Rasool Bux

Community-based interventions to promote blood pressure control in a developing country: a cluster randomized trial.

Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in resource-poor settings. Contribution Among 1341 patients living in 12 communities in Pakistan that were randomly assigned to general practitioner education, home health visits by trained lay workers, both, or neither, patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure (10.8 mm Hg) after 2 years. Improvements were similar in all other groups (about 5 mm Hg). Caution Twenty-two percent of patients were lost to follow-up. Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in resource-poor settings. The Editors Cardiovascular disease has, in just a few decades, become the leading cause of death in adults worldwide, accounting for 1 in 5 deaths. Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease (1, 2). Despite the demonstrated benefits of effective drug treatment (3, 4) and the existence of many clinical practice guidelines (5), hypertension prevention, treatment, and control rates remain suboptimal worldwide (6). The situation is particularly acute in developing countries, such as Pakistan, India, and China, where hypertension has reached epidemic proportionsaffecting more than 20% of the adult population (7)yet control rates are less than 6% (8). Poor health literacy and unhealthy lifestyles, compounded by lack of awareness of hypertension (7), are part of the cause. In addition, the health systems in these countries are often dysfunctional: More than 80% of the expenditure for chronic disease care is out-of-pocket; private care general practitioners (GPs), who primarily treat acute conditions, are the front-line service providers; and national programs for preventing and controlling hypertension are inadequate. Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers. (9) However, evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking. We conducted the COBRA-1 (Control of Blood Pressure and Risk Attenuation-1) trial in Karachi, Pakistan, to test the effectiveness of 2 community-based strategies: family-based home health education (HHE), delivered by trained community health workers, to improve population-level health literacy and behaviors, and hypertension management training for GPs. We tested the effect of these interventions, alone and in combination, on blood pressure in adults with hypertension. We hypothesized that HHE would be more effective than no education, that the specially trained GPs would provide more effective care than that usually received in Karachi, and that the combined interventions would provide additional benefit. Methods Study Design and Setting We performed a cluster randomized, controlled trial with a 22 factorial design to determine the effect of family-based HHE and special training for GPs on blood pressure in adults 40 years or older with hypertension. We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level, and an individual approach would be prone to contamination of interventions and biased outcomes (10). The Aga Khan University Ethics Review Committee granted ethical approval. The sampling frame is described elsewhere (11). In brief, we used a multistage random sampling technique to select 12 of 4200 low- to middle-income, geographic census-based clusters (mean household monthly income,

Cost-Effectiveness of Community-Based Strategies for Blood Pressure Control in a Low-Income Developing Country Findings From a Cluster-Randomized, Factorial-Controlled Trial

70; about 250 households in each cluster) in Karachi, the most populous city in Pakistan (about 16 million inhabitants). We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention. Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits (mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg) were eligible for inclusion. We excluded pregnant women, persons who could not give informed consent, and bed-bound persons. Randomization and Intervention We used computer-generated codes to randomly assign 3 clusters each to the following groups: HHE alone, GP alone, HHE and GP combined, and no intervention. Home Health Education We trained 6 community health workers (1 for each cluster) over 6 weeks in methods for using behavior-changing communication strategies to convey standardized health education messages to all households in clusters assigned to receive HHE. The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan (8 or preferably 10 years of schooling) (12). Salary scales and assigned workload were similarly consistent. The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease, as well as advice on the importance of engaging in moderate physical activity; maintaining normal body weight; reducing salt intake; consuming a diet rich in fruit, vegetables, and low-fat dairy products; reducing intake of saturated and total fat (including suggestions on sample recipes for culturally acceptable and economically feasible food products); and smoking cessation (Appendix 1). The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized. The first HHE session, lasting 90 minutes, was held at a time when all members of the household could be present. Follow-up reinforcement visits of 30 minutes were made every 3 months. Appendix 1. Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training, with the aim of training at least two thirds of the GPs in each area. We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training. Training was a 1-day session that focused on standard treatment algorithms for the stepped-care management of hypertension, which were based on the seventh report of the Joint National Committee (3) and the Fourth Working Party of the British Hypertension Society guidelines (4) and modified for the Indo-Asian population (Appendix 2). The course included components on nonpharmacologic (diet, exercise, weight loss, and smoking cessation) and pharmacologic interventions, prescription of low-cost and appropriate generic drugs, preferential use of single-dose drug regimens, scheduled follow-up visits guided by blood pressure, the stepped-care approach for titrating drugs to achieve target blood pressure, and satisfactory consultation sessions for patients, with explanations of treatment and use of appropriate communication strategies. For managing persons with known hypertension, GPs were advised to review medication and blood pressure; simplify regimens; and aim to return to a regimen that was in line, as reasonably as possible, with that recommended for those with newly diagnosed hypertension. The recommended target blood pressure was <140/90 mm Hg for all patients. Although this diverges from recent guidelines for special subgroups (such as diabetic persons or those with end-organ damage), we reasoned that we needed to keep the intervention, guidelines, and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3% (7). The training sessions for GPs used a case-based curriculum and were interactive. We provided a certificate of training at the end of the course. Appendix 2. Training Manual for General Practitioner All study participants were advised to consult a local GP. If participants in the clusters randomly assigned to a trained GP group did not already have a preferred GP, we gave them a list of trained GPs in their cluster from which to choose. However, it remained the participants choice whether they attended a physician on the list. We did not provide for medications or fee-for-health care services. Participants were blinded to intervention status (training of GP). Neither the patients nor the GPs received reimbursement for participation. Screening and Recruitment All households in each cluster were visited, and we obtained informed consent for screening from all adults 40 years and older, whose blood pressure was then measured 3 times with a calibrated automated device (Omron HEM-737 IntelliSense; Omron Healthcare, Vernon Hills, Illinois) in the sitting position after 5 minutes of rest. Those with known hypertension were invited to participate. Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit. If mean blood pressure remained elevated, these persons were also invited to participate. A routine physical examination was performed, and the following information was collected: smoking status, food frequency, and physical activity by questionnaire, the latter by using the international physical activity questionnaire; blood pressure, measured as described above; anthropometric characteristics (height, weight, and waist and hip circumferences); and fasting blood glucose level (Synchron Cx-7/Delta, Beckman Coulter, Fullerton, California) and lipid profile (Hitachi-912, Roche, Basel, Switzerland) (11). Follow-up Procedures Trained outcomes assessors (who were not part of and had no relationship with the community health worker team) evaluated part

