Older adults receive most of their end-of-life care in the community, but there are few published data to guide researchers on recruitment to studies in primary care. The aim of this study was to compare recruitment of patients and bereaved carers from general practices in areas with different research network support, and identify challenges in obtaining samples representative of those in need of end-of-life care.Comparative analysis of recruitment from general practices to two face-to-face interview studies concerned with 1) carers’ perceptions of transitions between settings for decedents aged over 75 years and 2) the experiences of older patients living with cancer at the end-of-life.33 (15% of invitees) patients and 118 (25%) carers were interviewed. Carers from disadvantaged areas were under-represented. Recruitment was higher when researchers, rather than research network staff, were in direct contact with general practices. Most practices recruited no more than one carer, despite a seven fold difference in the number of registered patients. The proportion identified as eligible for patient interviews varied by a factor of 38 between practices. Forty-four Primary Care Trusts granted approval to interview carers; two refused. One gave no reason; a second did not believe that general practitioners would be able to identify carers.Obtaining a representative sample of patients or carers in end-of-life research is a resource intensive challenge. Review of the regulatory and organisational barriers to end-of-life researchers in primary care is required. Research support networks provide invaluable assistance, but researchers should ensure that they are alert to the ways in which they may influence study recruitment. End-of-life research presents a range of specific challenges. Deteriorating health for patients and strain on carers limit the desire and the ability to participate in research at the end-of-life. The resulting high rates of attrition and low levels of participation in studies have been widely discussed in the literature,2. WhilsThe requirement for research to be approved by a Research Ethics Committee and the organisation where the research will be carried out  research governance in the United Kingdom (UK)) provides important safeguards for patients. These safeguards are in place to protect potentially vulnerable people from being exploited or distressed by research that is intrusive or inappropriate. In common with many other countries, the UK does not allow direct approaches by researchers to patients. Data prAs with all safeguards, it is important that protection should be commensurate with the level of risk. In the If end-of-life care research is to be methodologically sound and useful to clinicians-15, it nParticipant accrual is one of the most important issues in end-of-life care research. There iThere have been a number of changes since much of the published work on the research process was completed. The processes of applying for NHS Research governance in the UK have recently been centralised. UK data protection law has been strengthened and applications for research ethics committee approval streamlined. In the UK, there has been substantial investment in research infrastructure, with the establishment of research networks in every English region, with staff funded to assist recruitment to approved studies.The aim of this paper is to report on the processes of recruitment to end-of-life studies with carers and patients in three different health regions of England, and identify any common challenges. We compare recruitment in areas where researchers are in direct contact with GPs with those in which research network staff intervene between researchers and GPs.Data in this paper are drawn from two separate studies.This study aimed to understand bereaved carers’ perspectives on the end-of-life care experiences of their friend or relative. The focus of enquiry was on movements or transitions between places of care in the last year of life. One hundred and eighteen bereaved carers were recruited and interviewed. They had looked after adults aged over 75 years who died with heart failure, stroke, chronic obstructive pulmonary disease, lung, colorectal or breast cancers. Interviews took place between four and nine months after the death of the care recipient.Study two aimed to explore the experiences of and preferences for care at the end-of-life, amongst older adults in their last year of life. Participants were identified from lists of patients registered with general practitioners. They were eligible if they were in the study age range (75 years and above), had a cancer diagnosis recorded in their medical notes, and if the responsible health professional judged that the patient was in the last year of life.  Interviews were conducted with 33 older adults aged over 69 years and living with advanced cancer. A majority (20) lived alone, the rest had co-resident spouse or children.NHS research governance approval was obtained from 44 NHS Primary Care Trusts (PCTs). Two refused: one felt that the recruitment method would not work, the other gave no reason. A resubmission with more detailed argument to the first PCT was also unsuccessful.In 107 out of 118 cases, carers were identified by the general practitioners who had looked after the older adult decedent. Eleven carers were recruited through local publicity, or word of mouth amongst health professionals in the study areas.In all three regions of England, help with identifying general practitioners who were interested in participating, was given by NHS funded research support network. In the two regions in the south of England, the research network staff publicised the study to general practices that had previously identified themselves to the network as being interested and able to participate in research studies. The network staff then put the research team into direct contact with interested GPs. In the third region, network staff publicised the study, liaised with practices, and then visited to search the patient database. They also assisted with sending invitation letters to potential participants.Figureth percentile 0%, 50th percentile 12.5%, 75th percentile 33.3%). TableIn regions 1 and 2 where detailed data were available on recruitment by GP practice, the number of people interviewed per practice was generally one or none. Three practices identified five or six interviewees. The number of potential participants identified was not related to the number of patients on the GP list. The proportion of people invited who went on to be interviewed, ranged from zero to 100%, with a median of 12.5%, . In general practice, the number of patients identified as potential interviewees was unrelated to the size of the practice, or the level of socioeconomic disadvantage with the Primary Care Trust. Two PCTs were amongst the most disadvantaged in England, whilst the other two contained a greater range of socioeconomic experiences Table.The number of patients identified and invited to participate by each GP practice are shown in TableEnd-of-life care research is sensitive by the nature of the subject matter it seeks to investigate. Researchers working in this area must also consider the role of research networks, research governance authorities and gatekeeping clinicians, when planning studies.The data in this study provide an insight into the efficiency of recruitment of bereaved carers or older adult patients into interview studies via primary care. The number of interviewees identified per general practice varied widely, and was unrelated to the size of the population from which the interviewees were drawn, or the socioeconomic characteristics of the area in which the practice was located. In the areas where research network staff negotiated between researcher and GP practice, fewer interviews were completed and detailed information on the research process was not readily available. Refusal to grant research governance permission was unpredictable, and in this case, removed an area of high socioeconomic deprivation from the study.The variation in the number of potential interviewees identified by different practices was so wide, it suggests that there was significant selection going on at that level. This is not surprising in the case of carers, as we did not expect that GPs would be aware of the identity of the carer for all their deceased patients, or that they would necessarily feel comfortable contacting all of the known carers. The practices varied in size from fewer than two thousand to more than fifteen thousand registered patients, yet the majority managed to find at most, one carer to be interviewed. Similarly, the proportion of patients invited to be interviewed varied by a factor of 38 between practices. The carers were drawn disproportionately from less disadvantaged areas. This may reflect the socioeconomic circumstances of the regions involved, but it is possible that GPs selected people who they felt would be better interviewees, because of their education, or availability, or people with whom they had built closer relations during the decedent’s last illness. It is also plausible that people in less deprived areas felt more comfortable about responding to the invitation to be interviewed. We have no data to suggest that the social patterning in the group of carers is related to the way in which research network staff were involved in recruitment.Data on recruitment are seldom presented in detail, despite this being a fundamental influence on the potential value of research outputs. The response rate of around 25% for carers was lower than some postal surveys of carers with broader inclusion criteria, and other disease-specific studies-23. EwinLow participation rates may be accommodated more readily in qualitative enquiry, when the aim is to extend our understanding of patient and caregiver experiences. However, it would be a serious limitation to any study where obtaining a representative sample was crucial. Qualitative studies with older people near the end-of-life often do not reveal how many people were approached to find their interviewees, and the denominator population is also unknown for studies that recruit via local or national advertising.Three different researchers were involved in the work reported here, and we cannot be certain that variation in their tenacity or sensitivity to the clinical context did not contribute to differential recruitment rates. The inclusion and exclusion criteria were specific to our studies, and may have made our recruitment of participants