The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure , but low for diastolic blood pressure .
INTERPRETATION Task-sharing interventions are effective in reducing blood pressure .
BACKGROUND Task sharing for the management of hypertension could be useful for understaffed and re source -poor health systems .
We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries .
Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana
Background Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa . Implementation of evidence -based systems-level strategies targeted at these barriers are lacking . We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage ( HIC ) alone versus a nurse-led task shifting strategy for hypertension control ( TASSH ) plus HIC on systolic blood pressure ( SBP ) reduction among patients with uncontrolled hypertension in Ghana . Methods and findings Using a pragmatic cluster r and omized trial , 32 community health centers within Ghana ’s public healthcare system were r and omly assigned to either HIC alone or TASSH + HIC .  A total of 757 patients with uncontrolled hypertension were recruited between November 28 , 2012 , and June 11 , 2014 , and followed up to October 7 , 2016 . Both intervention groups received health insurance coverage plus scheduled nurse visits , while TASSH + HIC comprised cardiovascular risk assessment , lifestyle counseling , and initiation/titration of antihypertensive medications for 12 months , delivered by trained nurses within the healthcare system . The primary outcome was change in SBP from baseline to 12 months . Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months . Of the 757 patients ( 389 in the HIC group and 368 in the TASSH + HIC group ) , 85 % had 12-month data available ( 60 % women , mean BP 155.9/89.6 mm Hg ) . In intention-to-treat analyses adjusted for clustering , the TASSH + HIC group had a greater SBP reduction ( −20.4 mm Hg ; 95 % CI −25.2 to −15.6 ) than the HIC group ( −16.8 mm Hg ; 95 % CI −19.2 to −15.6 ) , with a statistically significant between-group difference of −3.6 mm Hg ( 95 % CI −6.1 to −0.5 ; p = 0.021 ) . Blood pressure control improved significantly in both groups ( 55.2 % , 95 % CI 50.0 % to 60.3 % , for the TASSH + HIC group versus 49.9 % , 95 % CI 44.9 % to 54.9 % , for the HIC group ) , with a non-significant between-group difference of 5.2 % ( 95 % CI −1.8 % to 12.4 % ; p = 0.29 ) . Lifestyle behaviors did not change appreciably in either group . Twenty-one adverse events were reported ( 9 and 12 in the TASSH + HIC and HIC groups , respectively ) . The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits , if any , of the TASSH + HIC group . Conclusions Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone , among patients with uncontrolled hypertension in Ghana . Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost – benefit analysis . Trial registration Clinical Trials.gov
The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure , but low for diastolic blood pressure .
INTERPRETATION Task-sharing interventions are effective in reducing blood pressure .
BACKGROUND Task sharing for the management of hypertension could be useful for understaffed and re source -poor health systems .
We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries .