Conectar
Hypertension is the leading global risk factor for mortality, causing over 10 million deaths annually. In sub-Saharan Africa, hypertension prevalence is high, particularly in rural areas, where it is less likely to be diagnosed, treated or controlled effectively. This results in a high burden of complications, including heart failure, stroke and kidney disease. Community-centred approaches using community health workers (CHWs), risk-based approaches and simplified treatment regimens have shown promise in improving hypertension management. However, there is limited evidence on the effectiveness of such approaches in rural sub-Saharan Africa.
The primary aim of this study is to assess the feasibility of a community-centred intervention for hypertension management in rural Kenya and The Gambia. The objectives are to evaluate the intervention’s adoption, fidelity, reach and dose; understand the mechanisms of action and contextual factors affecting its implementation; assess acceptability from the perspectives of patients, healthcare providers and policymakers; estimate the costs associated with the intervention; and evaluate study procedures to inform the design of a future full-scale trial.
We will conduct a mixed-methods, non-randomised, single-arm feasibility study, designed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) framework and checklist for feasibility and pilot studies, including best practice guidance for non-randomised feasibility studies. The study will be conducted in two rural sites: Kilifi, Kenya and Kiang West, The Gambia. The intervention was codesigned with stakeholders and includes community-based hypertension screening by CHWs, risk stratification and hypertension-mediated organ damage assessment at primary healthcare facilities, followed by treatment initiation using single-pill combination (SPC) antihypertensive therapy for eligible individuals. Training will be provided to all healthcare providers involved in the study. We will screen 500 participants aged 30–80 years at their residence (250 from each country), and we expect that about 45% will be referred for additional assessments and of these 25% (or 10% of the total sample) will be prescribed treatment with SPC. Data collection to evaluate the intervention and its implementation will involve quantitative measures of feasibility and clinical outcomes; observations to assess fidelity and costing measures; and qualitative interviews and focus group discussions with patients, healthcare providers and policymakers to understand the acceptability and contextual influences on intervention implementation.
Ethics approval was obtained from the Kenyan National Committee for Science, Technology and Innovation (ref: 415561), the Gambia Government/Medical Research Council Joint Ethics Committee (ref: 31372) and the London School of Hygiene and Tropical Medicine Ethics Committee (ref: 31372). Study findings will be disseminated through peer-reviewed publications, conferences, policy briefs, community engagement forums and accessible summaries shared via the Improving Hypertension Control in Rural sub-Saharan Africa and partner newsletters.
This study is registered with the ISRCTN- The UK’s Clinical Study Registry (ISRCTN81228019), and Pan African Clinical Trials Registry (PACTR202504839027548).
To critically analyse the federal Program of All-Inclusive Care for the Elderly (PACE) using the Integration Continuum Framework and the Conceptual Model for Nursing and Health Policy, identifying system-level strengths, equity gaps and nursing implications for long-term care reform.
The U.S. long-term care system remains fragmented and institutionally biased, disproportionately affecting dual-eligible older adults who account for outsized healthcare expenditures despite comprising just 17% of Medicare beneficiaries. Permanently authorised under the Balanced Budget Act of 1997, PACE delivers fully integrated, community-based care for individuals aged 55 and older who qualify for nursing home-level services but prefer to remain in their communities.
A policy analysis guided by dual conceptual frameworks assessing PACE structure, implementation and impact across four policy outcome levels: efficacy, effectiveness, equity and justice.
This policy analysis was conducted between May and July 2025. Two conceptual frameworks were applied to examine PACE structure, implementation and outcomes. Data sources included peer-reviewed studies, federal legislation, policy documents and grey literature published between 2020 and 2025, supplemented by international integrated care literature.
PACE demonstrates strong efficacy and effectiveness, with fully integrated interdisciplinary teams and reduced institutionalisation for enrolled older adults. However, the program falls short on equity and justice due to limited geographic reach, racial and ethnic disparities in enrollment, exclusion of Medicare-only populations and persistent nursing workforce challenges.
PACE exemplifies a high-functioning integrated model of community-based long-term care, but current policy constraints prevent it from achieving scale and equity. Without eligibility expansion, financing reform and workforce investment, its transformative potential will remain unrealised. Nurses are central to this vision and must be empowered as clinical leaders and policy advocates to sustain care coordination and advance health equity in aging populations.
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