Effectiveness of a scalable group-based education and monitoring program, delivered by health workers, to improve control of hypertension in rural India: A cluster randomised controlled trial

New methods are required to manage hypertension in resource-poor settings. We hypothesised that a community health worker (CHW)-led group-based education and monitoring intervention would improve control of blood pressure (BP). We conducted a baseline community-based survey followed by a cluster randomised controlled trial of people with hypertension in 3 rural regions of South India, each at differing stages of epidemiological transition. Participants with hypertension, defined as BP ≥ 140/90 mm Hg or taking antihypertensive medication, were advised to visit a doctor. In each region, villages were randomly assigned to intervention or usual care (UC) in a 1:2 ratio. In intervention clusters, trained CHWs delivered a group-based intervention to people with hypertension. The program, conducted fortnightly for 3 months, included monitoring of BP, education about hypertension, and support for healthy lifestyle change. Outcomes were assessed approximately 2 months after completion of the intervention. The primary outcome was control of BP (BP < 140/90 mm Hg), analysed using mixed effects regression, clustered by village within region and adjusted for baseline control of hypertension (using intention-to-treat principles). Of 2,382 potentially eligible people, 637 from 5 intervention clusters and 1,097 from 10 UC clusters were recruited between November 2015 and April 2016, with follow-up occurring in 459 in the intervention group and 1,012 in UC. Mean age was 56.9 years (SD 13.7). Baseline BP was similar between groups. Control of BP improved from baseline to follow-up more in the intervention group (from 227 [49.5%] to 320 [69.7%] individuals) than in the UC group (from 528 [52.2%] to 624 [61.7%] individuals) (odds ratio [OR] 1.6, 95% CI 1.2-2.1; P = 0.001). In secondary outcome analyses, there was a greater decline in systolic BP in the intervention than UC group (-5.0 mm Hg, 95% CI -7.1 to -3.0; P < 0.001) and a greater decline in diastolic BP (-2.1 mm Hg, 95% CI -3.6 to -0.6; P < 0.006), but no detectable difference in the use of BP-lowering medications between groups (OR 1.2, 95% CI 0.8-1.9; P = 0.34). Similar results were found when using imputation analyses that included those lost to follow-up. Limitations include a relatively short follow-up period and use of outcome assessors who were not blinded to the group allocation. While the durability of the effect is uncertain, this trial provides evidence that a low-cost program using CHWs to deliver an education and monitoring intervention is effective in controlling BP and is potentially scalable in resource-poor settings globally. The trial was registered with the Clinical Trials Registry-India (CTRI/2016/02/006678)

Novel approach to assessing dietary intake in populations with poor literacy

Background and Objectives: Cultural and/or environmental barriers make the assessment of dietary intake in rural populations challenging. We aimed to assess the accuracy of a meal recall questionnaire, adapted for use with impoverished South Indian populations living in rural areas. Methods and Study Design: Dietary data collected by recall versus weighed meals were compared. Data were obtained from 45 adults aged 19-85 years, living in rural Andhra Pradesh, who were recruited by convenience sampling. Weighed meal records (WMRs) were conducted in the household by a researcher aided by a trained field worker. The following day, field workers conducted a recall interview with the same participant. Eight life size photographs of portions of South Indian foods were created to aid each participant's recall and a database of nutrients was developed to calculate nutrient intake. Pearson correlations were used to assess the strength of associations between intake of energy and nutrients calculated from meal recalls versus WMRs. Least products regression was conducted to examine fixed and proportional bias. Bland-Altman plots were constructed to measure systematic or differential bias. Results: Significant correlations were observed between estimates for energy and nutrients obtained by the two methods (r(2)=0.19-0.67,

Additional file 1: of Evaluation of a training program of hypertension for accredited social health activists (ASHA) in rural India

Table S1. Description of Training Materials and Sessions. All downloadable from https://figshare.com/s/7bbfcc22e0c9c91a5ca03 DOI: https://doi.org/10.4225/03/5967f9a94970d . ASHA Training Manual. Table S2. Evaluation Materials and ASHA Resources. All downloadable from https://figshare.com/s/b94c7af22ae220540c45 DOI: https://doi.org/10.4225/03/5975a0f9da160 . (DOC 78 kb

Cluster randomised feasibility trial to improve the Control of Hypertension in Rural India (CHIRI):A study protocol

INTRODUCTION: Hypertension is emerging in rural populations of India. Barriers to diagnosis and treatment of hypertension may differ regionally according to economic development. Our main objectives are to estimate the prevalence, awareness, treatment and control of hypertension in 3 diverse regions of rural India; identify barriers to diagnosis and treatment in each setting and evaluate the feasibility of a community-based intervention to improve control of hypertension

ASHA Training on Hypertension (evaluation materials)

<div>These are resources to evaluate training of health care workers about hypertension. </div><div><div>Details of the training program, and its evaluation, are described in: </div></div><div><div>BMC Health Serv Res. 2018 May 2;18(1):320. </div></div><div><div>doi: 10.1186/s12913-018-3140-8</div></div><div>The resources include questionnaires, focus group discussion questions, and forms for record keeping and evaluation.</div><div><br></div

ASHA Manual and Meeting Resources

<div>These are resources that can be used by trained health workers to teach people in their communities about hypertension, and empower them to self-manage their hypertension. </div><div><div>Details of the training program, and its evaluation, are described in: </div></div><div><div><div>BMC Health Serv Res. 2018 May 2;18(1):320. </div></div></div><div><div><div>doi: 10.1186/s12913-018-3140-8</div></div></div><div><div>The resources include a training manual, flipcharts to aid in teaching, record keeping and handouts for patients to use at home.<br></div></div