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Zaman MA, Awais N, Satnarine T, Ahmed A, Haq A, Patel D, Gutlapalli SD, Hernandez GN, Seffah K, Khan S. Comparing Triple Combination Drug Therapy and Traditional Monotherapy for Better Survival in Patients With High-Risk Hypertension: A Systematic Review. Cureus 2023; 15:e41398. [PMID: 37546040 PMCID: PMC10401897 DOI: 10.7759/cureus.41398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
High-risk hypertension patients are more susceptible to cardiovascular disease, stroke, and mortality. Monotherapy and triple combination drug therapy are two different approaches to treating hypertension. Monotherapy involves using a single medication to manage hypertension, whereas triple combination therapy involves the simultaneous use of three different antihypertensive medications from different drug classes. Making a fast switch from monotherapy to combination medication is one method to regulate blood pressure (BP) better. It is widely recognized that a significant proportion of individuals with hypertension require combination therapy to manage their condition effectively. This review aims to evaluate the mortality rates across monotherapy and triple combination drug therapy in high-risk hypertension patients. A systematic literature review was conducted across multiple scientific literature repositories. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for systematic reviews and meta-analyses. Based on the end outcome of each published journal on the effectiveness of triple combination drug therapy as a treatment option for high-risk hypertension patients, there was a notable difference in overall survival, mortality rates, BP reduction, and adherence datasets. Triple combination drug use correlated with increased timeframes for multiple patient survival parameters within the articles shortlisted in this investigation. However, it is crucial for healthcare providers to weigh the risks and benefits of triple combination drug therapy when deciding which treatment approach is best for their patients.
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Affiliation(s)
- Mustafa Abrar Zaman
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, St. George's University School of Medicine, Newcastle upon Tyne, GBR
| | - Nimra Awais
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Travis Satnarine
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Areeg Ahmed
- Internal Medicine, California Institute of Neuroscience, Thousand Oaks, USA
| | - Ayesha Haq
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Deepkumar Patel
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sai Dheeraj Gutlapalli
- Internal Medicine, Richmond University Medical Center Affiliated With Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, USA
- Internal Medicine Clinical Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Grethel N Hernandez
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Kofi Seffah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Use of Perindopril Arginine/Indapamide/Amlodipine in the Management of Hypertension in Two Sub-Saharan African Island Countries of Madagascar and Mauritius. Adv Ther 2022; 39:2850-2861. [PMID: 35438448 PMCID: PMC9122888 DOI: 10.1007/s12325-022-02134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/16/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Most patients with hypertension in sub-Saharan Africa require two or more drugs to control their blood pressure. Triple fixed-dose combination therapy of perindopril arginine/indapamide/amlodipine is more effective in lowering blood pressure, offers better target organ protection and has increased adherence compared to monotherapy and free combination therapy, and is safe to use. This observational study evaluates the effectiveness of perindopril arginine/indapamide/amlodipine in controlling blood pressure at least 1 month after treatment initiation and assesses patient- and physician- reported drug tolerance over a 3-month period in Madagascar and Mauritius. METHODS A total of 198 patients with hypertension in ambulatory care who had been on fixed-dose combination of perindopril arginine, indapamide, and amlodipine for at least 4 weeks were included. The main outcome measures were changes in systolic and diastolic blood pressure, attainment of blood pressure control under 140/90 mmHg and 130/80 mmHg, self-reported drug tolerance by the patient, and perceived drug tolerance by the treating physician. Data was collected at 1 month and 3 months. RESULTS Mean systolic blood pressure was significantly lower at the 1-month (- 3.4 mmHg, p = 0.002) and 3-month (- 8.5 mmHg, p < 0.0001) visits. Diastolic blood pressure also decreased significantly (- 2.4 mmHg at 1-month, p = 0.017 and - 5.4 mmHg at the 3-month visits, p < 0.0001). At 3 months, 80.4% of the patients attained blood pressure targets less than 140/90 mmHg and 42.7% attained targets less than 130/80 mmHg on the basis of their baseline blood pressure. Excellent drug tolerance was reported by more than 90% of patients and physicians at the 1-month visit and by more than 95% at the 3-month visit. CONCLUSION Triple fixed-dose therapy of perindopril arginine/indapamide/amlodipine continues to show additional blood pressure-lowering capacity even months after initiating the treatment in patients with hypertension in Madagascar and Mauritius. It is also well tolerated by patients with hypertension and assessed as safe to use by physicians.
