I-RREACH: an engagement and assessment tool for improving implementation readiness of researchers, organizations and communities in complex interventions.

BACKGROUND: Non-communicable chronic diseases are the leading causes of mortality globally, and nearly 80% of these deaths occur in low- and middle-income countries (LMICs). In high-income countries (HICs), inequitable distribution of resources affects poorer and otherwise disadvantaged groups including Aboriginal peoples. Cardiovascular mortality in high-income countries has recently begun to fall; however, these improvements are not realized among citizens in LMICs or those subgroups in high-income countries who are disadvantaged in the social determinants of health including Aboriginal people. It is critical to develop multi-faceted, affordable and realistic health interventions in collaboration with groups who experience health inequalities. Based on community-based participatory research (CBPR), we aimed to develop implementation tools to guide complex interventions to ensure that health gains can be realized in low-resource environments. METHODS: We developed the I-RREACH (Intervention and Research Readiness Engagement and Assessment of Community Health Care) tool to guide implementation of interventions in low-resource environments. We employed CBPR and a consensus methodology to (1) develop the theoretical basis of the tool and (2) to identify key implementation factor domains; then, we (3) collected participant evaluation data to validate the tool during implementation. RESULTS: The I-RREACH tool was successfully developed using a community-based consensus method and is rooted in participatory principles, equalizing the importance of the knowledge and perspectives of researchers and community stakeholders while encouraging respectful dialogue. The I-RREACH tool consists of three phases: fact finding, stakeholder dialogue and community member/patient dialogue. The evaluation for our first implementation of I-RREACH by participants was overwhelmingly positive, with 95% or more of participants indicating comfort with and support for the process and the dialogue it creates. CONCLUSIONS: The I-RREACH tool was designed to (1) pinpoint key domains required for dialogue between the community and the research team to facilitate implementation of complex health interventions and research projects and (2) to identify existing strengths and areas requiring further development for effective implementation. I-RREACH has been found to be easily adaptable to diverse geographical and cultural settings and can be further adapted to other complex interventions. Further research should include the potential use of the I-RREACH tool in the development of blue prints for scale-up of successful interventions, particularly in low-resource environments.

Improving health equity for First Nations, Inuit and Métis people: Ontario's Aboriginal Cancer Strategy II.

Cancer incidence is increasing more rapidly and cancer survival is worse among Ontario's First Nations, Inuit and Métis (FNIM) populations than among other Ontarians. Cancer Care Ontario's Aboriginal Cancer Strategy II aims to reduce this health inequity and to improve the cancer journey and experience for FNIM people in Ontario. This comprehensive, multi-faceted strategy was developed and is being implemented with and for Aboriginal Peoples in Ontario in a way that honours the Aboriginal Path of Well-being.

Hypertension management initiative: qualitative results from implementing clinical practice guidelines in primary care through a facilitated practice program.

The goal of the Hypertension Management Initiative (HMI) is to improve the management and control of hypertension by both primary care providers and patients. The HMI was in effect in 11 primary care sites across the province of Ontario, Canada. This was a qualitative study. Focus groups and a lobby survey were completed with a total of 199 of the 3934 patients enrolled in the study. Interviews with 41 participating health care providers from all sites were performed. A qualitative description approach was used to give a rich description of each informant's experiences. Patients expressed motivation and engagement in their own health care and became more knowledgeable about hypertension and how to manage it with their health care providers. Most reported satisfaction with the discipline of regular appointments and ongoing monitoring and counseling of the program including identifying and working on goals for their modifiable risk factors. Their health care providers felt the HMI program had a positive impact on the treatment and management of hypertension and also that it improved the functioning of the interprofessional team. The HMI helped to improve patient self-empowerment and self-management and also improved physicians' and nurses' confidence in diagnosing accurately and in hypertension management. Physician buy-in is key to maintaining clinical hypertension management. Interprofessional collaboration was improved for physicians and nurses but less so for pharmacists. Greater confidence among the nurses to manage hypertension more independently reduced demands on physician time.

Therapeutic benefit of internet-based lifestyle counselling for hypertension.

