Study characteristics
This evaluation included eight primary health facilities; four pilots and four non-pilots from two Administrative Zones and one Metropolitan City in the Amhara region. For treatment and control domains, of 474 hypertensive patient-chart pairs involved in the study in each stratum, 422 in pilot facilities and 415 in non-pilot facilities met the inclusion criteria, response rate, 89% and 87.6% respectively. The median age of patients was 56 years, IQR 47-66 years in pilot facilities and 55 years, IQR 46-64 years in non-pilot facilities. Nearly half 421(50.3%) were females (Data not shown)
The HEARTS Technical Packages implementation
Healthy Life style
All pilot (4/4) and all non-pilot (4/4) facilities had incorporated healthy lifestyle counseling practice into routine healthcare and used a standardized healthy lifestyle counseling tool. Half (2/4) of pilot and none (0/4) of non-pilot facilities had incorporated a routine NCD-related health education program in the morning sessions (Table 1)
Evidence-based treatment
All (4/4) pilot and none (0/4) of non-pilot facilities utilize the WHO’s hypertension diagnosis and treatment guideline. All pilot (4/4) and half (2/4) of non-pilot facilities use a standard case definition of hypertension. Furthermore, all (4/4) pilot facilities and none (0/4) of non-pilot utilize the major NCD treatment guidelines of Ethiopia (Table 1)
Availability and affordability of core antihypertensive medications and technologies
All (4/4) pilot and all (4/4) non-pilot facilities ensured the availability of essential anti-hypertensive medicines. Half of (2/4) pilot facilities and quarter of (1/4) non-pilot facilities were equipped with essential technologies including BP measuring apparatus and basic laboratory tests like renal function test, complete blood count, and lipid profile (Table 1)
Risk-based management
All pilot (4/4) and non-pilot facilities had incorporated CVD risk monitoring indicators in their reporting form as: low risk (< 10%), moderate risk (10-20%), high risk (20-30%) and very high risk (≥ 30%). The system to predict a 10-year CVD risk of a patient also existed in half of pilot and quarter of non-pilot facilities. The CVD risk treatment threshold was clearly indicated and delineated in all facilities (Table 1)
Team care and task-sharing
In half of pilot and non-pilot facilities, physicians initiate, refill, and update anti-hypertensive medications, assess the CVD risk and decide next appointment while non-physician health workers counsel patients, document relevant records, and compile and report data. Hypertension care was decentralized to the community level in all pilot facilities. Health extension workers were actively involved in lost to follow-up tracing and resuming care (Table 1)
Systems for monitoring
All pilot and non-pilot facilities had clear indicators to monitor BP control trends at three, six, 12, 24 and 36 months. However, all pilot and non-pilot facilities neither did analyzed the routine data nor did use it for action and response (Table-1)
Hypertension prevention
All (4/4) pilot and one-fourth of non-pilot facilities had incorporated the opportunistic BP screening practice for adults’ ≥ 30 years in the routine care. Three hundred eighty four (91%) of individuals in pilot facilities were screened thier BP 95% CI: 87.8–93.5%, which is significantly higher when compared to non-pilot facilities 314 (75.7%), 95% CI: 71.2–79.7%. One in five (19.9%), 95% CI: 16.2–24% of individuals screened for hypertension in pilot facilities and 14.9%, 95% CI: 11.7–18.6% in non-pilot facilities were confirmed to have hypertension (Figure 2)
Hypertension treatment
The initial antihypertensive medications were prescribed according to WHO protocol for 321 (76.1%), 95% CI: 71.7–80.1% of patients in pilot facilities and 295 (71.3%), 95% CI: 66.6–75.6% in non-pilot facilities, with a statistically significant difference in the protocol adherence between facilities. Likewise, there was a statistically significant difference in anti-hypertensive treatment intensification for patients between pilot facilities 349 (82.7%) 95% CI: 78.7–86.2% and non-pilot facilities 330 (77.8%) 95% CI: 73.5–81.7%. Moreover, patients in pilot facilities had better understanding of anti-hypertensive therapy (98.3% vs 96.1%) and its treatment target (59.5% vs 42%), chi-square test, p < 0.05 (Table 2)
Hypertension control
Three hundred fifty four (83.9%) of hypertensive patients in pilot facilities had reported never use of tobacco 95% CI: 80–87.3%, with no a statistically significant difference among patients in non-pilot health facilities 350 (84.5%), 95% CI: 80.7–87.9%. However, there was a statistically significant difference in avoidance of alcohol among patients in pilot facilities 345 (81.8%), 95% CI: 77.7–85.3% and those in non-pilot facilities 319 (77.1%), 95% CI: 72.7–81%. Moreover, the rate of BP control was better in pilot facilities 219 (51.9%), 95% CI: 47–56.8% than non-pilot facilities 179 (42.4%) 95% CI: 37.7–47.3% (Table 2)
Effectiveness of hypertension prevention, treatment and control efforts
The pilot facilities demonstrated better implementation of the WHO HEAERTS package than non-pilot facilities (75% vs 50.9%), chi-square test, X2=37.4; p < 0.001. The corresponding hypertension prevention, treatment and BP control performances among pilot and non-pilot facilities were 72.8%, 85.3% and 49.8%, and 43.6%, 55% and 42.7%, respectively. There was a statistically significant difference in mean performances of three domains between pilot and non-pilot facilities (76% vs 51.2%) t-test, t=2.13; p=0.042. Furthermore, pilot facilities demonstrated better BP control than non-pilot facilities, chi-square, X2=0.823; p < 0.001 (Table 3).