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Wang N, Salam A, Webster R, de Silva A, Guggilla R, Stepien S, Mysore J, Billot L, Jan S, Maulik PK, Naik N, Selak V, Thom S, Prabhakaran D, Patel A, Rodgers A. Association of Low-Dose Triple Combination Therapy With Therapeutic Inertia and Prescribing Patterns in Patients With Hypertension: A Secondary Analysis of the TRIUMPH Trial. JAMA Cardiol 2021; 5:1219-1226. [PMID: 32717045 DOI: 10.1001/jamacardio.2020.2739] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Fixed-dose combination (FDC) therapies are being increasingly recommended for initial or early management of patients with hypertension, as they reduce treatment complexity and potentially reduce therapeutic inertia. Objective To investigate the association of antihypertensive triple drug FDC therapy with therapeutic inertia and prescribing patterns compared with usual care. Design, Setting, and Participants A post hoc analysis of the Triple Pill vs Usual Care Management for Patients With Mild-to-Moderate Hypertension (TRIUMPH) study, a randomized clinical trial of 700 patients with hypertension, was conducted. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. Data were analyzed from September to November 2019. Interventions Once-daily FDC antihypertensive pill (telmisartan, 20 mg; amlodipine, 2.5 mg; and chlorthalidone, 12.5 mg) or usual care. Main Outcomes and Measures Therapeutic inertia, defined as not intensifying therapy in those with blood pressure (BP) above target, was assessed at baseline and during follow-up visits. Prescribing patterns were characterized by BP-lowering drug class and treatment regimen potency. Predictors of therapeutic inertia were assessed with binomial logistic regression. Results Of the 700 included patients, 403 (57.6%) were female, and the mean (SD) age was 56 (11) years. Among patients who did not reach the BP target, therapeutic inertia was more common in the triple pill group compared with the usual care group at the week 6 visit (92 of 106 [86.8%] vs 124 of 194 [63.9%]; P < .001) and week 12 visit (81 of 90 [90%] vs 116 of 179 [64.8%]; P < .001). At the end of the study, 221 of 318 patients in the triple pill group (69.5%) and 182 of 329 patients in the usual care group (55.3%) reached BP targets. Among those who received treatment intensification, the increase in estimated regimen potency was greater in the triple pill group compared with the usual care group at baseline (predicted mean [SD] increase in regimen potency: triple pill, 15 [6] mm Hg; usual care, 10 [5] mm Hg; P < .001), whereas there were no significant differences at the week 6 or at week 12 visit. Clinic systolic BP level was the only consistent predictor of treatment intensification during follow-up. During follow-up, there were 23 vs 54 unique treatment regimens per 100 treated patients in the triple pill vs usual care groups, respectively (P < .001). Conclusions and Relevance Triple pill FDC therapy was associated with greater rates of therapeutic inertia compared with usual care. Despite this, triple pill FDC therapy substantially simplified prescribing patterns and improved 6-month BP control rates compared with usual care. Further improvements in hypertension control could be achieved by addressing therapeutic inertia among the minority of patients who do not achieve BP control after initial FDC therapy. Trial Registration ANZCTR Identifier: ACTRN12612001120864.