Community based lifestyle intervention for blood pressure reduction in children and young adults in developing country: cluster randomised controlled trial

Background— Evidence on economically efficient strategies to lower blood pressure (BP) from low- and middle-income countries remains scarce. The Control of Blood Pressure and Risk Attenuation (COBRA) trial randomized 1341 hypertensive subjects in 12 randomly selected communities in Karachi, Pakistan, to 3 intervention programs: (1) combined home health education (HHE) plus trained general practitioner (GP); (2) HHE only; and (3) trained GP only. The comparator was no intervention (or usual care). The reduction in BP was most pronounced in the combined group. The present study examined the cost-effectiveness of these strategies. Methods and Results— Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on (1) intervention cost; (2) cost of physician consultation, medications, diagnostics, changes in lifestyle, and productivity loss; and (3) change in systolic BP. Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications. Bayesian probabilistic sensitivity analysis was also performed. The annual costs per participant associated with the combined HHE plus trained GP, HHE alone, and trained GP alone were

Estimation of GFR in South Asians: A Study From the General Population in Pakistan

3.99,

Level and Determinants of Kidney Function in a South Asian Population in Pakistan

3.34, and

Control of Blood Pressure and Risk Attenuation: Post Trial Follow-Up of Randomized Groups

0.65, respectively. HHE plus trained GP was the most cost-effective intervention, with an incremental cost-effectiveness ratio of

Association of parental blood pressure with retinal microcirculatory abnormalities indicative of endothelial dysfunction in children

23 (95 confidence interval, 6–99) per mm Hg reduction in systolic BP compared with usual care, and remained so in 97.7 of 1000 bootstrapped replications. Conclusions— The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan, and possibly other countries in Indochina with similar healthcare infrastructure. Clinical Trial Registration— http://www.clinicaltrials.gov. Unique identifier: NCT00327574.

Cost-Effectiveness of Community-Based Strategies for Blood Pressure Control in a Low-Income Developing Country

Objective To assess the effectiveness of a community based lifestyle intervention on blood pressure in children and young adults in a developing country setting. Design Cluster randomised controlled trial. Setting 12 randomly selected geographical census based clusters in Karachi, Pakistan. Participants 4023 people aged 5-39 years. Intervention Three monthly family based home health education delivered by lay health workers. Main outcome measure Change in blood pressure from randomisation to end of follow-up at 2 years. Results Analysed using the intention to treat principle, the change in systolic blood pressure (adjusted for age, sex, and baseline blood pressure) was significant; it increased by 1.5 (95% confidence interval 1.1 to 1.9) mm Hg in the control group and by 0.1 (−0.3 to 0.5) mm Hg in the home health education group (P for difference between groups=0.02). Findings for diastolic blood pressure were similar; the change was 1.5 mm Hg greater in the control group than in the intervention group (P=0.002). Conclusions Simple, family based home health education delivered by trained lay health workers significantly ameliorated the usual increase in blood pressure with age in children and young adults in the general population of Pakistan, a low income developing country. This strategy is potentially feasible for up-scaling within the existing healthcare systems of Indo-Asia. Trial registration Clinical trials NCT00327574.