particularly challenging. Both the aim of interviewing carers between four and nine months after the death and the requirement for the decedent to have moved between places of care, limited our population of potential interviewees. Nevertheless, our choice of patients and decedents aged over 75 years captures the majority of deaths in England and Wales, and the conditions specified account for the common causes of predictable death. It is a strength of this analysis that we have information on a large number of participants from qualitative interview studies. And by working across regions, we were able to evaluate the different modes of working with research networks.The nature and extent of gatekeeping by health professionals is an important issue for researchers, as data protection or privacy legislation prevent direct approaches to patients. Gaining the trust of referring clinicians is thought to be important for success, and thaThe regulatory framework may leave some GPs with difficult judgements to make. Any desire they have to shield vulnerable older adults from potentially unwanted approaches by researchers, must be reconciled with avoiding paternalism, and a policy rhetoric that promotes empowering patients to make their own choices. In the UK, the combination of organisational reform, increasing workloads and greater involvement of private providers in NHS care present a particularly challenging context for researchers in primary care.The UK Royal College of General Practitioners is currently encouraging its members to identify the 1% of patients on their lists who are likely to die within the following twelve months, in order to improve their care. Even taPeople from lower socioeconomic groups or areas are often classified as ‘hard to reach.’ This study provides some data to support that assertion, as the recruited sample of carers was made up of disproportionately fewer people from poorer areas. Allowing sufficient time for purposive recruitment by socioeconomic status may help to overcome this problem, along with raising awareness amongst recruiting health professionals. Without particular attention to social patterning in study recruitment, research has the potential to inadvertently perpetuate inequalities in access to care. NHS authorities play a crucial role in study regulation, and the process by which they allow access to different populations should be transparent and follow nationally agreed criteria.In summary, end-of-life research in primary care must often recruit to studies from a denominator population of unknown size, coping with inconsistent application of research governance regulations and gatekeeping by clinicians. In the short term, planning and funding of studies should take this context into account. To resolve these issues and enable investigators to develop robust research, review of the regulatory and organisational barriers to end-of-life researchers in primary care is required.Ethical approval was granted by Liverpool Central Research Ethics Committee (09/H1005/42) and North West 2 REC (10/H1005/16).The authors declare that they have no competing interests.BH, EL and LH collated and analysed the data and BH drafted the manuscript. BH, TA, JAH, GG, SP and JS participated in the design of the study. All participated in the interpretation of the analysis, helped to draft the manuscript and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/342/prepub


There are notable differences in the incidence and mortality rates for prostate cancer between Asia and Western countries. It is also recognized that there are differences in thinking with regard to treatment options. Recently it is also the case that opinions have been reported concerning the differences between Asian and Western patients with regard to their reaction to androgen depletion therapy (ADT). Given that ADT is a method of treatment that focuses on the elimination of testosterone, an inevitable symptom of its administration is testosterone losing syndrome. It is for this reason that in Western countries ADT has only been recommended in cases of advanced or metastatic cancer. On the other hand, in Asia, ADT is used in relatively many cases, including non-metastatic localized cancer and invasive localized cancer. To date, however, there has been little substantive discussion concerning this difference in utilization of ADT. ADT-related drugs for prostate cancer and the development of new drugs for castration resistant prostate cancer (CRPC) have been actively tested in recent years. It could be the case that analyzing the differences in concepts about ADT between Asia and the West could contribute to the effective use of ADT-related drugs and also help to build new treatment strategies for prostate cancer. It is well known that there are significant regional differences in the incidence and mortality rates of prostate cancer. The difference is particularly notable between the Asian region and European countries. Prostate cancer is an androgen sensitive cancer and responds well to androgen depletion therapy (ADT), however, one of the unique drawbacks to this treatment is that it causes testosterone losing syndrome. It is for this reason that in Western countries the role of ADT in treating prostate cancer is generally limited to metastatic cancer and incurable advanced-stage cancer. On the other hand, in many of the countries in Asia, including Japan, ADT has for many years been relatively often used also for localized cancer, which perhaps reflects the social and philosophical background of Asia.However, comparative studies of the outcomes of ADT in Asia and the West have actually only recently been initiated, and the clinical significance of ADT in both Asia and the West remains unclear.In this paper the history of a unique joint collaborative study in Asia on ADT will be introduced and an overview of a registry study, which has developed out of previous efforts, will also be introduced. The significance of ADT for prostate cancer treatment will be discussed.-An international conference titled “Asian trends in prostate cancer hormone therapy” was first held in 2001, with committee members comprising primarily urology specialists from a number of regions, including Japan, China, Korea, Singapore, Indonesia and Taiwan. The first conference in 2001 was held in Singapore, followed by the second in Hong Kong (2002), third in Tokyo (2003), fourth in Honolulu (2004), and the fifth in Bali, Indonesia (2006)th Asia-Pacific Cancer Conference (APCC) in Tsukuba, Japan in 2010Similar meetings were also held in 2005 on a bilateral basis between Japan and Korea. These various approaches were discussed and brought together at a Prostate Cancer Working Group meeting held at the 204 patients who received ADTThrough the course of these various meetings, a wide-ranging discussion took place on the current status of ADT for prostate cancer treatment in Asia and the various issues being faced overall. At the first meeting data was collected concerning the patient characteristics of prostate cancer patients in Asia, including the proportion that was administered ADT at various stages of cancer. Although the scale of data sources differed from country to country, the proportion of patients being administered ADT as an initial therapy at each cancer stage was compared, and it was shown that at each cancer stage ADT was selected as a therapy for a relatively large proportion of patientsThe National Comprehensive Cancer Network (NCCN) clinical practice guidelines are used widely and frequently in all regions of the world, not just in the cancer center in the United States where they originated. They have become the standard for cancer treatment. However, given the various conditions in each country and region, it does not necessarily mean that all medical institutions can provide treatment that is exactly in accordance with the guidelines. In particular, various factors in Asia, including those of a social, economic, philosophical, medical and religious nature, are obstructing implementation in accordance with the guidelines. The compilation of any guideline should be implemented on the basis of medical evidence, using cohort studies, and the situation in Asia is that there is still a lack of such medical evidence, meaning that the only option is to utilize the global guidelines as set forth by the NCCN.,The Asian consensus statement (ACS) for NCCN clinical practice guidelines takes these various constraints into consideration and represents the results of discussion about how the countries of Asia can implement treatment that matches the conditions in each particular country. In the field of urological malignant tumors, the ACS is being followed in the two areas of renal cancer and prostate cancerFrom these efforts it has become apparent that the method of use of endocrine therapy for prostate cancer is different in Asia compared to the West. In other words, in Asia, even in cases where prostate cancer has been diagnosed at a relatively early stage, the use of primary androgen depletion therapy (PADT) is being promoted. In September 2013 ACS committee meeting for NCCN clinical practice guideline for prostate cancer was held in Inchon, Korea under the auspice of Asia Pacific Prostate Society, Asia Pacific Society of Uro-oncology and Japanese Society of Clinical Oncology.Clinical trials tend to have stringent entry criteria. Even patients who are eligible to enter a clinical trial may not be willing to participate because of the more extensive study procedures, the risk of not receiving the medication they want or for a host of other reasons. These factors significantly limit the generalizability of the study results to the general population.Registries mitigate these limitations by casting a wider net to include a wider range of patients. Thus, results of registry studies are closer to real-world situations and have greater generalizability. Two such important long-term, large-scale, longitudinal observational databases on prostate cancer are J-CaP (Japan Study Group for Prostate Cancer) from Japan and CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) from the United States.J-CaP surveillance is a nationwide longitudinal observational study of patients newly starting hormone therapy for prostate cancer from January 2001 to December 2003 with more than 26,000 cases enrolled. CaPSURE on the other hand, was initiated in 1995 to document national trends in prostate cancer epidemiology, disease management, oncologic outcomes, and health-related quality of life (HRQOL) outcomes. It is a longitudinal