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Affiliation(s)
- Nelson Wang
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Abdul Salam
- The George Institute for Global Health, New Delhi, India
| | - Ruth Webster
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Rama Guggilla
- Division of Dentistry, Division of Medical Education in English, Department of Population Medicine and Civilization Diseases Prevention, Faculty of Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Sandrine Stepien
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Jayanthi Mysore
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi, India
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Simon Thom
- Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation, New Delhi, India
| | - Anushka Patel
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia
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Efficacy and safety of triple versus dual combination blood pressure-lowering drug therapy: a systematic review and meta-analysis of randomized controlled trials. J Hypertens 2020; 37:1567-1573. [PMID: 31058799 DOI: 10.1097/hjh.0000000000002089] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Most patients with hypertension need at least two drugs to achieve goal blood pressure. This systematic review assessed efficacy and safety of triple versus dual combination therapy for the management of hypertension. METHODS Publication databases, clinical trial registries and regulatory agency websites were searched until April 2018 for double-blind randomized controlled trials (RCTs) comparing triple with dual therapy of BP-lowering drugs, for at least 3 weeks, among patients with hypertension. Meta-analyses for efficacy and safety outcomes were performed using random-effects model. Regimen efficacy was predicted using the Therapeutic Intensity Score (TIS) and the Law et al. method (which predict dose doubling increases efficacy by 100% and around 20%, respectively), and compared with observed efficacy. RESULTS Fourteen RCTs (11 457 participants) were included. Overall, triple compared with dual therapy reduced BP by 5.4/3.2 mmHg (P < 0.001), and improved BP control by 58 versus 45% [relative risk (RR) 1.33 (95% CI 1.25-1.41)], whereas incidence of withdrawals because of adverse events were 3.3 versus 3.4% [RR 1.24 (95% CI 1.00-1.54), P = 0.05]. Law et al.'s method was superior to TIS in predicting differences in efficacy between triple and dual therapies. For patients uncontrolled on submaximal dose dual therapy, adding a third drug achieved on average approximately four times more BP reduction than doubling the dose of dual therapy component drugs (6.0/3.6 versus 1.5/0.8 mmHg, respectively). CONCLUSION Addition of a third drug is likely to be more efficacious without increasing adverse events, compared with increasing dose of existing dual therapy. Early use of triple therapy can significantly improve hypertension control.
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Efficacy and safety of dual combination therapy of blood pressure-lowering drugs as initial treatment for hypertension: a systematic review and meta-analysis of randomized controlled trials. J Hypertens 2020; 37:1768-1774. [PMID: 30986788 DOI: 10.1097/hjh.0000000000002096] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the efficacy and tolerability of dual combination of blood pressure (BP)-lowering drugs as initial treatment for hypertension. METHODS MEDLINE, Embase, CENTRAL were searched until August 2017 for randomized, double-blind trials of dual combination therapy vs. monotherapy in adults with hypertension who were either treatment naïve or untreated for at least 4 weeks. Regimens were classified with reference to usual daily 'standard-dose'; for example, <1 + <1 for a combination of two drugs both at less than one standard-dose. Random-effects models were used for meta-analysis. RESULTS Thirty-three trials (13 095 participants) with mean baseline mean BP 155/100 mmHg were included. Compared with standard-dose monotherapy, dual combinations of <1 + <1, 1 + <1 and 1 + 1 (i.e. low-to-standard dose), showed a dose-response relationship in reducing SBP [mean differences (95% confidence interval) of 2.8 (1.6-4.0), 4.6 (3.4-5.7) and 7.5 (5.4-9.5) mmHg, respectively], and in improving BP control [risk ratio (RR) (95% confidence interval) 1.11 (0.92-1.34), 1.25 (1.16-1.35) and 1.42 (1.27-1.58), respectively]. Withdrawals due to adverse events were uncommon with low-to-standard dose dual combinations, with no significant difference compared with standard-dose monotherapy [2.9 vs. 2.2%; RR 1.28 (0.85 to 1.92)]. There were fewer data for higher dose dual combinations, which did not appear to produce substantial additional efficacy and could potentially be less tolerable. CONCLUSION Compared with standard-dose monotherapy, initiating treatment with low-to-standard dose dual combination therapy is more efficacious without increasing withdrawals due to adverse events. PROSPERO REGISTRATION CRD42016032822.