Cost-Effectiveness of Community-Based Strategies for Blood Pressure Control in a Low-Income Developing CountryClinical Perspective: Findings From a Cluster-Randomized, Factorial-Controlled Trial

BACKGROUND South Asians are at high risk for chronic kidney disease. However, unlike those in the United States and United Kingdom, laboratories in South Asian countries do not routinely report estimated glomerular filtration rate (eGFR) when serum creatinine is measured. The objectives of the study were to: (1) evaluate the performance of existing GFR estimating equations in South Asians, and (2) modify the existing equations or develop a new equation for use in this population. STUDY DESIGN Cross-sectional population-based study. SETTING & PARTICIPANTS 581 participants 40 years or older were enrolled from 10 randomly selected communities and renal clinics in Karachi. PREDICTORS eGFR, age, sex, serum creatinine level. OUTCOMES Bias (the median difference between measured GFR [mGFR] and eGFR), precision (the IQR of the difference), accuracy (P30; percentage of participants with eGFR within 30% of mGFR), and the root mean squared error reported as cross-validated estimates along with bootstrapped 95% CIs based on 1,000 replications. RESULTS The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation performed better than the MDRD (Modification of Diet in Renal Disease) Study equation in terms of greater accuracy at P30 (76.1% [95% CI, 72.7%-79.5%] vs 68.0% [95% CI, 64.3%-71.7%]; P < 0.001) and improved precision (IQR, 22.6 [95% CI, 19.9-25.3] vs 28.6 [95% CI, 25.8-31.5] mL/min/1.73 m(2); P < 0.001). However, both equations overestimated mGFR. Applying modification factors for slope and intercept to the CKD-EPI equation to create a CKD-EPI Pakistan equation (such that eGFRCKD-EPI(PK) = 0.686 × eGFRCKD-EPI(1.059)) in order to eliminate bias improved accuracy (P30, 81.6% [95% CI, 78.4%-84.8%]; P < 0.001) comparably to new estimating equations developed using creatinine level and additional variables. LIMITATIONS Lack of external validation data set and few participants with low GFR. CONCLUSIONS The CKD-EPI creatinine equation is more accurate and precise than the MDRD Study equation in estimating GFR in a South Asian population in Karachi. The CKD-EPI Pakistan equation further improves the performance of the CKD-EPI equation in South Asians and could be used for eGFR reporting.

Cost-Effectiveness of Community-Based Strategies for Blood Pressure Control in a Low-Income Developing CountryClinical Perspective

BACKGROUND People of South Asian origin are at high risk of chronic kidney disease. Some have suggested that the usual level of glomerular filtration rate (GFR) in South Asians may be lower than in populations of European origin. However, measured GFR in a general adult population of South Asian origin has not been studied. DESIGN Cross-sectional observational study. SETTING & PARTICIPANTS 530 patients 40 years or older randomly selected from communities in Karachi, Pakistan, using multistage cluster sampling. Patients with both diabetes and hypertension were excluded. PREDICTOR Age, sex, diabetes, and hypertension. OUTCOME Measured GFR using urinary clearance of inulin. RESULTS Mean age of participants was 49.7 ± 9.5 (standard deviation [SD]) years, 51% were men, 34.9% had hypertension, and 30.5% had diabetes. Mean measured GFR was 94.1 ± 28.6 mL/min/1.73 m(2). GFR was lower by 0.79 ± 0.11 mL/min/1.73 m(2) for each 1-year older age. The 5-year age- and sex-specific mean GFR of the study population generally was within 1 SD of the mean of previously reported values for US adults. Factors independently associated with GFR were younger age (β coefficient, -3.84 [95% CI, -5.46 to -2.21] mL/min/1.73 m(2) per 5 years older), higher serum albumin level (4.58 [95% CI, 0.74-8.42] mL/min/1.73 m(2) per 0.5-g/dL increase), higher fasting plasma glucose level (0.81 [95% CI, 0.44-1.18] mL/min/1.73 m(2) per 10-mg/dL increase), high versus low meat intake (7.81 [95% CI, 1.14-14.48] mL/min/1.73 m(2) for ≥11 vs ≤5 servings/wk), and higher estimated protein intake (1.46 [95% CI, 0.41-2.51] mL/min/1.73 m(2) per 1.0-g/d increase) from urine urea nitrogen. LIMITATIONS Moderate sample size, lack of validation of some items in the dietary assessment for this study population. CONCLUSIONS Mean measured GFR in South Asian adults from the general population in Karachi, Pakistan, is only modestly lower than in European-origin counterparts, with similar age association. This may reflect lower dietary protein intake in South Asians.