Task sharing with non-physician health-care workers for management of blood pressure – Authors' reply
Authors: Panniyammakal Jeemon, Linju M Joseph, T N Anand
Journal: The Lancet Global Health (2019)

We 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.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 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. We would further like to assert that no major difference existed in the pooled estimate after removing studies with pharmacological interventions (appendix). Non-physician health workers were involved in dose titration and drug initiation in studies with pharmacological interventions (appendix). Therefore, task-sharing of both pharmacological and non-pharmacological interventions are relevant in improving blood pressure control in low-income and middle-income countries. The second point raised was related to the unaccounted white coat effect on blood pressure. Although we acknowledge that studies included in the Review did not mention white coat syndrome as a confounding variable, this variable is unlikely to contribute to any bias in our analyses. We used difference of mean difference in blood pressure to estimate the population average pooled blood pressure response. Any white coat effect on measurements after the intervention is automatically adjusted against the white coat effect before the interventions. Multiple blood pressure measurements were taken during the study period and therefore the white coat effect in the final measurement would have regressed to the mean effect. Hence, the difference in mean blood pressure because of the white coat effect will work in favour of the usual care group of task-shared intervention studies. As Choy and colleagues pointed out, we agree that the application of task sharing in hypertension management can be expanded to management of hypertension in pregnancy. A study in Pakistan from 2016 highlights the potential for task sharing interventions in emergency management of pre-eclampsia in community settings.2Salam RA Qureshi RN Sheikh S et al.Potential for task-sharing to lady health workers for identification and emergency management of pre-eclampsia at community level in Pakistan.Reprod Health. 2016; 13: 107Crossref PubMed Scopus (12) Google Scholar However, methodologically robust evaluation studies might be required to show the effectiveness of such approaches in real-life settings. We appreciate the comments by Choy and colleagues on the need for adequate training of non-physician health-care workers for managing hypertension. Our exploratory analyses suggest that the blood pressure response to task-shared interventions is better in places with high doctor–population ratios.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 To reiterate, task sharing should be done according to the needs of the health system and with adequate support in terms of training, supervision, and written standard operating procedures or policies.3Joshi R Thrift AG Smith C et al.Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases.BMJ Global Health. 2018; 3e001092Crossref PubMed Scopus (22) Google Scholar This work was supported by the Wellcome Trust and Department of Biotechnology India Alliance Fellowship [grant number IA/CPHI/14/1/501497] awarded to PJ. Download .pdf (.15 MB) Help with pdf files Supplementary appendix 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 pressureWe would like to thank Anand and colleagues (June, 2019)1 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,1 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. Full-Text PDF Open Access