A Community-Based Intervention for Managing Hypertension in Rural South Asia

Authors:
Tazeen H. Jafar, M.D., M.P.H., Mihir Gandhi, Ph.D., H. Asita de Silva, D.Phil., F.R.C.P., Imtiaz Jehan, F.C.P.S., Aliya Naheed, M.B., B.S., Ph.D., Eric A. Finkelstein, Ph.D., Elizabeth L. Turner, Ph.D., Donald Morisky, Sc.D., Anuradhani Kasturiratne, M.B., B.S., M.D., Aamir H. Khan, F.C.P.S., John D. Clemens, Ph.D., Shah Ebrahim, D.M., Pryseley N. Assam, Ph.D., and Liang Feng, Ph.D. for the COBRA-BPS Study Group

Citation:
N Engl J Med 2020; 382:717-726. DOI: 10.1056/NEJMoa1911965

Abstract

Background
The burden of hypertension is escalating, and control rates are poor in low- and middle-income countries. Cardiovascular mortality is high in rural areas.

Methods
We conducted a cluster-randomized, controlled trial in rural districts in Bangladesh, Pakistan, and Sri Lanka. A total of 30 communities were randomly assigned to either a multicomponent intervention (intervention group) or usual care (control group). The intervention involved home visits by trained government community health workers for blood-pressure monitoring and counseling, training of physicians, and care coordination in the public sector. A total of 2645 adults with hypertension were enrolled. The primary outcome was reduction in systolic blood pressure at 24 months. Follow-up at 24 months was completed for more than 90% of the participants.

Results
At baseline, the mean systolic blood pressure was 146.7 mm Hg in the intervention group and 144.7 mm Hg in the control group. At 24 months, the mean systolic blood pressure fell by 9.0 mm Hg in the intervention group and by 3.9 mm Hg in the control group; the mean reduction was 5.2 mm Hg greater with the intervention (95% confidence interval [CI], 3.2 to 7.1; P<0.001). The mean reduction in diastolic blood pressure was 2.8 mm Hg greater in the intervention group than in the control group (95% CI, 1.7 to 3.9). Blood-pressure control (<140/90 mm Hg) was achieved in 53.2% of the participants in the intervention group, as compared with 43.7% of those in the control group (relative risk, 1.22; 95% CI, 1.10 to 1.35). All-cause mortality was 2.9% in the intervention group and 4.3% in the control group.

Conclusions
In rural communities in Bangladesh, Pakistan, and Sri Lanka, a multicomponent intervention that was centered on proactive home visits by trained government community health workers who were linked with existing public health care infrastructure led to a greater reduction in blood pressure than usual care among adults with hypertension. (Funded by the Joint Global Health Trials scheme; COBRA-BPS ClinicalTrials.gov number, NCT02657746.)

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