and observational database accruing data from a total of 40 urologic practice sites over the history of the registry. It currently has around 14,000 patients in their database.,A joint initiative was established in 2007 with the objective of analyzing, reviewing, comparing and contrasting data from J-CaP and CaPSURE registries. This comparison has shown many similarities as well as differences in the treatment and treatment outcomes of prostate cancer between Japan and USPADT is endorsed as an option for monotherapy for localized prostate cancer by guidelines in Asia but not in the U.S. or Europevs. medical or surgical castration monotherapy] were analyzed. Men treated with PADT in J-CaP were slightly older than those in CaPSURE, and had a higher risk disease. They were more likely to be treated with CAB. In the multivariable regression analysis, the hazard ratio (HR) for PCSM was 0.31 for J-CaP compared to CaPSURE. In J-CaP, CAB improved survival compared to castration monotherapy, but this effect was not observed in CaPSURE. For all-cause mortality, the HR for J-CaP was 0.27.Data were analyzed from the CaPSURE registry representing community-based practice in the U.S., and from the J-CaP database. Risk adjustment was performed using the Japan Cancer of the Prostate Risk Assessment (J-CAPRA) score, validated specifically for men with advanced disease and those treated with PADTAdjusting for multiple factors including disease risk and type of androgen ablation, men treated with PADT in Japan compared to the U.S. have greater than three-fold better cancer-specific survival and four-fold better overall survival. CAB improves outcomes compared to castration monotherapy in J-CaP but not in CaPSUREet al.,CAD therapy is the standard treatment for metastatic prostate cancer. CAB is the regimen most often used in Japanet al.et al.According to the NCCN Clinical Practice Guidelines for prostate cancer (2013 v.4), “Intermittent ADT may reduce side effects without altering survival compared to continuous ADT, but the long-term efficacy of intermittent ADT remains unproven.”In this paper the results of two recent representative RCT that sought to compare IAD and CAD have been cited. It is believed that these two papers will continue to be cited in the future as important RCT in terms of both their scale and quality. At the same time, these trials examined cases of PSA relapse after radiotherapy in localized prostate cancer and also the uses of ADT for metastatic prostate cancer.So is the use of IAD a good or a bad thing?To sum up, IAD is linked to individualization of treatment. This may be simplistic, but at the current point this is all that can be said. The history of treatment of prostate cancer is relatively long and it has various aspects, depending on staging at the time of diagnosis and the pathological background. Although various RCTs have been implemented, it is virtually impossible to arrive at a universal conclusion with regard to the use of IAD.This is because it is necessary to consider and deal with countless confounding factors, including patient background, therapeutic drugs, dosage, timing of the start of administration, timing of halting of administration, establishment of endpoints for trials, and balancing QOL with treatment costs, etc.So why are such complex RCTs necessary?The answer to this question is deeply linked to the fact that even today more than 70 years since Dr. Huggins first proposed ADTBased on recent results of androgen-axis research, we cannot yet allow ourselves to believe at any time soon that drug therapy for prostate cancer will be free from the fixed notion that the principle for treatment is testosterone elimination.If it were possible to eliminate the clinical challenges presented by testosterone losing syndrome, the significance of comparing IAD and CAD would also virtually disappear.st line ADT. Furthermore, the possibilities for pathway control using AR receptors suggest that the adverse effects of testosterone elimination, namely testosterone losing syndrome, could be avoided in the future. It is believed that the role of ADT in prostate cancer treatment will become increasingly important.Prostate cancer is a classic androgen-sensitive cancer. The effectiveness of ADT at all clinical stages of prostate cancer is clear and significant. In other words, if testosterone is eliminated it is possible to easily control the disease. However, there are two significant issues that face ADT for prostate cancer. Firstly, ADT is not a radical treatment. Secondly, current ADT focuses on the elimination of testosterone. With regard to the first issue, a body of knowledge has been built up for ADT with regard to advanced cancer and metastatic cancer. Within these categories it is known that over the course of a number of years ADT becomes ineffective against many forms of prostate cancer. However, the fact that new drugs for CRPC have shown clinical effectiveness suggests that current ADT does not completely eliminate testosterone or completely inhibit the action of testosterone androgen receptors. These facts imply that in the future it will not be impossible to establish more powerful 1


Health workforce planning is important in ensuring that the recruitment, training and deployment of health workers are conducted in the most efficient way possible. However, in many developing countries, human resources for health data are limited, inconsistent, out-dated, or unavailable. Consequently, policy-makers are unable to use reliable data to make informed decisions about the health workforce. Computerized human resources information systems (HRIS) enable countries to collect, maintain, and analyze health workforce data.The purpose of this article is twofold. First, we describe Uganda's transition from a paper filing system to an electronic HRIS capable of providing information about country-specific health workforce questions. We examine the ongoing five-step HRIS strengthening process used to implement an HRIS that tracks health worker data at the Uganda Nurses and Midwives Council (UNMC). Secondly, we describe how HRIS data can be used to address workforce planning questions via an initial analysis of the UNMC training, licensure and registration records from 1970 through May 2009.The data indicate that, for the 25 482 nurses and midwives who entered training before 2006, 72% graduated, 66% obtained a council registration, and 28% obtained a license to practice. Of the 17 405 nurses and midwives who obtained a council registration as of May 2009, 96% are of Ugandan nationality and just 3% received their training outside of the country. Thirteen per cent obtained a registration for more than one type of training. Most (34%) trainings with a council registration are for the enrolled nurse training, followed by enrolled midwife (25%), registered (more advanced) nurse (21%), registered midwife (11%), and more specialized trainings (9%).The UNMC database is valuable in monitoring and reviewing information about nurses and midwives. However, information obtained from this system is also important in improving strategic planning for the greater health care system in Uganda. We hope that the use of a real-world example of HRIS strengthening provides guidance for the implementation of similar projects in other countries or contexts. In all countries, health systems rely on their health workforce in order to deliver effective, efficient, and high quality health services. Without strong human resources for health (HRH), health systems are unable to provide primary health and preventive services, diagnose and treat patients, and administer life-saving pharmaceuticals. Nurses, the first line of health care in most health systems, are in critically short supply throughout the globe. This shortage is of grave concern, as nursing skills and labour are crucial in order to achieve the Millennium Development Goals and to provide fundamental health services .Uganda is one of several sub-Saharan African countries that have experienced a shortage of health workers . ConsequManagers and health planners need information about the size, composition, skill sets, training needs, and performance of the public health workforce in order to make informed, well-timed decisions ,6. The aIn 2004, despite the existence of a variety of independent sources of health workforce data, , district level sources, independent research studies, and health professional council data) , Uganda Uganda has rich sources of data in each of its four health professional councils, including the Uganda Nurses and Midwives Council (UNMC). The UNMC is an official body charged with regulating standards for nursing and midwifery in Uganda. The UNMC is an arm of the MOH that makes recommendations to the Government of Uganda regarding issues pertinent to nurses and midwives . The CouOne of the UNMC's tasks is to track training information about nurses and midwives throughout Uganda, from pre-service training through licensure. Following graduation from a particular training program, all nurses and midwives from the public, private, faith-based (FBO), and nongovernmental (NGO) sectors are mandated to register with the Council. Uganda law states that nurses and midwives must have a license in order to practice nursing or midwifery, which must be renewed every three years following completion of the requisite number of continuing professional education credits. Prior to decentralization, the licensure requirement was not routinely exercised by employers because newly qualified nurses and midwives would receive an automatic posting immediately following examination results and would register at the UNMC at their leisure. However, employers are now demanding verification of Council registration prior to hiring. Thus, the UNMC serves as a repository of information, including licensure and registration data, which can be verified prior to employment. Prior to 2005, the UNMC maintained all of their workforce data using a system of paper files. However, the paper-based system was infrequently updated, records were subject to being misplaced or lost, and locating information about individuals was time-consuming. Most importantly from a health planning perspective, the paper filing system did not provide a way to aggregate and analyze the data. Therefore, the Council had no way of accurately determining how many nurses and midwives had been registered, much less where they were deployed. The Senior Nursing Officer at the UNMC stated, "I used to feel guilty when requested to talk about the total number of qualified