Adaptation, implementation, and evaluation of the HEARTS technical package in primary health care settings in Jordan to improve the management of hypertension: a pilot study

The majority of patients with hypertension in Jordan have uncontrolled blood pressure. This study aimed to adapt and implement the hypertension management protocol (a module in the HEARTS technical package) in health care centers in Jordan and evaluate its effectiveness on hypertension management and control. The hypertension management protocol was adapted and implemented in six health centers followed by training of the healthcare staff on the adapted protocol. Patients above 18 years old who attended health centers during the study period were recruited consecutively. The blood pressure of 852 patients was monitored over 4 months, using an individual patient treatment card. At the baseline visit, the proportion of patients with uncontrolled blood pressure was 71.5%. After 4 months of the implementation of the protocol, the proportion of patients with uncontrolled blood pressure decreased to 29.1%. Of all studied characteristics, age was the only significant predictor of achieving blood pressure control. Patients aged ≤50 had a higher rate of controlled blood pressure readings after 4 months of implementation of the protocol compared to patients older than 60 years (OR = 1.98, 95% CI: 1.07, 3.67; P value = 0.028). In conclusion, the implementation of the HEARTS hypertension management protocol has successfully achieved better control of the blood pressure of the enrolled patients after 4 months of implementation. To achieve better control of hypertension in the general population, integrating evidence-based strategies for hypertension control that are listed in the HEART technical package into routine care is strongly recommended.


INTRODUCTION
Hypertension is a major non-communicable disease (NCD) that increases the risk for coronary heart diseases, cerebrovascular diseases, and overall morbidity and mortality [1][2][3].The prevalence of hypertension is expected to increase by 7.2% between 2013 and 2030 [4].In low-and middle-income countries, the burden of hypertension is immense, increasing, and is felt disproportionately where two-thirds of cases are found, largely due to widespread risk factors in those populations in recent decades [1].In the Eastern Mediterranean Region (EMR), the crude prevalence rate of hypertension is estimated to be around 29.5% with wide variability between countries; ranging from 28% in the United Arab Emirates to 41% in Libya and Morocco [5].
The results of the Jordan National STEPwise Survey (STEPs) in 2019 have revealed that NCDs including cardiovascular diseases (CVD), cancer, hypertension, diabetes, and chronic respiratory diseases are the leading cause of morbidity and mortality in Jordan, constituting 78% of the total deaths [6].In 2020, hypertension was the second leading cause of death according to the data of the Jordan Ministry of Health (MoH) [7].
The few studies conducted in Jordan showed a high prevalence rate of hypertension and low rates of awareness, treatment, and control among hypertensive patients.The prevalence of hypertension has increased from 29.4% in 1994 to 32.0% in 2018, with more than two-thirds of Jordanians (70% of men and 65% of women) on antihypertensive medications having uncontrolled hypertension [8].Another study in Jordan reported an age-standardized prevalence rate of 33.8% among men and 29.4% among women and a hypertension awareness rate of 57.7% among men and 62.5% among women [9].Moreover, the study reported that more than two-thirds of Jordanian patients on antihypertensive medications had uncontrolled hypertension [9].The most probable reasons for the low rate of hypertension control among Jordanian adults include lack of evidence-based hypertension management practices, ineffective management of hypertension, and inadequate adherence to medications [9].
In many low-and middle-income countries, there is a wide gap between current practice and evidence-based recommendations.Treatment of major CVD risk factors remains suboptimal, and only a minority of patients who are treated reach their target levels for blood pressure, blood sugar, and blood cholesterol.In other areas, overtreatment can occur with the use of non-evidence-based protocols.A recent WHO assessment of the primary healthcare services (unpublished) in Jordan has identified main gaps, deficiencies, challenges, or problems in the management and control of hypertension such as shortage of equipment, commodities, and supplies; unavailability of the diagnostic procedures; problems in the infrastructure; shortage of staff and unavailability of an electronic system for patient medical information entry.In addition, another recent unpublished study by UNICEF in Jordan showed that most NCDs management guidelines were outdated and did not reflect the best available evidence.Therefore, standard treatment protocols are needed to improve the quality of clinical care, reduce clinical variability and simplify the treatment options in primary health care.
To improve hypertension management, the application of the evidence-based hypertension management protocol included in the HEARTS technical packages [10] appears as a good evidencebased solution in primary health care settings and aligns with WHO's Package of Essential Non-communicable Disease Interventions.The protocol provides guidance on when and how to measure blood pressure, how to establish and confirm diagnosis of hypertension, who should receive hypertension treatment, what medications should be used to treat hypertension, and what treatment targets to be achieved.Moreover, the protocol provides information on how to ensure adherence to medication by teaching the patient how to take the medications at home, informing the patient of the complications of untreated hypertension and checking the patient's understanding before the patient leaves the health center.The hypertension protocol is simple clinical-management protocol that is drug-and dose-specific, and includes a core set of medications.
Before the implementation of the hypertension management protocol, an assessment of the 23 Comprehensive Health Centers revealed many areas for improvement in human resources, equipment, infrastructures, and other resources such as developing an updated guideline/protocol for hypertension management, training the PHC staff on these guidelines, providing PHC centers with the necessary equipment and establishing e-registry to improve documentation of data [11].The main objectives of this study were to adapt and implement the hypertension management protocol of the HEARTS technical package in health care centers in Irbid and Mafraq governorates and evaluate its effectiveness on hypertension management and control.

