Integrating a Non-Communicable Disease Care Cascade within Ghana’s Community-Based Health Planning and Services (CHPS) Program: the COMBINE Pilot Implementation Trial
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Introduction
Hypertension is the world’s leading cause of death, and depression its leading cause of disability. Control rates for these non-communicable diseases (NCDs) are low in low- and middle-income countries (LMICs). Many LMICs have programs to screen and treat underserved communities for infectious diseases, but evidence to adapt them to treat NCDs is limited. We developed and tested a non-communicable disease program through Ghana’s Community-Based Health Planning and Services (CHPS) primary care initiative.
Methods
We trained 8 CHPS nurses to diagnose and treat hypertension and depression through door-to-door screening and pharmacotherapy. Physician assistants provided telehealth supervision. We combined this treatment with volunteer counseling to boost medication adherence, improve mood, and change health behaviors. We called the 90-day intervention the CHPS Opportunity for Mentally and Behaviorally Integrated NCD Engagement (COMBINE).
Results
We recruited 60 adults from 580 screened: 37 with hypertension (mean blood pressure (BP) of 149/91 mm Hg) and 23 with depression (mean physician health questionnaire (PHQ-9) score of 13.3). After 90 days, 57/60 (95%) completed the intervention: 32/37 (86%) achieved blood pressure control (mean BP 122/75 mm Hg), and 19 of 20 (95%) achieved depression control (mean PHQ-9 score 2.0). After 12 months, 51/60 were retained: 33/37 with hypertension (89%) and 18/23 with depression (78%), with a mean BP of 121/75 and PHQ-9 score of 1.4 respectively. All 51 (100%) achieved disease control at 12 months. 5 persons left by migration and 4 by escalation to higher-level care.
Conclusions
The COMBINE model achieved high levels of diagnosis, care retention, and disease control, with minimal adverse events, in a remote setting with limited usual NCD care. This model suggests a novel means to improve the care cascade for these and other noncommunicable diseases through existing non-physician care models in LMICs, warranting further controlled testing at scale.
What Is Already Known on This Topic?
Hypertension and depression are the leading causes of global death and disability respectively. In Ghana as in many low- and middle-income countries, evidence shows rural non-physician health workers can proactively screen persons with these and other noncommunicable diseases and refer them to higher-level clinics. However, such clinics are often few and distant from rural areas, limiting access and disease control.
What Does This Study Add?
Our program is the first to test the hypothesis that nurses and volunteers in Ghana’s primary care program can treat hypertension and depression in remote villages - through pharmacotherapy and behavior counseling. We found that 95% of trial participants completed the 90-day intervention, and 91% achieved disease control. At 1 year, 85% remained in care, of which 100% achieved disease control. These retention and control rates meet or exceed that of higher-level health centre care.
How Might This Study Affect Policy?
If effective at scale in a randomized trial, this intervention could allow CHPS to markedly increase awareness, treatment, and control rates for hypertension and depression in Ghana. Its focus on promoting behaviors relevant to many non-communicable diseases - such as physical exercise and alcohol and tobacco cessation - may make it applicable to the concurrent management of multiple chronic conditions. Further, this care model could be leveraged in other health systems with a national non-physician rural health program, improving noncommunicable disease control worldwide.
