Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study)

Abstract

Background Population-wide reduction in mean blood pressure is proposed as a key strategy for primary prevention of cardiovascular disease. We evaluated the effectiveness of a task-sharing strategy involving frontline health workers in the primary prevention of elevated blood pressure. Methods and Results We conducted DISHA (Diet and lifestyle Interventions for Hypertension Risk reduction through Anganwadi Workers and Accredited Social Health Activists) study, a cluster randomized controlled trial involving 12 villages each from 4 states in India. Frontline health workers delivered a custom-made and structured lifestyle modification intervention in the selected villages. A baseline survey was conducted in 23 and 24 clusters in the control (n=6663) and intervention (n=7150) groups, respectively. The baseline characteristics were similar between control and intervention clusters. In total 5616 participants from 23 clusters in the control area and 5699 participants from 24 clusters in the intervention area participated in a repeat cross-sectional survey conducted immediately after the intervention phase of 18-months. The mean (SD) systolic blood pressure increased from 125.7 (18.1) mm Hg to 126.1 (16.8) mm Hg in the control clusters, and it increased from 124.4 (17.8) mm Hg to 126.7 (17.5) mm Hg in the intervention clusters. The population average adjusted mean difference in difference in systolic blood pressure was 1.75 mm Hg (95% CI, -0.21 to 3.70). Conclusions Task-sharing interventions involving minimally trained nonphysician health workers are not effective in reducing population average blood pressure in India. Expanding the scope of task sharing and intensive training of health workers such as nurses, nutritionists, or health counselors in management of cardiovascular risk at the population level may be more effective in primary prevention of cardiovascular disease. Registration URL: https://www.ctri.nic.in; Unique identifier: CTRI/2013/10/004049.

Keywords: India; cardiovascular disease; high blood pressure; hypertension; systolic blood pressure.

Figure 1. Randomization, intervention, and follow‐up.

DBP indicates diastolic blood pressure; and SBP, systolic blood pressure.

Figure 2. Distribution of systolic and diastolic blood pressure at baseline and post intervention (mm Hg).

Figure 3. Adjusted mean values (95% CI) by control and intervention group at baseline and post intervention for systolic blood pressure (mm Hg) and diastolic blood pressure (mm Hg).

Adjusted‐GEE analysis with an exchangeable covariance matrix, to account for clustering of participants within clusters/villages and model is adjusted for baseline cluster mean systolic/diastolic blood pressure, age, sex, education, and season and duration of intervention. DBP indicates diastolic blood pressure; GEE, generalized estimating equation; and SBP, systolic blood pressure.