Task sharing with non-physician health-care workers for management of blood pressure
Authors: Bennett Choy, Krishanth Ganesan, Nien Sze Fong
Journal: The Lancet Global Health (2019)

We would like to thank Anand and colleagues (June, 2019)1Anand T Joseph L Geetha A Prabhakaran D Jeemon P Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e761-e771Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar for their systematic review and meta-analysis on task sharing with non-physician health-care workers for the management of hypertension in adults from low-income and middle-income countries. In their study,1Anand T Joseph L Geetha A Prabhakaran D Jeemon P Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e761-e771Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar they found that task-sharing interventions had successfully reduced systolic blood pressure (SBP) in different groups of health-care workers, concluding that task sharing is a potentially viable and low-cost strategy for low-income and middle-income countries in managing hypertension. First, they compared the differences in the reduction of SBP in various groups of health-care workers in their study1Anand T Joseph L Geetha A Prabhakaran D Jeemon P Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e761-e771Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar regardless of whether the intervention provided was a lifestyle or pharmacological intervention. Such inconsistencies in comparison might cause the results obtained to be unreliable. We feel that comparing similar interventions between adopting a task-sharing strategy versus physician-only care would show clearer differences in the reduction of SBP. For example, to analyse the differences in SBP between pharmacological interventions provided by task sharing versus physician-only care might be more useful. Second, the white coat effect is unaccounted for and could result in higher SBP readings than when the readings are taken in a non-medical setting.2Jhalani J Goyal T Clemow L Schwartz J Pickering T Gerin W Anxiety and outcome expectations predict the white-coat effect.Blood Press Monit. 2005; 10: 317-319Crossref PubMed Scopus (36) Google Scholar Moreover, because the white coat effect is more pronounced in measurements made by physicians compared with nurses,3Clark C Horvath I Taylor R Campbell J Doctors record higher blood pressures than nurses: systematic review and meta-analysis.Br J Gen Pract. 2014; 64: e223-e232Crossref PubMed Scopus (41) Google Scholar the improvement of SBP in task sharing might not be as reliable. Third, although we agree that task sharing is a viable option, we feel that the initial diagnosis and initiation of pharmacological management of hypertension should still be done by a physician to rule out secondary causes of hypertension, especially in younger adults (<30 years).4Puar T Mok Y Debajyoti R Khoo J How C Ng A Secondary hypertension in adults.Singapore Med J. 2016; 57: 228-232Crossref PubMed Scopus (19) Google Scholar As correctly pointed out by Anand and colleagues,1Anand T Joseph L Geetha A Prabhakaran D Jeemon P Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2019; 7: e761-e771Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar adequate standardised training and education for non-physicians on lifestyle modifications and pharmacological management of hypertension are required for the provision of safe and optimal care. In conclusion, this Review has been useful to improve understanding of the benefits of task sharing on the management of hypertension in low-income and middle-income countries. This study could be further expanded to involve other allied health professionals, such as midwives for the management of hypertension in pregnancy, and Physician-Associated Clinicians and Advanced Nurse Practitioners in countries such as Tanzania, India, and Mozambique,5Rick T Ballweg R Physician assistants and the expanding global health-care workforce.Am J Trop Med Hyg. 2017; 97: 643-644Crossref PubMed Scopus (4) Google Scholar where such professionals are prevalent. We declare no competing interests. Task sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysisTask-sharing interventions are effective in reducing blood pressure. Long-term studies are needed to understand their potential impact on cardiovascular outcomes and mortality. Full-Text PDF Open AccessTask sharing with non-physician health-care workers for management of blood pressure – Authors' replyWe welcome the review of our work by Choy and colleagues. We agree that the heterogeneity introduced by the type of interventions was ignored in our pooled average estimate of blood pressure response.1 The magnitude of the effect might be influenced by task-shared roles such as health promotion, repeated blood pressure measurements, adherence support, and case management. However, to tease out the individual components from each study was difficult as they were offered as a package of interventions. Full-Text PDF Open Access