Salma H. Badruddin

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,

Anemia prevalence and risk factors in pregnant women in an urban area of Pakistan.

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

Child's gender and household food insecurity are associated with stunting among young Pakistani children residing in urban squatter settlements.

Background Anemia affects almost two-thirds of pregnant women in developing countries and contributes to maternal morbidity and mortality and to low birthweight. Objective To determine the prevalence of anemia and the dietary and socioeconomic factors associated with anemia in pregnant women living in an urban community setting in Hyderabad, Pakistan. Methods This was a prospective, observational study of 1,369 pregnant women enrolled at 20 to 26 weeks of gestation and followed to 6 weeks postpartum. A blood sample was obtained at enrollment to determine hemoglobin levels. Information on nutritional knowledge, attitudes, and practice and dietary history regarding usual food intake before and during pregnancy were obtained by trained interviewers within 1 week of enrollment. Results The prevalence of anemia (defined by the World Health Organization as hemoglobin < 11.0 g/dL) in these subjects was 90.5%; of these, 75.0% had mild anemia (hemoglobin from 9.0 to 10.9 g/dL) and 14.8% had moderate anemia (hemoglobin from 7.0 to 8.9 g/dL). Only 0.7% were severely anemic (hemoglobin < 7.0 g/dL). Nonanemic women were significantly taller, weighed more, and had a higher body mass index. Multivariate analysis after adjustment for education, pregnancy history, iron supplementation, and height showed that drinking more than three cups of tea per day before pregnancy (adjusted prevalence odds ratio [aPOR], 3.2; 95% confidence interval [CI], 1.3 to 8.0), consumption of clay or dirt during pregnancy (aPOR, 3.7; 95% CI, 1.1 to 12.3), and never consuming eggs or consuming eggs less than twice a week during pregnancy (aPOR, 1.7; 95% CI, 1.1 to 2.5) were significantly associated with anemia. Consumption of red meat less than twice a week prior to pregnancy was marginally associated with anemia (aPOR, 1.2; 95% CI, 0.8 to 1.8) but was significantly associated with lower mean hemoglobin concentrations (9.9 vs. 10.0 g/dL, p = .05) during the study period. A subanalysis excluding women with mild anemia found similar associations to those of the main model, albeit even stronger. Conclusions A high percentage of women at 20 to 26 weeks of pregnancy had mild to moderate anemia. Pica, tea consumption, and low intake of eggs and red meat were associated with anemia. Women of childbearing age should be provided nutritional education regarding food sources of iron, especially prior to becoming pregnant, and taught how food choices can either enhance or interfere with iron absorption.

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

Background The nutritional status of children is a good indicator of the overall well-being of a society and reflects food security as well as existing health-care and environmental conditions. In Pakistan, it is estimated that nearly 40% to 50% of children under the age of five are stunted. Due to greater economic opportunities available to the urban population as compared to the rural, it was believed that economic resources existed in poor urban Pakistani households but that the households lacked the skills and knowledge to translate their resources into good care and feeding practices. Objective This study aimed 1) to assess the prevalent care and feeding practices among children aged 6 to 18 months residing in the squatter settlements of Karachi and 2) to identify care and feeding practices, as well as any other underlying factors, associated with stunting. Methods A cross-sectional survey was conducted in eight settlements between October and December 2000. A total of 433 mothers of eligible children were interviewed with the use of structured questionnaires. Final analysis using multiple logistic regression was conducted on 399 mother—child pairs. Results Female children were nearly three times more likely to be stunted than male children. Households that were food insecure with hunger were also three times more likely than other households to have a stunted child. Lack of maternal formal schooling (adjusted prevalence odds ratio, 2.9; 95% confidence interval, 1.4 to 3.8) and large household size (adjusted prevalence odds ratio, 1.7; 95% confidence interval, 1.0 to 3.8) were also associated with stunting. Even though certain care and feeding practices were significant at the univariate level, they were not significant in the final multivariate analysis and so were excluded from the final model. Conclusions In households where food insecurity exists, knowledge of care practices may not be sufficient, and interventions such as food subsidies must precede or accompany educational efforts. Further follow-up is required to explore the effect of gender differences on child care.

Validating MOSPA questionnaire for measuring physical activity in Pakistani women

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.

