Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial

Abstract

Background: There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy.

Objective: Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India.

Methods: We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs.

Results: We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ± 21 to 128.3 ± 15; intervention 130.3 ± 21 to 127.6 ± 15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001).

Conclusion: A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.

Figure 1:

Study flow

Figure 2:

Change in mean systolic BP, body mass index, waist hip ratio and median INTERHEART risk score from baseline to 12 months (active intervention) and at 18 months (passive follow-up) in control and intervention groups. Significant declines are observed in mean systolic BP and INTERHEART risk scores and no significant differences in intergroup comparisons.

Figure 3:

Participants adherent to on anti-hypertensive drug therapies, smoking cessation and nonsmoked tobacco cessation at 12 months in control and intervention groups