Implementation Research and Results of Hypertension Control Strategy and Model in Rural Areas
Hypertension has become a major risk factor for cardiovascular disease (CVD) and premature mortality worldwide, with high prevalence and relatively poor control rate, especially in rural areas.[1] Blood pressure (BP) control in rural areas is the most vulnerable spot in hypertension control and is a key target to reduce cardiovascular and cerebrovascular events and total mortality. Medical workers globally have devoted considerable efforts to solving this problem and some progress has been made [Table 1].[2–6] Our recent study proved that a novel, village doctor-led, multifaceted intervention strategy for BP control was an effective, feasible, and safe method for controlling hypertension in rural China.[6]
1. The huge challenge of rural hypertension control
According to the 2012–2015 national hypertension survey, the overall prevalence of hypertension among Chinese residents aged 18 years or older was 27.9%, but this prevalence would double in the general population if hypertension was defined as a BP of 130/80 mmHg or higher.[7] However, the control rate of hypertension was only 16.9% from the 2012–2015 survey, although this was a slight increase from 6.1% in 2002.[8] The prevalence of hypertension increased faster in rural areas than in urban areas when regional disparity was taken into consideration. The prevalence in rural areas (28.8%) surpassed that in urban areas (26.9%) for the first time in the 2012–2015 national survey. Similarly, approximately 75% of people with hypertension live in low- and middle-income countries (LMICs).[9] Furthermore, the prevalence of hypertension rose by 7.7% in LMICs from 2000 to 2010, whereas it dropped by 2.6% in high-income countries in the same period. With this trend, it is foreseeable that the burden of hypertension will continue to increase in LMICs and rural areas. Thus, hypertension control is an important issue, especially in these areas.
2. Implementation strategies to improve the hypertension control rate
Marked efforts have been made to solve the problem of poor control rates of hypertension. However, the obstacles to hypertension control are complex.[10] In rural areas, health care resources are limited, most health care providers have poor knowledge of clinical guidelines, and the individual with hypertension have low adherence to prescribed medications and self-management of lifestyle modifications. To remove these barriers, the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline stated that the integration of social and community services was more conducive to achieving clinically defined treatment goals.[11] Guidelines from China and other countries have similar descriptions.[12]
Various hypertension control strategies have been explored and a series of implementation studies were conducted. Recently, Mills et al[13] systemically assessed the effectiveness of different implementation strategies for BP control. A total of 121 comparisons involving 55,920 people with hypertension were included in this meta-analysis. Multilevel strategies were found to be more effective than single-level strategies. Among these strategies, a multilevel strategy with team-based care and medication management by a non-physician resulted in a systolic BP reduction of 7.1 mmHg, while the reduction was also significant by team-based care and a physician, with a decrease of 6.2 mmHg. Patient-level strategies of health teaching and home BP monitoring were also effective with reductions in systolic BP of 3.9 and 2.7 mmHg, respectively. Therefore, multilevel and multicomponent implementation strategies are very effective and these should be disseminated and scaled up to improve the global control rates of hypertension. However, key questions remain as to how and by whom will these strategies be implemented.
3. The important role of health workers in rural hypertension control
The Electronic Communications and Home Blood Pressure Monitoring study was an early implementation study, which was conducted from June 2005 to December 2007.[2] In this randomized controlled trial (RCT), 778 participants with uncontrolled hypertension were included and were randomly divided into 3 groups. The first group received usual care, the second one received home BP monitoring and website training, and the third group received additional pharmacist care beyond the second group. After a 1-year follow-up, the third group with Web-based pharmacy care had a significantly higher control rate of hypertension (<140/90 mmHg, 56%) compared with that of the first 2 groups (36% and 31%, respectively; both P < 0.001). This implementation study was the first to prove that pharmacist management through Web communications could significantly improve BP control in individuals with hypertension and identified the crucial role of pharmacist. However, most LMICs and rural China lack physicians and pharmacists for the management of the whole population and are not well-equipped in network infrastructure. Consequently, this strategy was indeed effective but not feasible in rural areas.
A health worker-led multicomponent intervention strategy (Comprehensive Approach for Hypertension Prevention and Control in Argentina (HCPIA)) was proposed by He et al[3] and assessed in a poor urban area. The RCT was designed to determine whether a community health worker-led multicomponent intervention could increase the control rate of low-income hypertension. This cluster randomized trial was performed in 18 centers in Argentina, where the patients could receive primary health care and free medications from the national public system. In this study, community health workers referred to someone “trained to coach patients and their family members on lifestyle modification, home BP-monitoring, and medication adherence during a 2-day interactive training session followed by onsite field testing and certification.”[3] These community health workers were trained to function as case managers for the patients and their families by coordinating intervention activities and facilitating patient care. A total of 1,432 participants with uncontrolled hypertension and a low income were enrolled in the trial. Nine centers were assigned to the multi-component intervention, which included health worker-led home intervention, physician intervention, and text-messaging management. The remaining 9 centers formed the control group, where participants were given the usual care without study intervention. After an 18-month follow-up, the control rate of hypertension increased from 17.0% to 72.9% in the intervention group, while the control group had a relatively smaller increase from 17.6% to 52.2%, and the difference between the 2 groups increased by 20.6% (P < 0.001). Furthermore, no adverse events were reported during the follow-up. This study demonstrated the crucial role of the health worker in hypertension control.
