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Althuwaikh S, Albassam I, Alrashed A, Alhaji F, Al-Adawi A, Sindi MA, Alhibshi A, Al Dehaini A, Alqaysi L. Optimizing Antihypertensive Management for Hypertensive Patients With Secondary Complications: A Systematic Review and Meta-Analysis in Primary Care Settings. Cureus 2023; 15:e45834. [PMID: 37750065 PMCID: PMC10518047 DOI: 10.7759/cureus.45834] [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] [Accepted: 09/23/2023] [Indexed: 09/27/2023] Open
Abstract
Despite significant pharmacological advancements, hypertension management remains challenging, with varying quality of primary care. Digital tools and other non-pharmacological interventions hold promise in addressing this challenge. Consequently, a thorough examination of these interventions is recommended. This meta-analysis focuses on clinician-oriented strategies aimed at improving hypertension management, to assess the most effective approaches for improving antihypertensive prescribing and blood pressure control for secondary prevention. This was done through a systematic review of randomized controlled trials published in PubMed and Embase since the beginning of 2010 that aimed to enhance antihypertensive medication prescription in primary care settings for hypertensive patients with secondary complications while reporting changes in blood pressure or target achievement. We screened 6305 records. Four studies met the inclusion criteria, with reported interventions including physician education and the implementation of electronic decision support systems. All studies showed that the control group had a statistically significant lower systolic blood pressure, but the effect on diastolic blood pressure was not statistically significant. The overall mean difference was 2.12 mmHg (95% CI = 0.98; 3.26, P-value = 0.0003) for systolic blood pressure in favor of the control group and 1.22 mmHg (95% CI = -0.48; 3.26, P-value = 0.16) for diastolic blood pressure, which was not statistically significant. Despite considerable efforts to control hypertension, it remains a significant obstacle to optimal cardiovascular risk reduction. This review is also limited by a scarcity of studies.
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Affiliation(s)
| | | | | | - Fahad Alhaji
- Internal Medicine, University of Glasgow, Glasgow, GBR
| | | | | | - Ahmad Alhibshi
- Internal Medicine, King Abdulaziz University Hospital, Jeddah, SAU
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Gamlath L, Nandasena S, Silva PD, Morrell S, Linhart C, Lin S, Sharpe A, Nathan S, Taylor R. Community intervention for cardiovascular disease risk factors in Kalutara, Sri Lanka. BMC Cardiovasc Disord 2020; 20:203. [PMID: 32345219 PMCID: PMC7187517 DOI: 10.1186/s12872-020-01427-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/12/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The effectiveness of a 2015-17 community intervention to reduce cardiovascular disease (CVD) and type 2 diabetes (T2DM) risk factors is assessed in a Sri Lanka adult population, using a before-and-after study design. METHODS Four contiguous Public Health Midwife (PHM) areas in Kalutara district (Western Province) were exposed to a Sri Lankan designed community health promotion initiatives (without screening) to lower CVD and T2DM risk factors. Pre- and post-intervention surveys (2014, n=1,019; 2017, n=908) were of 25-64 year males (M) and females (F) from dissimilar randomly selected clusters (villages or settlements) from PHMs, with probability of selection proportional to population size, followed by household sampling, then individual selection to yield equal-probability samples. Differences in resting blood pressure (BP), fasting plasma glucose (FPG), total cholesterol, body mass index and tobacco smoking, adjusting for cluster sampling, age and socio-economic differences, were examined. RESULTS Hypertension prevalence declined from 25% to 16% (F) (p<.0001), and 21% to 17% (M). Both mean systolic and diastolic BP declined. T2DM declined from 18% to 13% (F), and 18% to 15% (M), as did mean fasting plasma glucose. Elevated total cholesterol declined from 21% to 15% in women (p=0.003) and mean cholesterol declined. Frequency distributions, medians and means of these continuous CVD risk factors shifted to lower levels, and were mostly statistically significant (p< 0.05). CONCLUSIONS Community health promotion can lower key CVD and T2DM risk factors. Lowering tobacco consumption in males and obesity remain challenges in Sri Lanka.
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Affiliation(s)
- L Gamlath
- Ministry of Health, Colombo, Sri Lanka; formerly Director, National Institute of Health Sciences, Kalutara, Sri Lanka
| | - S Nandasena
- Office of the Regional Director of Health Services, Kalutara, Sri Lanka
| | | | - S Morrell
- School of Public Health and Community Medicine, University of NSW, Sydney, Australia
| | - C Linhart
- School of Public Health and Community Medicine, University of NSW, Sydney, Australia
| | - S Lin
- School of Public Health and Community Medicine, University of NSW, Sydney, Australia
| | - A Sharpe
- School of Public Health and Community Medicine, University of NSW, Sydney, Australia
| | - S Nathan
- School of Public Health and Community Medicine, University of NSW, Sydney, Australia
| | - R Taylor
- School of Public Health and Community Medicine, University of NSW, Sydney, Australia.