Study sites and settings
The intervention was implemented in 6 health centers in two governorates in North of Jordan, namely Irbid and Mafraq governorates.Irbid governorate has the second largest population in Jordan after Amman Governorate and the highest population density in the country.The 6 centers provide primary care services including services for NCDs such as screening, treatment, and follow-up.The selection of health facilities was guided by meeting with the staff at Primary Health Directorate at the MoH and the Health Directorates.

Adaptation of the HEARTS hypertension management protocol
The study team has engaged stakeholders through meeting with national policymakers to guarantee strong, high-level political commitment, leadership, and ownership by the MoH, and has established a technical working group (TWG) that includes local subject-matter experts and representatives from institutions.Strategic planning and a consensus workshop were convened to provide an opportunity for stakeholders to contribute their expertize in the implementation plan of the project, adaptation, and approval of HT and DM management guidelines and service delivery models.This was followed by an adaptation of the HEARTS hypertension management protocol and service delivery models in collaboration with the TWG according to the Jordanian context.The guidelines and other materials were prepared using HEARTS Technical Package as a reference.TWG had the chance to contribute their expertize and recommendations to the preparation of materials through the consensus workshop.

Implementation
The intervention included a package of HT, DM, and CVD Risk Assessment guidelines, HT and DM Service Delivery Models and CVD Risk Assessment posters, and two brochures: one targeting health care providers and the other for patients with hypertension.The hypertension management protocol and educational materials were distributed to the 6 health centers.This was followed by training the healthcare staff on the hypertension management protocol.All health service providers (primary health care providers, health-facility managers, and district supervisors) were trained in 3-day workshops.In these workshops, an assigned core trainer provided comprehensive training on issues related to local/global CVD burden, treatment protocols, service delivery, patient monitoring, assessment, and supervision for patients with hypertension or diabetes mellitus.Topics included evidence-based hypertension management protocol, healthy lifestyle, CVD Risk assessment, service delivery model, and communication skills.

Data collection
Patients above 18 years old were recruited consecutively in health centers (n = 852).A review of patient data took place at each visit of an individual patient.At the health-facility level, individual patient monitoring involved monitoring the health status and the management of hypertension over 4 months, using an individual patient treatment card (Annex 1).A patient treatment card was used to monitor BP control, adherence to medication, follow-up examinations, investigations, and complications.It contained patients' identification information, diagnosis of hypertension and/or diabetes mellitus, brief medical history, treatment of hypertension and/or diabetes mellitus, lifestyle modification, blood pressure and blood sugar readings for the initial and follow-up visits, investigations, and complications.A minimum of four visits were needed for each patient, hence, a minimum of four blood pressure readings were obtained.