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Lung T, Jan S, de Silva HA, Guggilla R, Maulik PK, Naik N, Patel A, de Silva AP, Rajapakse S, Ranasinghe G, Prabhakaran D, Rodgers A, Salam A, Selak V, Stepien S, Thom S, Webster R, Lea-Laba T. Fixed-combination, low-dose, triple-pill antihypertensive medication versus usual care in patients with mild-to-moderate hypertension in Sri Lanka: a within-trial and modelled economic evaluation of the TRIUMPH trial. LANCET GLOBAL HEALTH 2019; 7:e1359-e1366. [PMID: 31477545 DOI: 10.1016/s2214-109x(19)30343-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Elevated blood pressure incurs a major health and economic burden, particularly in low-income and middle-income countries. The Triple Pill versus Usual Care Management for Patients with Mild-to-Moderate Hypertension (TRIUMPH) trial showed a greater reduction in blood pressure in patients using fixed-combination, low-dose, triple-pill antihypertensive therapy (consisting of amlodipine, telmisartan, and chlorthalidone) than in those receiving usual care in Sri Lanka. We aimed to assess the cost-effectiveness of the triple-pill strategy. METHODS We did a within-trial (6-month) and modelled (10-year) economic evaluation of the TRIUMPH trial, using the health system perspective. Health-care costs, reported in 2017 US dollars, were determined from trial records and published literature. A discrete-time simulation model was developed, extrapolating trial findings of reduced systolic blood pressure to 10-year health-care costs, cardiovascular disease events, and mortality. The primary outcomes were the proportion of people reaching blood pressure targets (at 6 months from baseline) and disability-adjusted life-years (DALYs) averted (at 10 years from baseline). Incremental cost-effectiveness ratios were calculated to estimate the cost per additional participant achieving target blood pressure at 6 months and cost per DALY averted over 10 years. FINDINGS The triple-pill strategy, compared with usual care, cost an additional US$9·63 (95% CI 5·29 to 13·97) per person in the within-trial analysis and $347·75 (285·55 to 412·54) per person in the modelled analysis. Incremental cost-effectiveness ratios were estimated at $7·93 (95% CI 6·59 to 11·84) per participant reaching blood pressure targets at 6 months and $2842·79 (-28·67 to 5714·24) per DALY averted over a 10-year period. INTERPRETATION Compared with usual care, the triple-pill strategy is cost-effective for patients with mild-to-moderate hypertension. Scaled up investment in the triple pill for hypertension management in Sri Lanka should be supported to address the high population burden of cardiovascular disease. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Thomas Lung
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Rama Guggilla
- Department of Population Medicine and Civilization Diseases Prevention, Faculty of Medicine with the Division of Dentistry and Division of Medical Education in English, Medical University of Bialystok, Bialystok, Poland
| | - Pallab K Maulik
- The George Institute for Global Health, University of New South Wales, New Delhi, India; The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi, India
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Arjuna P de Silva
- Department of Medicines, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Senaka Rajapakse
- Department of Medicines, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sandrine Stepien
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Simon Thom
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Tracey Lea-Laba
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Pandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, Ovbiagele BI, Lavados PM, Gandhi DBC, Thrift AG. Prevention of stroke: a global perspective. Lancet 2018; 392:1269-1278. [PMID: 30319114 DOI: 10.1016/s0140-6736(18)31269-8] [Citation(s) in RCA: 209] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/04/2018] [Accepted: 05/29/2018] [Indexed: 12/16/2022]
Abstract
Along with the rising global burden of disability attributed to stroke, costs of stroke care are rising, providing the impetus to direct our research focus towards effective measures of stroke prevention. In this Series paper, we discuss strategies for reducing the risk of the emergence of disease (primordial prevention), preventing the onset of disease (primary prevention), and preventing the recurrence of disease (secondary prevention). Our focus includes global strategies and campaigns, and measurements of the effectiveness of worldwide preventive interventions, with an emphasis on low-income and middle-income countries. Our findings reveal that effective tobacco control, adequate nutrition, and development of healthy cities are important strategies for primordial prevention, whereas polypill strategies, use of mobile technology (mHealth), along with salt reduction and other dietary interventions, are effective in the primary prevention of stroke. An effective collaboration between various health-care sectors, government policies, and campaigns can successfully implement secondary prevention strategies, through surveillance and registries, such as the WHO's non-communicable diseases programmes, across high-income and low-income countries.
