Factors influencing primary care access, utilisation and quality of management for patients living with hypertension in West Africa: a scoping review protocol

Background

Cardiovascular disease accounts for 17.9 million deaths every year,1 most of which are in low- and middle-income countries (LMICs). In 2016, for example, 78% of all non-communicable disease (NCD) deaths, and 85% of premature adult NCD deaths, were in LMICs.2 An estimated 74.7 million individuals in sub-Saharan Africa are hypertensive and this number is projected to increase to 125.5 million by 2025.3

Hypertension, also known as raised blood pressure, is diagnosed when blood pressure is measured on two different days and the systolic blood pressure readings on both days is greater or equal to 140 mm Hg and/or the diastolic blood pressure readings on both days is greater or equal to 90 mm Hg.4 Hypertension is a precursor for various diseases such as ischaemic and haemorrhagic stroke, chronic kidney disease and coronary artery disease.5 In 2015, 27% of the population in the African region had high blood pressure.2 Hypertension is common in West Africa.6 A study on hypertension prevalence, awareness, treatment and control done in seven communities in East and West Africa comprising 3547 participants, showed that a quarter of participants had hypertension, about 40% were unaware, half of those aware were treated and half of those treated had controlled blood pressure.7 Another study on the rural–urban difference in the prevalence of hypertension in West Africa showed prevalence of hypertension was 32.6% in men, and 30.0% in women with a lower odd of hypertension in rural compared with urban dwellers.8

Primary care is defined by the WHO as ‘a model of care that supports first-contact, accessible, continuous, comprehensive and coordinated person-focused care’.9 It is the most basic form of care available to patients at the base of the healthcare pyramid. It should be accessible to all citizens and be able to provide primary and secondary prevention for common diseases in the community. Primary care is very important because it has been shown to meet the needs of the majority of people throughout their lives.9 With the increasing emergence of NCDs as a health problem, there is the need to strengthen primary care in their management in the West African subregion. This scoping review explores access, utilisation and quality of primary care for hypertension management to contribute evidence for strengthening primary care for one of the most common NCDs in West Africa.

Healthcare access is ‘concerned with helping people to command appropriate health care resources in order to preserve or improve their health’. Access requires adequate service quality and availability or supply, as well as removal of financial, organisational, social and cultural barriers that can limit service use10 even when it is in adequate supply.11 Access to healthcare for hypertension in West Africa is often quite low for multiple reasons such as cost, lack of knowledge, essential equipment, tools and supplies as well as medicines.12 13 People use healthcare for many reasons including preventing and curing health problems, promoting maintenance of health and well-being or obtaining information about their health status and prognosis. Access and utilisation or use of healthcare go hand in hand, as good access to healthcare improves utilisation. Quality of care according to the WHO is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes.14 Quality primary healthcare should be timely, equitable, integrated and efficient. These three components—access, utilisation and quality of care have intersecting features that come together to ensure that patients receive the care they need. Good access to and utilisation of adequate quality primary care for people living with hypertension can potentially reduce complications and avoidable hospitalisation and mortality.15 16 Weak and under-resourced health systems and the marginalisation of NCD care in LMICs make it harder to ensure prevention, early diagnosis, access to and utilisation of adequate quality primary care and treatment of patients with hypertension.

The Economic Community of West African States (ECOWAS) subregion is made up of 15 LMICs who share similar social, economic and political environments. The countries in the ECOWAS are Benin, Burkina Faso, Cabo Verde, Cote d’Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo.17 A study of 192 441 patients with hypertension in 44 LMICs, including countries in West Africa, to determine the cascade of hypertension care—and its variation between countries and population groups showed that only 18%–29.9% of participants received treatment for hypertension, with 5%–10.3% achieving control of their hypertension.18 Countries in the Caribbean and Latin America did better than countries in SSA. Hypertension control encompasses not just medications but also preventive practices like lifestyle and dietary changes.1 To achieve SDG goal 3.4, that is, to reduce by one-third premature mortality from NCDs through prevention and treatment, there is the need to explore the barriers at the primary care level in West Africa.

Contextual factors are a range of factors that make up the wider setting within which the individual and the health system exist. They include personal, social, cultural, economic and political factors that have differing impacts across population groups.19 In this study, we analyse context using the four categories in Leichter’s framework.20 These are Situational factors such as wars, famine, epidemics, political instability; Structural factors such as economic structure, political system, technological change, degree of urbanisation, structure of the labour markets and demographic structure; Cultural factors such as the level of literacy, and values on issues such as religion, gender, participation and corruption; and Environmental or international/exogenous factors external to the political system such as the role of transnational companies and international agreements and events. These contextual factors influence access to care and individual’s decision to seek and maintain treatment for hypertension and are therefore relevant in exploring the barriers to hypertension care at primary care level in West Africa.

Individual, community, primary healthcare facility and health system factors also influence access, quality and utilisation. Some individual/patient factors like medication non-adherence, poor lifestyle and dietary choices, lack of awareness and funds to purchase medications leads to poor management of high blood pressure.21–23 Health system challenges such as poor referral systems, inadequate tools and equipment, insufficient funding and lack of sufficient health personnel poses challenges in the access to care and quality of management of hypertension at primary care facilities.22 24 25

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