased with age [17]. screening and reduced-cost treatment. The programme is
In Kibera, three models of care have been implemented funded by AstraZeneca and has four local partners in
by Amref Health Africa in Kenya (Amref) to address Kenya implementing different models of care; Amref is
compliance issues related to hypertension. The goal of one of these partners.
the programme is to make it more convenient for patients In Kibera, the project is implemented in collaboration
to have their BP monitored and medications prescribed. with the Ministry of Health in government-run health
The programme is based in three locations: the health facilities and some private clinics. The Kibera Community
facility, walkway clinics (drop-in centres on main roads) Health Centre (KCHC), an Amref-sponsored clinic, is an
and weekend clinics. A previous study found that overall example of a public-private partnership in health where
enrolment was significantly higher using three types of some of the staff at the clinic are supported by Amref,
locations than a single facility-based location [18]. while the rest are Ministry of Health (MOH) staff. In this
Although enrolment in the clinics was improved with this health facility, HHA supports – through Amref – aware-
novel approach, it is not known whether it produced bet- ness creation, BP screening, provision of highly subsidised
ter clinic attendance or adherence to medication. Multi- medication and support group formation by patients. As
ple sites to improve adherence to medication have been the health facility is partly owned by Amref, a small fee
tried before [13], but the use of walkways and dedicated is charged for treatment and medication. This goes into a
hypertension weekend clinics is new and has never been revolving fund for sustainability (Box 1).
systematically evaluated in literature. The main objective of the project is to reduce the
These models are different from other multiple site burden of hypertension by creating awareness, provid-
approaches in that they have been adapted for informal ing quality BP screening, diagnosis, counselling and

786 © 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
Tropical Medicine and International Health volume 23 no 7 pp 785–794 july 2018

N. Kuria et al. Effective hypertension management models

care, including medication. When the project started in Weekend services

2014, we aimed to screen around 134 000 people and
Weekend services are offered on Saturdays and Sundays
treat 13 200 people with hypertension in Kibera
at the Amref facility. Again, comprehensive services are
between April 2014 and June 2017. The main service
offered and once registered, patients can continue to be
delivery models included a community education strat-
followed up on weekends. Similarly, comprehensive care
egy and triaging at health facilities. Due to low linkage
is offered in places of worship between 0900 and
to care, two other sites were introduced in October
1600 hours on worship days; once registered, patients can
2015: the walkway and weekend services to make
continue to be followed up on weekends or if they prefer,
screening, diagnosis, treatment and follow-up more
are referred to a clinic near their home for follow-up.
accessible to patients, thereby improving adherence to
The walkway and weekend clinics are manned by
care.
CHVs who take BP readings and a clinician who super-
vises the CHVs, diagnoses, treats patients and dispenses
Facility-based services medication. The clinicians are drawn from project sites
and work on a rotational basis.
All patients at Amref-supported clinics are required to
have their BP taken (Box 1). This is either done by a
triage nurse or a trained community health worker Patient movement
(CHV). The information is recorded in screening regis-
The population of Kibera is very transient and patients
ters. Those found to have elevated BP are transferred into
move between treatment sites in and outside the settle-
the linkage register for follow-up. Diagnosis is made after
ment. Common reasons are treatment costs at the Amref
three elevated BP measurements are recorded on three
facility and incentives offered by other NGOs running
separate visits within 2 months. Once diagnosed with
hypertension projects. Patients also tend to move to clin-
hypertension, a patient file is opened and all subsequent
ics closest to their homes if enrolled in a clinic further
visit information is recorded there. A risk factor analysis
away. Movement to clinics outside Kibera occurs when
is done for all patients upon enrolment. Patients are given
patients with severe hypertension are referred to tertiary
a one-month supply of antihypertensive medication
referral hospitals for care, or when they relocate to their
(Box 1) and asked to return in one month unless the doc-
rural home or temporarily for work or travel. As in most
tor advises a shorter or longer appointment period.
slums, many residents of Kibera were born outside Nair-
obi; hence, the considerable in and out-migration [21].
Community strategy of care To address this issue, our patients are issued with a ‘Pass-
port to a Healthy Heart’, a booklet containing a sum-
A community model was tried between 2014–2015 where
mary of their hypertension information including lifestyle
CHVs were deployed in the community, going from
modification advice, risk factors, ongoing BP readings,
house to house, taking BP readings of people aged
medication history and their unique identification num-
18 years and above and referring those with elevated BP
ber. This makes patients’ identification easy as they move
to the health centres for treatment. This was very effec-
between project sites and other clinics in Kibera. Defini-
tive in increasing screening coverage but poor in terms of
tions of hypertension and treatment guidelines are
linkage; most of the patients referred to the clinic did not
described in Box 1.
show up due to work-related issues, long wait times and
poor customer care. Hence, we introduced the walkway
and weekend clinics. Patient population
All patients with hypertension from three clinics, six
Walkway services walkway clinics and a weekend clinic in Kibera who were
on antihypertensive medication and considered actively in
The “walkways” are a drop-in-clinics located on com-
care for at least 6 months during the study period (April
monly-used roadways outside or near the clinic that iden-
2015–December 2016) were included.
tified patients are linked to after diagnosis. They operate
between 1630 h and 1830 h, three days a week, and
Data variables, sources of data and data collection. The
offer comprehensive care (screening and treatment) for
variables collected included: unique patient identifier,
the newly-diagnosed and existing patients who would
date enrolled into care, last visit, point of enrolment and
have otherwise been unable to keep their facility appoint-
point of care (health facility, walkway and weekend
ments during normal working hours.

