Title: NIHR Global Research Group on Improving Hypertension Control in Rural Sub-Saharan Africa (IHCoR-Africa)
Funder: Department of Health and Social Care

Abstract: Sub-Saharan Africa (SSA) has one of the highest prevalences of hypertension worldwide. The impact is particularly damaging in rural SSA where the prevalence of hypertension is as high as urban settings, but awareness, treatment and control is lower. _x000D_ _x000D_ The failure to control hypertension in rural SSA has multiple and complex causes across the hypertension control cascade, including limited access to healthcare services. _x000D_ _x000D_ Community-centred approaches using community health workers can play a key role in managing hypertension in areas remote from health facilities. However, no study has been conducted in rural SSA that demonstrates this. _x000D_ _x000D_ We will co-develop (with strong community and stakeholder engagement) a feasible and sustainable community-centred approach to target hypertension management more effectively and efficiently. _x000D_ _x000D_ Our activities will take place across two rural sites in: Kilifi, Kenya, and Kiang West, The Gambia; settings with a high burden of both hypertension and poverty. _x000D_ _x000D_ Our objectives are to:_x000D_ 1) Understand the experiences, needs, and practices at the individual, organisational and system levels to detect, treat and control hypertension;_x000D_ 2) Determine the optimal diagnostic and risk stratification approaches for people with hypertension;_x000D_ 3) Develop and evaluate the feasibility of a community-centred programme to improve the management of hypertension;_x000D_ The research will be divided into three linked work packages that match the specific objectives above. We will adopt a multidisciplinary research approach including document review; in-depth interviews, focus groups with patients living with hypertension, healthcare workers and other key stakeholders; cross-sectional studies to determine the accuracy of different blood pressure measurement methods and novel risk stratification approaches with point-of-care devices; a co-creation design to develop the intervention; and a study to evaluate its feasibility. _x000D_ _x000D_ The IHCoR-Africa Group is a partnership between KEMRI Wellcome Trust Kenya Research Programme, Medical Research Council The Gambia and The London School of Hygiene & Tropical Medicine. We also have participation from government (Ministries of Health in Kenya and The Gambia), civil society (Non-Communicable Disease Alliance Kenya and Alcohol Policy Alliance in The Gambia), scientific organizations (Pan African Society of Cardiology, Kenya Society of Cardiology and African Academy of Science), and community representatives._x000D_ _x000D_ Our established and strong engagement with key stakeholders and community will ensure grassroots dissemination and sustained implementation of findings beyond the research period. We will also pursue traditional dissemination routes including publishing results in academic journals and presenting at international conferences._x000D_ _x000D_ The project will take place over 42 months and will also provide a focused, but ambitious, capacity strengthening programme including four post-doctoral positions, and strong technical skills and research strengthening programmes for over 200 African researchers. _x000D_ _x000D_ Finally, through collaboration with our multiple partners and other hypertension research groups from Uganda, Tanzania, Ghana, and Nigeria we will further develop an African multidisciplinary hypertension network which will serve as platform for future research.

Lay abstract: Background_x000D_ Many people live with high blood pressure in Sub-Saharan Africa (SSA, the areas of Africa south of the Sahara Desert), where the rate is amongst the highest in the world. In SSA, high blood pressure occurs at young ages, few people are treated, and high blood pressure causes severe complications and premature deaths. This is a serious health concern particularly in SSA where there is little knowledge of, or treatment for this condition._x000D_ The causes of the high impact of high blood pressure in rural SSA are multiple including lack of clear symptoms; restricted access to healthcare; and competing demands on time which may prevent people from going to clinics and seeking care._x000D_ One suggested approach to improve the management of people with high blood pressure in rural SSA is to use a community-centred approach, where care is more actively promoted and brought into the community to remove obstacles in accessing it. _x000D_ Aims_x000D_ Our proposed NIHR Group will develop and assess a community-based approach to improve the identification and management of high blood pressure in rural SSA (in Kilifi, Kenya and Kiang West, the Gambia)_x000D_ To achieve this aim, we have the following specific objectives:_x000D_ 1) To understand what is currently done (and what needs to be done) at all levels from patients to the whole healthcare system. To understand how the current healthcare system operates, and what changes need to be made, from patients upwards. _x000D_ 2) To improve the way community workers can decide whom to treat for high blood pressure._x000D_ 3) To co-create, with patients and health workers, and test a new community-based programme for treating high blood pressure. _x000D_ _x000D_ Methodology_x000D_ The research will be divided into three linked work packages that match the specific objectives above. We will adopt a multidisciplinary research approach including document reviews; in-depth interviews, focus groups with patients living with high blood pressure, healthcare workers and other key stakeholders; cross-sectional studies; a co-creation design to develop the intervention; and, a cluster feasibility trial to test it. _x000D_ The work is being developed in partnership by the KEMRI-Wellcome Trust in Kenya, MRC the Gambia and The London School of Hygiene & Tropical Medicine. Within the core research team, there is a strong expertise in high blood pressure research. There is support from other key stakeholders including existing local community health organisations and the Ministries of Health in Kenya and the Gambia. Community engagement and involvement are key to this work. Existing community health worker organisations and patients have been consulted in the development of this work and will contribute throughout the research as part of interviews, focus groups and the co-creation process._x000D_ In addition to the research, we will provide a training programme in hypertension research in SSA._x000D_ _x000D_ Dissemination_x000D_ The research team involved in this work includes staff closely linked with the local community and community health workers, collaborators from non-governmental and governmental organisations who will ensure grassroots dissemination and sustained implementation of the findings beyond the research period. We will also pursue traditional dissemination routes including publishing results in academic journals and presenting the results at international conferences.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CARDIOVASCULAR