Assessment of hypertension management in primary health care settings in Kinshasa, Democratic Republic of Congo

Background Hypertension-related complications have become more diagnosed at secondary and tertiary care levels, in the Democratic Republic of the Congo (DRC), probably indicative of poor management of hypertensive patients at primary health care level. This study aimed to assess the management of hypertension in primary health care settings by using guidelines of the International Forum for Prevention and Control of HTN in Africa (IFHA). Methods A multi-center cross-sectional study was carried out in primary health care settings. A total of 102 nurses were surveyed using a structured interview. Mean and proportion comparisons were performed using the t Student test and the Chi-square test respectively. The Kinshasa Primary Health Care network facilities were compared with non-Kinshasa Primary Health Care network facilities. Results From the 102 nurses surveyed; 52.9 % were female with a mean age of 41.1, (SD = 10) years, merely 9.5 % benefited from in-job training on cardiovascular diseases or their risk factors, and 51.7 % had guidelines on the management of hypertension. Less than a quarter of the nurses knew the cut-off values of hypertension, diabetes and obesity. Merely 14.7 % knew the therapeutic goals for uncomplicated hypertension. Several of the indicators for immediate referral recommended by IFHA were unmentioned. The content of patient education was lacking, avoiding stress being the best advice provided to hypertensive patients. The antihypertensive most used were unlikely to be recommended by the IFHA. Conclusions This study showed a considerable gap of knowledge and practices in the management of hypertensive patients at primary health care facilities in Kinshasa pertaining to the IFHA guidelines. We think that task-shifting for management of hypertension is feasible if appropriate guidelines are provided and nurses trained. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1236-y) contains supplementary material, which is available to authorized users.


Background
Africa is actually experiencing one of the most rapid epidemiological transitions characterized by a double disease burden with a mix of high incidence of infectious diseases and a growing prevalence of non-communicable diseases NCDs [1,2]. Moreover 80 % of the NCDs induced deaths occur in the low and middle income countries [3]. Hypertension is among the commoner NCDs.
In Sub-Saharan Africa (SSA), the prevalence of hypertension varies from 6 to 48 % [4]. In the Democratic Republic of Congo (DRC), the prevalence of hypertension has increased significantly from 14.2 % in urban areas and 9.9 % in rural areas in 1987 to 26.7 % in 2005 [5,6]. Hypertension is a major cardiovascular risk factor (CVRF); it increases cardiovascular morbidity and mortality [7].
Health System (HS) related factors have a significant impact on the control of blood pressure control [8,9]. HS in African countries is essentially oriented to managing infectious diseases. Therefore, health professionals are unprepared to deal with NCDs, given the environment with its limited resources [10,11]. Thus, cost-effective approaches are needed to lift health systems-level barriers for the management of NCDs in low and middle income countries (LMICs). The taskshifting strategy defined as the rational distribution of primary health care duties from physician to nonphysician health care providers is one of these approaches [12,13]. Previous studies carried out in LMICs have reported the effectiveness of this strategy in the management of HTN [14,15].
Task-shifting is also considered in the Health policy of the DRC which is based on Primary Health Care (PHC). A Health Center (HC) is run by a nurse. This represents the first level of care, the first-contact setting between patients and healthcare systems. Screening and management of NCDs such as hypertension and diabetes are included in the essential health activities package of HCs [16]. Patient management at the HC should comply with the Ministry of Health's guidelines. These guidelines, however, do not provide a clear indication on the management of HTN [17]. HCs have to refer patients to the General Referral Hospital (GRH) [16].
Actually, the referral health care facilities register more and more patients with HTN-related complications including stroke and chronic kidney disease (CKD) [18][19][20][21]. The Vitaraa study conducted in Southern Kivu (DRC), found that 86.4 % of hypertensive patients were uncontrolled [22]. This shows the poor control of HTN in the country.
In 2003, the International Forum for Prevention and Control of HTN in Africa (IFHA) developed the guidelines for the management of hypertension in SSA countries [23]. These guidelines were adapted from the 2002 WHO Cardiovascular Risk Management Package in lowmedium Resource Settings. The IFHA guidelines use the global approach in the management of HTN, which aims to reduce the absolute risk by the management of multiple individual risk factors [24]. These recommendations emphasize the treatment of HTN, with particular attention to cost-effectiveness and affordability in SSA countries [23].
This study aimed to assess the management of Hypertension adhering to the IFHA guidelines in the primary health care facilities.