nurses and midwives in the country because I knew that we did not have accurate data" . Simply The UNMC desired an electronic database with the ability to quickly update, aggregate, and analyze HRH information. To achieve this objective, the Uganda MOH and UNMC partnered with the Capacity Project, a USAID-funded global initiative led by IntraHealth International to strengthen the health workforce in developing countries. The goal of this collaboration was to transition the UNMC's records from the paper files into an electronic HRIS capable of aggregating the data and creating reports. Although the Project conducted HRIS strengthening activities in all four of Uganda's professional councils  and the MOH, the focus of this paper is the HRIS strengthening process applied at the UNMC.Prior experience in health information system strengthening has demonstrated the need for advocacy and continuous dialogue between decision-makers and information system implementers in order for system strengthening to be successful . In UganIt should be noted that when the Capacity Project started work in Uganda, a separate, Government-recognized Human Resources Technical Working Group (HRTWG) already had an official charter. The purpose of the HRTWG was to meet formally to discuss HR issues and provide input to the MOH and other ministries; however, although the HRTWG existed on paper, the group had not met in several years. Throughout the time period when the HWAB was established and held regular meetings, the Capacity Project simultaneously supported the revitalization of the official HRTWG. Eventually, the HRTWG began to hold formal meetings. Rather than having two separate groups, the HWAB subsequently became a recognized subcommittee of the HRTWG. As of the time of this writing, consultations are on-going for the purpose of developing the HWAB into an HRH Observatory. The HWAB holds regular quarterly meetings and meets more frequently when required. The HWAB continues to make recommendations to the HRTWG regarding HRIS implementation.The next step in HRIS strengthening was to assess and improve the UNMC's information and communication technology (ICT) infrastructure. This process included an evaluation of the existing ICT hardware, software, and web connectivity, all of which were upgraded in order to be able to operate and sustain the new HRIS. A Local Area Network (LAN) was installed at the UNMC and staff received training about the administration and maintenance of the upgraded ICT system.Following ICT upgrades, iHRIS Qualify was installed at the UNMC. iHRIS Qualify is an Open Source software program, designed for use at a health professional regulation authority, which can be used to track information about health workers from pre-service training through registration and licensure.  The software is web-accessible, server-based, regularly backed up, and can be accessed by multiple users at once. Data are stored in a central database.While a new HRIS provides substantial benefit, the system itself has little meaning out of context -18. For To ensure system sustainability, UNMC staff, including system administrators, data entry clerks, managers, analysts, and decision-makers received training on the development, maintenance, and continued use of the HRIS software, as well as general training on data quality and project management. The goal of these one-on-one and group training initiatives was to ensure that UNMC staff would be equipped to fully support, use, and continue to improve the HRIS once project support ended.The need for good data quality was emphasized during trainings with HRIS staff and data collectors. Data collection and entry processes were put in place with the goal of improving and maintaining data integrity. To ensure data quality, data were entered using pull-down menus rather than having data entry specialists manually type information into collection forms. The UNMC also adopted a new data validation process following system implementation. When a nurse physically comes to the Council for registration, licensure, or other purposes, he or she reviews either a printout or an on-screen copy of his or her personnel information and can verify the data. At the time of this writing, the UNMC's Commissioner of Nursing is working with district health offices to validate information in the HRIS. The Commissioner of Nursing prints hard copies of district staff lists, and uses this information to determine whether the nurses and midwives working in the district have registered with the UNMC and have renewed their licenses.Several security measures were implemented to maintain data confidentiality. Password protected logins were assigned so that only authorized users would be able to access the system. Roles were assigned to users in order to control who had the ability to enter, update, and generate reports. For auditing purposes, the system logged the username, date, and time any data were entered or changed. Finally, the UNMC has also been developing a data use agreement, to be used when sharing the HRIS data with agencies external to the Council. This policy, created with key stakeholders and local legal authorities, will be used to protect data confidentiality and to assure the various stakeholders that the data will not be used inappropriately.The goal of the remainder of this paper is to demonstrate how HRIS data can be used to address health workforce planning questions via an initial analysis of the UNMC training, licensure, and registration records.Our analysis relied on secondary data provided by UNMC training, licensure, and registration records. The Council maintained historical records of registration dates, exam results, and other pertinent information for nurses and midwives who had physically come to the UNMC offices to register. In addition, principal tutors submitted the names of all new students to the Council and these students obtained an index number within a month (note: this practice is no longer in effect since the Ministry of Education has taken over training nurses). UNMC data entry clerks transferred paper records dating from 1970 onward into iHRIS Qualify. Initial data entry was completed in March 2009. At the time of writing this manuscript, data entry of present day training, licensure, and registration data is ongoing.The present descriptive study included records for nurses and midwives who entered training or registered with the Council between 1970 and 23 May 2009.  previously marked "duplicate" or "deleted" by data entry clerks were removed. In addition, all records (N = 245) without a training record ID were removed from the database, as none of these individuals entered nursing or midwifery training or obtained index numbers. We believe these records were entered into the system erroneously by data entry clerks, who did not have the necessary access levels to delete any records from the system.To further ascertain data quality, frequencies were run on all data fields to identify and eliminate obvious outliers due to errors in data entry. Analyses were also conducted on all dates to ensure that dates were entered in a way that made sense chronologically (e.g. ensuring that dates of birth preceded dates of training and ensuring that dates of training at lower levels preceded dates of training at more advanced levels). In cases where data appeared to be in error, comparisons were made to hard copy records. However, it should be noted that in many cases, the hard copy records themselves were incomplete or were filled out incorrectly. The hope of the UNMC is that once the UNMC's new on-site verification process  becomes routine, the number of errors in the database will decrease over time.Variables of interest in this study included demographic data, such as gender and nationality. In addition, the study examined data related to entering training, graduating, registering with the Council, and cadre classification. Basic descriptive statistics were used to examine the characteristics of the nurses and midwives in the dataset. To our knowledge, this study presents the first analysis of the most comprehensive data available on the nursing and midwifery workforce in Uganda.The data indicate that, as of 23 May 2009, a total of 26 046 people in Uganda have entered nursing or midwifery training (this number includes 527 nurses and midwives who received training outside of Uganda). Training programs typically last 3 years from intake to graduation. To determine completion rates for training programs, we first limited the dataset to nurses and midwives who entered training before 2005 (N = 25 482). The nurses and midwives who did not report a training intake date (N = 533) were not included in this dataset, nor were the nurses and midwives who reported a training intake date in 2006 or later N = 31). Of those who reported a training intake date prior to 2006, 19 170 graduated and 16 847 obtained a council registration. Licensure data, available beginning in 2005, indicates that approximately 43% of the registered nurses and midwives (N = 7168) obtained a license to practice from the UNMC. Please see Figure . Of thosOther concerns regarding the deployment of nurses and midwives include both training completion rates and UNMC registration rates for those who begin nursing or midwifery training. Nursing education involves the investment of limited resources, including funding, instructor time, training materials, etc. To ensure that resources are used as efficiently as possible, data from the UNMC database can be used to target specific areas of need or locations in which training completion rates are lower than desired. For example, graduation rates from nursing and midwifery training programs can be disaggregated by training institution. This information is reported in Table The remainder of this analysis is concerned with the 17 405 nurses and midwives who obtained a UNMC registration. Along with the 16 847 nurses and midwives who entered training prior to 2006 and obtained a Council registration, there are 558 additional nurses and midwives included here that were not included in the prior analyses. This addition takes into account the 527 nurses and midwives who completed training outside of Uganda (and therefore did not report a training intake date) as well as the 31 nurses and midwives who reported entering training in Uganda after 2006. These are the health workers who most likely compose the actual nursing and midwifery workforce in 2009, as only those nurses and midwives with a Council registration are legally eligible to work. However, we