BACKGROUND: Preventive electronic (e)-counselling has been shown to reduce cardiovascular risk factors. However, heterogeneity in outcomes is commonly reported due to differences in e-protocols. We incorporated key features of an established behavioural therapy, motivational interviewing, to help standardize e-counselling in order to reduce blood pressure in patients with hypertension. METHODS: Subjects (n = 387, mean age = 56 years, 59% female, 72% taking ≥ 1 antihypertensive drug) were diagnosed with stage 1 or 2 hypertension. Subjects were randomized to a 4-month protocol of e-counselling (beta version of the "Blood Pressure Action Plan", Heart and Stroke Foundation of Canada) vs waitlist control (general e-information on heart-healthy living). Outcomes were systolic, diastolic, and pulse pressures, and total lipoprotein cholesterol after treatment. RESULTS: Intention to treat analysis did not find a significant group difference in outcomes due to contamination across the 2 arms of this trial. However, per protocol analysis indicated that subjects receiving ≥ 8 e-counselling messages (a priori therapeutic dose) vs 0 e-counselling messages (control) demonstrated greater reduction in systolic blood pressure (mean, -8.9 mm Hg; 95% confidence interval [CI], -11.5 to -6.4 vs -5.0 mm Hg; 95% CI, -6.7 to -3.3, P = 0.03), pulse pressure (-6.1 mm Hg; 95% CI, -8.1 to -4.1 vs -3.1 mm Hg; 95% CI, -4.3 to -1.8, P = 0.02) and total cholesterol (-0.24 mmol/L; 95% CI, -0.43 to -0.06 vs 0.05 mmol/L; 95% CI, -0.06 to 0.16, P = 0.03), but not diastolic blood pressure. CONCLUSIONS: These findings support the merit of evaluating whether e-counselling can improve blood pressure control and reduce cardiovascular risk over the long-term.

A framework for discussion on how to improve prevention, management, and control of hypertension in Canada.

Increased blood pressure is a leading risk for premature death and disability. The causes of increased blood pressure are intuitive and well known. However, the fundamental basis and means for improving blood pressure control are highly integrated into our complex societal structure both inside and outside our health system and hence require a comprehensive discussion of the pathway forward. A group of Canadian experts was appointed by Hypertension Canada with funding from Public Health Agency of Canada and the Heart and Stroke Foundation of Canada, Canadian Institute for Health Research (HSFC-CIHR) Chair in Hypertension Prevention and Control to draft a discussion Framework for prevention and control of hypertension. The report includes an environmental scan of past and current activities, proposals for key indicators, and targets to be achieved by 2020, and what changes are likely to be required in Canada to achieve the proposed targets. The key targets are to reduce the prevalence of hypertension to 13% of adults and improve control to 78% of those with hypertension. Broad changes in government policy, research, and health services delivery are required for these changes to occur. The Hypertension Framework process is designed to have 3 phases. The first includes the experts' report which is summarized in this report. The second phase is to gather input and priorities for action from individuals and organizations for revision of the Framework. It is hoped the Framework will stimulate discussion and input for its full intended lifespan 2011-2020. The third phase is to work with individuals and organizations on the priorities set in phase 2.

Heart and Stroke Foundation of Ontario (HSFO) high blood pressure strategy's hypertension management initiative study protocol.

BACKGROUND: Achieving control of hypertension prevents target organ damage at both the micro and macrovascular level and is a highly cost effective means of lowering the risk for heart attack and stroke particularly in people with diabetes. Clinical trials demonstrate that blood pressure control can be achieved in a large proportion of people. Translating this knowledge into widespread practice is the focus of the Hypertension Management Initiative, which began in 2004 with the goal of improving the management of this chronic health condition by primary care providers and patients in the community. METHODS: This study will test the effect of a systems change on the management of high blood pressure in real world practice in primary care in Ontario, Canada. The systems change intervention involves an interprofessional educational program bringing together physicians, nurses and pharmacists with tools for both providers and patients to facilitate blood pressure management. Each of two waves of subjects were enrolled over a 6 month period with the initial enrollment between waves separated by 9 months. Blood pressure will be measured with the BpTru automated blood pressure device. To determine the effectiveness of the intervention, a before and after analysis within all subjects will compare blood pressure at baseline to annual measurements for the three year study. To assess whether the intervention has an impact on blood pressure control independent of community trends, a betwen group comparison of baseline blood pressures in the delayed wave will be made with the immediate wave during the same time period, so that the immediate wave has experienced the intervention for at least 9 months. The total enrollment goal is 5,000 subjects. The practice locations include 10 Family Health Teams (FHTs) and 1 Community Health Centre (CHC) and approximately 49 primary care physicians, 15 nurse practitioners, 37 registered nurses and over 150 community pharmacists across the 11 communities throughout the province of Ontario. The 11 primary care sites will be divided into immediate and delayed groups based on geography and the use of an electronic versus a traditional chart patient record. DISCUSSION: Initial consideration was given to randomizing the groups, however, for a number of reasons, this was deemed to not be possible. In order to ensure that the sites in the immediate intervention and delayed intervention groups are not different from each other, the sites will be assigned to the intervention groups manually to ensure a distribution of the variables as evenly as possible. Given that HSFO approached this particular group of health care providers to participate in a program relating to hypertension, this may have heightened their awareness of the issue and affected their management of patients with hypertension. Thus, data will be collected to allow an assessment of previous practice patterns and determine any impact of the Hawthorne Effect. TRIAL REGISTRATION: Clinicaltrials.gov NCT00425828.