© 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 787
Tropical Medicine and International Health volume 23 no 7 pp 785–794 july 2018

N. Kuria et al. Effective hypertension management models

Box 1 Definitions of elevated blood pressure and treatment guidelines for hypertension
Not all patients were triaged in the health facilities Amref works with before HHA. BP readings were mostly taken
on a need-to-know basis mostly under direction from the doctor/clinician when patients presented with symptoms of
hypertension. There were no protocols for hypertension management and doctors prescribed antihypertensive medi-
cation with the aim of short-term BP control. Once the patient’s BP was controlled, some patients were taken off
medication. Currently in all HHA sites, treatment guidelines endorsed by the Ministry of Health and AstraZeneca
are used to determine appropriate advice, including lifestyle changes and medications.
Treatment guidelines: Before taking blood pressure (BP) measurements, the patient should sit quietly for 3–5 min.
The correct size cuff and bladder should be used. Measurement of the BP is made while the patient is seated on a
chair with a back rest and with the arm relaxed and supported at the level of the heart. Two BP readings are taken
at least 2 min apart. BP in both arms should be taken at the first visit, and the arm with the highest BP should be
used for future measurements. Patients with diabetes, patients complaining of symptoms suggestive of postural
hypotension (e.g. dizziness, unsteadiness or fainting when changing posture) and the elderly patients should stand
while having their blood pressure taken. This BP is then compared with their sitting BP.
Hypertension is defined in different stages as: mild (140/90–159/99 mmHg), moderate (Systolic BP ≥160 and/or
diastolic BP ≥100 mmHg) and severe (Systolic BP ≥180 and/or diastolic BP ≥110 mmHg). Three elevated blood pres-
sure readings are required before a diagnosis is made, and patients are started on treatment. For those with mild-to-
moderate hypertension and without risk factors, they are enrolled into care on contact.
Patients with mild hypertension and no risk factors are treated with lifestyle modification only for up to 3 months,
upon which medication is prescribed if the desired BP (of ≤140/90 mmHg and <150/90 mmHg for age ≥80 years) is
not achieved. For those with risk factors, treatment decisions are made on a case by case basis while those with sev-
ere hypertension are treated with antihypertensive medications on contact and referred for specialized treatment. All
patients receive lifestyle modification education on every clinic visit before and after treatment.
The first line of treatment is a long-acting calcium channel blocker (CCB) or thiazide diuretic. If the desired BP is
not achieved, a combination of therapies of CCB plus a thiazide diuretic, and then an angiotensin converting enzyme
inhibitor (ACEI) are used. Patients at the ACEI plus CCB level require referral. The protocol for the identification
and management of HTN is appended below (Appendix 1).
Patients in the project are given antihypertensive medication from two sources: the government-run Kenya Medical
Supplies Authority (KEMSA) and Mission for Essential Drugs and Supplies (MEDS) funded by AstraZeneca. Medi-
cation supplied by KEMSA is provided free of charge at government clinics while those from AstraZeneca are pro-
vided at a highly subsidized cost of USD$1 (Ksh100) per month. Patients started on drugs from KEMSA can get
access to project drugs if they are out of stock in the clinics or they require more potent drugs. The ministry of
health treatment protocol is used by clinicians to decide which drugs to start patients on, when to increase or
decrease doses and when to prescribe the next class of drugs class of drugs [37].

clinic), demographics (age, sex), hypertension risk factors carried out from patient files, the patients’ master list
(smoking, drinking, body mass index [BMI], diabetes, and clinic appointment books. Data were stratified by
diet, physical inactivity, family history of CVDs) and health facility, walkway and weekend for analysis.
HIV status. Information routinely recorded on each clinic Compliance with scheduled clinic visits was defined as
visit included: date of clinic appointment, BP, self- a proportion of visits attended against those scheduled.
reported adherence, medication regimen and next Compliance was defined as when a patient came for a
appointment date. visit not more than 90 days before the scheduled appoint-
All patient data were recorded in patient files by clini- ment for an early visit and not later than 7 days after the
cians and later keyed into an electronic database, Interna- appointment date. Adherence to medication was self-
tional Quality Care (IQ Care), by Futures group [22]. reported as a “yes” or “no” and only calculated for those
For this study, the primary data source was IQ Care. who attended a clinic visit. The binary response was
Data retrieval and cleaning took place between April recorded after clinicians enquired with several questions
and October 2017. Verification and comparison were to ascertain adherence.

788 © 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
Tropical Medicine and International Health volume 23 no 7 pp 785–794 july 2018

N. Kuria et al. Effective hypertension management models

Analysis
11 396 clinic visits between Apr2015-
To determine attendance to clinic visits and self-reported Dec2016 by 3861 HTN patients
adherence to medication, we analysed patients who had
been in the programme for more than 6 months and
were active between April 2015 and December 2016.
Excluded 3069 patients in
Data were downloaded to Excel and exported to STATA
project <6 months
Version 12 for analysis. Data were summarised using
ranges, means,  standard deviations (SDs) and frequen-
cies (percentages) where appropriate. Compliance with 5917 clinic visits from 792 patients who
clinic visits and adherence was compared between models had been in the project >6 months

using the chi-square test. Univariate and multivariate

logistic regression models were used to estimate the odds
Excluded 38 visits from 7
of overall adherence to medication. Sex and age of the
patients without a model
patient at enrolment were a priori included in the multi- of care indicated
variable model while other risk factors for hypertension
were not included because they were not significant at
P < 0.05 level. Model results were shown as odds ratios 5879 clinic visits from 785 patients

(OR) and adjusted OR (aOR) with 95% confidence inter-

vals (CI).
Excluded 919 unscheduled
clinic appointments
Ethics approval
Ethics approval was obtained from the Amref Health 4960 scheduled clinic appointments
Africa in Kenya Ethics & Scientific Review Committee.
This research fulfilled the exemption criteria set by the
Medecins Sans Frontieres Ethics Review Board for a pos- 3102 (62.5%) honoured 1858 (37.5%) missed
teriori analysis of routinely collected clinical data and clinic appointments clinic appointments

thus did not require MSF ERB review. The study was
also approved by the Ethics Advisory Group of the Inter- Figure 1 The number of clinic visits from April 2015–December
national Union Against Tuberculosis and Lung Disease, 2016.
Paris, France.

