title: Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study.
abstract: BACKGROUND
  Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community.
  
  
  METHODS
  We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching.
  
  
  RESULTS
  NCDSS had data for 65,619 individuals aged 25 years or older (11,686 of whom in rural areas); of these, 64,694 (11,521 in rural areas) had data for SBP and 50,202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (-0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (-0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method.
  
  
  CONCLUSIONS
  Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel.
  
  
  BACKGROUND
  None.
authors.affiliation: Tehran University of Medical Sciences, Diabetes Research Centre and Endocrinology and Metabolism Research Center, Tehran, Iran.
authors.forename: Farshad
authors.initials: F
authors.lastname: Farzadfar
authors.forename: Christopher J L
authors.initials: CJ
authors.lastname: Murray
authors.forename: Emmanuela
authors.initials: E
authors.lastname: Gakidou
authors.forename: Thomas
authors.initials: T
authors.lastname: Bossert
authors.forename: Hengameh
authors.initials: H
authors.lastname: Namdaritabar
authors.forename: Siamak
authors.initials: S
authors.lastname: Alikhani
authors.forename: Ghobad
authors.initials: G
authors.lastname: Moradi
authors.forename: Alireza
authors.initials: A
authors.lastname: Delavari
authors.forename: Hamidreza
authors.initials: H
authors.lastname: Jamshidi
authors.forename: Majid
authors.initials: M
authors.lastname: Ezzati
mesh_terms: D000328:Adult; D001786:Blood Glucose / Q000032:analysis; D001794:Blood Pressure; D003150:Community Health Workers / Q000600:supply & distribution; D003920:Diabetes Mellitus / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D007492:Iran / Q000453:epidemiology; D008297:Male; D011320:Primary Health Care; D019035:Rural Health Services; D012424:Rural Population
chemical_list: D001786:Blood Glucose