Hypertension Research Programme - HT06

Improving the control of HT in rural India: overcoming the barriers to diagnosis and effective treatment

Project location: India

Project duration: 2012 - 2016

Funding organisation

• National Health and Medical Research Council

Primary research aim

There are significant barriers to the diagnosis and treatment of hypertension in both urban and rural regions of India, and there is some evidence that system barriers differ according to the stage of transition of the population. Our research is being undertaken in three diverse rural regions in India, each of which is at a different stage of economic and epidemiological transition (early, middle, late) to identify and explore these potentially different barriers and knowledge gaps in the diagnosis treatment and management of hypertension

Research objectives and methodology

We are employing common recruitment and study methods across these settings in order to address the following aims:

• To quantify and identify the determinants of the prevalence, awareness, treatment, and control of hypertension in three different rural populations in India.
• Identify barriers to hypertension control.
• Develop and pilot intervention strategies to improve the control of hypertension. The pilot program will be based on those factors identified as contributing to hypertension control in these settings and will include both management and prevention strategies aimed at the individual, health service delivery and policy levels.

Current status

Process achievements

We have obtained ethics approval from all institutes, including ICMR and each sponsor partner (n=5). We have successfully harmonised the cross sectional survey across three disparate rural settings (English plus two additional languages), and trained staff to administer the survey and collect anthropometric data using identical techniques.

Outcome achievements

We have recruited approximately 6500 participants into the baseline survey over the three locations (approx. 40% of target recruitment).

We have conducted at least one in-depth interview at each site with the Primary Health Centre Clinician, Staff nurse, and other associated non-physician health care worker (Auxiliary nurse midwife [ANM], Accredited Social Health Activist [ASHA]), i.e. three in-depth interviews at each location. These interviews were conducted to determine current practice in the diagnosis and management of hypertension. The data will be presented, discussed and considered during our investigator meeting and will be used to develop the pilot intervention.

We have conducted an audit of pharmacies at each site to capture medicines availability and cost in the public and private sector. This information will inform potential opportunities for the inclusion of pharmacological activities within the intervention plan.

We have conducted at least one focus group discussion with male participants and one with female participants at each location to further investigate any potential barriers and obstacles to hypertension diagnosis and management in each population. This information will be presented, discussed and considered during our investigator meeting and will also be used to develop the pilot intervention(s).

Methodological challenges

To develop common recruitment and study methods that take into account the great diversity of culture, systems, and communities.

Across three sites with divergent cultural attitudes it has been challenging to promote and maintain consistency of anthropometric measurements.

Investigating divergent and varied potential barriers and gaps with respect to diagnosis and management of hypertension whilst minimizing participant burden.

Stakeholder engagement

Major administrative and health policy stakeholders (Indian Council of Medical Research, Public Health Foundation India, State Program officer from the National Programme for Prevention and Control of Cancer, diabetes Cardiovascular diseases and stroke, Director of Andhra Pradesh Public Health and Family Welfare) have attended our annual investigator meeting in October 2014.

Stakeholders were asked to comment, critique and assist in further refining the intervention in the context of the existing health delivery frameworks, clinical guidelines, and current clinical practice. Our underlying aim with this approach is to develop an effective intervention that would be easily incorporated into the Indian health system, thereby enhancing the scalability of the intervention.

Key lessons from last 12 months

As hypothesised, we have encountered differences in the prevalence of hypertension and barriers to its control across these three rural settings. There is also variation in both lifestyle factors and availability of goods and services, including health care services and food variety. We will be able to explore how the variability in lifestyle and services impacts on hypertension and associated health outcomes.

Aims/priorities for next 12 months

We will complete our cross sectional survey of barriers, and other important factors, associated with control of hypertension in rural populations across the epidemiological divide.

We will develop and implement a pilot intervention that is low cost, and culturally and economically appropriate for each setting. This may include lifestyle, social support and pharmacological interventions.

Other research impact

Our findings might impact on other research activities for other non-communicable diseases in the region, as we will have self-reported data on diabetes, hyperlipidaemia, and memory loss. The intervention designed might be applicable to managing these other conditions.

Project contact: Dr Michaela Riddell - Michaela.riddell [at] monash.edu

Investigators

• Amanda Thrift, Monash University, Melbourne, Australia
• Brian Oldenburg, Monash University, Melbourne, Australia
• Velandai Srikanth, Monash University, Melbourne, Australia
• Ajay Mahal, Monash University, Melbourne, Australia
• Roger Evans, Monash University, Melbourne, Australia
• Clara Chow, The George Institute, Sydney, Australia
• Rohina Joshi, The George Institute, Sydney, Australia
• Nihal Thomas, CMC Vellore, India
• Kartik Kalyanram, Rishi Valley Education Centre, Madanapalle, India
• Kamakshi Kartik, Rishi Valley Education Centre, Madanapalle, India
• Kavumpurathu Thankappan, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, India) 
• Pallab Maulik, The George Institute, India

Publications

Riddell MA, Joshi R , Oldenburg B, Chow C, Thankappan KR, Mahal A, Thomas N, Srikanth VK, Evans RG, Kartik K, Kamakshi K, Maulik PK, Arabshahi S, Varma RP, Guggilla RK, Suresh O, Mini GK, D’Esposito F, Sathish T, Alim M, Thrift AG. Cluster randomised feasibility trial to improve the Control of Hypertension In Rural India (CHIRI): a study protocol. BMJ Open 2016;6(10):e012404. doi:10.1136/bmjopen-2016-012404.