Challenges and opportunities in the continuity of care for hypertension: a mixed-methods study embedded in the Tajikistan Health Services Improvement Project

Background: Hypertension, a significant risk factor for ischemic heart disease and other chronic conditions, is the third-highest cause of death and disability in Tajikistan. Thus, ensuring the early detection and appropriate management of hypertension is a core element of strategies to improve population health in Tajikistan. For a strategy to be successful, it should be informed by the causes of gaps in service delivery and feasible solutions to these challenges. The objective of this study was to undertake a systematic assessment of hypertension case detection and retention in care within Tajikistan’s primary health care system, and to identify challenges and appropriate solutions. Methods: Our mixed-methods study drew on the cascade of care framework to examine patient progression through the recommended stages of hypertension care. We triangulated data from household surveys and facility registries within Tajikistan’s Health Services Improvement Project (HSIP) to describe the cascade. Focus group discussions with local HSIP stakeholders identified the barriers to and facilitators for care. Drawing on global empirical evidence on effective interventions and stakeholder judgments on the feasibility of implementation, we developed recommendations to improve hypertension service delivery that were informed by our quantitative and qualitative findings. Results: We review the results for the case detection stage of the cascade of care, which had the most significant gaps. Of the half a million people with hypertension in Khatlon and Sogd Oblasts (administrative regions), about 10 percent have been diagnosed in Khatlon and only 5 percent in Sogd. Barriers to case detection include misinformation about hypertension, ambiguous protocols, and limited delivery capacity. Solutions identified to these challenges were mobilizing faith-based organizations, scaling up screening through health caravans, task-shifting to increase provider supply, and introducing job aids for providers.