recognize that not all nurses and midwives with a Council registration are active in the workforce; therefore, these results should be interpreted as approximations rather than definitive numbers.The vast majority of the nurses and midwives  were Ugandan nationals. Just 3.55% reported a nationality other than Uganda, most frequently Kenya (N = 186), Germany (N = 71), the United States of America (N = 39), and the United Kingdom of Great Britain and Northern Ireland (N = 38). Seventy of the nurses and midwives did not report a nationality. As noted above, just 527 nurses and midwives in the dataset were trained in countries other than Uganda. Not surprisingly, the most frequently reported outside countries of nationality were similar to the most frequently reported outside countries of training. Kenya was the most frequently mentioned outside country of training (N = 97), followed by the United Kingdom (N = 93), Germany (N = 72), the United States of America (N = 47), and the United Republic of Tanzania (N = 32). Note that some nurses and midwives obtained a UNMC registration for multiple trainings outside of Uganda. None of the nurses and midwives who were trained outside of Uganda reported a date of entering training, graduating, or taking the qualifying exam. However, all 527 nurses and midwives who received training outside of Uganda did report a date of registration with the UNMC and 66 reported dates of licensure.Approximately 13% N = 2291) of the nurses and midwives obtained Council registrations for two or more trainings. For example, a worker may have obtained a Council registration following an initial training as an enrolled midwife, then again after completing a second training at the registered nurse level. Few workers (N = 205) obtained a Council registration for 3 trainings, and very few (N = 13) obtained a registration for four trainings. No worker in the database obtained more than four different registrations. In total, there are 20 141 different Council registrations in the database, including 12 807 registrations for nursing trainings and 7195 midwifery trainings. Note that the total number of nurses and midwives in this dataset remains 17 405; however, there are 20 141 registrations because 2291 of these nurses and midwives obtained more than one registration at the UNMC following completion of one or more trainings. Please see Table 291 of thThe largest number of trainings with a Council registration are at the enrolled nurse level , followed by enrolled midwife , registered nurse , and registered midwife . The more specialized trainings make up only 8.54% (N = 1720) of the total number of registrations. There are fewer specialized trainings in the Ugandan nursing and midwifery workforce because most of the specialty training programs are relatively new. Moreover, many students first complete a basic training at either an enrolled or registered level before beginning training in a specialty.Since training at the registered level is more advanced than training at the enrolled level, for the purposes of this paper, nurses who had obtained a council registration for trainings at both the 'enrolled' and 'registered' levels were grouped in the 'registered' level. When using this classification method, the majority of the nursing and midwifery workforce has been trained at the enrolled level ; there are 6913 nurses and midwives at the registered level in the Ugandan health workforce.2 = 0.455, df = 1, n.s.).Approximately 88% (N = 15 334) of nurses and midwives were female, 11.5% (N = 2007) were male and the remaining 64 did not report a gender. Chi-square statistics demonstrated that there were no significant differences in gender distributions between the enrolled and registered levels Second, data were entered into the HRIS from historical paper records, which may not have been updated when nurses retired, left the public sector, moved, or passed away. Therefore, the database may contain information from individuals who have exited the workforce and may overestimate the number of nurses and midwives available to serve the public.Third, we included 82 nurses and midwives in the database who appeared to be over the age of 60, the retirement age in Uganda. We decided to retain the information collected for these nurses in the dataset, as some people in Uganda continue to work past the age of 60 in non-public sector jobs. However, we recognize that some of these nurses may have retired, which may not have been reflected in their personnel files. Therefore, we may have inadvertently included data for nurses who are no longer active in the workforce.Fourth, we used Council registration rather than licensure to estimate the number of nurses and midwives in the Ugandan workforce. Again, it is likely that some of these 17 405 nurses and midwives have retired, died, migrated, or otherwise left the workforce. Licenses to practice, which must be renewed every 3 years, have only been recorded in the database if they were obtained in 2005 or later. We decided to analyze data for all nurses and midwives with a UNMC registration rather than a license, so as not to underestimate the size of the available workforce. We recognize that some nurses and midwives who have not obtained a registration with the UNMC may be active in the workforce, albeit illegally. Consequently, the numbers reported in this paper should be treated as approximations.Finally, the large amount of missing data in the system limited our ability to infer information about some health worker characteristics. For example, in the dataset of nurses and midwives with a registration, 23.09% (N = 4018) did not report birth dates, 96.78% (N = 16 845) did not report marital status, 38.21% (N = 6651) did not report information about home district, and 28.96% (N = 5040) did not report information about birth district. Because some of the paper records entered into the system were incomplete or illegible, it was not possible to remedy these gaps in data. Additionally, since birth dates were missing in 23% of the cases, it was not possible to determine the number of registered nurses and midwives 60 years old or less.The UNMC is clearly still in the beginning stages of a transition from an entirely paper-based system to an electronic HRIS. Because the data are largely limited to the historical records, unless a nurse or midwife has verified the information in person, it is not possible to use these data to definitively determine whether that individual is currently active in the workforce. This uncertainty is a major limitation of the dataset and should be considered when interpreting our results. However, at the same time, the HRIS represents an enormous step forward for the UNMC and the larger Ugandan health system. Previously, this workforce information was only accessible in hard copy files; now, these data are electronically available and can be aggregated and analyzed for decision-making. It is the hope of the HWAB and the UNMC that as the system continues to be used and nurses and midwives regularly review and update their information, the data in the system will become increasingly more reliable and accurate.The UNMC's HRIS is a valuable source of information on Uganda's nursing and midwifery workforce. Health planners are now able to assess the skill mix of the national nursing and midwifery workforce as well as to examine its composition based on demographic variables, like gender. The data provide an estimate of total number of each type of training that Ugandan nurses and midwives have received. The majority of trainings with registrations have been at the enrolled level, the most basic and general level of nursing and midwifery instruction. However, the data also allow planners to estimate the number of registrations for more specialized trainings, such as the 665 trainings received for mental health nursing.The data can also be used to determine district-level training needs and gaps. Prior research by Nguyen et al. 2008) indicated that Ugandan nurses born in rural areas were more likely to continue to work in those areas following completion of training 08 indica. Once inData on graduation and registration rates from training institutions can be used to identify successful training programs. Follow-up studies can then be conducted to determine the reasons why some programs graduate a greater percentage of students than do others. Lessons learned from the successful programs can be applied to institutions where graduation rates are not as high.Our analyses demonstrated that the rates of licensure were very low, due to the fact that licenses to practice were only recorded at the UNMC from 2005 onward. Legally, nurses and midwives should have an active license in order to practice in Uganda . The UgaDuring a phone conversation on 17 September 2010, Margaret Chota, the Commissioner of Nursing at the UNMC, noted that part of the reason hiring agencies have not routinely insisted on licensure as a prerequisite for hiring, despite the existence of the law, was that the data were not previously accessible. The HRIS at the UNMC now serves as a source of aggregated information that can be used to assist the regulatory authorities to enforce the legal mandates. Mrs. Chota noted that the UNMC plans to ensure that all nurses and midwives working for the government of Uganda meet the licensure qualification. In addition, in recognition of the importance of ensuring that all health professionals meet the legal requirements for practice, the MOH has established District Supervisory Authorities (DSAs) who represent the health professional councils at the district offices. The DSAs will work in collaboration with District Health Officers and other authorities to ensure that health workers are registered and licensed, regardless of whether they are working in the public, private, faith-based, or NGO sectors. According to Mrs. Chota, the HRIS database will be available at all districts to monitor the regulatory status of all health workers in each district. Since the majority of health workers are hired at the district level and not by the central MOH, the HRIS will be a useful tool in this decentralized system.The ability to link records by a single license number, which can be used to identify individuals and link multiple trainings to a single identifier, will be a critical factor in ensuring that the HRIS remains up-to-date and useful. Having a single identifier ensures that nurses and midwives are not double counted if they attend multiple trainings, which is the case for almost a quarter of them. The