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Affiliation(s)
- Jeyaraj D Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India.
| | - Seana L Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Mahesh P Kate
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Gisele S Silva
- Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rufus O Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Bruce I Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Pablo M Lavados
- Vascular Neurology Unit, Neurology Service, Department of Neurology and Psychiatry, Clínica Alemana de Santiago, Santiago, Chile; Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile; Department of Neurological Sciences, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Dorcas B C Gandhi
- College of Physiotherapy, Christian Medical College and Hospital Ludhiana, Ludhiana, India
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Salam A, Webster R, Patel A, Godamunne P, Pathmeswaran A, de Silva HA, Rogers A, Jan S, Laba TL. Process evaluation of a randomised controlled trial of a pharmacological strategy to improve hypertension control: protocol for a qualitative study. BMJ Open 2018; 8:e022317. [PMID: 30121609 PMCID: PMC6104790 DOI: 10.1136/bmjopen-2018-022317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Globally, the prevalence of uncontrolled hypertension is high, particularly in low- and middle-income countries. There is a critical need for strategies to improve hypertension control. The early use of a fixed low-dose combination of three antihypertensive drugs (triple pill) has the potential to significantly improve hypertension control. The TRI ple Pill vs. U sual care M anagement for P atients with mild-to- moderate H ypertension (TRIUMPH) randomised controlled trial (RCT) is designed to test the effects of this strategy compared with usual care in patients with mild-to-moderate hypertension. This paper reports the protocol of a process evaluation of the TRIUMPH RCT. The objectives are to understand factors related to implementation of the intervention, mechanisms of effect, contextual factors that underpin the effectiveness of the triple pill strategy and the potential barriers and facilitators to implementing the strategy in clinical practice. METHODS AND ANALYSIS Face-to-face semistructured in-depth interviews with a purposive sample of TRIUMPH RCT participants and healthcare professionals in Sri Lanka will be conducted. Healthcare professionals will include physicians and their staff who were involved in conducting the TRIUMPH RCT. Interviewees will be recruited sequentially until thematic saturation is achieved. Interviews will be audio recorded, transcribed verbatim and analysed in NVivo using framework analysis methods. ETHICS AND DISSEMINATION The TRIUMPH RCT and process evaluation have received approval from the relevant Ethics Review Committee. All participants will be asked to provide written consent before participation. Findings from the study will be disseminated through publications and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12612001120864 , SLCTR/2015/020 ; Pre-results.
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Affiliation(s)
- Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Pavithra Godamunne
- Department of Medical Education, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Arunasalam Pathmeswaran
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - H Asita de Silva
- Clinical Trials Unit, Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Anthony Rogers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Tracey-Lea Laba
- Menzies Centre for Health Policy, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
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Webster R, Salam A, de Silva HA, Selak V, Stepien S, Rajapakse S, Amarasekara S, Amarasena N, Billot L, de Silva AP, Fernando M, Guggilla R, Jan S, Jayawardena J, Maulik PK, Mendis S, Mendis S, Munasinghe J, Naik N, Prabhakaran D, Ranasinghe G, Thom S, Tisserra N, Senaratne V, Wijekoon S, Wijeyasingam S, Rodgers A, Patel A. Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka: A Randomized Clinical Trial. JAMA 2018; 320:566-579. [PMID: 30120478 PMCID: PMC6583010 DOI: 10.1001/jama.2018.10359] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Poorly controlled hypertension is a leading global public health problem requiring new treatment strategies. OBJECTIVE To assess whether a low-dose triple combination antihypertensive medication would achieve better blood pressure (BP) control vs usual care. