Status of hypertension control in urban slums of Central India: A community health worker-based two-year follow-up
Abhijit Pakhare1, Anuja Lahiri1, Neelesh Shrivastava2, Krishna N Subba1, Vaishnavi Veera Durga Kurra1, Ankur Joshi1, Shubham Atal3, Sagar Khadanga4, Rajnish Joshi4
1 Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
2 Department of Sociology, Barkatullah University, Bhopal, Madhya Pradesh, India
3 Department of Pharmacology, AIIMS, Bhopal, Madhya Pradesh, India
4 Department of General Medicine, AIIMS, Bhopal, Madhya Pradesh, India
|Date of Submission||09-Aug-2022|
|Date of Acceptance||26-Apr-2023|
|Date of Web Publication||27-Jul-2023|
Dr. Rajnish Joshi
Department of General Medicine, AIIMS Bhopal, Saket Nagar, Bhopal - 462 020
Source of Support: None, Conflict of Interest: None
Background: Hypertension (HTN) is a leading cause of cardiovascular diseases and its control is poor. There is heterogeneity in levels of blood pressure control among various population subgroups. The present study was conducted within the framework of the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in India. It aims to estimate the proportion of optimal blood pressure control and identify factors associated with uncontrolled HTN consequent to initial screening.
Materials and Methods: We assembled a cohort of individuals with HTN confirmed in a baseline screening in sixteen urban slum clusters of Bhopal (2017–2018). Sixteen accredited social health activists were trained from within these slums. Individuals with HTN were linked to primary care providers and followed up for the next two years. Obtaining optimal blood pressure control (defined as SBP <140 and DBP <90 mm of Hg) was a key outcome.
Results: Of a total of 6174 individuals, 1571 (25.4%) had HTN, of which 813 were previously known and 758 were newly detected during the baseline survey. Two-year follow-up was completed for 1177 (74.9%). Blood pressure was optimally controlled in 301 (26%) at baseline and in 442 (38%) individuals at two years (an absolute increase of 12%; 95% CI 10.2–13.9). Older age, physical inactivity, higher body mass index, and newly diagnosed HTN were significantly associated with uncontrolled blood pressure.
Conclusion: We found about six of every ten individuals with HTN were on treatment, and about four were optimally controlled. These findings provide a benchmark for NPCDCS, in terms of achievable goals within short periods of follow-up.
Keywords: Community health workers, high blood pressure, management, risk factors, sedentary lifestyle
|How to cite this article:|
Pakhare A, Lahiri A, Shrivastava N, Subba KN, Veera Durga Kurra V, Joshi A, Atal S, Khadanga S, Joshi R. Status of hypertension control in urban slums of Central India: A community health worker-based two-year follow-up. Adv Biomed Res 2023;12:197
|How to cite this URL:|
Pakhare A, Lahiri A, Shrivastava N, Subba KN, Veera Durga Kurra V, Joshi A, Atal S, Khadanga S, Joshi R. Status of hypertension control in urban slums of Central India: A community health worker-based two-year follow-up. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 26];12:197. Available from: https://www.advbiores.net/text.asp?2023/12/1/197/382397
| Introduction|| |
Hypertension (HTN) is a significant risk factor for cardiovascular diseases (CVDs), and poor control of blood pressure is a common issue, particularly in India. The screening, awareness, treatment, and control pathway for HTN is weak, resulting in less than half of those with HTN being aware of their elevated blood pressure, and only a small proportion of individuals achieving optimal blood pressure control. For instance, studies from central India found that 22.3% of individuals aged 18–69 years had HTN, and only 11.8% of those with HTN were being treated. In Madhya Pradesh, treatment coverage for HTN was found to be 14.4%, while only 9.3% of individuals with HTN had their blood pressure in the controlled range. Moreover, a large-scale study across different urban sites found that control rates varied from 3% to 18%, with an overall control rate of 15.4% among those with HTN.
Effective HTN control requires quality healthcare access and improved adherence., Strategies such as mobile health apps, telemedicine, and community health worker engagement have been used. Clusters where more members have uncontrolled HTN at baseline, with a higher baseline blood pressure, have reported greater and more significant reductions. Even amongst a homogenous health system, variation in blood pressure control exists, attributable to better patient engagement. The literature reviewed indicate that the control rates of HTN may vary due to several factors such as geographic location, sociodemographic characteristics, and health system-related factors. It is therefore imperative to conduct local-level studies to determine the prevalence of controlled HTN and the extent of the burden of uncontrolled HTN. Furthermore, such studies should identify specific subgroups that are more vulnerable, including those based on gender, wealth, access to care, and personal traits such as obesity and tobacco use.
The current study aimed to estimate the proportion of individuals with optimal blood pressure control and to identify factors associated with uncontrolled HTN in the context of the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in India. The NPCDCS program involves annual HTN screening for all adults, linkage to primary health care facilities, and monitoring of the program by indicators such as the proportion of individuals with optimal blood pressure control. In line with this, the study aimed to identify various factors that contribute to uncontrolled HTN, which can inform the development of effective strategies for improving access to HTN care and achieving optimal blood pressure control.
| Materials and Methods|| |
Design and ethics: We established a community-based cohort. The study design was approved by the Institutional Human Ethics Committee (Ref: IHEC-LOP/2017/EF00045) and funded by the Indian Council of Medical Research. All participants provided written informed consent before the initiation of any study procedures.
