Community-based interventions to promote blood pressure control in a developing country: a cluster randomized trial.

Tazeen Jafar, Aga Khan University
Juanita Hatcher, Imperial College London
Neil Poulter, Imperial College London, United Kingdom
Muhammad Islam, Tufts Medical School, Boston, Massachusetts.
Shiraz Hashmi, Aga Khan University
Zeeshan Qadri
Rasool Bux, Aga Khan University
Ayesha Khan, Aga Khan University
Fahim H. Jafary, Aga Khan University
Aamir Hameed, Aga Khan University
Ata Khan, Aga Khan University
Salma H. Badruddin, Aga Khan University
Nish Chaturvedi

Comment in Summaries for patients. Home health education and physician training to improve care for patients with high blood pressure in a developing country. [Ann Intern Med. 2009]


BACKGROUND: Despite convincing evidence that lowering blood pressure decreases cardiovascular morbidity and mortality, the hypertension burden remains high and control rates are poor in developing countries.

OBJECTIVE: To assess the effectiveness of 2 community-based interventions on blood pressure in hypertensive adults.

DESIGN: Cluster randomized, 2 x 2 factorial, controlled trial. ( registration number: NCT00327574)

SETTING: 12 randomly selected communities in Karachi, Pakistan.

PATIENTS: 1341 patients 40 years or older with hypertension (systolic blood pressure >or=140 mm Hg, diastolic blood pressure >or=90 mm Hg, or already receiving treatment).

MEASUREMENTS: Reduction in systolic blood pressure from baseline to end of follow-up at 2 years.

INTERVENTION: Family-based home health education (HHE) from lay health workers every 3 months and annual training of general practitioners (GPs) in hypertension management.

RESULTS: The age, sex, and baseline blood pressure-adjusted decrease in systolic blood pressure was significantly greater in the HHE and GP group (10.8 mm Hg [95% CI, 8.9 to 12.8 mm Hg]) than in the GP-only, HHE-only, or no intervention groups (5.8 mm Hg [CI, 3.9 to 7.7 mm Hg] in each; P < 0.001). The interaction between the main effects of GP training and HHE on the primary outcome approached significance (interaction P = 0.004 in intention-to-treat analysis and P = 0.044 in per-protocol analysis).

LIMITATIONS: Follow-up blood pressure measurements were missing for 22% of patients. No mechanism was detected by which interventions lowered blood pressure.

CONCLUSION: Family-based HHE delivered by trained lay health workers, coupled with educating GPs on hypertension, can lead to significant blood pressure reductions among patients with hypertension in Pakistan. Both strategies in combination may be feasible for upscaling within the existing health care systems of Indo-Asian countries.