(Table 3). The difference was statistically significant (P

Results
0.006).
There were 3861 patients with hypertension registered in Overall, self-reported adherence to medication of those
the programme, of whom 785 had visited a clinic who complied with scheduled clinic visits was 94%, with
6 months after enrolment and whose visits were eligible walkway at 96%, facility at 94% and weekend at 88%.
for analysis (Figure 1). Table 1 describes their demo- These results were significant (P 0.001).
graphic characteristics. The average age was 48 and two- In univariate logistic regression analysis, patients who
thirds were women with almost all married/cohabiting. accessed hypertension services through walkway clinics
Between April 2015 and December 2016, 11 396 clinic were two times more likely to adhere to antihyperten-
visits were recorded. Of these, 5879 were clinic visits sive medications than those who received services at
from patients who had been in the project >6 months the health facility (OR 1.97, 95% CI 1.25–3.10).
(Table 2). The health facility had the highest number of Patients who received hypertension services through the
visits (64%) while the weekend clinics had the fewest weekend clinic were 76% less likely to adhere to anti-
(3%). In 5705 of these clinic visits, patients were given hypertensive medication than those who received ser-
antihypertensive medication with the vast majority pre- vices at the facility (AOR 0.24, 95% CI 0.10–0.57).
scribed a single pill per day. The association between the model of hypertension ser-
Of the 4960 scheduled follow-up visits, the health vice delivery and self-reported adherence to medication
facility group were more compliant (64%) than either remained significant even after adjusting for sex and
walkway (60%) or weekend clinic attenders (55%) age at enrolment.

© 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 789
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N. Kuria et al. Effective hypertension management models

Table 1 Demographic and clinical characteristics of hypertensive patients in the Healthy Heart Africa project in Kibera, Kenya
2015–16

Characteristic Overall Health facility N (%) Walkway N (%) Weekend N (%)

Total number of patients 785 485 (62) 277 (35) 23 (3)

Age (years), Mean [standard deviation] 48 (11) 48 (12) 49 (11) 51 (13)
Gender
Male 290 (37) 170 (35) 107 (39) 13 (56)
Female 495 (63) 315 (65) 170 (61) 10 (44)
Marital status
Married/Cohabiting 505 (73) 306 (74) 182 (71) 17 (74)
Single/separated/divorced/widowed 187 (27) 108 (26) 73 (29) 6 (26)
Risk factors
Diabetic 10 (1.3) 6 (1.2) 4 (1.4) 0
Tobacco use 24 (3) 17 (4) 7 (3) 0
Harmful alcohol consumption 51 (7) 35 (8) 14 (5) 2 (9)
Physical inactivity 389 (84 301 (88) 70 (70) 17 (85)
Unhealthy diet (low fruit and vegetable consumption) 75 (16) 45 (13) 29 (28) 1 (5)
Medication Regimen
Taking a single pill 729 (99) 450 (99) 257 (100) 22 (100)
Taking multiple pills 5 (1) 5 (1) 0 0
Time in project (months)*, median [IQR] 10 [8–13] 12 [8–14] 9 [7–11] 10 [8–13]

IQR, interquartile range.

*Time in project after 6 months of treatment.

Discussion
Table 2 Visits made to a Healthy Heart Africa project clinic by
hypertension patients in care for 6 months in Kibera, Kenya This study shows that the use of multiple sites/models for
2015–16 the management of hypertensive patients leads to reason-
able compliance with scheduled clinic visits and very
One pill/day Multiple
Model Visits N (%) N (%) pills/day N (%)
good self-reported adherence to medication among those
who attended clinic.
Facility 3785 (64) 3641 (99%) 49 (1%) Compliance with the health facility model was better
Walkway 1940 (33) 1858 (99.7%) 5 (0.3%) than in walkway and weekend clinics. A study in Latin
Weekend 154 (3) 152 (100) 0 America found that frequent patient follow-up yielded
Total 5879 (100) 5651* 54*
good BP control as it offered opportunities for frequent
*Total = 5705 clinic visits had medication BP monitoring, access to information especially on life-
(*5651 + *54 = *5705), 104 had no meds or patients were put style modification and medication adjustments if BP was
on lifestyle modification only. uncontrolled [23].
Self-reported adherence in the walkway model was bet-
Table 3 Compliance with scheduled clinic appointments in
ter than in health facility and weekend clinics. The self-
Healthy Heart Africa project clinics by hypertension patients in reported adherence in this study is much higher than
care for ≥6 months in the in Kibera, Kenya 2015–16 shown in other studies in Africa: 53.8% in Korogocho
slum, Nairobi [24], 57.2% in Nigeria [25] and 67.2% in
Scheduled Attended North-west Ethiopia [26]; it is also higher than in Pak-
Model visits (N) visits N (%) P-Value*
istan (76.6%) [27] and Sunderland (79%) [28]. The dif-
Health Facility 3220 2064 (64) ference in results may be due to sociodemographic
Walkway 1609 966 (60) 0.006* characteristics, self-reported adherence or models of care.
Weekend 131 72 (55) 0.03* Most of the other studies were based in hospitals,
Total 4960 3102 0.006* whereas ours was conducted in multiple sites with a lar-
*P = 0.006 is the comparison of trend for the three models, it is
ger sample size. However, the Sunderland study was simi-
also the P-value we got when we compared the health facility to lar to ours in that study participants had been enrolled
the walkway model, *P = 0.03 compares health facility to the on treatment and taking antihypertensive medication for
weekend model. more than 6 months [28].