3 Conclusions: Translating findings on discontinuities in care for hypertension and other chronic diseases to actionable policy insights can be facilitated by collaboration with local stakeholders, triangulation of data sources, and identifying the intersection between the feasible and the effective in defining solutions to service delivery challenges. Background Tajikistan has achieved significant success in reducing mortality from acute illness resulting in an increase in life expectancy at birth from 63.1 years in 1990 to 71.2 years in 2017 [1]. However, the burden of non-communicable diseases (NCDs) is increasing.
Compared to 1990, when lower respiratory diseases and diarrhea caused the most deaths, ischemic heart disease was the leading cause of death in Tajikistan in 2017, increasing in its contribution to the share of premature mortality by 44 percent from 2007 [2]. High blood pressure (BP), a risk factor for ischemic heart disease and other chronic conditions, was the third-largest driver of all-cause death and disability in 2017 [2]. Therefore, ensuring the early detection and appropriate management of hypertension can contribute towards reducing death and disability from NCDs in Tajikistan.
However, there are significant gaps in hypertension detection and management in Tajikistan. In a 2013 survey of male and female adults, above 18 years, in Tajikistan by the World Bank, only 10 percent of hypertension cases had been diagnosed, and 42 percent of respondents had ever had their BP measured. Furthermore, only 10 percent of diagnosed cases had attained BP control, indicating that their management could be improved [3]. In a nationally-representative survey of women aged 15 to 49 years carried out four years later in 2017, these challenges persisted. Only 17 percent of respondents with hypertension were aware of their condition and actively managed their BP, while 60 percent were unaware of their hypertensive status [4]. Cases of undiagnosed and inappropriately-managed hypertension represent missed opportunities to address the 4 growing burden of cardiovascular diseases in Tajikistan. Hence, the Government of Tajikistan and other stakeholders have invested in policies and programs to address gaps in service delivery for hypertension.
In Tajikistan's National Health Strategy for 2010-2020, there is a clear focus on decreasing the burden of NCDs by increasing preventive activities and promoting proactive management at the primary health care (PHC) level [5]. Furthermore, the NCD Strategy for 2013-2023 aims to reduce the prevalence of hypertension by 3 to 5 percent between 2017 and 2023 [6]. There are also national strategies focused on population health measures to reduce the risk for cardiovascular diseases and hypertension, by promoting physical activity and healthy eating, and to facilitate the appropriate management of complications of hypertension. Furthermore, Tajikistan has national clinical guidelines for hypertension diagnosis and management at the PHC level, and prescriptions have been oriented towards generic drugs by a ministerial order [7].
There have also been concerted efforts to translate these policies into practice.
Significantly, since 2013, in partnership with the World Bank, the Tajikistan Ministry of Health and Social Protection (MoHSP) has implemented results-based financing (RBF) and collaborative quality improvement (CQI) through the Health Services Improvement Project (HSIP) to increase the coverage and quality of PHC for selected conditions, including hypertension. The investment focuses on 400 PHC facilities in eight districts in Khatlon and Sogd Oblasts. Through RBF, facilities and health care providers receive monetary incentives if they attain service coverage targets, including for the diagnosis and management of hypertension. About 200 clinics, through CQI, also adopted a system for monitoring and improving service delivery for hypertension and maternal and child healthcare, including 1) guideline-informed flowsheets to facilitate evidence-based diagnosis and treatment, 2) electronic medical records to monitor patient care, 3) monthly 5 reviews of patient management and opportunities to improve services, and 4) data aggregation tools to assess facility-level trends [8].
Despite these strategies and investments since 2010, the 2017 DHS revealed that there are persistent gaps in the diagnosis and proactive treatment of hypertension in Tajikistan.
Thus, in partnership with the MoHSP, the World Bank undertook a systematic assessment of service delivery for hypertension in PHC, embedded within the ongoing investments in RBF and CQI, to assess service delivery barriers and identify appropriate solutions to these challenges. This effort is an example of implementation research, which integrates systematic assessments within ongoing programs or policies to enable learning from realworld successes and failures. Through partnerships with local stakeholders, implementation research can ask the right questions, identify context-specific causes, and delineate feasible solutions, while drawing on the global evidence on what works in other contexts. A recently-published open-access report of the MoHSP and World Bank team summarizes the results of this assessment of service delivery of hypertension [9].
In this paper, we review the process of describing the cascade of care for hypertension and identifying potential solutions to address gaps in the continuum of care. The cascade of care framework has been used in a wide range of contexts to describe retention of service users in the continuum of care for conditions requiring multiple provider-user contacts, including HIV, tuberculosis, hypertension, and diabetes [10], [11], [12], [13], [14]. These studies provide useful descriptions of discontinuities in care use and correlations with patient characteristics. Our paper builds on these analyses by drawing on the cascade of care framework and using a mixed methods approach embedded in realworld programs to understand gaps in continuity of care and propose contextually appropriate solutions. Our paper may provide useful lessons for practitioners in similar contexts who aim to use the cascade of care to develop actionable insights for improving 6 service delivery.

Methods
We use mixed methods to identify drop offs in the hypertension cascade of care, to triangulate findings, and explore potential reasons and solutions for these gaps in care.
Our quantitative approach includes analyzing household survey data and HSIP evaluation data to estimate retention across the care cascade. Our qualitative approach includes conducting focus group discussions with patients, providers, and health administrators and using thematic analysis to describe barriers and facilitators to hypertension care. We also conduct a scoping literature review of evidence-based approaches for improving health service delivery for hypertension and other chronic diseases. We integrate findings from this convergent mixed methods study design to recommend potential policy solutions to improve hypertension continuity of care in Tajikistan.

A. Describing the Hypertension Care Cascade
The management of hypertension involves multiple contacts between the provider and service user-screening, diagnosis, treatment, and monitoring-to achieve and maintain BP control, which is essential to reducing complications and preventing mortality. The cascade of care disaggregates these contacts and provides a useful framework for examining patient progression and identifying drop-offs, that is a discontinuity of recommended care by service users along the cascade of care ( Figure 1).
We defined critical stages in patient-provider interactions from pre-diagnosis to the initial attainment of BP control and their accompanying measures:  By triangulating data sources, including household surveys and facility registries, we were able to estimate the proportion of hypertensive individuals who initiated care and were retained along each step of the care cascade. Graphical descriptions of the cascade of care in both Oblasts, by age group, were presented to facilitate assimilation by the target policy and practitioner audience. The quantitative data on retention along the cascade of care illustrated the magnitude of the burden of undiagnosed hypertension and the poor treatment outcomes among diagnosed cases, and motivated discussions on the causes of 9 these gaps.

