Assessing Mobile Health Capacity and Task Shifting Strategies to Improve Hypertension Among Ghanaian Stroke Survivors

Abstract

Background

There has been a tremendous surge in stroke prevalence in sub-Saharan Africa. Hypertension (HTN), the most potent, modifiable risk factor for stroke, is a particular challenge in sub-Saharan Africa. Culturally sensitive, efficacious HTN control programs that are timely and sustainable are needed, especially among stroke survivors. Mobile health (mHealth) technology and task-shifting offer promising approaches to address this need.

Methods

Using a concurrent triangulation design, we collected data from stroke survivors, caregivers, community leaders, clinicians and hospital personnel to explore the barriers, facilitators and perceptions toward mHealth related to HTN management among poststroke survivors in Ghana. Exploration included perceptions of a nurse-led navigational model to facilitate care delivery and willingness of stroke survivors and caregivers to use mHealth technology.

Results

Two hundred stroke survivors completed study surveys while focus groups (n = 4) were conducted with stroke survivors, caregivers and community leaders (n = 28). Key informant interviews were completed with clinicians and hospital personnel (n = 10). A total of 93% of survey respondents had HTN (60% uncontrolled). Findings support mHealth strategies for poststroke care delivery and HTN management and for task-shifting through a nurse-led model. Of survey and focus group participants, 76% and 78.6%, respectively, have access to mobile phones and 90% express comfort in using mobile phones and conveyed assurance that task-shifting through a nurse-led model could facilitate management of HTN. Findings also identified barriers to care delivery and medication adherence across all levels of the social ecological model.

Conclusions

Participants strongly supported enhanced care delivery through mobile health and were receptive toward a nurse-led navigational model.

Introduction

There has been tremendous surge in stroke prevalence over the past 4 decades in low- and middle-income countries (LMIC), including sub-Saharan Africa (SSA).1, 2 This scenario has been engendered by profound escalations in rates of traditional vascular risk factors such as hypertension (HTN), dyslipidemia and diabetes mellitus among adult populations in SSA.³ HTN is the most potent modifiable risk factor for incident and recurrent strokes.4, 5, 6 Differences in the levels of awareness and control of vascular risk factors, particularly HTN between populations in LMIC and high-income countries, may account for the diverging secular trends in stroke incidence and prevalence in these 2 settings over the past 40 years.

Unfortunately, the burden of stroke in SSA,7, 8 is projected to increase substantially over the next several decades,⁹ a situation likely to be compounded by the low prevalence of awareness, treatment and control of HTN in SSA.10, 11 Achieving and sustaining blood pressure (BP) control is a particular challenge in SSA.7, 12 Key factors responsible for uncontrolled HTN are medication nonadherence, failure to intensify therapy in a timely manner (i.e., therapeutic inertia) and treatment resistant HTN.13, 14, 15, 16 However, systematic reviews of randomized control trials have indicated that BP self-monitoring, medication reminder tactics and use of case managers each improve adherence, therapeutic inertia and BP levels.17, 18, 19, 20

Occurrence of prior stroke is the strongest predictor of future stroke, with this risk being greatest during the first 3 months poststroke.²¹ Initiation of prevention strategies are most effective when implemented early, monitored frequently and maintained long term after an index stroke.22, 23 Thus, culturally sensitive, efficacious BP control programs, which are acceptable, feasible, timely and sustainable are needed, especially among hypertensive stroke survivors, the group at highest risk for future stroke.²⁴ Mobile health (mHealth) technology offers a promising approach to address this need.25, 26 Most adults in SSA own a cell phone (~73%),27, 28 smart phone ownership is burgeoning (~25%)²⁹ and mHealth has produced promising results in chronic disease (i.e., HIV) management in SSA.30, 31, 32 However, the potential for mHealth for the management of vascular risk factors among stroke survivors has not been explored within the African context.

The aims of our study were to explore the barriers, facilitators and recommended mHealth intervention strategies to control HTN in poststroke survivors. Specifically, we sought to assess stroke survivors willingness to use mHealth services for stroke and HTN care, to identify what educational and training needs they would have, and explore what types of technical support was readily available. We assessed the demographics, self-reported medication adherence and attitudes of 200 stroke survivors toward mobile phone for remote monitoring for chronic disease management and then assessed perceptions and willingness of stroke survivors to participate in research studies to evaluate the feasibility of mHealth for HTN control.