title: Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka: feasibility trial results.
abstract: High blood pressure (BP) is the leading attributable risk for cardiovascular disease globally. There is little information on effective and sustainable public health system strategies for managing hypertension in South Asian countries. We conducted a feasibility study to gather preliminary data to optimize BP-lowering strategies for a public health intervention in rural communities in Bangladesh, Pakistan, and Sri Lanka.
  
  
  
  A mixed method feasibility study comprised a 3-month pre and postevaluation of a multicomponent intervention (MCI), including BP screening and home health education by trained government community health worker (CHW); providers trained in hypertension management, and compensation of CHW for additional services. Checklists were used to document care. Stakeholder interviews were also conducted. Individuals aged 40 years and above with high BP (systolic ≥140 mmHg or diastolic ≥90 mmHg based on two readings from 2 separate days, or receiving antihypertensive medications) were enrolled from rural communities in Bangladesh, Pakistan, and Sri Lanka. BP was measured at baseline and 3 months postintervention.
  
  
  
  A total of 412 (90%) of the 454 eligible individuals were recruited. Of those recruited, 90% received home health education session by trained CHWs, 80% were referred to trained providers, of whom 83% completed the management checklist. A follow-up rate of 95.6% was achieved. The mean SBP declined significantly by 4.5 mmHg 95% confidence interval (2.3, 6.7) mmHg (P < 0.001) in the overall pooled analysis in three countries; however, it varied among countries. BP decline was 10.5 mmHg (8.1, 13.0 mmHg) (P < 0.001) in the pooled analysis of individuals with uncontrolled hypertension at baseline, and was also significant each of the three countries. All 98 stakeholders strongly supported upscaling the proposed MCI strategies.
  
  
  
  The proposed MCI is feasible for implementation and requires long-term, large-scale evaluation in the rural public health infrastructure in South Asian countries to determine sustainability of health system changes and BP control. If these long-term effects are confirmed, MCI may be a long-term strategy for tackling rising rates of cardiovascular disease in low-resourced countries.Clintrial.gov NCT02341651.
authors.affiliation: aProgram in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore bDuke Global Health Institute, Durham, North Carolina, USA cDepartment of Pharmacology, Faculty of Medicine, Clinical Trials Unit, University of Kelaniya, Kelaniya, Sri Lanka dInternational Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh eDepartment of Community Health Sciences, Aga Khan University, Karachi, Pakistan fSingapore Clinical Research Institute, Singapore, Singapore gSaw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore hLondon School of Hygiene and Tropical Medicine, London, UK iDepartment of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka jFaculty of Health, York University, Toronto, Ontario, Canada kDepartment of Medicine, Section of Cardiology, Aga Khan University, Karachi, Pakistan *Asita de Silva, Aliya Naheed, and Imtiaz Jehan contributed equally to the writing of this article.
authors.forename: Tazeen H
authors.initials: TH
authors.lastname: Jafar
authors.forename: Asita de
authors.initials: Ad
authors.lastname: Silva
authors.forename: Aliya
authors.initials: A
authors.lastname: Naheed
authors.forename: Imtiaz
authors.initials: I
authors.lastname: Jehan
authors.forename: Feng
authors.initials: F
authors.lastname: Liang
authors.forename: Pryseley N
authors.initials: PN
authors.lastname: Assam
authors.forename: Helena
authors.initials: H
authors.lastname: Legido-Quigley
authors.forename: Eric A
authors.initials: EA
authors.lastname: Finkelstein
authors.forename: Shah
authors.initials: S
authors.lastname: Ebrahim
authors.forename: Rajitha
authors.initials: R
authors.lastname: Wickremasinghe
authors.forename: Dewan
authors.initials: D
authors.lastname: Alam
authors.forename: Aamir Hameed
authors.initials: AH
authors.lastname: Khan
mesh_terms: D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001459:Bangladesh; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000517:prevention & control; D057189:Checklist; D005240:Feasibility Studies; D005260:Female; D006266:Health Education; D006801:Humans; D006973:Hypertension / Q000175:diagnosis* / Q000188:drug therapy / Q000517:prevention & control*; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D010154:Pakistan; D010353:Patient Education as Topic; D011634:Public Health; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012424:Rural Population; D013188:Sri Lanka
chemical_list: D000959:Antihypertensive Agents