title: A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol.
abstract: 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. 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.
  
  
  METHODS
  Using a cluster randomized design, 32 community health centers (CHCs) and district hospitals in Ghana will be randomized to either the intervention group (16 CHCs) or the control group (16 CHCs). A total of 640 patients with uncomplicated hypertension (BP 140-179/90-99 mm Hg and absence of target organ damage) will be enrolled in this study (20 patients per CHC). The intervention consists of WHO Package of CV risk assessment, patient education, initiation and titration of antihypertensive medications, behavioral counseling on lifestyle behaviors, 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.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  NCT01802372.
authors.affiliation: Center for Healthful Behavior Change, Division of Health & Behavior, Department of Population Health, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA. Olugbenga.ogedegbe@nyumc.org.
authors.forename: Gbenga
authors.initials: G
authors.lastname: Ogedegbe
authors.forename: Jacob
authors.initials: J
authors.lastname: Plange-Rhule
authors.forename: Joyce
authors.initials: J
authors.lastname: Gyamfi
authors.forename: William
authors.initials: W
authors.lastname: Chaplin
authors.forename: Michael
authors.initials: M
authors.lastname: Ntim
authors.forename: Kingsley
authors.initials: K
authors.lastname: Apusiga
authors.forename: Kiran
authors.initials: K
authors.lastname: Khurshid
authors.forename: Richard
authors.initials: R
authors.lastname: Cooper
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use; D001794:Blood Pressure; D002985:Clinical Protocols; D003151:Community Health Centers / Q000458:organization & administration*; D003376:Counseling; D005869:Ghana / Q000453:epidemiology; D015438:Health Behavior; D006801:Humans; D006973:Hypertension / Q000188:drug therapy / Q000628:therapy*; D008019:Life Style; D055118:Medication Adherence; D010353:Patient Education as Topic; D012107:Research Design; D012307:Risk Factors; D012959:Socioeconomic Factors; D014944:World Health Organization
chemical_list: D000959:Antihypertensive Agents