B. Understanding the Determinants of Retention in Hypertension Care Cascade
To understand the context-specific reasons for drop-offs along the hypertension care cascade, we held focus group discussions (FGDs) with service users, health providers, and health care administrators in Khatlon and Sogd Oblasts. Service users included male and female adult patients from age 18 years and above, and pregnant women with a diagnosis of hypertension. We recruited health providers at the district level and health administrators who were heads of rural health centers (RHCs) or representatives of the Oblast Health Department. In total, we included 208 participants in 18 FGDs (Table 1).  provider-, and administrator-level perspectives, which are fully described in a recentlypublished report [9].

C. Identifying Fit-for-Purpose Solutions to Improve Retention in the Hypertension Care Cascade
We defined fit-for-purpose solutions as interventions that met three criteria: 1) focuses on a barrier to or facilitator of retention in hypertension care identified in the diagnostic process; 2) empirical evidence of effectiveness in the published or grey literature, and 3) perceived by local stakeholders as applicable to PHC in Tajikistan.
Based on the identified barriers to and facilitators of retention in hypertension care, the characteristics of appropriate solutions were defined as illustrated in Table 2 below:  Figure   3.
We screened the abstracts of resulting articles and retained those that met our inclusion criteria of evaluating a program or intervention's measurable hypertension care cascaderelated outcome. We extracted the following information into a spreadsheet template: the country the intervention took place in, the target population, care cascade focus area, type of program or policy, health service level, health personnel involved, sample size, primary and secondary outcomes, and any available cost information. Whether  Discussions with key stakeholders revealed that screening and diagnosis rates are negatively affected by a lack of understanding of hypertension in the general population; ambiguous clinical protocols; the low priority given to hypertension screening; and the limited capacity to reach rural and remote communities. Prenatal care and community screening were identified as avenues that have been successful at identifying undiagnosed cases. We review these themes below.
It is common for hypertensive individuals to be unaware of their condition and for the first encounter with the health facility to occur following complications of chronic hypertension.
The connection between high BP and these complications, including cardiovascular diseases, is also not well understood by individuals with hypertension.
"Patients do not come for screening because they don't know the risks and negative consequences of hypertension." (Participant 5, Health Administrator, Khatlon Oblast).
Even in the absence of information barriers, communities face costs in terms of money and time to obtaining a screen for hypertension in the health facility or at home.
Households in remote areas are often also located a far distance from the nearest health center and may find the facility challenging to reach. These locations are also less likely to participate in community screening. Among rural populations that may not be remote, farm work during the day may prevent individuals from being screened by healthcare workers, even at home.
On the supply-side, particularly in rural and remote areas, an insufficient supply of equipment and human resources has limited the ability of service providers to screen their catchment population for hypertension, at home or in the facility. Sphygmomanometers are not replaced and calibrated regularly, reducing their accuracy in measuring BP. A high caseload for limited health workers implies that routine screening in the community and facility is de-prioritized. Furthermore, current protocols have an unclear scope of work for each health care level, lack clear guidance for service delivery in remote and rural areas, provide insufficient information on case finding, treatment adherence and common barriers to adherence, and do not consider the perspectives of providers and service user.
There are also no readily-available guides that providers could refer to when needed.
"Clinical protocols are available for the medical workers, but the language in the protocols are not easy to understand, and not adapted to existing conditions. When national protocols are being developed, they should consider realistic conditions in rural areas and geographic landscapes." (Participant 4, Health Care Provider, Sogd Oblast).
In terms of policy and programming, health administrators were unaware of the high hypertension burden and the levels of under-diagnosis. As analysis related to the burden of hypertension, diagnosis, and management of cases, was not routinely done, these statistics could not inform strategic plans for the health sector. In addition to constraints from limited financing, the NCD strategy, which is the guiding policy document, does not include specific recommendations to improve service delivery for hypertension.  [19].
Finally, introducing easy-to-use job aids can address concerns among providers about the relevance, accessibility, and clarity of guidelines for care. Job aids can provide practical and evidence-based guidance to health workers that are easy to refer to even during interactions with service users. In combination with mobilizing lower skilled health workers for hypertension screening and care management, using simplified job aids may be necessary to promote high-quality care across all skill levels. In a multi-component hypertension intervention in Bangladesh, Pakistan, and Sri Lanka, checklists were used by community health workers, nurses, and general practitioners in screening and managing care for hypertensive individuals, and resulted in substantial BP reductions [20].
While the ongoing investments in monetary incentives for health care providers and mechanisms for facility quality improvement have facilitated increases in the diagnosis of hypertension, our study revealed that there were other barriers to care that prevented case detection. A series of in-depth conversations with stakeholders and reviews of the global literature suggests that these gaps in hypertension diagnosis can be addressed in part by scaling up community screening, mobilizing lower-skilled health care providers 20 and pharmacies, and providing accessible and relevant guides for health workers.
Through the ongoing investment project, there is an entry point to introduce these solutions within the 400 participating PHCs in Sogd and Khatlon Oblasts, to monitor the resulting changes in hypertension detection rates, and to engage iteratively in the above process of diagnosing other gaps in service delivery.

