A novel cardiovascular prevention program in the slums of Nairobi, Kenya: SCALE UP Study

Transcription

1 A novel cardiovascular prevention program in the slums of Nairobi, Kenya: SCALE UP Study Steven van de Vijver, MD, Samuel Oti, MD, Gabriela B. Gomez PhD, Charles Agyemang PhD, Joep Lange, Prof, Catherine Kyobutungi, PhD Steven van de Vijver 3 November 214, City Health Conference Amsterdam

2 The new global epidemic: Cardiovascular Diseases Cardiovascular Diseases (CVD) killer number one worldwide Caused by globalisation and urbanisation Epidemic from high to low-income Billions unaware but at risk Majority of urban population lives in slums Lack of sustainable models of management in slum settings 1

3 Blood pressure in the African natives Over two years at a native hospital in the South of Kavirondo in Kenya, during which period approximately 18 patients were admitted, no case of raised blood pressure was encountered, although abnormally low blood pressure was not uncommonly encountered. On no occasion was a diagnosis of arteriosclerosis or chronic interstitial nephritis made. Donnison C. Blood pressure in the African natives: its bearing upon aetiology of hyperpiesa and arteriosclerosis. Lancet. 1929;1:6 7. 2

4 Kenya Luo Migration Study Demonstrate the magnitude, timing, and cause of changes in blood pressure that occur in migrants from a low blood pressure population on moving to an urban area. A controlled longitudinal observational study of migrants as soon after migration as possible and follow up at three, six, 12, 18, and 24 months after migration. A cohort of controls living in a rural area who were matched for age, sex, and locality were also observed at the same periods. Poulter NR, et all BMJ. 199;3(673):

5 Urbanization and slums in Africa Africa continent with highest urbanization rate In 2 years >5% African population urban Kampala, Mbuji-Mayi, Niamey 5-57% growth From 395 million 29 > 1,23 billion in 25 African urban population 72% in slums Increasing Gini coefficient African cities (,73) 4

6 The problem of CVD in Sub Saharan Africa Deaths from CVD are among highest causes of death in SSA (28) Deaths of CVD compared to other diseases in Header SSA % of all deaths Deaths (mln People) 2.5 HIV/AIDS CVD 1,32 1, % 12.5% CVD Respiratory Infections Diarrhoeal Diseases Malaria,77,96 1, % 9.1% 7.3% HIV/AIDS Injuries,74 7.1% Tuberculosis Tuberculosis,41,,5 1, 1,5 Million Deaths 3.9% Year Malaria 5

7 Raised blood pressure most important risk factor for CVD... Hypertension #1 risk factor for CVD Even more pronounced in Sub Saharan Africa Hypertension Cholesterol Insufficient Fruits & Vegetables intake High Salt intake BMI Tobacco Insufficient phycical activity Alcohol % of DALYs (world wide) from CVD attributable to risk factor Sources: WHO - Comparative Quantification of Health Risks, WHO - Global atlas of CVD prevention and control (211) Prevalence of raised blood pressure in Africa significantly higher than other regions 6

8 ... and increasing over time in Sub Saharan Africa Mean SBP of the male population has increased in Kenya......and even more apparent difference in the female population SBP (mmhg), age standardized mean 14 SBP (mmhg), age standardized mean Uganda South Africa 135 Uganda 13 Kenya Tanzania Netherlands 13 South Africa Tanzania Kenya United States 12 Netherlands United States Year Year Note: Age standardized mean is calculated as if each country has the same age composition as the world population. Source: MRC-HPA Centre for Environment and Health 7

9 SCALE UP Aim: to develop, implement and evaluate a cost-effective model for prevention of CVD in slum settings that is sustainable and scalable July 211- July 212 Development model Aug 212- Jan 214 Implementation model Feb 214- Dec 214 Evaluation and dissemination Partners: Amsterdam Institute for Global Health and Development (AIGHD), African Population and Health Research Center (APHRC), Ministry of Health Kenya Location: Viwandani and Korogocho slums in Nairobi, Kenya 8

