A multi-country research study in Pakistan, Bangladesh and Sri Lanka, has found that a low-cost, multi-component intervention driven by community health-workers in rural settings helped effectively control high blood pressure, or hypertension, among hypertensive patients.
Published in the New England Journal of Medicine, the multi-country intervention trial, Control of Blood Pressure and Risk Attenuation – Bangladesh, Pakistan, Sri Lanka (COBRA-BPS), evaluated the effectiveness of a multi-component intervention among 2,550 individuals with hypertension living in 30 rural communities in the three South Asian countries over two years.
In Pakistan the trial was conducted by Aga Khan University in ten rural communities in district Thatta in collaboration with the district health program, other private healthcare stakeholders and general practitioners. Lady health workers (LHW) in the study's intervention areas monitored blood pressure (BP) of hypertensive patients at homes using a digital blood pressure machine and provided health promotion education on how to follow a healthy diet and lifestyle. The LHWs referred the patients with uncontrolled hypertension to the basic health units. LHWs and public and private practitioners were trained in the trial- intervention.
Overall results at the end of trial demonstrate that the COBRA intervention led to a clinically meaningful and sustained reduction in the mean systolic blood pressure of 5 mmHg (millimeters of mercury) among the hypertensive patients who received it. The intervention also increased adherence to anti-hypertensive medicineuse and reduced deaths due to heart attack or stroke.
At the end of the study, the decline in mean systolic BP was 5 mmHg greater in the intervention group versus the control group, which received the usual care. Reduction in mean diastolic BP and BP control (<140/90 mmHg) was also better in the intervention group. The intervention also increased adherence to anti-hypertensive medications and lipid-lowering medicines, and improved some aspects of self-reported health. Additionally, there was a suggestion of a reduction in deaths in the intervention group.
Uncontrolled hypertension is a major risk factor for cardiovascular diseases (such as heart attack, stroke and heart failure) as well kidney diseases, and a leading cause of premature death globally leading to adverse economic consequences. In Pakistan one in three adults suffer from high blood pressure, according to a 2016 study by the Pakistan Health Research Council. The control and prevention of cardiovascular and other non-communicable diseases (NCDs) is a global health priority with targets under goal 3 of the Sustainable Development Goals calling for a one-third reduction in deaths caused by such diseases by 2030.
Hypertension is a lifestyle disease and can be prevented and controlled by changing dietary and living habits. Risk factors that can cause hypertension include an unhealthy diet, being overweight or obese, physical inactivity and a sedentary lifestyle, smoking, diabetes, psychosocial stressors, and excess alcohol consumption.
Aga Khan University’s Dr Imtiaz Jehan, the principal investigator of the study in Pakistan and country lead, said: “Uncontrolled hypertension, a lack of public awareness of the disease and its contributing risk factors, as well as low anti-hypertensive medicine use are alarmingly high in Pakistan. Controlling BP through lifestyle modifications and antihypertensive therapy can be the single most important way to prevent rising rates of cardiovascular disease and deaths in Pakistan.
"This trial seems timely to furnish evidence regarding sustainable and low-cost pragmatic solutions for effective BP control that can be integrated into our public primary healthcare system of lady health workers as well as referrals to basic health units through standardised training and task shifting,” Dr Jehan added.
Aga Khan University’s Dr Aamir Hameed Khan, the study’s co-investigator in Pakistan and a co-author, highlighted the need for refresher trainings on standardised management and control of hypertension for public and private sector physicians in order to effectively manage and control hypertension. He noted that the trainings provided through the trial were well received by physicians and local authorities.
“A sustained 5 mmHg reduction in systolic BP at a community level translates into about a 30 per cent reduction in death and disability from cardiovascular disease,” said Professor Tazeen H. Jafar from Duke-NUS Medical School, Singapore. “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.”
This is the first multi-country trial of its kind and a model of South-South collaboration. While there are differences in the health systems and some population characteristics in the countries involved, BP control rates are uniformly poor in all of them. Nonetheless, the study found that similar results were achieved in all three countries with the standardised strategies, suggesting that the intervention has validity in different settings. The researchers called for the trial intervention to be scaled up in the three countries.
The study is funded by the Joint Global Health Trials scheme, which includes the Medical Research Council, the UK Department for International Development (DFID), the National Institute for Health Research (NIHR) and the Wellcome Trust. The COBRA-BPS study is led by Professor Tazeen Jafar and her team at Duke-NUS Medical School in Singapore.