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Alaofè H, Asaolu I, Ehiri J, Moretz H, Asuzu C, Balogun M, Abosede O, Ehiri J. Community Health Workers in Diabetes Prevention and Management in Developing Countries. Ann Glob Health 2017; 83:661-675. [PMID: 29221543 DOI: 10.1016/j.aogh.2017.10.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/17/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is limited evidence regarding the effect of community health worker (CHW) interventions for prevention and management of the burgeoning epidemic of noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs). The objective of this review was to critically appraise evidence regarding the effectiveness of CHW interventions for prevention and management of type 2 diabetes mellitus (T2DM) in LMICs. METHODS To identify studies that reported the effect of CHW interventions for prevention and management of T2DM in LMICs, Medline/PubMed, EMBASE, Web of Science (Science and Social Science Citation Indices), EBSCO (PsycINFO and CINAHL), POPLINE, the Cochrane Metabolic and Endocrine Disorders Group's Specialized Register, the Cochrane Central Register of Controlled Trials, the Grey literature (Google, Google Scholar), and reference lists of identified articles were searched from inception to May 31, 2017. FINDINGS Ten studies were included (4 pre- and post-studies, 2 randomized controlled trials, 2 cohort studies, 1 cross-sectional study, and 1 case-control study). The role of CHWs consisted of patient education, identification and referral of high-risk individuals to physicians, and provision of social support through home visits. Positive outcomes were reported in 7 of 10 studies. These outcomes included increased knowledge of T2DM symptoms and prevention measures; increased adoption of treatment-seeking and prevention measures; increased medication adherence; and improved fasting blood sugar, glycated hemoglobin, and body mass index. Three studies showed no significant outcomes. CONCLUSIONS CHWs have the potential to improve knowledge, health behavior, and health outcomes related to prevention and management of T2DM in LMICs. Given the limited number of studies included in this review, robust conclusions cannot be drawn at the present time.
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Affiliation(s)
- Halimatou Alaofè
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Ibitola Asaolu
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Jennifer Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Hayley Moretz
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Chisom Asuzu
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Olayinka Abosede
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - John Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona.
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Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. PLoS One 2017; 12:e0180640. [PMID: 28704405 PMCID: PMC5509237 DOI: 10.1371/journal.pone.0180640] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 06/19/2017] [Indexed: 11/19/2022] Open
Abstract
Background National programs for non-communicable diseases (NCD) prevention and control in different low middle income countries have a strong community component. A community health worker (CHW) delivers NCD preventive services using informational as well as behavioural approaches. Community education and interpersonal communication on lifestyle modifications is imparted with focus on primordial prevention of NCDs and screening is conducted as part of early diagnosis and management. However, the effectiveness of health promotion and screening interventions delivered through community health workers needs to be established. Objective This review synthesised evidence on effectiveness of CHW delivered NCD primary prevention interventions in low and middle-income countries (LMICs). Methods A systematic review of trials that utilised community health workers for primary prevention/ early detection strategy in the management of NCDs (Diabetes, cardiovascular diseases (CVD), cancers, stroke, Chronic Obstructive Pulmonary Diseases (COPD)) in LMICs was conducted. Digital databases like PubMed, EMBASE, OVID, Cochrane library, dissertation abstracts, clinical trials registry web sites of different LMIC were searched for such publications between years 2000 and 2015. We focussed on community based randomised controlled trial and cluster randomised trials without any publication language limitation. The primary outcome of review was percentage change in population with different behavioural risk factors. Additionally, mean overall changes in levels of several physical or biochemical parameters were studied as secondary outcomes. Subgroup analyses was performed by the age and sex of participants, and sensitivity analyses was conducted to assess the robustness of the findings. Results Sixteen trials meeting the inclusion criteria were included in the review. Duration, study populations and content of interventions varied across trials. The duration of the studies ranged from mean follow up of 4 months for some risk factors to 19 months, and primary responsibilities of health workers included health promotion, treatment adherence and follow ups. Only a single trial reported all-cause mortality. The pooled effect computed indicated an increase in tobacco cessation (RR: 2.0, 95%CI: 1.11, 3.58, moderate-quality evidence) and a decrease in systolic blood pressure ((MD: -4.80, 95% CI: -8.12, -1.49, I2 = 93%, very low-quality evidence), diastolic blood pressure ((MD: -2.88, 95% CI: -5.65, -0.10, I2 = 96%, very low-quality evidence)) and blood sugar levels (glycated haemoglobin MD: -0.83%, 95%CI: -1.25,-0.41). None of the included trials reported on adverse events. Conclusions Evidence on the implementation of primary prevention strategies using community health workers is still developing. Existing evidence suggests that, compared with standard care, using CHWs in health programmes have the potential to be effective in LMICs, particularly for tobacco cessation, blood pressure and diabetes control.