10 SCALE-UP: Development phase Methods 1. Secondary analysis of earlier CVD studies: less than 2% of hypertension patients aware, and 85% dropout mainly in the first six months 2. Qualitative research for clarification earlier studies and implementation new interventions: Medication cost major issue 3. Systematic review of best practices: training and involvement guidelines for CHW and nurses 4. Cost-effectiveness and feasibility study by BCG 9 9

11 CVD Risk factors in Nairobi slums Female Male Hypertension 23.8% 17.2% Diabetes 4.9% 4.1% Overweight 27.9% 17.2% Obesity 21.9% 5.% Smoking.9% 21.1% 1

12 High dropouts with basic screening/treatment 87% of patients with hypertension have dropped out 63% of patients with diabetes have dropped out 49% of patients with diabetes and hypertension have dropped out Patients with hypertension Patients with diabetes Patients with hypertension and diabetes (1%) 256 (87%) Average duration enrollment drop outs: 162 days (1%) 114 (63%) Average duration enrollment drop outs: 258 days (1%) 15 (49%) Average duration enrollment drop outs: 292 days (13%) (37%) (51%) Total Drop outs Still enrolled Total Drop outs Still enrolled Total Drop outs Still enrolled Note: Patients that only come one visit and have a BP of >14 systolic or >9 diastolic are taken into account.patients that are not hypertensive at first visit are left out Note: Patients that have had a visit in last two months of WDF study are considered to still be enrolled in study and are not considerd drop outs Source: WDF study 11

13 If compliant: BP 16mmHg reduced Improvement for patients that dropped out of the program Improvement for patients that are still enrolled in the program # of drop-out patients # of enrolled patients Average reduction systolic BP 7 mmhg Average reduction systolic BP 16 mmhg Total dropouts < >6 Total enrolled patients < >6 BP reduction (mmhg) BP reduction (mmhg) 12

14 SCALE UP Study 13

15 2 Address the key leakages Leakage model: a lot of people are 'lost' along the way from 'being in risk group' to 'reduced risk for CVD' -x% x% -x% -x% -x% -x% People diagnosed with low risk People informed about need for lifestyle change People change lifestyle -x% -x% -x% -x% -x% People in risk group People aware of risk on hypertension People aware of possibility of screening People coming to screening People adequately diagnosed with risk People diagnosed with medium/ high risk People aware and understanding of diagnosis People seeking treatment People getting right medicines / lifestyle advice People taking meds for 1st time / Adopt healthier lifesty People being long-term compliant Reduced risk on CVD / Controlled BP Awareness Access to screening People seeking and getting treatment People being long term compliant Population screening Population intervention Patient intervention 14

16 Based on earlier study and expert opinions, several key leakages have been identified 2 Address the key leakages -5-75% ~% -x% ~ -5-75% ~ People diagnosed with low risk People informed about need for lifestyle change People change lifestyle ~ -6% ~ ~ -8% People in risk group People aware of risk on hypertension People aware of possibility of screening People coming to screening People adequately diagnosed with risk People diagnosed with medium/ high risk People aware and understanding of diagnosis People seeking treatment People getting right medicines / lifestyle advice People taking meds for 1st time / Adopt healthier lifesty People being long-term compliant Reduced risk on CVD / Controlled BP Source: CVD study, WDF study, APHRC expert opinion Current hypotheses for key causes of leakages Population screening Population intervention Patient intervention 15

17 Example of measure cost effectiveness in screening Options Explanation Total coverage Total costs (KES) Door-2-door screening 1 person per village Screening + counselling: 3 min Intro / exit: 1 min Total 4 min Utilization : 8% Target: Home during 1st visit Home during 2nd visit Want screening? Total screening 15. 5% 3% 9% 88 people Preparation Medical supplies Patient materials Salaries Total costs Medical camp Medical camp with ~6 nurses screening people Every Saturday on a different location Aware: Want to go: Is able to go: Has time to go: Not working: Total screening % 85% 6% 85% 36 people Preparation Camp materials Medical supplies Patient materials Salaries Total costs chemistry Location within pump (or chemistry) Aware Anyway to pump And willing for screening Especially to pump Total screening 11. 5% 8% 2% 6 people Preparation Location Medical supplies Patient materials Salaries Total costs Permanent ASK (within existing facility) ASK Permanent facility 1 per village open 3 days a week Aware Will go to ASK Total screening 11. 5% 5.5 people Preparation Location Medical supplies Patient materials Salaries Total costs