790 © 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
Tropical Medicine and International Health volume 23 no 7 pp 785–794 july 2018

N. Kuria et al. Effective hypertension management models

These positive results may be attributed to the strategic show improvements [33]. The pharmacies may have ben-
placement of places where patients can have their BP efited from the convenience factor for their results. How-
monitored easily and medications refilled conveniently. ever, these services did not provide comprehensive
The same medical staff in the health facilities worked in services at a convenient location for patients.
the walkway and weekend clinics as in the community A strength of this study is that it was sub-county
and clinic sites. They provided the same consistent care wide and is likely representative of the situation in
that facilitated follow-up. Other very important factors Kibera. The same medical staff and CHVs worked in
were the single-pill-per-day regimen for the vast majority all three locations and followed the same protocol for
of patients and the availability of free or highly sub- hypertension management. The study followed sound
sidised treatment and medication in project sites [26]. ethical practices and adhered to STROBE guidelines
The proportion of females was significantly higher than [34, 35].
males. Studies have shown that women have better Our study had some limitations. Adherence to medica-
adherence than men [29]. Also, most patients had been tion was self-reported and hence could have been influ-
on medication less than 10 months; and adherence may enced by social desirability; a binary assessment of
be better early in treatment [30]. adherence was used in the report, precluding assessment
The much smaller number of patients at the weekend of partial adherence [36]. As is usual for use of routinely
clinic was disappointing but it did seem to provide some collected data, there were some gaps and we were unable
access for men, who were more represented there. to account for all followed up patients.
Despite the small number of uptakers, and resources per- There are a number of operational lessons from this
mitting, continuing this clinic might be justified [18]. study: (i) placing full-service clinics in strategic locations
The gap in clinic attendance is still concerning but to account for travel to work may be effective; (ii) offer-
may be partly caused by the mobile nature of the popu- ing services for men outside working hours may increase
lation. A cohort of patients with hypertension and/or their participation; (iii) using a simple pill regimen likely
diabetes in Kibera lost 31% to follow-up (LTFU), which increases adherence; (iv) it is worth investing in a porta-
is in line with our findings (36%) [31]. Patients have ble method of recording BP and current medication (pass-
many reasons to miss a scheduled appointment and ports) for patients when they move to different points of
convenience of placement does not address them all. care.
Expanding the use of the “Passport to a Healthy Heart” Implications for policy and practice are that hyper-
may permit better continuity of care for patients moving tension screening coverage in Kenya is still very low.
from one clinic to another and improve follow-up. The use of the three models of care can increase
Countrywide implementation of a unique patient identi- awareness levels, screening and treatment coverage [18].
fier and connection of electronic medical records may Among those on treatment, these models have the
also aid with tracing and continuing care for patients potential to improve compliance with clinic visits and
who move upcountry. self-reported adherence to medication. They are scalable
Both the walkway and health facility models had good and can be implemented cost-effectively if integrated
compliance and adherence. This is a new finding and into existing infrastructure as funding for NCD control
important in the context of non-communicable disease is scarce.
(NCDs) care in Africa, which does not have a strong
infrastructure. To our knowledge, no studies have evalu-
Conclusion
ated the placing of clinics in areas of convenience for
patients as a strategy to improve clinic attendance and Conveniently placed treatment sites for hypertension,
adherence to medication in an African context, particu- manned by trained healthcare providers and offering
larly in an informal setting. comprehensive care at times suitable to patients resulted
In high-income countries, the use of outpatient centres, in good compliance with scheduled clinic visits and self-
general practitioners’ offices and stand-alone outpatient reported adherence to medication. Our model may be
hospital clinics provides some level of convenient access successful in low-income contexts.
for patients with hypertension [13]. Some studies that
focused on the convenience of access (one based on home
Acknowledgements
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whereas others on hypertension management by commu- Operational Research and Training Initiative (SORT IT),
nity pharmacies in a patient-centred model of care did a global partnership led by the Special Programme for