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label trial of a low-dose triple BP therapy vs usual care for adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg; or in patients with diabetes or chronic kidney disease: >130 mm Hg and/or >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. INTERVENTIONS A once-daily fixed-dose triple combination pill (20 mg of telmisartan, 2.5 mg of amlodipine, and 12.5 mg of chlorthalidone) therapy (n = 349) or usual care (n = 351). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion achieving target systolic/diastolic BP (<140/90 mm Hg or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months. Secondary outcomes included mean systolic/diastolic BP difference during follow-up and withdrawal of BP medications due to an adverse event. RESULTS Among 700 randomized patients (mean age, 56 years; 58% women; 29% had diabetes; mean baseline systolic/diastolic BP, 154/90 mm Hg), 675 (96%) completed the trial. The triple combination pill increased the proportion achieving target BP vs usual care at 6 months (70% vs 55%, respectively; risk difference, 12.7% [95% CI, 3.2% to 22.0%]; P < .001). Mean systolic/diastolic BP at 6 months was 125/76 mm Hg for the triple combination pill vs 134/81 mm Hg for usual care (adjusted difference in postrandomization BP over the entire follow-up: systolic BP, -9.8 [95% CI, -7.9 to -11.6] mm Hg; diastolic BP, -5.0 [95% CI, -3.9 to -6.1] mm Hg; P < .001 for both comparisons). Overall, 419 adverse events were reported in 255 patients (38.1% for triple combination pill vs 34.8% for usual care) with the most common being musculoskeletal pain (6.0% and 8.0%, respectively) and dizziness, presyncope, or syncope (5.2% and 2.8%). There were no significant between-group differences in the proportion of patient withdrawal from BP-lowering therapy due to adverse events (6.6% for triple combination pill vs 6.8% for usual care). CONCLUSIONS AND RELEVANCE Among patients with mild to moderate hypertension, treatment with a pill containing low doses of 3 antihypertensive drugs led to an increased proportion of patients achieving their target BP goal vs usual care. Use of such medication as initial therapy or to replace monotherapy may be an effective way to improve BP control. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12612001120864; slctr.lk Identifier: SLCTR/2015/020.
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Affiliation(s)
- Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - H. Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sandrine Stepien
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Senaka Rajapakse
- Department of Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Arjuna P. de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | | | - Rama Guggilla
- General Directorate of Health Affairs in Jizan, Ministry of Health, Sabya, Saudi Arabia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Pallab K. Maulik
- The George Institute for Global Health, University of New South Wales, New Delhi, India
| | | | | | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi
| | | | | | - Simon Thom
- International Centre for Circulatory Health, Imperial College London, London, England
| | | | | | - Sanjeewa Wijekoon
- Department of Medicine, Faculty of Medical Sciences, University of Sri Jayawardenapura, Nugegoda, Sri Lanka
| | | | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Zuidgeest MG, Goetz I, Grobbee DE. PRECIS-2 in perspective: what is next for pragmatic trials? J Clin Epidemiol 2017; 84:22-24. [DOI: 10.1016/j.jclinepi.2016.02.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/29/2016] [Indexed: 12/17/2022]
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Chow CK, Thakkar J, Bennett A, Hillis G, Burke M, Usherwood T, Vo K, Rogers K, Atkins E, Webster R, Chou M, Dehbi HM, Salam A, Patel A, Neal B, Peiris D, Krum H, Chalmers J, Nelson M, Reid CM, Woodward M, Hilmer S, Thom S, Rodgers A. Quarter-dose quadruple combination therapy for initial treatment of hypertension: placebo-controlled, crossover, randomised trial and systematic review. Lancet 2017; 389:1035-1042. [PMID: 28190578 DOI: 10.1016/s0140-6736(17)30260-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/06/2017] [Accepted: 01/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Globally, most patients with hypertension are treated with monotherapy, and control rates are poor because monotherapy only reduces blood pressure by around 9/5 mm Hg on average. There is a pressing need for blood pressure-control strategies with improved efficacy and tolerability. We aimed to assess whether ultra-low-dose combination therapy could meet these needs. METHODS We did a randomised, placebo-controlled, double-blind, crossover trial of a quadpill-a single capsule containing four blood pressure-lowering drugs each at quarter-dose (irbesartan 37·5 mg, amlodipine 1·25 mg, hydrochlorothiazide 6·25 mg, and atenolol 12·5 mg). Participants with untreated hypertension were enrolled from four centres in the community of western Sydney, NSW, Australia, mainly by general practitioners. Participants were randomly allocated by computer to either the quadpill or matching placebo for 4 weeks; this treatment was followed by a 2-week washout, then the other study treatment was administered for 4 weeks. Study staff and participants were unaware of treatment allocations, and masking was achieved by use of identical opaque capsules. The primary outcome was placebo-corrected 24-h systolic ambulatory blood pressure reduction after 4 weeks and analysis was by intention to treat. We also did a systematic review of trials evaluating the efficacy and safety of quarter-standard-dose blood pressure-lowering therapy against placebo. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614001057673. The trial ended after 1 year and this report presents the final analysis. FINDINGS Between November, 2014, and December, 2015, 55 patients were screened for our randomised trial, of whom 21 underwent randomisation. Mean age of participants was 58 years (SD 11) and mean baseline office and 24-h systolic and diastolic blood pressure levels were 154 (14)/90 (11) mm Hg and 140 (9)/87 (8) mm Hg, respectively. One individual declined participation after randomisation and two patients dropped out for administrative reasons. The placebo-corrected reduction in systolic 24-h blood pressure with the quadpill was 19 mm Hg (95% CI 14-23), and office blood pressure was reduced by 22/13 mm Hg (p<0·0001). During quadpill treatment, 18 (100%) of 18 participants achieved office blood pressure less than 140/90 mm Hg, compared with six (33%) of 18 during placebo treatment (p=0·0013). There were no serious adverse events and all patients reported that the quadpill was easy to swallow. Our systematic review identified 36 trials (n=4721 participants) of one drug at quarter-dose and six trials (n=312) of two drugs at quarter-dose, against placebo. The pooled placebo-corrected blood pressure-lowering effects were 5/2 mm Hg and 7/5 mm Hg, respectively (both p<0·0001), and there were no side-effects from either regimen. INTERPRETATION The findings of our small trial in the context of previous randomised evidence suggest that the benefits of quarter-dose therapy could be additive across classes and might confer a clinically important reduction in blood pressure. Further examination of the quadpill concept is needed to investigate effectiveness against usual treatment options and longer term tolerability. FUNDING National Heart Foundation, Australia; University of Sydney; and National Health and Medical Research Council of Australia.
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Affiliation(s)
- Clara K Chow
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.
| | - Jay Thakkar
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia
| | - Alex Bennett
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Graham Hillis
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; The University of Western Australia, Perth, WA, Australia
| | | | | | - Kha Vo
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Kris Rogers
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Emily Atkins
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Ruth Webster
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Michael Chou
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Abdul Salam
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Imperial College, London, UK; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Henry Krum
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - John Chalmers
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Mark Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tas, Australia
| | | | - Mark Woodward
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Sarah Hilmer
- The University of Sydney, Sydney, NSW, Australia
| | | | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia
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Vedanthan R, Bernabe-Ortiz A, Herasme OI, Joshi R, Lopez-Jaramillo P, Thrift AG, Webster J, Webster R, Yeates K, Gyamfi J, Ieremia M, Johnson C, Kamano JH, Lazo-Porras M, Limbani F, Liu P, McCready T, Miranda JJ, Mohan S, Ogedegbe O, Oldenburg B, Ovbiagele B, Owolabi M, Peiris D, Ponce-Lucero V, Praveen D, Pillay A, Schwalm JD, Tobe SW, Trieu K, Yusoff K, Fuster V. Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries. Cardiol Clin 2017; 35:99-115. [PMID: 27886793 PMCID: PMC5131527 DOI: 10.1016/j.ccl.2016.08.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control.
