The Long and Winding Road: A Systematic Literature Review Conceptualising Pathways for Hypertension Care and Control in Low- and Middle-Income Countries

Background: Hypertension control is poor everywhere, especially in low-and middle-income countries (LMICs). An effective response requires understanding factors acting at each stage on the patients' pathway through the health system from entry or first contact with the health system, through to treatment initiation and follow up. This systematic review aimed to identify barriers to and facilitators of hypertension control along this pathway and, respectively, ways to overcome or strengthen them. Methods: MEDLINE, EMBASE, Global Health, CINAHL Plus, and Africa-Wide Information (1980-April 2019) were searched for studies of hypertensive adults in LMICs reporting details of at least 2 adequately described health system contacts. Data were extracted and analysed by 2 reviewers. Themes were developed using NVivo in patient-related (sociodemographic, knowledge and health beliefs, health status and co-morbidities, trade-offs), social (social relationships and traditions) and health system domains (resources and processes). Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: From 2584 identified records, 30 were included in the narrative synthesis. At entry, 'health systems resources and processes' and 'knowledge and beliefs about hypertension' dominated while 'social relations and traditions' and 'comorbidities' assume greater importance subsequently, with patients making 'trade-offs' with family priorities during follow up. Socio-demographic factors play a role, but to a lesser extent than other factors. Context matters. Conclusion: Understanding the changing barriers to hypertension control along the patient journey is necessary to develop a comprehensive and efficient response to this persisting problem. PROSPERO Registration: CRD42017074786 Copyright: (c) 2020 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Brathwaite R, Hutchinson E, McKee M Palafox B, Balabanova D. The long and winding road: a systematic literature review conceptualising pathways for hypertension care and control in low-and middle-income countries. Int J Health Policy Manag. 2020;x(x):x-x. doi:10.34172/ijhpm.2020.105

Automated summary

This systematic review aims to identify barriers to and facilitators of hypertension control in low-and middle-income countries along the patients' pathway through the health system. The results show that at entry, health system resources and processes, as well as knowledge and beliefs about hypertension, dominate as barriers. Subsequently, social relations and traditions, as well as comorbidities, become more important. Patients make trade-offs with family priorities during follow-up. Socio-demographic factors play a smaller role compared to other factors, and context matters.