Study design and population
A multi-center, cross-sectional study was carried in Kinshasa, the capital city of the Democratic Republic of Congo (DRC) in July 2013. A total of 36 HCs were selected using a multiple stage sampling and a total of 102 nurses were surveyed. During the first stage, 12 Health Zones (HZ) were selected out of the 35 HZ situated in the city using simple random sampling technique. During the second stage, in each selected HZ, a list of HCs was generated and HCs were stratified according to their ownership (public, private and confessional). From each category, three HCs were randomly selected. From each selected HC, three nurses involved in curative activities and present on the day of the survey, were interviewed.
The study protocol was approved by the Kinshasa School of Public Health Ethical Committee (ESP/CE/ 002/2012). All participants gave their verbal informed consent according to the Helsinki Declaration II. Participants' confidentiality was assured by not recording their identity or the name of health care facilities.

Variables
Data were collected during face-to-face interviews using a structured questionnaire. Variables were mainly drawn from the IFHA guidelines which have been adapted for the first level of care; with particular emphasis placed on clinical evaluation of risk factors adapted from the 2002 WHO Cardiovascular Risk Management Package in lowmedium Resource Settings scenario [25]. The IFHA guidelines have been summarized in terms of main skills expected from care-providers, as shown in Table 1.

Statistical analysis
Statistical analyses were performed using the statistical package for social sciences (SPSS) version 21.0. Categorical data were summarized as percentages and continuous data as mean and standard deviation (SD). Means and proportions comparisons were performed using respectively Student t-test, Chi-square test and the Fisherexact test when Chi-square could not be applied. The Kinshasa Primary Health Care network facilities (KPHC) and the non-KPHC network facilities were compared. The KPHC network facilities comprise a constellation of confessional health centers organized around referral hospitals. The KPHC network facilities have worked using an integrated approach in order to improve diabetes and hypertension care as previously described [26]. The non-KPHC network facilities are the other healthcare facilities which do not belong to this network.

Facilities identification and sample characteristics
We interviewed 102 of 108 nurses (response rate: 94.4 %). As summarized in Table 2, the majority of surveyed health facilities did not belong to the KPHC network (78.0 %). More than half of the nurses were female (52.9 %). Nurses from the KPHC network were older (44.9 ± 9.3 years vs. 40.0 ± 10.0 years) (p = 0.043) and had a lower level of qualification (72.7 % vs. 36.2 %) (p = 0.002) than those working in the non-KPHC network. In terms of responsibility in the facility, 71.6 % were not the head nurses.
Job training and existence/availability of guidelines Table 2 also summarizes the existence of job training and guidelines. Although, 84 nurses declared they had already received in-job training, only a negligible proportion of them (9.5 %) have received in-job training on cardiovascular diseases or on their risk factors (hypertension, diabetes…). Furthermore, the proportion of those who had received injob training on cardiovascular diseases and on related risk factors was significantly lower in the non-KPHC network facilities compared to the KPHC network facilities (3.1 %  Assessment of health-care providers' knowledge Table 3 presents an assessment of health-care providers' knowledge. More than 50 % of health providers in both groups were able to mention at least one CVD. Nurses from the KPHC network were more capable than those from non KPHC network in naming at least three cardiovascular risk factors (68.2 % vs. 30.0 %) (p = 0.001). The most common cardiovascular risk factor mentioned was stress (60.0 %). The cut-off values of BP for HTN (≥140/90 mmHg) was reported by less than half of them and this proportion was lower among nurses of non-KPHC network compared to those of KPHC network (17.5 % vs. 40.9 %) (p = 0.040). The cut-off value of diabetes (≥126 mg/dl) was mentioned by less than one fifth of nurses, but this proportion was lower among nurses from non KPHC network (1.3 % vs. 13.6 %) (p = 0.031).