HRIS will be the authoritative data source to track nurses across the public, private, NGO, and FBO sectors. Reports generated by the system should be triangulated the with other data sources such as the census.The HWAB remained involved in the strategic direction and guidance of the UNMC's HRIS from its inception. The Commissioner of Nursing Officer, an HWAB member, has directly benefited from the system as it has enabled reports to be quickly generated from the UNMC's data. In addition, as mentioned previously, an electronic HRIS with aggregated licensure and registration data permits the Commissioner of Nursing Officer and the District Supervisory Authorities to verify applicant credentials at time of hire. During recruitment, in addition to using an MS Excel spreadsheet  to shortlist applicants for interviews, health worker registration numbers are verified against the data in the HRIS. Enforcing licensure will better enable the UNMC to verify that nurses and midwives working in Uganda have attained a minimum standard of training, knowledge, and skills prior to practicing, thereby promoting quality of care and preventing those with falsified records to practice.It should be noted that the UNMC's HRIS is just one component of the larger system. The UNMC's data, along with the HRIS data from the Uganda Medical and Dental Practitioners Council, the Allied Health Professional Council, and the Uganda Pharmacy Council were used in an HRH Action Framework (HAF) evaluation to project the costs and resources required to staff up Uganda's health workforce to meet the national norms. These data were also used in an official evidenced-based supplement to the Uganda Human Resources for Health Strategic Plan 2005-2020, one of the components of the President's Master Plan for Accelerating Performance in the Health Sector -24.On a broader level, the HWAB became an important forum for stakeholders to express their views and work collaboratively to further the progress of HRIS development among all councils. One of the outcomes of the HWAB was the creation of a semi-annual report that used the HRIS data to determine the number of filled and vacant positions in public hospitals and health centers throughout the country. Hard copies of the semi-annual report have been printed and used by the Commissioner of Nursing Office during supportive supervision visits to District Health Offices, in order to verify the registration and licensure status of nurses and midwives in those districts. The semi-annual report was used during meetings with the MOH, the Ministry of Public Service, and the Ministry of Finance, as an evidence-based advocacy tool to encourage increasing financial support for training greater numbers of nurses and midwives. The MOH has also used the semi-annual report to expedite recruitment. The report contains information about the number of health workers projected to retire. The MOH has used this information to post advertisements for positions before the retirees leave, which has reduced the gap time to hire replacement workers.In addition, the HWAB developed an advisory relationship with the Human Resources Technical Working Group (HRTWG), a formal working group created by the Government to discuss national HR policies. The HRTWG advises the Government directly on policy and budgetary decisions regarding HRH issues throughout the country.The electronic HRIS added significant value to the UNMC's way of 'doing business'. Electronic records are easier to find and update, enabling Council staff to more efficiently verify a prospective employee's training qualifications. Checking a nurse's registration prevents unregistered nurses (who may not have graduated from school) and those with fraudulent credentials from obtaining employment. In addition, the system provides a way to ensure that nurses and midwives have completed the continuous professional development courses required to maintain licensure. This verification process enables the UNMC to fulfil its social contract of maintaining a minimum standard of nursing care, thereby instilling public confidence in the health care system.At the time of this writing, the data from the UNMC database are being used to verify qualifications at the time of hire, to develop a semi-annual HR report, to advocate for training an increased number of health workers, and to expedite the recruitment process in the public sector. The system currently has substantial gaps in data accuracy and completeness. However, the existence of an electronic system with the ability to aggregate health workforce data for reporting and analysis represents a huge step forward from the former paper filing system. Furthermore, as new information is entered into the system, the database becomes increasingly refined, accurate, and complete. Information gleaned from the UNMC HRIS can be fed back into the information systems at the central MOH for planning and administration purposes beyond the nursing and midwifery workforce. Rather than a standalone program, the UNMC system is an important component of a larger, national HRIS. Once data on licensure are complete, the system can be used to determine whether the majority of nurses with a license are active in the workforce and whether they are eligible to apply for out-migration. Nevertheless, the database is not in itself a complete solution. To remain sustainable, an HRIS must be continuously updated and maintained. As of the time of this writing, the HRIS at the UNMC is under-utilized for routine operations. Future work should focus on designing new approaches to engage staff and stakeholders in fully utilizing the system. Building support for a culture that values evidence-based decision making is crucial to generate enthusiasm and forward momentum for such a system.The authors declare that they have no competing interests.JCS contributed to the study conception and design, analysis and interpretation of data, and drafting the manuscript. PAM contributed to the study conception and design, interpretation of data, and critical revision of the manuscript. RM contributed to acquisition of the data and the critical revision of the manuscript. All authors have read and approved the final manuscript.List of Data Fields Collected in the UNMC HRISClick here for file


Hypertension has always been regarded as a disease of affluence but this has changed drastically in the last two decades with average blood pressures now higher in Africa than in Europe and USA and the prevalence increasing among poor sections of society. We have conducted a literature search on PubMed on a broad range of topics regarding hypertension in Africa, including data collection from related documents from World Health Organization and other relevant organizations that are available in this field. We have shared the initial results and drafts with international specialists in the context of hypertension in Africa and incorporated their feedback. Hypertension is the number one risk factor for CVD in Africa. Consequently, cardiovascular disease (CVD) has taken over as number one cause of death in Africa and the total numbers will further increase in the next decades reflecting on the growing urbanization and related lifestyle changes. The new epidemic of hypertension and CVD is not only an important public health problem, but it will also have a big economic impact as a significant proportion of the productive population becomes chronically ill or die, leaving their families in poverty. It is essential to develop and share best practices for affordable and effective community-based programs in screening and treatment of hypertension. In order to prevent and control hypertension in the population, Africa needs policies developed and implemented through a multi-sectoral approach involving the Ministries of Health and other sectors including education, agriculture, transport, finance among others. Hypertension, otherwise known as high blood pressure, is a leading cause of cardiovascular disease (CVD) worldwide . The proUntil recently, hypertension was mainly associated with more affluent regions of the world. However, the condition is increasingly emerging in low and middle-income countries (LMICs) , 6 whereTraditionally in Africa, communicable diseases and maternal, perinatal and nutritional causes of morbidity and mortality accounted for the greatest burden of morbidity and mortality . This buHealth and disease patterns change over time in societies depending, among other factors, on the degree of changes in population structure and the rate of economic development, to result in the so-called epidemiological transition . As sociFor the first time, in 2009, Africa's total population exceeded one billion, of which 395 million, almost 40 percent lived in urban areas . This urThis increasing urbanization is one of the mean reasons for the rise of prevalence in hypertension . The levThe world is increasingly becoming older. In less than twenty years there will be globally more people aged older than 60 than children under 10 . It is iHypertension prevalence data are crucial for understanding the magnitude of the problem, identifying groups at high risk for CVD, and evaluating the effects of interventions in policy and practice . An incrAvailable data on hypertension prevalence are from a wide range of studies , 31, 32,The WHO STEPS survey conducted between 2003 and 2009 in 20 African countries reported high rates of hypertension in most countries, particularly among men . The preApart from sex differences in the prevalence of hypertension, there are also large differences based on residence. In all countries where data are available from the World Health Study (WHS), the urban population has a higher prevalence of hypertension than the rural population . We usedIn South Africa and Democratic Republic Congo, the urban has almost 10 percentage points higher prevalence than the rural population. This is in comparison to countries like Ethiopia and Tanzania where the prevalence is only a bit more than 5 percent higher. It is noteworthy that since countries are at different stages of the epidemiological transitions, there are some rural populations in some countries whose prevalence is higher than some urban populations in other countries. For instance, rural populations in Ghana, South Africa, and DRC have a higher prevalence than the urban populations in Ethiopia and Tanzania.It is well known that urban averages mask great intra-urban disparities largely due to the presence of large populations in poor slum settlements that characterize most urban centers