Blood pressure measurement
According to the HEARTS hypertension management protocol, blood pressure was measured using an automated electronic device with an appropriate cuff size, while the patient in a sitting position with back supported and legs uncrossed.The diagnosis of hypertension was confirmed if systolic blood pressure (SBP) on two visits on different days was ≥140 mmHg and/or diastolic blood pressure (DBP) on both days was ≥90 mmHg.Blood pressure was considered controlled when SBP < 140 mmHg and DBP < 90 mmHg.For patients with diabetes or a high risk of CVD, lower targets (SBP < 130 mmHg and DBP < 80 mmHg) were used.

Ethical approval
Ethical approval was obtained from the Institutional Review Board of the Jordan MoH and Jordan University of Science and Technology.Written informed consent was obtained from all participants.

Data analysis
Blood pressure was considered controlled if <140/90 mmHg.Data were entered and analyzed using the Statistical Package for Social Sciences software (IBM SPSS version 24).Categorical data were described using percentages and quantitative data were described using means and standard deviation.Chi-square was used to compare the patients' characteristics according to blood pressure control at the baseline visit and to compare blood pressure control after 4 months of the intervention according to demographic and clinical characteristics.Paired t-test was used to compare the mean SBP and DBP measurements at the baseline and after the implementation of the intervention.Binary logistic regression was used to determine factors associated with controlled hypertension after 4 months of the hypertension management protocol implementation among patients who had uncontrolled hypertension at the baseline.All tests assumptions were tested and met.A p value of <0.05 was considered statistically significant.

RESULTS
Patients' characteristics as the baseline A total of 852 patients were enrolled in the study and followed up for 4 months after the baseline visit.The number of patients with uncontrolled blood pressure at the baseline visit was 609 (71.5%) and the number with controlled hypertension was 243 (28.5%).
Table 1 shows the patients' demographic and clinical characteristics according to blood pressure control at the baseline visit.At the baseline, patients with controlled and those with uncontrolled blood pressure did not differ significantly in age, gender, history of heart attack and stroke, and chronic kidney disease.The prevalence of smoking was significantly higher among patients with uncontrolled blood pressure compared to patients with controlled blood pressure (21.9% vs. 15.3%, p = 0.030).
Blood pressure control after 4 months of the intervention implementation Figure 1 shows the changes in the mean SBP and DBP over time.The mean SBP and DBP decreased significantly over time during the 4 months period of the implementation of the intervention.After 4 months of the implementation of the hypertension protocol, the mean SBP decreased significantly from 147.3 mmHg at the baseline to 132.8 mmHg (p < 0.001) and the mean DBP decreased significantly from 91.4 mmHg at the baseline to 82.4 mmHg (p < 0.001).
At the baseline visit, the proportion of patients with uncontrolled blood pressure was 71.5%.After 4 months of the implementation of the hypertension management protocol, the proportion of patients with uncontrolled blood pressure decreased to 29.1%.Of the total 609 patients with uncontrolled blood pressure at the baseline visit, 380 (62.4%) had controlled blood pressure readings after 4 months of the implementation of the hypertension management protocol (Fig. 2).
The proportion of patients who achieved controlled blood pressure after 4 months did not differ significantly according to age, sex, prior heart attack, prior stroke, diabetes, and smoking.Table 2 shows blood pressure control after 4 months of the protocol implementation among patients who had uncontrolled hypertension at the baseline (N = 609) according to demographic and clinical characteristics.Although it was not significantly different (P value = 0.067), patients with no chronic kidney disease had a higher rate of controlled blood pressure readings after the implementation of the hypertension protocol (63.0% vs. 41.2%).

Multivariate analysis
Table 3 shows the multivariate analysis of factors associated with achieving blood pressure control after 4 months of the protocol implementation among patients who had uncontrolled hypertension at the baseline.Of all studied characteristics, age was the only significant predictor of achieving blood pressure control.Patients aged ≤50 had a higher rate of controlled blood pressure readings after 4 months of implementation of the protocol compared to patients older than 60 years (OR = 1.98, 95% CI: 1.07, 3.67; P value = 0.028).