Nutrient absorption and weight gain in persistent diarrhea: comparison of a traditional rice-lentil/yogurt/milk diet with soy formula

BackgroundPrecise measurements of activity at a population level are important for monitoring trends and evaluating health promotion strategies. Few studies have assessed the measurement of physical activity in developing countries. The aim of this study was to validate the MOSPA (Monica Optional Study of Physical Activity) questionnaire which was developed for the WHO-Monitoring trends and determinants of cardiovasculr disease (MONICA) study sites.MethodsThe MOSPA questionnaire assesses energy expendtiture (EE) related to physical activity (employment, household work, transportation, and leisure time) over a one year period. This questionnaire has been described in the manuscript as the long term (LT) questionnaire. An adapted short term (ST) 5 day questionnaire was developed to assess convergent validity. Questionnaire data were compared with physical activity EE estimates from a Caltrac accelerometer and with body composition measures (height, weight and bioelectrical impedance) in 50 women from the Aga Khan University (AKU) hospital antenatal clinics, Pakistan. Other forms of EE i.e. resting EE and thermic effect of food were not assessd in this study.ResultsSubjects were aged 26 ± 3.8 years and were 16.1 ± 6.7 weeks pregnant. Their average weight was 58.8 ± 10.7 Kg. The average EE/day assessed by the Caltrac accelerometer, was 224 kcal and by MOSPA LT questionnaire it was 404 kcal. The questionnaires and Caltrac data were reasonably well correlated: r = 0.51 and r = 0.60 (P < 0.01) for LT and ST questionnaires respectively. Energy expenditure from questionnaire data was not correlated with body composition measures.ConclusionThe MOSPA questionnaire is useful in assessing physical activity levels in a sedentary population over a one year period.

A Nutrition Education Intervention to Combat Undernutrition: Experience from a Developing Country

Summary: We prospectively studied clinical outcome and nutrition absorption in male children (6–36 months of age) with persistent diarrhea (PD) and severe protein-energy malnutrition (mean z score for age, −4.2 × 0.8). Fifty-one children were randomly allocated to receive a combination of khitchri, a rice-lentil mixture, yogurt, and half-strength buffalo milk (group A; n = 26) or full-strength soy formula (group B; n = 25) for 14 days. The initial caloric intake (p < 0.02) and mean weight gain (p < 0.02) were greater in the group B patients. The mean stool volume and frequency were comparable between the two groups. Seven children in group A were considered clinical failures by criteria of weight loss and PD, compared to three in group B. The coefficients of absorption (COA) for protein were similar between the two groups, but group B patients had higher values of COA for energy and fat (p < 0.05) in the second week of nutritional rehabilitation. The majority (63%) of the children improved on the khitchri-yogurt-milk diet but the nutritional outcome was not as good as with the soy formula. These data indicate that a traditional diet can be successfully used in the dietary management of PD and severe malnutrition but that a more optimal composition, yielding a higher success rate, should be sought.

Weaning recommendations : the scientific basis

Introduction. Undernutrition in children is a major public health concern in Pakistan. A number of interventions which focused only on providing nutrient supplementation have failed to change child undernutrition status during the last 2 decades. The present study aimed to assess the impact of nutrition education on the nutritional status of children living in resource-limited environments. Methods. Subjects were 586 children from Tando Jam and Quetta, Pakistan, aged from 6 months to 8 years. Children were characterized as mild, moderate, or severely wasted on Z-scores. Anthropometry and 24-hour dietary recall were used for nutritional assessment. Intervention strategy was nutrition counselling targeting mothers. Primary outcome was decrease in the severity of wasting and changes in the feeding practices. Results. Nearly 36% children in Tando Jam and 32% children in Quetta progressed to a normal nutritional status. There was a significant increase in the number of meals taken per day (Tando Jam—P ≤ 0.000/Quetta—P ≤ 0.025). In Tando Jam, significant increase was reported in the intake of high starch food items, vegetables, and fruits (P ≤ 0.000). In Quetta, significant increase was noted in the intake of plant protein (P ≤ 0.005), dairy foods (P ≤ 0.041), and vegetables (P ≤ 0.026). Conclusion. Nutrition education was successful in reducing undernutrition in food insecure households.