in Africa. Data from Nairobi collected from the adult population in two slum settlements  show a hHypertension is mainly associated with environmental and lifestyle factors rather than with genetics and has a stronger association and causal link with five particular behaviors: tobacco use, excessive use of alcohol, physical inactivity, unhealthy diet  and obesity. Risk factors leading to hypertension can be reversible (modifiable), irreversible (non- modifiable), or associated with other predisposing disorders (Annex 1).This section describes the distributions of these main modifiable risk factors for hypertension in Africa. Analysis is based on findings in African countries from the 2003 World Health Survey (WHS) and the WHO STEPS survey (2003-2009) on chronic disease risk factors. Data for the described modifiable risk factors are presented at the end of this section.Tobacco Use Tobacco smoking is known to increase the risk of developing hypertension and cardiovascular diseases like stroke, thrombosis and heart attack. Smoking causes an immediate increase in blood pressure resulting in higher ambulatory blood pressure levels for smokers than for non-smokers. Smoking cessation is known to reduce the overall risk of cardiovascular diseases [diseases . In ordediseases .The prevalence of tobacco smoking varied widely in the 2003 WHS. In all countries, men smoked more than women, with the largest disparities observed in Central and Western Africa. Among men, the prevalence of smoking was highest in Southern Africa followed by Eastern Africa. Remarkably, smoking was more prevalent in rural than in urban areas in most countries. Only in Kenya, Mauritania, Senegal and South Africa, were smoking levels higher among the urban population than their rural counterparts. A similar trend is observed in results from the STEPS survey. Daily smokers represented a greater proportion of actual smokers and were disproportionately male. Smoking was more likely in the island nations of Seychelles (22.2 percent), Madagascar (19.6 percent) and Mauritania (19.0 percent) and less pronounced in Western and Eastern African countries. For example, Ethiopia reported prevalence at 4.6 percent in 2006 and Benin was slightly lower at 3.8 percent in 2007.Alcohol consumption is relatively frequent in Africa . There iIn both the STEPS and the World Heath Survey (WHS), prevalence of alcohol consumption did not vary significantly between rural and urban populations. This implies an increase in prevalence rates in the rural, to levels similar to those previously only found in urban areas. Men show higher prevalence of alcohol consumption in terms of current and daily drinkers and are more likely to be frequent drinkers (defined as having more than four standard drinks/day on average on most days of the week) than women.Adequate physical activity has been shown to have many health-promoting effects and has a direct, independent role in reducing hypertension , 40. TraFrom the STEPS survey, adequate physical activity, defined as more than 150 minutes per week walking/moderate activity/vigorous activity, reported by males was markedly higher than that of females. In the WHS, women also reported lower levels of physical activity than men, probably because of their traditionally defined roles, such as caregiving, that require less physical strain. Adequate physical activity is more prevalent in rural than urban regions of Africa, which partly explains the high prevalence of obesity in urban areas.A high intake of sodium is common, in Africa mostly from salt used to preserve food or to make it tastier . Also, sFew intervention studies have been conducted to show that a reduction in salt intake and an increase in potassium improve the blood pressure in African populations. A study done in Tanzania indicated that a low sodium diet leading to a low urinary excretion level of 52 mmols per day, reduced blood pressure in normotensive people significantly within four to five days . A studyFruit and vegetable consumption is one element of a healthy diet and varies considerably among countries, reflecting economic, cultural and agricultural production environments . Most ofThe STEPS surveys reported sufficient fruits and vegetables intake, defined as five or more servings of fruits or vegetables per one typical day, as being very low across all countries. There were slight gender variations in mean servings of fruit and vegetables reported with women more likely to consume the recommended number of servings than men. This finding was mirrored in the WHS where also, rural people were more likely to consume insufficient amounts of fruits and vegetables compared to their urban counterparts.The World Health Organization (WHO) defines obesity as a condition in which excess body fat has accumulated to such an extent that health may be adversely affected. The degree of body weight is usually expressed as BMI; this is the ratio of weight in kilograms to the square of height in meters. The BMI is used to classify a person's body weight as underweight (BMI less than 18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), or obese (BMI greater than 30). Obesity greatly increases the risk for hypertension and has also been shown to be associated with coronary artery disease and some cancers, and to reduce life expectancy . As obesSTEPS findings show that there is a high prevalence of overweight and obesity in many African countries particularly among urban women. The mean BMI was significantly higher for women compared to men across all countries as was the standardized prevalence of overweight (BMI> 25Kg/m2) and obesity (BMI>30Kg/m2). Presumably, the lower male prevalence relates, in part, to the much higher rate of heavy manual labor commonly reported in men while the higher prevalence rates among women may be explained by the physiological changes related to pregnancy and childbirth, and cultures that put a high premium on overweight and obesity among women. In The low rates of awareness, treatment and control of hypertension in Africa are a major public health concern as the population in this region is growing . The lowAnother common occurrence is the non-adherence to treatment and follow-up for hypertension. In one intervention study in Cameroon, for instance, just about half of the participants were still in the program at one-year follow-up . Indeed,Studies in Tunisia, Cameroon and Kenya assessed the levels of awareness, treatment, and control . All levManagement of hypertension involves lifestyle changes as well as drug treatment. Lifestyle measures are useful both in the control of high blood pressure and in risk factor management. They include weight reduction, increase in physical activity, reduction in salt intake, moderation of alcohol intake and cessation of smoking. As regards drug treatment, several classes of drugs are recommended for the treatment of hypertension and this is dependent on co-existing disease conditions and on the presence or absence of complications. Often, more than one drug is necessary to achieve control. The five main classes with proven effect are: Beta-blockers (BB), Diuretics (DIU), Calcium channel blockers (CCB), Angiotensin converting enzyme inhibitors (ACEI) and, Angiotensin receptor blockers (ARB).In Africa, providing medication is considered an important and cost effective way to reduce hypertension , but accThe efficacy of blood pressure lowering medications is well demonstrated and treatment of high-risk individuals has been advocated as a major strategy for CVD prevention in all regions, including Africa . HoweverRecently, there has been increasing awareness of the threat that the looming non-communicable diseases epidemic poses to the health of the population in the region at different levels. This increasing awareness has catalyzed initiatives aimed at improving access to detection and care of chronic diseases including hypertension in many countries of the region. The pace of the above developments suggests that data on the burden of hypertension must be updated regularly, in order to provide the reliability needed in drawing up effective health service and policy solutions.Historically, hypertension guidelines focused on blood pressure values as the only or main variables determining the need and the type of treatment. The current approach emphasizes that diagnosis and management of hypertension should be related to quantification of total  CVD risk. Few guidelines for the management of hypertension in Africa have been published. The region as a whole published its most recent guidelines in 2003 , and theIn Africa, if the definition for treatment eligibility were 160/95 mm Hg, which was the cut-off for guidelines in South Africa in 1995, then approximately 4 percent of the adults over the age of 30 would be eligible for treatment. Under the current WHO-ISH guidelines, which use 140/90 mmHg as a cut-off, nearly 22 percent of the population is eligible for treatment, which is nearly a six-fold increase. If the cut-off were eventually dropped to 120/80 mmHg, which the United States Joint National Commission on Hypertension now defines as pre-hypertension, then nearly 70 percent of the adult population in South Africa would be eligible for intervention. Even if the interventions do not include drug treatment, these are large increases in the proportion of the population that would require lifestyle interventions and follow-up, which could not be sustained given the current human and financial resources devoted to healthcare in Africa.There will be two major challenges, however, for those implementing risk-based guidelines in African countries (i) to build the capacity of current physicians or other cadre of health professionals who, over the years have been trained to target individual risk factors, and (ii) to find simplified measures of assessing risk, given the high cost and impracticality of measuring cholesterol in many regions of Africa. The cost-effective use of health services to control hypertension is particularly needed in countries with multiple burdens of disease and these countries will have to set priorities appropriately in order to use scarce resources most effectively. The failure of countries to adopt the necessary steps, early in the twenty first century, to promote healthy lifestyles, however difficult such decisions might be, will inevitably lead to increasing levels of hypertension and CVD in the populations of African countries. This, in turn, will be the cause of an avoidable chronic disease epidemic within the next few decades.The crucial role of