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Community-Based Interventions to Promote Blood Pressure Control in a Developing Country: A Cluster Randomized Trial

Tazeen H. Jafar, MD, MPH; Juanita Hatcher, PhD; Neil Poulter, MD; Muhammad Islam, MSc; Shiraz Hashmi, MD; Zeeshan Qadri, MSc; Rasool Bux, MSc; Ayesha Khan, MSc; Fahim H. Jafary, MD; Aamir Hameed, MD; Ata Khan, MD; Salma H. Badruddin, PhD; Nish Chaturvedi, MD, Hypertension Research Group
[+] Article, Author, and Disclosure Information

From Aga Khan University, Karachi, Pakistan; Imperial College London, London, United Kingdom; and Tufts Medical School, Boston, Massachusetts.

Acknowledgment: The authors thank the members of Hypertension Research Group, including Drs. Saleem Jessani, Muhammed Saleem, Malik Anas Rabbani, Anwar Gilani, Shehla Zaidi, Nadir Ali Syed, and Peter Cosgrove, more than 40 field workers, and support staff (including Mr. Rahim Rehmani), whose hard work was critical to the success of the study. They also thank Drs. Umer Daar and Bhojo Khealani and Ms. Yasmin Parpio of the Data Safety and Monitoring Committee, and all study participants for their cooperation.

Grant Support: By the Wellcome Trust, United Kingdom (research award 070854/Z/03/Z).

Potential Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Jafar (tazeen.jafar@aku.edu). Data set: Available with approval of analysis plan by the Steering Committee; contact Dr. Jafar (tazeen.jafar@aku.edu).

Requests for Single Reprints: Tazeen H. Jafar, MD, MPH, Department of Community Health Sciences and Department of Medicine, Aga Khan University, Stadium Road, Karachi, Pakistan; e-mail, tazeen.jafar@aku.edu.

Current Author Addresses: Drs. Jafar and Hashmi, Mr. Islam, Mr. Bux, and Ms. Khan: Department of Community Health Sciences, Aga Khan University, 3500 Stadium Road, Karachi 74800, Pakistan.

Dr. Hatcher: Population and Public Health, Alberta Health Services, 14th Floor, Sun Life Place, 10123 99th Street, Edmonton, Alberta T5J 3H1, Canada.

Drs. Poulter and Chaturvedi: National Heart & Lung Institute, Imperial College at St. Mary's, Norfolk Place, London W2 1PG, United Kingdom.

Mr. Qadri: Department of Human Cancer Genomic Research, King Faisal Specialist Hospital and Research Centre, Box 3354, Riyadh 11211, Saudi Arabia.

Drs. Jafary, Hameed, and Khan: Department of Medicine, Aga Khan University, 3500 Stadium Road, Karachi 74800, Pakistan.

Dr. Badruddin: 81/2, Lane 3, off Khayaban-e-Badr, DHA Phase VI, Karachi, Pakistan.

Author Contributions: Conception and design: T.H. Jafar, J. Hatcher, N. Poulter, N. Chaturvedi.

Analysis and interpretation of the data: T.H. Jafar, J. Hatcher, M. Islam, Z. Qadri, R. Bux, N. Chaturvedi.

Drafting of the article: T.H. Jafar, J. Hatcher, N. Chaturvedi.

Critical revision of the article for important intellectual content: T.H. Jafar, J. Hatcher, N. Poulter, F.H. Jafary, A. Hameed, S.H. Badruddin, N. Chaturvedi.

Final approval of the article: T.H. Jafar, J. Hatcher, N. Poulter, M. Islam, S Hashmi, Z. Qadri, R. Bux, A. Khan, F.H. Jafary, A. Hameed, A. Khan, S.H. Badruddin, N. Chaturvedi.

Provision of study materials or patients: T.H. Jafar, S Hashmi, F.H. Jafary, A. Hameed, A. Khan, S.H. Badruddin.

Statistical expertise: T.H. Jafar, J. Hatcher, M. Islam, N. Chaturvedi.

Obtaining of funding: T.H. Jafar, J. Hatcher, N. Poulter, N. Chaturvedi.

Administrative, technical, or logistic support: T.H. Jafar, M. Islam, R. Bux, A. Khan, F.H. Jafary, A. Hameed, A. Khan, S.H. Badruddin, N. Chaturvedi.

Collection and assembly of data: T.H. Jafar, J. Hatcher, S Hashmi, Z. Qadri.

Ann Intern Med. 2009;151(9):593-601. doi:10.7326/0003-4819-151-9-200911030-00004
Text Size: A A A

Background: Despite convincing evidence that lowering blood pressure decreases cardiovascular morbidity and mortality, the hypertension burden remains high and control rates are poor in developing countries.

Objective: To assess the effectiveness of 2 community-based interventions on blood pressure in hypertensive adults.

Design: Cluster randomized, 2 × 2 factorial, controlled trial. (ClinicalTrials.gov registration number: NCT00327574)

Setting: 12 randomly selected communities in Karachi, Pakistan.

Patients: 1341 patients 40 years or older with hypertension (systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or already receiving treatment).

Measurements: Reduction in systolic blood pressure from baseline to end of follow-up at 2 years.

Intervention: Family-based home health education (HHE) from lay health workers every 3 months and annual training of general practitioners (GPs) in hypertension management.

Results: The age, sex, and baseline blood pressure–adjusted decrease in systolic blood pressure was significantly greater in the HHE and GP group (10.8 mm Hg [95% CI, 8.9 to 12.8 mm Hg]) than in the GP-only, HHE-only, or no intervention groups (5.8 mm Hg [CI, 3.9 to 7.7 mm Hg] in each; P < 0.001). The interaction between the main effects of GP training and HHE on the primary outcome approached significance (interaction P = 0.004 in intention-to-treat analysis and P = 0.044 in per-protocol analysis).

Limitations: Follow-up blood pressure measurements were missing for 22% of patients. No mechanism was detected by which interventions lowered blood pressure.

Conclusion: Family-based HHE delivered by trained lay health workers, coupled with educating GPs on hypertension, can lead to significant blood pressure reductions among patients with hypertension in Pakistan. Both strategies in combination may be feasible for upscaling within the existing health care systems of Indo-Asian countries.

Primary Funding Source: Wellcome Trust.


Grahic Jump Location
Study flow diagram.

GP = general practitioner; HHE = home health education.

* One pregnant woman and 1 man withdrew because of target organ damage and severe debility.

† Participants who successfully completed 2 years of follow-up were included in the analyses.

Grahic Jump Location




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Summary for Patients

Home Health Education and Physician Training to Improve Care for Patients With High Blood Pressure in a Developing Country

The summary below is from the full report titled “Community-Based Interventions to Promote Blood Pressure Control in a Developing Country. A Cluster Randomized Trial.” It is in the 3 November 2009 issue of Annals of Internal Medicine (volume 151, pages 593-601). The authors are T.H. Jafar, J. Hatcher, N. Poulter, M. Islam, S. Hashmi, Z. Qadri, R. Bux, A. Khan, F.H. Jafary, A. Hameed, A. Khan, S.H. Badruddin, and N. Chaturvedi.


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