Another implementation study about the role of health workers in the management of patients with hypertension in townships was conducted in Colombia and Malaysia.[4] The Heart Outcomes Prevention and Evaluation 4 (HOPE 4) project was the first attempt to test whether a comprehensive model of health care led by non-physician health workers, involving primary care physicians and family, could substantially reduce the risk of CVD. It was an open-label, community-based, cluster RCT involving a total of 1,371 participants with hypertension from 30 communities. Among these, 727 patients were randomly assigned to the control group and 644 were assigned to the intervention group.
The comprehensive intervention included management of CVD risk factors and medications by non-physician health workers under the supervision of physicians. After a 12-month follow-up, the reduction of the Framingham Risk Score for 10-year CVD risk was 11.17% in the intervention group and 6.40% in the control group. The group difference of 4.78% was significant (P < 0.000,1). Moreover, the control rate of hypertension reached 69% in the intervention group, which was significantly higher than that of the control group (P < 0.000,1). Considering that health workers might lack medical knowledge, safety was analyzed in the trial and no safety concerns were found within the intervention.
Recently, the Control of Blood Pressure and Risk AttenuationBangladesh, Pakistan and Sri Lanka (COBRA-BPS) study in rural South Asia was performed to test the effectiveness of a multicomponent intervention led by trained government community health workers.[5] A total of 2,645 adults with hypertension were enrolled in the study. After a 24-month follow-up, the mean reduction of systolic BP in the intervention group was 5.2 mmHg greater than that of the control group (P < 0.001), and the mean reduction in diastolic BP was 2.8 mmHg greater in the intervention group (P < 0.001). The intervention group also achieved a higher BP control rate (<140/90 mmHg) of 53.2% compared with 43.7% in the control group (P < 0.001). This study further demonstrated that health worker-led multicomponent intervention could achieve a greater reduction in BP than usual care.
Collectively, these studies have primarily demonstrated that non-physician health workers can play a practical role in the conduction of multilevel and multicomponent implementation strategies. Such models have been proven to be effective in hypertension control across poor urban, township, and rural areas.
4. A novel, village doctor-led strategy for rural hypertension control
In rural China, hypertension has become a serious public health problem with increasing prevalence. Consequently, this condition needs to be controlled in these rural areas. In China, each village has a village doctor (community health worker on the front line of primary health care) who is responsible for the basic health care of the village and has a high school or higher education with antihypertensive medication-prescribing privileges.[6,14] We conducted a large open cluster randomized trial (Rural China Hypertension Control Project (CRHCP)) to test the effectiveness of a multifaceted intervention led by village doctors for the control of BP in rural China, and the results were published in The Lancet. [6] The study demonstrated that the village doctor-led multifaceted intervention was a technically feasible strategy in rural areas and could effectively control BP. In addition, the study proved that setting the intensive target (which was also the goal of the Systolic Blood Pressure Intervention Trial (SPRINT),[15] Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP)[16] trials, and the 2017 ACC/AHA Guideline for hypertension[11]) of 130/80 mmHg in the general population achieved a good result in BP control rate without treatment-related serious adverse events.
In the CRHCP study, 326 villages that had a regular village doctor and participated in the China New Rural Cooperative Medical Scheme were randomly assigned to either village doctor-led multifaceted intervention or enhanced usual care, with stratification by provinces, counties, and townships. A total of 33,995 participants were enrolled in the trial, with 17,407 participants from 163 villages in the intervention group and 16,588 participants from 163 villages in the control group. Participants were aged 40 years or older with an untreated BP of 140/90 mmHg or higher (≥130/80 mmHg among those with a history of CVD, diabetes, or chronic kidney disease) or a treated BP of 130/80 mmHg or higher. In the intervention group, village doctors (having the right to prescribe in China) received standardized training for BP measurement, protocol-based antihypertensive treatment, and health coaching,[17] and then initiated and titrated antihypertensive medications according to a protocol supervised by primary care physicians. Village doctors also performed health coaching for home BP monitoring, lifestyle management, and medication adherence. After an 18-month follow-up, the control rate (<130/80 mmHg) was 57.0% in the intervention group, which was significantly higher than 19.9% in the control group, with a group difference of 37.0% (P < 0.000,1). Mean systolic BP in the intervention group decreased by 26.3 mmHg, which was much greater than the decrease of 11.8 mmHg in the control group, with a group difference of 14.5 mmHg (P < 0.000,1). The mean diastolic BP decreased by 14.6 and 7.5 mmHg in the intervention and control groups, respectively, with a significant group difference of 7.1 mmHg (P < 0.000,1). Furthermore, no treatment-related serious adverse events were caused by the village doctor-led multifaceted intervention, proving the safety of this approach.
5. Summary
In summary, multilevel and multicomponent implementation strategies are extremely effective methods for rural hypertension control, and health workers, including village doctors, are crucial to conduct the methods and manage the patients with hypertension in rural areas. Such approach acting on the weakest link of hypertension control would subsequently improve the overall hypertension control rate, reduce the incidence of cardiovascular and cerebrovascular events, and reduce the total mortality of the population. With the use of these novel strategies, the goals of the Healthy China 2030 Plan[18] will be achieved, along with other targets highlighted by Jafar and Jabbour’s[19] commentary on the CRHCP study in The Lancet, “Such efforts, especially if coupled with other population-wide initiatives, can undoubtedly accelerate progress towards meeting the national and global targets for non-communicable diseases and consequently the Sustainable Development Goal 3.4 target of a 30% reduction in premature cardiovascular mortality by the year 2030, relative to 2015.”
作者简介
孙英贤 教授（通信作者）
Citation: Sun G, Wu J, Zhang P, et al. Implementation Research and Results of Hypertension Control Strategy and Model in Rural Areas. Cardiol Discov 2024; 4(1): 1–4. doi: 10.1097/CD9.0000000000000102
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