Local community health workers in rural China successfully treated patients with hypertension, enabling more than half to reach normal blood pressures, in a new study involving almost 34,000 patients.
In the study, local health workers (known as village doctors), most of whom had minimal formal medical education and were trained with a standard protocol that included regularly measuring blood pressure, prescribing and adjusting antihypertensive medications, and offering health coaching on home blood pressure monitoring, lifestyle changes, and medication adherence, under the supervision of primary care physicians and hypertension specialists.
The study included patients with high blood pressure from 326 villages in rural China. The villages were randomly assigned to an intervention program led by a community health worker or no intervention (usual care).
Results showed that 57% of the patients in the villages involved in the intervention program achieved normal blood pressure after 18 months, compared to just 20% of those in villages where usual care was given.
The results were presented by lead study author Jiang He, MD, at the American Heart Association (AHA) Scientific Sessions 2021 on November 13.
“We showed that nonphysician health workers can be trained to manage patients with hypertension effectively. Together with affordable antihypertensive medication and self-monitoring of blood pressure, this is an important strategy for blood pressure control in low-income settings.” He commented to theheart.org | Medscape Cardiology.
“This effective approach could be scaled up in rural China and other low-resource settings for global hypertension control, with the overall aim of reducing cardiovascular disease and all-cause mortality. This model could also be used for hypertension control in underserved populations in the US,” he added.
He, who is professor of epidemiology and the director of the Translational Science Institute at Tulane University in New Orleans, Louisiana, reported figures from a national survey in 2014, showing that 27.8% of the Chinese population, or 292 million adults, had hypertension (blood pressure ≥140/90 mm Hg), with fewer than 14% having their condition under control. Levels of blood pressure control fall to around 5% in rural communities, where residents often do not have access to medical care.
“Access to high-quality healthcare services in rural China is challenging due to the physical distance from major medical centers and difficulty in attracting physicians to practice medicine in remote rural areas,” he said.
“Community health workers fill this gap by providing essential primary healthcare to rural residents. Traditionally, they play an important role in infectious disease control and maternal and child health and have recently engaged in chronic disease management.”
A nationally representative survey of these community health workers showed that 63% had just secondary vocational school training, 19% had higher education, and 18% had no formal medical education, He reported.
“Our results show these ‘village doctors’ can be successfully trained to follow standard blood pressure measurement and treatment protocols,” he noted. “They live in the same communities as their patients, which allows them to not only provide convenient healthcare access but also establish a more trustworthy relationship with patients. In addition, health coaching can be integrated into their routine responsibilities of health education and promotion.”
Cluster Randomized Trial
This study is the first large cluster randomized trial to test the effectiveness of nonphysician-led hypertension management program on blood pressure control, He noted.
Study participants included 34,000 individuals older than age 40 years with blood pressure of 140/90 mm Hg or higher who were not being treated when the study began, people with blood pressure of 130/80 mm Hg or higher who were already taking blood pressure medication, or people with blood pressure of 130/80 mm Hg or higher who also had a history of clinical cardiovascular disease.
Community health workers in the villages assigned to the intervention were trained in blood pressure measurement and protocol-based antihypertensive treatment adapted from the 2017 American College of Cardiology/American Heart Association hypertension clinical guideline, aiming to achieve a target systolic blood pressure less than 130 mm Hg and diastolic pressure less than 80 mm Hg. The community health workers also received performance-based financial incentives based on the proportion of their patients with controlled blood pressure.
Patients in the intervention group received discounted or free antihypertensive medications. They were also supplied with home blood pressure monitors and were trained on using them. In addition, they received regular health coaching, including information on the risks of high blood pressure and lifestyle changes, as well as motivation and methods on taking their medication routinely, as prescribed.
Results showed that after 18 months, 57% of adults in the intervention group had blood pressure lower than 130/80 mm Hg, compared with 20% in the usual care group. In addition, 77% of participants in the intervention group had blood pressure lower than 140/90 mm Hg, compared with 45% in the group who received usual care.
From baseline to 18 months, systolic blood pressure was reduced by 26.3 mm Hg and diastolic blood pressure by 14.6 mm Hg in the intervention group, compared with an average decrease of 11.8 mm Hg for systolic blood pressure and 7.5 mm Hg for diastolic blood pressure in the usual care group.
He and colleagues are continuing to follow the participants for clinical cardiovascular outcomes and are hoping to scale up the program in other rural areas in China.
“We anticipate a large reduction in cardiovascular events and all-cause mortality if this program is scaled up to the entire rural China,” He said.
Commentators at the AHA meeting were impressed with the study’s results.
Discussant of the study at the breaking science session at which it was presented, Keith Ferdinand, MD, professor of medicine and Gerald S. Berenson Endowed Chair in Preventative Cardiology at Tulane University, said, “These are really robust results showing a clinical and significant reduction in blood pressure. This approach may be an appropriate model for other low-resource parts of world.”
Ferdinand added: “Nonphysician and lay team–based approaches and home blood pressure monitoring should make up part of the future strategy to address hypertension.”
Manesh Patel, MD, chief of the Division of Cardiology and co-director of the Heart Center at Duke University, Durham, North Carolina, and chair of the Scientific Sessions scientific program, was also positive. “The blood pressure reduction seen in this study is most certainly going to lead to a reduction in mortality. The message for us is how do we translate that to other parts of the world,” he stated.
Also commenting, Mitchell Elkind, MD, professor of neurology and epidemiology at Columbia University Irving Medical Center, New York City, and immediate past president of the AHA, said, “We don’t need a lot of fancy medications and fancy approaches to take care of hypertension. The underlying message here is it is all about implementation — getting treatments to patients in the best way.”
He agreed that this approach in China could be adapted to the United States using pharmacists and nurses.
At an AHA press conference on the study, Joanna Chikwe, MD, chair of the Cardiac Surgery Department in the Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, California, pointed out that a similar approach using pharmacists at Black-owned barbershops in Los Angeles to engage with older Black American men reduced their blood pressures in a similarly impressive way.
“This Chinese study is really compelling, and together with the barbershop study, it shows that you don’t necessarily need a conversation with a physician to effectively manage blood pressure,” she said.
The Ministry of Science and Technology of China provided funding for the study. United States–based investigators did not receive funding. The authors report no disclosures.
American Heart Association (AHA) Scientific Sessions 2021. Presented November 13, 2021. LBS2. Abstract
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