Regular visits to track high blood pressure by community health workers can dramatically reduce cardiovascular mortality and disability in low- and middle-income countries, a new study suggests.
Exacerbated high blood pressure or hypertension is a leading cause of death worldwide, as a significant risk factor for cardiovascular where kidney diseases.
But since a person with hypertension has no obvious symptoms, it’s considered a silent killer by many doctors and health care professionals.
Many adults living in low- and middle-income rural areas have hypertension, about 70% of which is exacerbated by medicine.
According to an article in the New England Journal of Medicine, cardiovascular mortality in these countries is thus increasing. The risk is particularly high in areas of significant deprivation, and health care systems are fractured.
There’s enough evidence that hypertension management decreases cardiovascular disease deaths.
In low-income countries the goal is to develop effective approaches to enable people with hypertension to take medications to reduce blood pressure and lower cholesterol.
Door-to-door service
Community health workers in South Asia, India, Mexico and Africa perform home visits to provide maternity and child care.
Researchers were thus wondering if implementing a similar door-to-door healthcare service for people with hypertension would boost high blood pressure regulation.
They recruited 2,465 hypertensive adults living in 30 rural villages in Bangladesh, Pakistan and Sri Lanka to find out.
These 30 groups were randomly assigned by qualified community health workers to continue their routine care or to receive a visit every 3 months.
The health workers used automated devices to assess blood pressure and gave people advice on diet and the importance of taking medicine.
The health workers referred patients at local primary care clinics with poorly controlled blood pressure and those at high risk for cardiovascular disease to specially trained physicians.
A reading of blood pressure has two numbers– 140/90 millimeters of mercury (mm Hg, for example). The first number is the systolic pressure, as the heart muscle contracts, which corresponds to the pressure in the arteries. The second involves diastolic pressure, measuring blood pressure between heartbeats.
Two years after the research started, the intervention group saw a decrease in mean systolic blood pressure of 5 mm Hg greater than in the control group.
Decrease in mean diastolic blood pressure among people in the intervention group has also been higher, and more people have managed to regulate their blood pressure. Experts define that as less than 140/90 mm Hg reading.
The study’s results, called COBRA-BPS (Blood Pressure Reduction and Risk Attenuation — Bangladesh, Pakistan, Sri Lanka), appear in The New England Journal of Medicine.
Reduced death and disability
According to other studies, Professor Tazeen H. Jafar of the Duke-NUS Medical School in Singapore, who led the study, has shown that a sustained reduction of 5 mm Hg in systolic BP across a population can lead to a 30% reduction in cardiovascular disease death and disability.
A full cost-effectiveness analysis is ongoing but early results suggest that the system would cost less than $11 per person per year if carried out across all three countries.
Commenting on the findings, Prof. Jafar, who is also a global health professor at the Duke Global Health Institute in the USA.
“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.”
– Prof. Tazeen H. Jafar
Dr. Imtiaz Jehan of Aga Khan University in Karachi, who was the principal investigator of the study in Pakistan, says uncontrolled hypertension and lack of knowledge of the disease in her country is “alarmingly high.”
“Regulation of BP by lifestyle modification and antihypertensive therapy can be the single most important way of preventing rising rates of cardiovascular disease and death in Pakistan,” she says.
Keep taking the pills
The study showed that community health workers visited at home and referrals to specially qualified doctors made people more likely to take antihypertensive and lipid-lowering medicines.
Despite people with hypertension having free access to the drugs through state healthcare in Sri Lanka, only about 25 percent manage their blood pressure successfully, says Prof. H. Asita de Silva of Kelaniya University, principal investigator in Sri Lanka.
“Traditional approaches to providing health care are simply not good enough, based on people coming to clinics,” he adds.
“Rather, creative cardiovascular treatment models will integrate primary healthcare approaches that expand access to underserved populations.”
Prof. Jafar suggests that the public health consequences of the new findings are far-reaching in developing nations.
“A low-cost program like ours could be adapted and scaled up in many other settings globally, using the existing healthcare infrastructure to reduce the growing burden of uncontrolled hypertension and potentially save millions of lives, as well as reduce suffering from heart attacks, strokes, heart failure, and kidney disease.”
–Professor Tazeen H. Jafar
