While cardiovascular disease (CVD) remains the leading cause of death worldwide, new research led by NYU Grossman School of Medicine and Moi University School of Medicine (Kenya) found that adapting and incorporating social determinants of health (such as poverty and social isolation) in the clinical management of blood pressure in Kenya may improve outcomes for patients with diabetes such as hypertension.
The study – recently published online in Journal of the American College of Cardiology – found that after one year, patients who received a multi-component intervention that combined community microfinance groups with medical group visits (where patients with similar medical conditions met with a clinician and health care provider) had a 44 percent greater reduction in systolic blood pressure (SBP) compared with patients receiving standard care for hypertension or diabetes.
The combined intervention proved particularly beneficial for patients with uncontrolled baseline hypertension. Group medical visits, according to the researchers, may also have benefits that extend beyond harsh health outcomes, such as combating social isolation, increasing social cohesion, and improving clinician-patient confidence.
“We know that health outcomes are largely determined by the circumstances in which people are born, live and work, along with numerous other socio-economic factors. The patient population in our study faced significant financial barriers to access to care, ranging from inadequate health insurance, transportation costs, lost work time, and numerous other challenges, “says lead author Rajesh Vedanthan, MD, MPH, a cardiologist and director of the Section for Global Health in the Population Health Department at NYU Grossman School of Medicine .
According to Vedanthan, the approach of the study of combining microfinance and group medical visits could serve as a model for analogous programs in the United States that seek to integrate social determinants of health into healthcare delivery. The challenges faced by populations in Kenya-; financial stress, unemployment, housing instability, and food security; are experienced by various communities in the United States.
“While the exact form of implementation will need to be adapted to the local context, it is clear that people in the US are struggling with poverty, unemployment, racial discrimination and housing challenges that could benefit from a similar approach,” says Vedanthan.
How the study was conducted
The study (known as BIGPIC: Bridging Income Generation with Group Integrated Care) protocol was developed by Dr. Vedanthan and colleagues from AMPATH Kenya, a collaboration between Moi University, Moi Teaching and Referral Hospital and North American universities led by Indiana University.
The team of researchers registered 2,890 patients with diabetes and hypertension in western Kenya in four subgroups. The first group received normal AMPATH chronic disease care, which is multicomponent facility based care consisting of individual visits to a clinician and medication management. The second group received common care in combination with microfinance initiatives, such as creating savings groups for communities to bundle emergency savings and providing interest-bearing loans to group members in financial distress. The third group received group medical visits, where participants met for months with a health care worker, a clinician, and other patients with similar health challenges. The fourth received a combination of group medical visits and microfinance interventions. Researchers collected participants’ data at baseline, three and 12 months.
Financial hardship was a common thread for the majority of participants. Nearly two-thirds were unemployed, more than 75 per cent had an international wealth index of less than 40 (an indicator of poverty), and less than 17 per cent were enrolled in Kenya’s national health insurance plan.
After 12 months, forty percent of the study participants achieved blood pressure management. The greatest results were among patients in the microfinance and group medical visits arms of the study. The group that received combined microfinance and interventions for medical visits from the group recorded a 44 percent greater reduction in blood pressure compared to the group that received normal benefit-based care. Overall, women (who made up 69.9 percent of enrollments for study) experienced greater SBP reductions than men, as did younger individuals compared to older individuals. Those who actively participated in the integrated medical visit groups for microfinance groups achieved greater SBP reduction.
The findings, Vedanthan hopes, will inform similar strategies to combat other chronic diseases worldwide, including in the US
NYU Grossman School of Medicine