Community health workers for blood pressure control in Nepal
Authors: Richard A Josephson, Aditya K Khetan
Journal: The Lancet Global Health (2017)

Noncommunicable diseases are the leading cause of mortality worldwide, with three-quarters of these deaths—and four out of five premature deaths globally—occurring in low-income and middle-income countries (LMICs).1WHONoncommunicable diseases. World Health Organization, Geneva2015http://www.who.int/mediacentre/factsheets/fs355/enGoogle Scholar In south Asia in particular, hypertension was the leading cause of mortality in 2016.2IHMEGBD compare data visualization. Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA2017http://vizhub.healthdata.org/gbd-compareGoogle Scholar Countries in south Asia, similar to many other LMICs, are dealing with a twin burden of communicable and noncommunicable diseases, which can place tremendous burden on health-care systems. Community health workers have had considerable success in improving maternal and child health and care for communicable diseases in LMICs.3Patel AR Nowalk MP Expanding immunization coverage in rural India: a review of evidence for the role of community health workers.Vaccine. 2010; 28: 604-613Crossref PubMed Scopus (51) Google Scholar Because of this historic success, community health workers have been proposed as frontline workers to tackle noncommunicable diseases through task shifting and health promotion.4WHOGlobal action plan for the prevention and control of NCDs 2013–2020. World Health Organization, Geneva2013Google Scholar Although numerous studies5Brownstein JN Chowdhury FM Norris SL et al.Effectiveness of community health workers in the care of people with hypertension.Am J Prev Med. 2007; 32: 435-447Summary Full Text Full Text PDF PubMed Scopus (196) Google Scholar have shown community health workers to be effective in improving control of hypertension in high-income countries, few studies6Khetan AK Purushothaman R Chami T et al.The effectiveness of community health workers in CVD prevention in LMIC.Glob Heart. 2017; 12: 233-243Crossref PubMed Scopus (41) Google Scholar have focused on LMICs. The Article by Neupane and colleagues7Neupane D McLachlan CS Mishra SR et al.Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial.Lancet Glob Health. 2018; 6: e66-e73Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar in The Lancet Global Health adds to the growing literature regarding use of community health workers for blood pressure control in LMICs. The study uses a cluster-randomised design, randomly assigning 1638 participants in 14 clusters in Nepal to usual care or to three visits by female community health volunteers (FCHVs) in 1 year. After 1 year, significant reductions in blood pressure were seen in participants who were normotensive, prehypertensive, or hypertensive in the intervention group compared with the control group. Given the political instability and recent natural disasters in Nepal, the authors should be congratulated for their efforts, particularly since the attrition rate in the study was 10%, a modest rate for trials of this type. The FCHVs were part of the existing health-care system in Nepal and were already providing care for maternal and child health. Such community health workers might be expected to be unwilling participants or to feel overburdened by the additional work. However, the high uptake of the intervention among the FCHVs, with 43 of 46 invited FCHVs completing training successfully, suggests a high rate of acceptance of the intervention. To aid development of community health workers, future studies could clarify the role of refresher training, assess obstacles in the field, test appropriate supervisory models, and establish appropriate compensatory levels. In the study by Neupane and colleagues,7Neupane D McLachlan CS Mishra SR et al.Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial.Lancet Glob Health. 2018; 6: e66-e73Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar there was one supervisor for 43 FCHVs, which might have made adequate supervision and mentoring by the supervisor challenging. By increasing supervision and providing quality-control mechanisms, the effectiveness of the intervention might be enhanced. This study is probably the first to show that community health workers can successfully ameliorate the usual increase in blood pressure in adults who are normotensive or prehypertensive. However, we must use caution when interpreting this success because regression to the mean probably arose from only taking blood pressure measurements on a single day.8Bland JM Altman DG Statistics notes: some examples of regression towards the mean.BMJ. 1994; 309: 780Crossref PubMed Scopus (308) Google Scholar To decrease this possibility, future studies should follow standards outlined in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure9Chobanian AV Bakris GL Black HR et al.The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.JAMA. 2003; 289: 2560-2571Crossref PubMed Scopus (16577) Google Scholar and measure blood pressure on two different days before classifying individuals as hypertensive. No significant change was seen in lifestyle factors in the study,7Neupane D McLachlan CS Mishra SR et al.Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial.Lancet Glob Health. 2018; 6: e66-e73Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar although use of antihypertensive medications in the control group had increased from baseline to 1 year, making the mechanism of benefit unclear. However, a trend towards decreased salt intake and increased physical activity was observed in the intervention group, so the synergistic effects of these lifestyle factors might have contributed to the decrease in blood pressure. Although home-based blood pressure screening and health promotion have clear advantages,7Neupane D McLachlan CS Mishra SR et al.Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial.Lancet Glob Health. 2018; 6: e66-e73Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar men who spend less time at home might be disadvantaged. Although everyone assessed for eligibility in this study was enrolled, 70% of the enrolled population were women. Clearly, men who spend a substantial amount of time away from home might not benefit from this approach, which is important because the study enrolled a reasonably young population (25–65 years) and the burden of cardiovascular disease is thought to be higher in men than in women in this age group. Moreover, because community health workers traditionally provide maternal and child care, they might not be comfortable shifting focus to a new population of middle-aged men, who are not as easily available at home. Because the study used existing cadres of community health workers, the intervention probably carried only a small cost. Nevertheless, data regarding the cost-effectiveness of such an intervention would be useful in advocacy and policy planning efforts. Barriers to scalability and sustainability will also have to be addressed, including durability of effect after intervention cessation and appropriate surveillance intervals. Future studies can also examine whether other noncommunicable disease imperatives, such as diabetes and smoking, can be successfully integrated within the framework of community health workers in LMICs. It is through initiatives such as these that the global burden of disability and death from hypertension and other cardiovascular diseases might ultimately be reduced. RAJ and AKK report grants from Marwari Yuva Manch, outside the submitted work. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trialA simple, FCHV-led lifestyle intervention coupled with monitoring of blood pressure is effective for reduction of blood pressure in individuals with hypertension and ameliorates age-related increases in blood pressure in adults without hypertension in the general population of Nepal. Full-Text PDF Open Access