18 Costs People 1 USD per year/per person Total population Awareness Access to screening Awareness Access High risk Incentive Seeking treatment Consultation + Meds Incentive Long term compliance Consultation + Meds Elements of model # of ppl enrolled Screening age above 35 34,491 Baraaza Religious Radio Door 2 Door campaign by CHW Patients with high risk Voucher for patient Incentive CHW Consultation Medication Train trainer SMS Discount for compliance Compliance bonus CHW 7,414 6,32 5,672 1, Consultation Medication 65% compliant in year 1 Leakage 21% 85% 9% 21% 8% 1% 65% 1% Variable pp Variable Fixed Investments % of people moving on to next step ,42 4,979 11,639 2,756 3, ,454 4,35 1,98 1,666 Total costs yr 1 Average running costs yr 2 1 Subtotal ,66 2,756 3,279 8,759 12,574 46,971 Prog mgmt 13,884 Total yearly costs Total costs (1 yrs) Note: All costs are in USD 6,855 27,16 35,29 17

19 Summary of selected interventions for treatment model for SCALE UP project in Korogocho Awareness Access to screening Seeking treatment Long term compliance Door-to-door screening (and awareness) campaign by CHW 1 Push campaign to reduce high leakage in screening step Voucher representing value of first treatment Lower barrier to go to clinic Group incentive: subsidizing medication Leverage social support to stay compliant Baraaza Community gathering to create buy in from local (political) leaders Incentive CHW for correct referral Convince and stimulate patient to go to clinic Incentivizing CHW Stimulate adherence in first six months Religious services Announce door-to-door screening campaign Train the trainer for patient support group members Build knowledge within local community Short radio commercials Announce door-to-door screening campaign SMS to improve adherence Use mobile technology to stay in touch with patient 1. CHW = Community Health Worker 18

20 Preliminary outcomes Total population Awareness Access to screening Awareness Access High risk Incentive Seeking treatment Consultation + Meds Incentive Long term compliance Consultation + Meds Screening age above 35 Baraaza Religious Radio Door 2 Door Patients with campaign by high risk CHW Voucher for patient Incentive CHW First consult Train trainer SMS Discount for compliance Compliance bonus CHW Follow up consults Follow up 23% 74% 23% 87% 67% 77% Real numbers 29,17 6,78 5, Estimations 34,491 21% 77% 21% 8% 1% 65% 19

21 Following the manual below allows for making required adjustment to the model for the new targeted location 1 Design of the intervention model Risk Factors Awareness Access to screening Seeking treatment Long term compliance Determine the relative importance of the different risk factors for CVD in the target location In case of different prevalence: adjust focus of the intervention model to relevant root causes Determine the best option for the awareness campaign Which channels are required for political buy-in? Which channels are trustworthy? Detail screening campaign based on local situation Determine the target age group What is the prevalence of hypertension in different age groups? Detail incentives for patients based on local situation Detail incentives for patients based on local situation Determine the incentive scheme for the community health coordinator Incentive for 'right referrals to the clinic' Incentive for long term compliance 6 Determine the overall cost effectiveness of the intervention model Using the provided excel tool, an estimation of the overall costs can be made based on the cost assessment per step Using the provided excel tool, an estimation of the health benefits can be made 2

22 Proposed Scale Up of intervention model in three waves Wave 3 Wave 2 Wave 1 1. Scale Up to other slum locations in Kenya Proposal to start with Scale Up to other slum locations in Kenya Proof of concept in Kenya Relationships built with key stakeholders in Kenya Involvement (on the side) of government in Korogocho project 2. Scale Up to other slum locations in Sub Saharan Africa Second wave of Scale Up in Sub Saharan Africa due to various similarities Similar prevalence of Risk Factors (a.o. related to prevalence of hypertension for people with similar ethnicity) Similar health care systems (in terms of design and maturity) 3. Scale Up to other slum locations world wide Third wave of Scale Up to other slums world wide Potentially (small) adjustments in the model required due to different levels of importance of risk factors and health care systems 21

23 Reverse innovation to migrants in Amsterdam 22

24 Thank you! 23