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Jafar TH, Gandhi M, de Silva HA, Jehan I, Naheed A, Finkelstein EA, Turner EL, Morisky D, Kasturiratne A, Khan AH, Clemens JD, Ebrahim S, Assam PN, Feng L. A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med 2020; 382:717-726. [PMID: 32074419 DOI: 10.1056/nejmoa1911965] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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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Affiliation(s)
- Tazeen H Jafar
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Mihir Gandhi
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - H Asita de Silva
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Imtiaz Jehan
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Aliya Naheed
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Eric A Finkelstein
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Elizabeth L Turner
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Donald Morisky
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Anuradhani Kasturiratne
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Aamir H Khan
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - John D Clemens
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Shah Ebrahim
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Pryseley N Assam
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
| | - Liang Feng
- From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.)
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