health research in general, and cardiovascular disorders research in particular cannot be overemphasized. Research is essential in formulating a rational health care policy, evaluating the performance of CVD control interventions and making managerial decisions in the health sector . The neeThe economic burden of CVD in Africa is significant . CVDs wiFurthermore, there are numerous indirect costs related to hypertension, data for which are, fragmented for most African countries. These costs include the lost productivity of workers struck by stroke, heart failure, and ischemic heart disease . Other cThe average amount of healthcare expenditure as a percentage of gross domestic product (GDP) for African countries is 6.3 percent. There is however a wide range of this metric ranging from 2.5 percent in the Democratic Republic of Congo to 12.9 percent of GDP in Malawi. There is also a wide range of health care expenditure per capita across African countries from as little as $6 per capita in Ethiopia to as much as $390 per capita in South Africa. Nonetheless, the amounts are still quite small compared with $ 3727 per capita for high-income countries. Effective management of hypertension usually requires treatments with more than one drug. A study in Ghana, found that only 18 percent of a group of patients with hypertension had one drug prescribed, whereas 60 percent had two drugs and 22 percent had three or more drugs prescribed. The use of two or more drugs will inevitably result in a high cost for anti-hypertensive medication, especially when newer medicines are used. However, there are cheaper, older, and effective medications available in most African countries. “Number needed to treat” analyses showed that the cost of drugs to prevent one death is US$ 14,000 to US$ 1 million in the United States, depending on which drug used . ObviousHypertension is one of the most important modifiable risk factor for CVD, yet the control of this condition in Africa is far from adequate. Available data from a few countries in Africa have highlighted the increasing importance of CVD and other chronic non-communicable diseases in this region, and some of these countries have taken steps to develop relevant policies and programs to address this issue . For a lWithin the context of limited resources, in most of Africa, the greatest gains in controlling the hypertension epidemic lie in its prevention, or at least early detection and adequate control. For most LMICs the major obstacle to the control of blood pressure is the absence of appropriate services at the primary health care levels of the health service delivery system . The comPrimordial prevention depends on health policies that create a congenial environment that promotes healthy behaviors. It entails population-wide education programs, which in turn depend on many factors, including political commitment, advocacy by health professionals and involvement of community leaders and the mass media . The chaPopulation screening activities are an important component of any prevention or control program and are particularly important in populations at high risk for developing hypertension, for example, urban populations and those with limited access to medical care . HoweverThe next step after the high risk group is detected is to give advice on lifestyle modification based on the CVD risk. The good news is that many risk factors of hypertension can be modified. In Africa, one hypothesis is that the rural diet is relatively protective, but is abandoned with urban exposure, with less carbohydrate and higher fat intake. Sodium restriction is feasible as a solitary measure, but to achieve general application, it clearly requires national governments’ commitment and multiple messages from different sources, as well as salt-reduction interventions by the food industry . The majWhile all efforts must be taken to prevent hypertension, there is also a clear need for appropriate care for those who already have the condition and its related complications. In general, the first aim is to cast the net widely and to make antihypertensive medication available to as many people with hypertension as possible. With regard to low-cost therapy, the first crucial point is which cutoff blood pressure values to use. Using 160 mm Hg systolic as a cutoff point would mean that only nine people would have to be treated each year to prevent a cardiovascular event and 50 would have to be treated each year to prevent one death . Lower cOnly five percent of individuals with hypertension will ultimately need tertiary care facilities for management of their advanced stage of hypertension complications. Examples of tertiary care needed include dialysis or kidney transplantation for renal failure, coronary angiography or bypass/angioplasty for coronary artery disease. Effective tertiary centers are costly and there is need for efficiency, quality control and accountability. Medical insurance schemes are one way of making such tertiary care accessible to many people while controlling unnecessary costs and ensuring quality through the schemes’ internal quality assurance mechanisms.As the interest in CVDs and their risk factors such as hypertension grows among policy makers and government institutions a number of documents have been developed with recommendations on how to tackle this public health concern at different levels. Specifically, the WHO has published several reports with action plans regarding non-communicable diseases, CVD and hypertension. Below is an overview of the various recommendations and guidance documents adapted to the situation of hypertension in Africa.Africa faces an unprecedented epidemic of CVDs. Hypertension is the key driver of cardiovascular complications. Whereas high blood pressure almost did not exist in native African populations in the first half of the twentieth century, hypertension now affects between 20 percent and 40 percent of these populations. Lowering blood pressure and controlling hypertension is key to CVD prevention.Many countries in Africa are undergoing a rapid demographic and epidemiologic transition. While much attention in the region has been focused on communicable diseases such as malaria, tuberculosis, and HIV/AIDS, changes in demographic and determinants of health, particularly changes in lifestyle associated with urbanization, have resulted in an epidemiological and nutrition transition towards a greater prevalence of non-communicable diseases. The dual burden of persistent infectious diseases and emerging chronic diseases such as hypertension, poses a serious threat to population health in the region.Prevalence and incidence of both hypertension and pre-hypertension are high. Efforts to prevent or attenuate high blood pressure could lead to a substantial reduction of complications. Lifestyle modifications play a crucial role in preventing elevation of and better control of high blood pressure. Weight loss, control of sodium intake and diet, and promoting physical activity are essential steps towards this direction. However, when medications are needed to reduce blood pressure levels, the selection of the appropriate drugs is important not only for effective control but also to minimize side effects.Awareness, treatment, and control of hypertension in Africa are lagging behind many world regions . SignifiThe problem of defining a strategy for hypertension control confronts most societies . HyperteThere remains a wide gap between international hypertension guidelines and national hypertension guidelines. For one, only in a handful of countries, for example South Africa, have national hypertension guidelines been developed and launched . SeparatCollating information on risk factors for cardiovascular diseases in Africa is an enormous task that is achievable only through collaboration. An active approach to hypertension must be driven by the ministries of health as well as by local organizations, with support from influential bodies such as the International Forum for Hypertension Control and Prevention in Africa. The current enthusiasm for collaboration is crucial for the development and implementation of health-care policies throughout the region. This collaboration is especially important when attempting to validate any developed guidelines for treatment or prevention of non-communicable diseases in Africa. The epidemiology of hypertension morbidity will at least provide the starting point for better health-care planning, which could mirror the way communicable diseases have been handled.An analysis in the different countries should be made of which stakeholders are involved in CVD prevention and control, which activities are currently ongoing. These stakeholders should be given the forum and opportunity to come up with a national plan of action following the WHO recommendations.Public health policies should be focused on reducing risk factors for hypertension and CVD in general like tobacco use, excessive alcohol intake, physical inactivity, and unhealthy diets. This can be done by fully implementing already existing policies like the Tobacco Control Act and crafting new policies to address the other risk factors.National and regional bodies should take the lead in strengthening hypertension surveillance and monitoring efforts. Data are critical for determining the burden of hypertension, characterizing the patterns among sub groups of the population, assessing changes in the problem over time, and evaluating the success of interventions. Effective monitoring and surveillance systems need to be in place, to track progress in reducing the prevalence of hypertension, and increasing awareness, treatment and control of hypertension.Besides implementing policies that are covering the society in general there should also be a strong focus on development and improvement of health service delivery system to address the management of chronic NCD. This can be done through community based screening programs and strengthening Primary Health Care settings to manage simple cases as well as establishing strong referral links to ensure continuity of care among diagnosed patients.It is essential that quality of care for hypertension patients improves as part of efforts to strengthen the health service delivery system for the management of chronic NCDs. This can be done through rigorous training of health care staff like nurses, community health workers and clinical officers. In order to ensure consistent quality of care, national standard guidelines for treatment and management of hypertension should be developed and implemented.