DISCUSSION
In Jordan, the lack of updated national guidelines for the management of hypertension that provide up-to-date information and facilitate the translation of new evidence into clinical practice contributes to the challenges in managing hypertension [11].
Therefore, this study aimed to adapt, implement, and evaluate hypertension control following the implementation of the HEARTS hypertension management protocol in six health centers in Jordan.The baseline analysis revealed that only 28.5% of adults already on antihypertensive medications in Jordan had achieved the target blood pressure control of <140/90 mm Hg.This finding is in agreement with the findings of a previous national study showing that the hypertension control rate in Jordan is as low as 30.7% of men and 35.1% of women [9].Studies in the EMR countries such as Iran, Sudan, and the United Arab Emirates reported higher blood pressure control rates of 38.9%, 54.3%, and 38%, respectively [12][13][14].However, blood pressure control rates in EMR countries are considered low, in contrast to those in Western European and North American countries [15].This is likely due to poor awareness and access to treatment in the EMR countries, and lack or poor adherence to updated, and evidencebased hypertension management guidelines.
The low blood pressure control rate in our study might be due to many factors.At the patient level, it has been suggested to result from patients' inadequate adherence to medications and recommended lifestyle [9].The financial constraints for those who pay out of pocket may also be related to the low control of blood pressure, considering that ~67% of Jordanian citizens are covered by health insurance [16].The low blood pressure control rate could also be explained by the Jordanian health system capacity and readiness for hypertension management.A recent assessment of 23 health centers in Jordan found poor availability of and training on evidence-based guidelines for hypertension in Jordan [11].In addition, a recent unpublished study in Jordan showed that most NCDs management guidelines were outdated and did not reflect the best available evidence [17].This may lead to inappropriate selection of antihypertensive medications by the physician as well as therapeutic inertia-defined as failure of the health care provider to initiate or intensify therapy when therapeutic goals are not met, which is considered a major cause of uncontrolled hypertension [18].There is also a shortage of equipment, commodities, and supplies, unavailability of diagnostic procedures, shortage of staff, and unavailability of an electronic system for patient medical information entry [11].
The baseline analysis also shows that the prevalence of smoking was significantly higher in patients with uncontrolled blood pressure than in patients with controlled blood pressure.This suggests that smoking cessation and other lifestyle changes need to be addressed comprehensively in practice.Thus, it is important to adopt an updated guideline for the management of hypertension that includes both nonpharmacological and pharmacological approaches.
After 4 months of implementing the hypertension management protocol, mean SBP and DBP decreased significantly and the proportion of patients with uncontrolled blood pressure decreased from 71.5 to 29.1%.These findings indicate that the implementation of the hypertension management protocol has successfully achieved better control of the blood pressure of the enrolled patients.It is difficult to decide on which component of the hypertension management protocol contributed more to reduction in blood pressure measurements.The approach included guidance on accurate blood pressure measurement, counselling and drug therapy using a core set of medicines and basic technology.The HEARTS hypertension management protocol is a simple treatment algorithm that a primary health team can effectively implement, which is fully aligned with the 2021 WHO guideline on hypertension.It emphasizes enough the quality of blood pressure measurement for diagnosis and treatment.
The study also showed that the odds of reaching blood pressure control after 4 months of implementing the hypertension management protocol in patients with uncontrolled hypertension at baseline was significantly higher in people aged 50 years or less than in patients older than 60 years.This is consistent with global studies showing that blood pressure controlling blood pressure is more difficult to achieve in the elderly, primarily because of agingrelated structural changes in the arteries, multimorbidity, and difficulty in making sustained lifestyle changes in this population [19].In addition, many physicians may be reluctant to adequately treat hypertension in older patients, possibly due to a lack of information or uncertainties about side effects, which may lead to undertreatment.