© 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 791
Tropical Medicine and International Health volume 23 no 7 pp 785–794 july 2018

N. Kuria et al. Effective hypertension management models

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Corresponding Author Ng’endo Kuria, Amref Health Africa in Kenya, P.O Box 30125-00100, Nairobi, Kenya. Tel.: +254 720
896733; E-mail: [email protected]

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N. Kuria et al. Effective hypertension management models

Appendix 1

Protocol for the identification and management of hypertension in adults in primary care

SBP ≥140 mmHg and/or DBP ≥90 mmHg

(Table 1)

CV directed history & clinical evaluation (Table 2) Baseline tests (Table 3)

• Family history • Urine dipsticks (protein, blood, sugar)
• Age • Random blood sugar (finger prick)
• Diabetes, dyslipidaemia • Blood tests if indicated and available‡
• Previous CV disease, heart failure, stroke • ECG if indicated and available‡
• Peripheral arterial disease ‡ Blood tests and ECG are not mandatory before starting
• Renal disease (CKD) treatment, but should be done within 3 months for
• Medications (Table 4) patients with a new diagnosis of hypertension (referral to
• Body weight, height, BMI, waist circumference a higher level facility may be necessary)

Indications for immediate referral? (Table 5) YES Refer

NO

All patients should receive education about lifestyle modification (Table 6)

Mild hypertension Moderate to severe hypertension

SBP 140-159 and/or DBP 90-99 mmHg SBP ≥160 and/or DBP ≥100 mmHg

Two or more of the following present?

Family history of premature CV disease, age >55 (men) >65 (women),
diabetes, high cholesterol, smoker, obesity

NO YES

Trial of lifestyle modification for up to 3 months

3 months

Goal BP achieved? §
<140/90 mmHg Consider combination antihypertensive therapy* with
(Age ≥80 years: <150/90 mmHg) Preferred regimen (1): CCB plus thiazide diuretic
Alternative regimens:
Option (2): ACEI plus thiazide diuretic
Option (3): ACEI plus CCB. If an ACEI plus CCB is
YES NO considered, seek consultation before prescribing or refer
the patient to the next level of care.
Start antihypertensive therapy* with
Long-acting CCB or Thiazide diuretic
8 weeks
8 weeks

Goal BP achieved?§ Goal BP achieved?§

<140/90 mmHg NO <140/90 mmHg
(Age ≥80 years: <150/90 mmHg) (Age ≥80 years: <150/90 mmHg)

YES
YES NO

Refer

Continue treatment and monitor

Patient should be reviewed at the clinic at least every 4-6 months
Blood tests should be repeated annually (Table 3)
At every visit:
• Educate about healthy lifestyle modifications, alcohol use and dietary salt restriction
• Ask about side effects (Table 8)
• Reinforce the importance of compliance with treatment and address obstacles to achieving/maintaining BP goals (Table 9)
• Make a follow up appointment

§If goal BP is not achieved, assess compliance with medication, alcohol use and use of NSAIDs before deciding to intensify antihypertensive therapy (see Table 9)
*If no contraindications (Table 7)
ACEI: Angiotensin converting enzyme inhibitor; CCB: Calcium channel blocker; CKD: Chronic kidney disease; CV: Cardiovascular; DBP: Diastolic blood pressure; NSAIDs: Nonsteroidal anti-inflammatory
drugs; SBP: Systolic blood pressure; < Less than; ; > Higher than; ≥ Equal to or higher than
This protocol is for use in the demonstration sites of the Healthy Heart Africa project

794 © 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.