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Community-led Interventions for Improving Blood Pressure Control

Multi-national intervention trial to reduce and better control blood pressure produces “clinically meaningful” results through multifactorial approach.

High blood pressure or hypertension is a major risk factor for chronic diseases such as cardiovascular and kidney disease. Particularly rural parts of low- and middle-income countries in Asia where public healthcare facilities are lacking, one in four adults suffer from hypertension and a staggering 70 percent of them suffer from uncontrolled hypertension.

In a recently published study in the New England Journal of Medicine, a cluster randomized trial was conducted using multi-component intervention to understand its effect on control and reduction of blood pressure. The interventions include home visits by community healthcare workers to monitor blood pressure and provide lifestyle coaching, coupled with physician training and coordination with public healthcare infrastructure.

The multi-country Control of Blood Pressure and Risk Attenuation – Bangladesh, Pakistan, Sri Lanka (COBRA-BPS) study is a cluster randomised trial that evaluated the effectiveness of the multi-component intervention among 2,550 individuals with hypertension living in 30 rural communities in the three South Asian countries over two years.

The research was led by Professor Tazeen H. Jafar from the Health Services and Systems Research Programme at Duke-NUS Medical School, Singapore, in partnership with the International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B), Aga Khan University in Pakistan, the University of Kelaniya in Sri Lanka and the Singapore Clinical Research Institute (SCRI). The study was funded by the Joint Global Health Trials scheme.

The study found that there was a 5 mmHg greater decline 5 mmHg greater in mean systolic blood pressure in the intervention group compared to the control group, which received the usual care. There was also an increase in adherence to antihypertensive medications and lipid-lowering medicines in the intervention group with improved self-reported health.

“Our study demonstrates that an intervention led by community health workers and delivered using the existing healthcare systems in Bangladesh, Pakistan, and Sri Lanka can lead to clinically meaningful reductions in BP as well as confer additional benefits – all at a low cost.” Said Professor Jafar, who is also a Professor of Global Health at the Duke Global Health Institute (DGHI), USA.

“Community health workers are an integral part of the primary care infrastructure for the successful door to door delivery of maternal and child healthcare in South Asia – as well as China, Mexico, and Africa,” Prof Jafar added. “Our findings show that community health workers can have an equally important role in managing hypertension.”

As the first multi-country trial, it serves as a model of South-South collaboration. Despite differences in health systems and population characteristics in countries involved, poor blood pressure control was common among all of them. The study found that similar results were achieved in all these countries with standardized strategies, this provides proof that the intervention is applicable in different healthcare settings.

A formal cost-effectiveness analysis is currently underway by Prof Eric Finkelstein, a health economist at Duke-NUS and DGHI. Early estimates by the study group suggest that scaling up the COBRA-BPS intervention nationally in the three countries would cost less than US$11 per patient annually. [APBN]