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Itoh H, Kurihara I, Miyashita K, Tanaka M. Clinical significance of 'cardiometabolic memory': a systematic review of randomized controlled trials. Hypertens Res 2017; 40:526-534. [PMID: 28100921 DOI: 10.1038/hr.2016.192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 12/13/2022]
Abstract
'Cardiometabolic memory' has been proposed based on clinical evidence to explain how, even after the cessation of a clinical trial, the superiority of one treatment over the outcome persists. To understand the cardiometabolic memory phenomenon, we performed a systematic review of randomized controlled trials (RCTs) using PubMed in August 2016. The search terms 'randomized controlled trial', 'post-trial follow-up' and 'diabetes, hypertension or dyslipidemia' were used, and articles published after the year 2000 were searched. We judged the memory phenomenon to be positive when the cardiovascular outcome at the end of the post-trial follow-up period in the intervention group was significantly superior even though the favorable control of a risk factor (blood glucose, blood pressure or lipid level) during the trial period was lost after the cessation of the intervention. Among 907 articles retrieved in the initial screening, 21 articles were judged as describing a positive memory phenomenon. Eight, six and seven of the articles concerned diabetes, hypertension and dyslipidemia, respectively. Transient intensive glucose lowering rather easily induced memory for the suppression of diabetic microangiopathies, while memory for the suppression of macroangiopathies tended to be first evident in the post-trial follow-up period. Transient intensive blood pressure lowering was generally effective in the formation of memory for the suppression of cardiovascular events and had an especially strong impact on risk reduction of chronic heart failure. Transient intensive LDL cholesterol lowering clearly had a long-term beneficial effect on risk reduction of cardiovascular events. Our systematic review revealed the clinical relevance of cardiometabolic memory.
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Affiliation(s)
- Hiroshi Itoh
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Isao Kurihara
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kazutoshi Miyashita
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Masami Tanaka
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
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Jafar TH, Allen JC, Jehan I, Hameed A, Saffari SE, Ebrahim S, Poulter N, Chaturvedi N. Health Education and General Practitioner Training in Hypertension Management: Long-Term Effects on Kidney Function. Clin J Am Soc Nephrol 2016; 11:1044-1053. [PMID: 27197908 PMCID: PMC4891747 DOI: 10.2215/cjn.05300515] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 02/10/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES In the Control of Blood Pressure and Risk Attenuation trial, a 2×2 factorial design study (2004-2007), the combined home health education and trained general practitioner intervention delivered over 2 years was more effective than no intervention (usual care) in lowering systolic BP among adults with hypertension in urban Pakistan. We aimed to assess the effectiveness of the interventions on kidney function. DESIGN, PARTICIPANTS, SETTINGS, & METHODS In 2012-2013, we conducted extended follow-up of a total of 1271 individuals aged ≥40 years with hypertension (systolic BP ≥140 mmHg, diastolic BP ≥90 mmHg, or receipt of antihypertensive treatment) and serum creatinine measurements with 2 years in-trial and 5 years of post-trial period in 12 randomly selected low-income communities in Karachi, Pakistan. The change in eGFR from baseline to 7 years was assessed among randomized groups using a generalized estimating equation method with multiple imputation of missing values. RESULTS At 7 years of follow-up, adjusted mean eGFR remained unchanged, with a change of -0.3 (95% confidence interval [95% CI], -3.5 to 2.9) ml/min per 1.73 m(2) among adults randomly assigned to the combined home health education plus trained general practitioner intervention compared with a significant decline of -3.6 (95% CI, -5.7 to -2.0) ml/min per 1.73 m(2) in those assigned to usual care (P=0.01, modified intention-to-treat analysis). The risk for the combined intervention of death from kidney failure or >20% decline in eGFR relative to usual care was significantly reduced (risk ratio, 0.47; 95% CI, 0.25 to 0.89). CONCLUSIONS The combined home health education plus trained general practitioner intervention is beneficial in preserving kidney function among adults with hypertension in communities in Karachi. These findings highlight the importance of scaling up simple strategies for renal risk reduction in low- and middle-income countries.
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Affiliation(s)
- Tazeen H. Jafar
- Program in Health Services & Systems Research and
- Department of Community Health Science and
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - John C. Allen
- Section of Cardiology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | - Aamir Hameed
- Section of Cardiology, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Seyed Ehsan Saffari
- Centre for Quantitative Medicine, Office of Clinical Sciences, Duke-National University of Singapore Graduate Medical School, Singapore
| | - Shah Ebrahim
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Neil Poulter
- International Centre for Circulatory Health and Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom; and
| | - Nish Chaturvedi
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
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