Speaker
Mark Siedner, MD, MPH
Professor of Medicine, Harvard Medical School
Faculty, Africa Health Research Institute
Keywords
Hypertension; Blood Pressure; Community-Based; Implementation Science; Global Health
Key Points
- Hypertension (HTN) is the leading preventable cause of death globally. Dr. Siedner’s research typically revolves around HIV, but he turned his attention to HTN after publishing a study on the convergence of infectious and non-communicable disease epidemics in rural South Africa. Unlike HIV, he noted, HTN control remains poor.
- The overarching goals of the IMPACT-BP study were to determine causes for poor HTN control in rural South Africa; co-develop an intervention with partners and end-users to address those causes; and implement and evaluate a novel model of care to improve blood pressure (BP) and increase disease control rates.
- They began by designing and determining the acceptability of and conducting a readiness assessment for a community-based hypertension control program. The decision to pursue a community-based care model was informed by decades of successful HIV care programs and innovative HTN care programs.
- The program had 3 main elements: Patients monitored their BP at home; community health workers (CHWs) visited patients to collect data, address challenges, and deliver medicines; and nurses managed care remotely with mobile health tools and decision support. Program goals included enhancing patient efficacy and self-empowerment; decongesting clinics and decreasing wait times; and task-shifting away from overburdened nurses.
- Once the program had been designed and assessed, the study team conducted a randomized trial to determine its effectiveness. The primary outcome was the change in systolic BP from enrollment to 6 months.
- Participants were randomized to 3 arms: Standard of care; “CHW,” which included self-monitoring of BP, home visits and medicine delivery by CHWs, and remote management of BP by nurses; and “eCHW+,” which differed from the “CHW” arm in that BP readings were automatically sent to nurses and the CHWs were less involved.
- Though the “eCHW+” arm was slightly more successful, the study team observed 8 – 10mm HG reductions in systolic BP and roughly 30% improvements in BP control in both intervention arms.
- This was a multidimensional intervention that sought to address multiple barriers to care. The team faced many real-world challenges, including a community health worker labor dispute, persistent nationwide power outages, destructive weather, and a carjacking spree.
- Next, the study team will estimate the fidelity, sustainability, acceptability, and cost-effectiveness of the program. Future directions may include an expansion to multimorbidity care; expansion of the model to urban settings; and transportability to the U.S.
Discussion Themes
When it comes to translating these lessons and insights for care coordination in a U.S. setting, a focus on convenience for healthcare workers and for patients will continue to be crucial.
Though eCHW+ arm was successful, participant feedback indicated that the human element was central to intervention acceptability. Participants felt they were getting a tremendous amount of support from their community health workers, and some expressed anger at the possibility of the intervention ending.
Dr. Siedner noted that he sees the success of the trial more as proof of principle that there are fundamental steps we can take to improve chronic disease care than the unveiling of a one-size-fits-all model.
With a trusted healthcare system and provider providing the right kind of health education, this study demonstrates that you can get people to engage in treatment of an asymptomatic disease.