Discussion
Our study is an example of implementation research that is motivated by and embedded in larger health system programs and policies. In this case, implementing the HSIP, which targeted health facility performance at the PHC level, revealed the need to better understand the current state of hypertension care in the population. We leveraged HSIP evaluation data to illustrate the magnitude of undiagnosed hypertension and the extent to which diagnosed individuals engage in care. We add to and complement HSIP efforts, highlighting opportunities and tailored solutions (e.g. screening, task shifting, and job aids) that aim to capture and retain more hypertensive individuals in care. Independent of  were several discussions about wrong beliefs about hypertension and its management in this context, including the fear of potential addiction to hypertension medication, stigma facing young women who were diagnosed with chronic conditions, and the assumption that individuals younger than 40 years did not require screening for hypertension. In reflecting over potential solutions to the service delivery challenges, the "Chaikhana" (tea house) meetings, which are social gathering places specific to the Central Asian context were identified as a means of engaging men in discussions on hypertension and its treatment.
Furthermore, health caravans, which have been used since 2009 for improving health care access in rural and remote areas in Tajikistan, was highlighted as an avenue for closing gaps in screening for hypertension in these localities.

Fit-for-purpose solutions as the intersection of feasibility and effectiveness
It was essential, in defining a solution to a service delivery challenge, that the

Consent for publication
Written informed consent for publication of study findings was obtained from all participants. A copy of the consent form is available for review by the Editor of this 26 journal.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the Ministry of Health and Social Protection on reasonable request, which includes submission of contact information, a description of the proposed analysis, and specification of data type requested to study authors. Qualitative data may not be available in full due to personally identifiable information.

Competing Interests
The motivations, findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The authors declare that they have no competing interests.

Funding
This work was supported by Decision and Delivery Science Global Solutions Group within the Health, Nutrition, and Population Global Practice in the World Bank Group.

Author's contributions
AC and NF conceived the study; AC, EG, ML, and NF designed the study protocol; EG and NF carried out the scoping review; ML and NF conducted the focus group discussions; NF undertook the data analysis describing the cascade of care; AC, EG, ML, and NF were involved in analysis and interpretation of the data; AC and EG drafted the manuscript; AC, EG, ML, and NF were involved in revisions of the manuscript for intellectual content. All authors read and approved the final manuscript. AC is guarantor of the paper.