A total of 18 countries have adopted the HEARTS technical package, mostly in Latin America and the Caribbean, in addition to Ethiopia, India, Nigeria, the Philippines, Thailand, Turkey, and Vietnam [20].Many of these countries are expanding the number of participating health care facilities and the geographic coverage of the program, as blood pressure control rates have improved considerably, consistent with the improvement observed in the current study [20].For example, after 1 year of implementing a hypertension management program based on the HEARTS technical package in a community health center in Matanzas, Cuba, the blood pressure control rate in treated registered patients, increased from 59.3 to 68.54%, prompting efforts to expand the program to the entire Cuban population [21].Similarly, in India, after an average of 6 months of implementation of a hypertension management program based on the HEARTS technical package in 4 different states, the blood pressure control rate increased from 22.3% at baseline to 70.4%.The absolute increase in blood pressure control rate in primary care of 48.1% in India is relatively comparable to the 39.3% reported in this study and may suggest that a longer duration of implementation is associated with better control rates [22].India's program has now been expanded to several states and is expected to cover 100 districts in all Indian states nationwide, reaching a population of ~200 million people [22].
The long-term implementation along with adherence to the guidelines in the HEARTS package would offer an opportunity for better management of hypertension in the elderly or other groups by educating physicians on the optimal drug doses and blood pressure targets.However, weak leadership capacity in primary health care in Jordan [23] might challenge the largescale implementation of the HEARTS package in Jordan.These barriers were similar to those identified in the implementation of a comprehensive health system improvement program for the management of hypertension in the Yaroslavl region, Russia [24].However, barriers were overcome by using data to understand the situation and focusing on understanding the causes of suboptimal performance, implementing sustained and targeted educational activities, and engaging administration from the top [24].
Studies in Jordan reported that health care workers in Jordan are poorly trained in the management of hypertension and that hypertension management practices of recent medical school graduates are no better than those of older graduates [11,25].Therefore, training on the most current hypertension treatment guidelines and protocols, such as the HEARTS package, is urgently needed.Reflecting on Cuba's experience, this issue was addressed at the beginning of the project, as the HEARTS program offered a certification course on accurate blood pressure measurement for health care providers, and medical students were involved in the intervention hypertension control program as part of their regular community practical training [21].Jordan may also face further challenges in the frequency training, as the high turnover of staff in Jordan requires regular training, for which more financial and human resources must be available [26].
The lack of a comprehensive data repository for the entire health information system in Jordan may lead to limited use of data in further developing, adapting, and updating the components of the HEARTS package [27].Here, the establishment of a comprehensive hypertension registry in Jordan will allow access to clinically important data that will enable the prioritization of patient subgroups.In addition, regular assessment of patients' clinical risk using registry data will help establish thresholds for initiating drug treatment tailored to local economic and cultural factors in Jordan.For example, the Egyptian hypertension guidelines use a higher diagnostic blood pressure value as a cost-effective strategy in a society with limited healthcare resources [28].In Cuba, the establishment of a hypertension registry with reporting capabilities for quality of care indicators was a critical success factor for the implementation of HEARTS strategies and was seen as a strong motivator for health care teams to improve their performance in controlling hypertension [20].Thus, the establishment of a hypertension registry in Jordan will provide highly generalizable data that can be used to improve population health surveillance, support research, and inform policy.It will also help health systems identify and prioritize patients with hypertension for updated and country-specific practice guidelines.

Limitations
One of the main limitation of this study was that we did not use 24 h blood pressure monitoring.This monitoring is of particular value in detecting patients with 'white coat' hypertension who may not need treatment.Another limitation is the lack of a control group which limits the inferences and conclusions we can draw from this pre-test/post-test study.The lack of a control group makes it difficult to compare if the amount of any observed change in blood pressure from pre-test to post-test differs from a group that did not receive the intervention.However, one should note that the intervention was conducted over a short period of time in the health centers where there was no any other event occurring at the same time that could be the cause of the change in blood pressure.

Fig. 1 Fig. 2
Fig.1Changes in the mean systolic and diastolic blood pressure between baseline and last visits.

Table 1 .
Patients' demographic and clinical characteristics according to blood pressure control at the baseline visit.

Table 2 .
Blood pressure control after 4 months of the HEARTS protocol implementation among patients who had uncontrolled hypertension at the baseline (N = 609) according to demographic and clinical characteristics.

Table 3 .
Multivariate analysis of factors associated with controlled hypertension after 4 months of the HEARTS protocol implementation among patients who had uncontrolled hypertension at the baseline.