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Affiliation(s)
- Rajesh Vedanthan
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
| | - Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Omarys I Herasme
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Rohina Joshi
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | | | - Amanda G Thrift
- School of Clinical Sciences at Monash Health, Monash University, Wellington Road and Blackburn Road, Clayton, VIC 3800, Australia
| | - Jacqui Webster
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Ruth Webster
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Karen Yeates
- School of Medicine, Queens University, 15 Arch Street, Kingston, ON K7L 3N6, Canada
| | - Joyce Gyamfi
- School of Medicine, New York University, 550 1st Avenue, New York, NY 10016, USA
| | - Merina Ieremia
- Samoan Ministry of Health, Motootua, Ifiifi street, Apia, Samoa
| | - Claire Johnson
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Jemima H Kamano
- College of Health Sciences, School of Medicine, Moi University, PO Box 3900, Eldoret 30100, Kenya
| | - Maria Lazo-Porras
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Felix Limbani
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg 2000, South Africa
| | - Peter Liu
- University of Ottawa, 75 Laurier Avenue East, Ottawa, ON K1N 6N5, Canada
| | - Tara McCready
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Sailesh Mohan
- Public Health Foundation of India, Plot No. 47, Sector 44, New Delhi, India
| | - Olugbenga Ogedegbe
- School of Medicine, New York University, 550 1st Avenue, New York, NY 10016, USA
| | - Brian Oldenburg
- School of Population and Global Health, University of Melbourne, Parkville, VC 3010, Australia
| | - Bruce Ovbiagele
- Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | | | - David Peiris
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Vilarmina Ponce-Lucero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Devarsetty Praveen
- The George Institute for Global Health, 301 ANR Centre, Road No 1, Banjara Hills, Hyderabad 500034, India
| | - Arti Pillay
- Pacific Research Centre for the Prevention of Obesity and Non-Communicable Diseases, Fiji National University, Suva, Fiji
| | - Jon-David Schwalm
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Sheldon W Tobe
- University of Toronto, 27 King's College Circle, Toronto, ON M5S 1A1, Canada
| | - Kathy Trieu
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selangor and UCSI University, Kuala Lumpur, Malaysia
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
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Peiris D, Thompson SR, Beratarrechea A, Cárdenas MK, Diez-Canseco F, Goudge J, Gyamfi J, Kamano JH, Irazola V, Johnson C, Kengne AP, Keat NK, Miranda JJ, Mohan S, Mukasa B, Ng E, Nieuwlaat R, Ogedegbe O, Ovbiagele B, Plange-Rhule J, Praveen D, Salam A, Thorogood M, Thrift AG, Vedanthan R, Waddy SP, Webster J, Webster R, Yeates K, Yusoff K. Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme. Implement Sci 2015; 10:158. [PMID: 26553092 PMCID: PMC4638103 DOI: 10.1186/s13012-015-0331-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 10/05/2015] [Indexed: 12/20/2022] Open
Abstract
Background The Global Alliance for Chronic Diseases comprises the majority of the world’s public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. Methods Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. Results There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation. Conclusions The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0331-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - David Peiris
- The George Institute for Global Health, The University of Sydney, Sydney, Australia.
| | | | | | | | | | - Jane Goudge
- University of the Witwatersrand, Johannesburg, South Africa.
| | - Joyce Gyamfi
- New York University School of Medicine, New York, USA.
| | | | - Vilma Irazola
- Institute for Clinical Effectiveness and Heath Policy, Buenos Aires, Argentina.
| | - Claire Johnson
- The George Institute for Global Health, The University of Sydney, Sydney, Australia.
| | - Andre P Kengne
- South African Medical Research Council, Cape Town, South Africa.
| | | | | | - Sailesh Mohan
- Public Health Foundation of India, New Delhi, India.
| | | | - Eleanor Ng
- Population Health Research Institute, Hamilton, Canada.
| | | | | | | | | | | | - Abdul Salam
- The George Institute for Global Health, New Delhi, India.
| | - Margaret Thorogood
- University of the Witwatersrand, Johannesburg, South Africa. .,University of Warwick, Coventry, UK.
| | - Amanda G Thrift
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.
| | | | | | - Jacqui Webster
- The George Institute for Global Health, The University of Sydney, Sydney, Australia.
| | - Ruth Webster
- The George Institute for Global Health, The University of Sydney, Sydney, Australia.
| | - Karen Yeates
- Queen's University School of Medicine, Kingston, Canada.
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