Antihypertensive medication use and blood pressure control: a community-based cross-sectional survey (ON-BP).

BACKGROUND: The Ontario Blood Pressure (ON-BP) survey reported high treatment and control rates for hypertension in the province of Ontario, Canada, in a survey performed in 2006. This study examined patterns of utilization of antihypertensive drug classes and their impact on blood pressure (BP) control. METHODS: Cross-sectional, population-based survey of adults, 20-79 years of age (population 7,996,653). Responses are weighted to the Ontario hypertensive population of 1,498,045. RESULTS: Of all hypertensives, 51 and 49% were on monotherapy vs. 2+ drug therapy with similar control rates (86 vs. 80%, respectively). In those on monotherapy a renin-angiotensin system (RAS) blocker was the most commonly used drug class (62%) and use of other drug classes was only approximately 10%. In those on 2+ therapy, a RAS blocker was also the most common class (80%), followed by a diuretic (67%). In diabetics with hypertension 46 and 54% were on monotherapy vs. 2+ drug therapy with significantly higher control rates on monotherapy (90 vs. 46%). RAS blocker was also the most common drug class (85 and 80%, respectively), but in those on 2+ drugs only 45% were on a diuretic. Control rates did not differ by type of drug treatment in the overall hypertensive population and those with a comorbidity, but were low in diabetics on 2+ therapy and particularly in those on a calcium channel blocker (CCB) or diuretic. CONCLUSIONS: High treatment and control rates of hypertension in Ontario are associated with high utilization of RAS blockers. Diabetics on 2+ therapy are the least effectively controlled, possibly reflecting the limited use of diuretics.

Results of the Ontario survey on the prevalence and control of hypertension.

BACKGROUND: Available information on the prevalence and management of hypertension in the Canadian population dates back to 1986-1992 and probably does not reflect the current status of this major risk factor for cardiovascular disease. We sought to evaluate the current prevalence and management of hypertension among adults in the province of Ontario. METHODS: Potential respondents from randomly selected dwellings within target neighbourhoods in 16 municipalities were contacted at their homes to request participation in the study. For potential respondents who agreed to participate, blood pressure was measured with an automated device. Estimation weights were used to obtain representative estimates of population parameters. Responses were weighted to the total adult population in Ontario of 7,996,653. RESULTS: From 6436 eligible dwellings, contact was made with 4559 potential participants, of whom 2992 agreed to participate. Blood pressure measurements were obtained for 2551 of these respondents (age 20-79 years). Hypertension, defined as systolic blood pressure of 140 mm Hg or more, diastolic blood pressure of 90 mm Hg or more, or treatment with an antihypertensive medication, was identified in 21.3% of the population overall (23.8% of men and 19.0% of women). Prevalence increased with age, from 3.4% among participants 20-39 years of age to 51.6% among those 60-79 years of age. Hypertension was more common among black people and people of South Asian background than among white people; hypertension was also associated with higher body mass index. Among participants with hypertension, 65.7% were undergoing treatment with control of hypertension, 14.7% were undergoing treatment but the hypertension was not controlled, and 19.5% were not receiving any treatment (including 13.7% who were unaware of their hypertension). The extent of control of hypertension did not differ significantly by age, sex, ethnic background or comorbidities. INTERPRETATION: In Ontario, the overall prevalence of hypertension is high in the older population but appears not to have increased in recent decades. Hypertension management has improved markedly among all age groups and for both sexes.