Based on 2017 census, the population of District Central is 2,971,382 [
19]. As 45% of Pakistan’s population is children (under 18 years of age) [
21], we estimate that 1,634,260 adults (>18 years) are residing in District Central with a population density of 23,685 adults/km2. The catchment area is estimated to have 19,074 adults(>18 years) [
20]. Considering the prevalence of HTN in urban Pakistan as 18% [
21], we assume that an estimated 3,433 adults in the catchment area will have HTN. We expect to serve 20% of patients with HTN at FMHC, thus aiming to improve health outcomes for an estimated n:700 adults with HTN.
A multidisciplinary team-based approach is being adopted to create and maintain the CBHIS, with community involvement vital to optimizing and implementing ongoing activities.
Formal and informal meetings: Creation of a CBHIS and its utility in health provision at FMHC has been introduced to community leaders, faith leaders, business leaders, and other key stakeholders in the catchment area. These meetings have allowed us to understand the community's cultural dynamics, current options of care, their openness to try alternative options, and identify ways of ensuring maximal community participation. The formation of a CAB has helped with ongoing bidirectional communication, ensuring participation by families in creating and maintaining the CBHIS and informing them about services at FMHC. As stakeholders, CAB members also provide inputs into study methods, such as the feasibility of hiring community members for conducting the HAS and identifying volunteer families for piloting HAS.
Focus group discussions: To better understand the community's health-related needs, exploratory FGDs have been conducted to understand: 1) the community's perception of quality health care, 2) self-perception of health needs, 3) self-perception of health status, 4) barriers to access care, 5) attributes of a facility perceived to offer quality care, 6) self-perception about role of continuity-of-care and comprehensive care in quality health care, and 7) the willingness and paying power for quality care . Working with community leaders a private space accommodating 15-20 people was arranged. Respecting cultural nuances, separate FGDs for men, women, youth, and key stakeholders were conducted. Subsequent FGDs will be conducted amongst a representative sample for insights on FMHC-based interventions.
(B)
Health Assessment Survey (HAS)
The HAS is the basis of the CBHIS, which serves as a platform to understand the disease burden of the community and guide in prioritizing service delivery and prevention efforts at FMHC. Survey questions have been derived from existing national standardized surveys and modified to cultural context [
22‐
24]. A door-to-door survey of all consenting families in the catchment area is being conducted at baseline. A household has been identified as "Person or group of related and unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating" [
23]. However, if there is subletting, or the extended family has separate income and expenses, each is considered an independent family within the apartment
. The survey includes family level (demographics, family income, healthcare expenditure) and individual-level data (such as medical history, healthcare utilization, anthropometrics (height, weight, waist circumference), BP, and perception of health). Subsequent annual surveys will be conducted to evaluate changing demographics and disease trends.
Survey administration: The survey is being conducted in Urdu, the local language. The survey was pilot tested in the community to determine face validity. Piloted and ERC-approved versions of HAS were incorporated as an e-questionnaire in REDCap [
25]. Trained community health workers (CHWs) record responses on Android tablets. After informed consent, the survey begins with the head of the family, followed by all other consenting members.
Selection and role of community health workers: With input from CAB members, CHWs have been recruited from outside the catchment area who , 1) map the catchment area, 2) conduct surveys, 3) strengthen connections between the community and FMHC team through care coordination, such as by helping community members with HTN access FMHC services, 4) provide informal counseling on healthy behaviors, and 5) provide input to improve survey response rate.
Training of community health workers: A two-day training was conducted to enhance CHWs' competency in 1) soft skills such as respectful communication with peers and community members, time management, etc. 2) technical skills such as the use of REDCap for HAS administration, 3) clinical skills to obtain BP and anthropometric measurements, and 4) knowledge about evidence-based algorithms modified for community settings to facilitate prompt identification of uncontrolled BP and early linkage to FMHC. The research team monitors data for accuracy, completeness, and consistency every week and provides feedback to the CHWs.
