Hypertension HT12, 2012 – 2017

Task shifting and blood pressure control - a cluster-randomized trial

Primary research aim

Countries in sub-Saharan Africa (SSA) are experiencing an epidemic of cardiovascular disease (CVD) propelled by rapidly increasing rates of hypertension. Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs. Although SSA bears 24% of the global disease burden, it has only 3% of the global health workforce. Given such limited resources, cost-effective strategies, such as task shifting, are needed to mitigate the rising CVD epidemic in SSA. Ghana, a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization (WHO) task-shifting strategy. This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage, on blood pressure (BP) reduction.

Research objectives and methodology

Using a cluster randomized design, 32 community health centers (CHCs) and district hospitals in Ghana will be randomized to either the intervention group (16 sites) or the control group (16 sites). A total of 640 patients with uncomplicated hypertension (BP 140-179/90-99 mmHg and absence of target organ damage) will be enrolled in this study (20 patients per site). The intervention consists of WHO Package of CV risk assessment, patient education, initiation and titration of antihypertensive medications, behavioral counselling on lifestyle behaviours, and medication adherence every three months for 12 months. The primary outcome is the mean change in systolic BP from baseline to 12 months. The secondary outcomes are rates of BP control at 12 months; levels of physical activity, percent change in weight, and dietary intake of fruits and vegetables at 12 months; and sustainability of intervention effects at 24 months. All outcomes will be assessed at baseline, six months and 12 months. Trained community health nurses will deliver the intervention as part of Ghana’s community-based health planning and services (CHPS) program. Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in resource-poor settings.

Current status

We have recruited and randomized all 32 health facilities (16 district hospitals, 16 health centers) into four cohorts. We have completed baseline recruitment with a total of 757 patients. Final patient recruitment was ~18% more than the estimated recruitment target of 640. Follow-up is almost completed for the first cohort of eight sites with a total of 198 patients. We are currently working on patient follow-up for all four cohorts.

Investigators

New York University Medical Center, New York, USA:

  • Olugbenga Ogedegbe
  • Joyce Gyamfi

Kwame Nkrumah University of Science and Technology, Kumasi, Ghana:

  • Jacob Plange-Rhule
  • Michael Ntim
  • Kingsley Apusiga

Loyola University Health System, USA

  • Richard Cooper

Publications

Funding organisations

  • Hypertension HT12
  • Ghana
  • 2012 – 2017

Programme contact
Joyce Gyamfi
joyce.gyamfi@nyumc.org