Discussion
This study shows a considerable gap in knowledge and practices among nurses in their management of hypertension according to the IFHA guidelines. Secondly, few health-care providers declared having used the guidelines for the management of HTN. Although, KPHC providers were more knowledgeable than those from non-KPHC facilities, their knowledge and practices were, however, sub-optimal according to the IFHA guidelines. The lack of an adequately trained health workforce for the management of non-communicable diseases is described as a challenge for SSA countries [27,28]. This is corroborated by our findings where it was reported that a low proportion of nurses have received in-job training on cardiovascular diseases or on their risk related factors while a majority of them have reported to have already received in-job training probably on infectious diseases.
In the global approach, the knowledge of cardiovascular risk factors is essential for patients' cardiovascular risk assessment but also for the patients' management which must be global. In this study, we found that a low proportion of nurses were knowledgeable on cardiovascular diseases and their risk related factors. Stress was the most cardiovascular risk related factor mentioned and its prevention the commonest advice provided to hypertensive patients; whereas the commoner cardiovascular risk factors such as tobacco consumption, unhealthy diet including excessive alcohol intake and physical inactivity were less mentioned. It is described that the control of these CVRFs has a favourable effect on blood pressure [29]. Counseling by health providers can have a significant impact in motivating and supporting patients' behavioural change; unfortunately very often health providers inappropriately counsel patients about their life style as also reported by previous studies [30,31]. This study indicates that the index of obesity was unknown by almost all care-providers. Nevertheless, it is established that obesity is a predictor of mortality among hypertensive patients and that weight loss significantly decreases blood pressure [20,32]. It suggests that health providers do not place emphasis on evaluating clearly patients' nutritional status. This finding is corroborated by Mongati et al. who reported that none of the health workers interviewed in their study knew how to measure waist circumference [31]. The awareness of therapeutic goals is a major element for preventing clinical inertia among healthcare providers and their ignorance is a factor in the poor control of blood pressure. Clinical inertia is defined as the failure of health-care providers to initiate or to intensify therapy when therapeutic goals are not reached [33]. Mendis et al. found that a lower proportion of non physician health care workers (NPHWs) knew the goals of treatment for uncomplicated hypertension compared to physicians (39 % vs. 75 %) [34]. This study provides an even worse conclusion than Mendis et al.
According to the IFHA guidelines, patients with a high or very high cardiovascular risk should be referred to a higher health care level. Among patients with a high cardiovascular risk are included hypertensive patients with antecedents of diabetes, cardiovascular diseases, CKD; patients with hypertension grade 1 or 2 associated to 3 or more other cardiovascular risk factors and all patients with hypertension grade 3 [18]. Some of them, namely patients with HTN grades 3, patients with signs of stroke and patients in coma have been the most mentioned indications for immediate referral among the surveyed nurses. Subsequently, the management of this category of patients should not be realized at primary health level but at a General Referral Hospital or at the highest level of health care. This study shows that some patients with a high or very high cardiovascular risk are being managed at the HC level which provides only an essential package of care, insufficient for managing patients in this category. This could explain the frequency of hypertension-related complications registered at the high care level.
Furthermore, this study showed that Alpha methyldopa, Furosemide and Thiazides were the most administered antihypertensive drugs by nurses; this finding corresponds almost to that of Mendis et al. [34], whereas the IFHA guidelines indicate that the anti-hypertensive drugs with central action like Methyldopa should only be used for resistant hypertension [23]. Also, it is more expensive than hydrochlorothiazide [34]. On the other hand, Furosemide is also recommended according to the IFHA guidelines for selected indications including congestive heart failure, advanced renal disease or refractory hypertension [23] and not for all patients.
Despite the fact that nurses of KPHC network had lower qualifications than others, their knowledge and practices were better probably because these healthcare providers received in-job training and were in possession of guidelines with a global approach that recommends hydrochlorothiazide as the first line drug. The non-KPHC network facilities had their guidelines included in the guidelines of care at Health Centers produced by the DRC Ministry of Health. These guidelines, place the diagnosis of hypertension in the symptoms' context notably headache or coma and recommends Furosemide associated with diazepam as antihypertensive medication. The DRC Ministry of Health recommends to HCs to manage hypertension but it does not provide them with suitable resources. We think that the task-shifting for hypertension management is feasible in DRC if appropriate guidelines are produced and nurses trained like reported by previous studies (14,15).
However, this study has some limitations. The first limitation is related to the setting and small sample size which makes findings unrepresentative of the country. There is also a limitation from data collection; nurses surveyed self-reported their practices which were not observed. To the best of our knowledge, this study is the first to have assessed the management of HTN at the primary level of care facilities including also facilities which do not belong to the KPHC Network. In addition, this study can be a starting point for improving the management of HTN in the DRC.

Conclusion
This study showed a considerable gap in knowledge and practices related to management of hypertensive patients at primary health care facilities in Kinshasa according to the IFHA guidelines. This situation was mainly due to the lack of in-job training and the non-optimal quality of therapeutic guidelines on the management of hypertension. These findings imply that the improvement of the healthcare service delivery for hypertension requires that healthcare providers be trained, and that appropriate therapeutic guidelines are designed.

Availability of supporting data
The data set supporting the results of this study is available in an additional file.