Data Analysis of HAS: We will use descriptive statistics to understand 1) the burden of HTN and other NCDs in the community, 2) HTN control rates, 3) the distribution of CVD risk factors (such as smoking, obesity, and physical activity), and 4) health care utilization (outpatient and hospitals settings). Additionally, sub-group analyses will be performed using appropriate statistical tests (e.g., ANOVA, Chi-square) comparing demographics, health expenditure, access to care, and presence of comorbid illnesses among patients with 1) controlled and uncontrolled HTN, and 2) patients at FMHC and FMHC non-users.
(C)
Optimization of Services at Family Medicine Health Center
Delivery of patient - centered care is ensured by offering evidence-based clinical care through a shared decision making process [
26]. Clinical team delivers onsite educational sessions to improve health literacy related to HTN and other co-morbid illnesses. [
26] These interactions incorporate environmental and social determinants of health to stimulate self-management in HTN through a heart-healthy diet, reduction in sodium intake, increased physical activity, reduction in overweight and obesity, as well as improved knowledge of HTN risk factors. The on-site, small-group educational sessions are publicized to the wider community by CHWs and CAB members. Additionally, CHWs invite HAS participants identified with elevated BP or HTN over the phone or in-person during routine field visits [
27]. If needed, specialty referrals are arranged at AKU’s community hospital in Karimabad which is 1.5 km from FMHC.
The research team and the clinical team at FMHC meet regularly to share insights about community-level and patient-level issues.
Training for the clinical team: A two-day training of FMHC doctors and nurses was conducted to enhance clinical knowledge about HTN management and CVD risk assessment based on World Health Organization (WHO) recommendations [
28]. Training for doctors included various aspects of HTN care to administer age – and sex-specific care packages in an opportunistic manner that support: 1) diagnosis of HTN, 2) CVD risk assessment and stratification, 3) treatment initiation using appropriate antihypertensive drug class, 4) counseling about lifestyle change, modified to cultural context, 5) medication dose adjustment, 6) recognition of red flags and points of referral, and 7) introduction to the monitoring and evaluation indicators.
The scope of training for nurses covered 1) standardized BP and weight measurement, 2) diagnosis of HTN, 3) counseling about lifestyle change, modified to cultural context, 4) early recognition of red flags and points of referral, and 5) introduction to the monitoring and evaluation indicators. Ongoing capacity-building sessions will be geared towards refresher training and the inclusion of new knowledge and skills to meet evolving needs of FMHC services.
Health information technology: FMHC has a customized electronic medical record (EMR) that uses ICD-11 codes for standardized data entry [
29]. This maximizes the potential of EMR to provide structured data for analyzing disease trends and recognizing upcoming health issues at individual, family, and community levels. The EMR incorporates the individual patient's HAS data from CBHIS into their medical record using a unique survey number. This allows the healthcare team access to survey data to guide personalized counseling based on identified barriers to care to enhance self-efficacy in HTN management. EMR includes the cost of different brands of antihypertensive medications to allow physicians to identify affordable medications based on patients' paying power [
30].
Analysis of EMR data: A dashboard provides access to data in real time to facilitate interpretation and ensure the availability of information for auditing and quality improvement. Patient-level data is being analyzed to follow trends of HTN control and how this varies with other health parameters such as body mass index (BMI) and biochemical measurements (such as serum creatinine level, cholesterol level, and fasting glucose level). Additionally, EMR-generated reports summarize the utilization of FMHC services (such as initial versus follow-up ratio, clinic no-shows and patient waiting time, etc.) to improve efficiencies in clinic workflow. Data will be analyzed at six-month intervals to track change in health outcomes of patients diagnosed with HTN.
(D)
Evaluation of Integrated Community-Based Health Information System and Patient-Centered Medical Home Model
We will use the RE-AIM framework to evaluate the effectiveness of this integrated model on HTN management at the patient and community levels. RE-AIM's five domains (Reach, Effectiveness, Adoption, Implementation, and Maintenance) have been used in various settings to evaluate the impact of both clinical and community-based interventions, including the management of disease-focused interventions [
31‐
33]. Both quantitative and qualitative data will be collected to help with the monitoring and evaluation of the program. Process and outcome indicators will encompass community-level, patient-level, and FMHC-level data, such as site audits leading to identifying and addressing HTN management gaps.