Evaluation of the World Health Organization-HEARTS hypertension control package in Bangladesh: a quasi-experimental trial

Abstract

Background: The World Health Organization (WHO) promotes the HEARTS technical package for improving hypertension control worldwide, but its effectiveness has not been rigorously evaluated.

Objective: To compare hypertension outcomes in clinics implementing HEARTS versus clinics continuing usual hypertension care in rural Bangladesh.

Methods: A matched-pair cluster quasi-experimental trial in Upazila Health Complexes (UHCs; primary healthcare facilities) was conducted in rural Bangladesh. A total of 3935 patients (mean age 52.3 years, 70.5% female) with uncontrolled hypertension (blood pressure (BP) ≥140/90 mm Hg regardless of treatment history) were enrolled: 1950 patients from 7 HEARTS UHCs and 1985 patients from 7 matched usual care UHCs. The primary outcome was systolic BP at 6 months measured at the patient's home; secondary outcomes were diastolic BP, hypertension control rate (<140/90 mm Hg) and loss to follow-up. Multivariable mixed-effects linear and Poisson models were conducted.

Results: Baseline mean systolic BP was 158.4 mm Hg in the intervention group and 158.8 mm Hg in the usual care group. At 6 months, 95.5% of participants completed follow-up. Compared with usual care, the intervention significantly lowered systolic BP (-23.7 mm Hg vs -20.0 mm Hg; net difference -3.7 mm Hg (95% CI -5.1 to -2.2)) and diastolic BP (-10.2 mm Hg vs -8.3 mm Hg; net difference -1.9 mm Hg (95% CI -2.7 to -1.1)) and improved hypertension control (62.0% vs 49.7%, net difference 12.3% (95% CI 9.0 to 16.8)). Rate of missed clinic visits was lower in the intervention group (8.8% vs 39.3%, p<0.001).

Conclusions: After WHO-HEARTS package implementation in rural Bangladesh, BP was lowered and hypertension control improved significantly compared with usual care.

Trial registration number: NCT04992039.

Keywords: global health; hypertension.

Figure 1

Drug-specific and dose-specific hypertension management protocol used in the Bangladesh HEARTS Hypertension Control Initiative. DBP, diastolic blood pressure; SBP, systolic blood pressure.

Figure 2

Central illustration: overview of the Bangladesh HEARTS trial. *Both models adjust for intervention, catchment area size, population, literacy rate, and other covariates (female vs male, age, diabetes, heart attack, stroke, CKD, prior use of antihypertensive medication, if flood prevents refill). Model for SBP additionally adjusted for interactions of visit with intervention and other covariates. BP, blood pressure; CKD, chronic kidney disease; HTN, hypertension; SBP, systolic blood pressure.

Figure 3

Inclusion and exclusion flow chart, the Bangladesh HEARTS trial.

Figure 4

Adjusted between-group differences in hypertension control outcomes at the 6-month follow-up visit, the Bangladesh HEARTS trial. (A) Adjusted difference in mean baseline and endline systolic blood pressure. (B) Adjusted difference in mean baseline and endline diastolic blood pressure. (C) Adjusted difference in hypertension control. DBP, diastolic blood pressure; SBP, systolic blood pressure.

Figure 5

Subgroup analysis results for between-group differences in hypertension control outcomes at the 6-month follow-up visit, the Bangladesh HEARTS trial. (A) Change in systolic BP. (B) Change in diastolic BP. (C) Proportion with hypertension control. DBP, diastolic blood pressure; SBP, systolic blood pressure.