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

Background

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.

Aims

This study evaluated 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.

Project plan

Using a cluster randomized design, 32 community health centers (CHCs) and district hospitals in Ghana were randomized to either the intervention group (16 sites) or the control group (16 sites). The team aimed to enrol a total of 640 patients with uncomplicated hypertension (BP 140-179/90-99 mmHg and absence of target organ damage) in this study (20 patients per site). The intervention consisted of a 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 was the mean change in systolic BP from baseline to 12 months. The secondary outcomes were 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. The team aimed to assess all outcomes at baseline, six months and 12 months. Trained community health nurses delivered the intervention as part of Ghana’s community-based health planning and services (CHPS) program. The aim was to 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.

Impact

The project showed that providing patients with health insurance and nurse-led prescription of anti-hypertensive medication was associated with a greater reduction in blood pressure than provision of health insurance coverage alone. The project findings provided evidence for policy makers to recommend addition of a nurse-led task shifting strategy for hypertension control to health insurance coverage for management of hypertension in sub-Saharan Africa.

The project team noted that future scale-up of this nurse-led strategy would require a cost–benefit analysis and establishment of a policy that grants nurses prescribing power to treat patients with uncomplicated hypertension.

Publications and output

GACD have published an end-of-programme report providing a comprehensive summary of the programme and outcomes.

Principal investigators

Team members

Funding organisations

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