Beyond the numbers: why the social sciences are essential for evaluating differentiated models of hypertension care and facilitating the decentralization of care
While hypertension now has comparable prevalence levels in low- and middle-income countries (LMICs) and high-income countries, the challenges associated with its monitoring and management remain major, particularly in rural and remote areas. In Homa Bay County, Kenya, prevalence is estimated at 21.4% (2), with very limited access to diagnosis, treatment and follow-up. In this context, the introduction of Single Pill Combinations (SPCs) and World Health Organization's (WHO) recommendations for simplified, decentralized initiation of treatment offer a unique opportunity to adapt care to the realities on the fields.
“Evidence is accumulating in favor of SPCs to improve therapeutic adherence, reduce toxicity and side effects, and therefore maintain controlled blood pressure,” explains Jihane Ben Farhat, study leader and epidemiologist at Epicentre. Kenya incorporated SPC into its national recommendations since 2018, but implementation remains low, due to their limited availability and to a lesser extent the lack of qualified human resources in rural areas."
In the face of these obstacles, the integration of differentiated models of care, inspired by successful experiences in the fight against HIV, should encourage their deployment. These models propose a patient-centered approach, combining decentralization of treatment, delegation of tasks and personalized follow-up. The aim is to make care accessible, adapted and effective, even in fragile contexts. MSF's experience in implementing decentralized models for HIV in Homa Bay also provides a solid basis for experimenting with these approaches in the management of hypertension.
As part of this study, several follow-up models are proposed for people living with stabilized hypertension (a prerequisite for study eligibility):
- Standard follow-up: an individual consultation with a nurse every three months.
- Rapid pharmacy renewal: recovery of treatments every three months from a pharmacist, with individualized advice. In the event of symptoms, the patient is referred to a nurse.
- Group community follow-up at the health center: treatment delivery, information and blood pressure measurement every three months, in a group, by a community health volunteer at the health center.
- Delocalized community follow-up: same as above but carried out within a group of patients living in the same region, to reduce travel to the health center.
An initial exploratory phase took place between April 2023 and April 2025 to assess the implementation, feasibility and early outcomes of integrating differentiated models.
"Across all 699 patients followed in the observational cohort, we found high retention in care of 95% at six months, and 85% of people had well-controlled blood pressure six months after inclusion. No significant difference was observed between those followed according to the classic model and those benefiting from differentiated management modes," reports Jihane Ben Farhat.
This first phase has confirmed that the implementation of differentiated models for hypertension, inspired by the HIV experience, is feasible without compromising medical follow-up, at least in the short term, but it needs to be continued and refined to go further and adapt these models even more to patients' needs.
A mixed methods approach for adapted, sustainable care
"Traditional assessments often rely on epidemiological indicators or routine data. However useful, these approaches are not sufficient to grasp the complexity of contexts, nor to understand the perceptions, behaviors and expectations of patients and caregivers alike," stresses Endashaw M Aderie, MSF Eastern Africa and study co-investigator.
Why do some patients adhere better to one model than another? What fears or preferences influence their decision? How can social norms, gender roles or stigmatization hinder the adoption of decentralized care? This is where the social sciences make an essential contribution.
The study currently being coordinated by Jihane Ben-Farhat in Kenya is therefore based on a mixed methodology - qualitative (interviews, observations, focus groups) and quantitative (surveys, analysis of care pathways) - to:
- Assess the acceptability and feasibility of differentiated models in different contexts;
- Identify the patient profiles most likely to benefit;
- Understand the sociocultural determinants and community dynamics influencing access and continuity of care;
- Inform implementation strategies adapted to local realities.
“The qualitative study should enable us to understand the facilitating factors and obstacles to the implementation of these models, in order to optimize their deployment on a larger scale,” explains Jihane Ben-Farhat.
The fight against hypertension in LMIC cannot rely solely on biomedical innovations, however promising they may be. SPCs represent a major therapeutic advance, but their success will depend on the ability to integrate them into differentiated, flexible and patient-centered models. This requires close collaboration between patients, caregivers, policymakers, communities... and social scientists.
"The latter must be fully involved in the design, implementation and evaluation of interventions. This is an essential condition for guaranteeing the effectiveness, equity and sustainability of care", concludes the epidemiologist.
- IAA-JAS-13120-24-2025.pdf
- Hypertension in Sub-Saharan Africa: Cross-Sectional Surveys in Four Rural and Urban Communities. Plos one. Hendriks et al, 2012
©Zainab Mohammed