Setting: The study was conducted in 16 urban slum clusters of Bhopal, a city with a population of about 20 lakhs, located in central India. A baseline door-to-door survey was conducted in the urban slum clusters between November 2017 and March 2018, details of which are provided elsewhere. Briefly, all consenting non-pregnant adults above the age of 30 years formed a cross-section, in whom CVD risk assessment was performed by accredited social health activists (ASHAs), who are CHWs in these communities. Individuals identified as a high CVD risk, especially those with HTN and diabetes were sought to be linked to urban primary health centers (UPHCs) which are primary-care public-health facilities in these communities. Limited generic antihypertensive drugs (amlodipine, losartan, and hydrochlorothiazide) are available at no cost from UPHCs with a prescription refill duration varying from two to four weeks. Participants who visit private primary-care providers usually incur out-of-pocket expenditures for their drug therapy, with a refill duration dependent on their capacity to pay.
Participants: All individuals residing in selected urban slum clusters of age 30 years or more were screened for HTN as part of the baseline assessment. Individuals with HTN (either a previously known or a newly detected HTN), were identified in a baseline survey. Individuals who reported themselves as diagnosed to have HTN in the past were defined as having previously known hypertension. ASHAs obtained the first set of blood pressure values using a digital sphygmomanometer (Omron digital apparatus, Model 7200, Kyoto, Japan) at the home of the participants. All the blood pressure readings were then confirmed in a second set of readings obtained by the study supervisor, using the same device. Each set of blood-pressure readings consisted of an average of three values, obtained one minute apart, using a standardized technique. A person was defined as a newly detected hypertensive if the blood pressure values were above systolic blood pressure (SBP) of 140 mm Hg or diastolic blood pressure (DBP) of 90 mm Hg on both occasions. This is the definition for the diagnosis of HTN under NPCDCS. All individuals with HTN were provided with referrals for physicians available at UPHC, who initiated them with or optimized their antihypertensive medication. We have also measured the waist circumference of the individuals enrolled and defined abdominal obesity as waist circumference > =90 cm among men and > =80 cm among women. All participants, who completed the two-year follow-up assessment in November–December 2019 are included in the current study.
Procedures: We followed individuals with HTN for a period of two years. Follow-up was performed using the existing human resources in the public health delivery system. We prepared a list of all individuals with HTN in a database and stratified them by cluster. We provided these lists of each cluster to respective ASHAs, who were responsible for visiting each member at least once every three months. The purpose of these visits was to promote adherence to drug therapies, measurement of blood pressure, and provide focused CVD-prevention health education. Monetary incentives were given to ASHAs for every completed follow-up (rupees 50 INR about one USD). In each visit, ASHAs recorded linkage to UPHC or a private care provider, and continuation of drug therapy. We defined treatment interruption as failure to obtain a prescription refill for two weeks or more after exhaustion of previously obtained drug supplies.
We designed a cloud-based digital tool using a CommCare-based application to facilitate follow-up. This tool was available on mobile phones of all ASHAs, and in addition to facilitating follow-up, it provided access to baseline values of the participants and also was to be used for data entry of each subsequent visit. Study supervisors monitored cohort follow-up using this CommCare-based application, and performed additional site visits for troubleshooting. A community clinic-based one-year adherence assessment was performed by a team of pharmacologists who were trained to assess pill burden and adherence to previously prescribed therapies. This assessment was limited to those who were on any antihypertensive drug therapy in the previous month.
Outcome assessment: Blood pressure control at the two-year assessment visit was the key outcome. It was defined as optimally controlled if the average SBP was less than 140 mm Hg and DBP was less than 90 mm Hg. This two-year assessment was performed by independent field investigators, who visited the households of all participants and measured their blood pressure. Multiple mop-up visits were conducted, and facilitation by ASHAs and study supervisors was solicited to improve the proportion of follow-ups.
Statistical analysis: ASHAs and study supervisors entered all study variables obtained in the baseline survey, confirmatory visits, UPHC visits, or follow-up using a mobile-phone-based data collection system. All the variables were stored on a cloud-based CommCare data-management system. The demographic and cardiovascular-risk variables (age, gender, education level, wealth quintiles, tobacco use, alcohol consumption, physical activity levels, body mass index [BMI], and waist circumference) were obtained from entries in the baseline questionnaire. History of HTN obtained at baseline and subsequently obtained SBP and DBP values were used for classification of HTN status. Primary-care physician consultation decisions culminating in drug escalation, de-escalation, or no action, were taken from UPHC visit logs. The distribution of these explanatory variables was compared with respect to outcome, using appropriate tests of significance. The difference was considered significant if the P value for the null hypothesis was less than 0.05.
We performed a multivariable logistic regression, to evaluate independent risk factors of uncontrolled HTN. All explanatory variables that were marginally significant on univariate analysis (P < 0.25) were included in the full model. Assumptions for using logistic regression were tested and Hosmer-Lemeshow goodness-of-fit was also used. All data analysis and visualizations were done using statistical software R and arsenal, finalfit, ggplot2, ggpubr, ggstatplot, gtsummary, performance and tidyverse packages.
| Results|| |
In November 2017, we initiated a baseline survey in 16 urban slum clusters of Bhopal. Of 6174 individuals surveyed at baseline, we identified a total of 1571 individuals (25.4%) with HTN; and all of these were sought to be visited by CHWs once every two months. A total of 1177 (74.9%) individuals completed a two-year follow-up visit in November–December 2019. Individuals who were lost to follow up and could not participate were more likely to be older men and were newly detected with HTN. [Table S1] Of 1177 individuals who completed follow-up, 623 (53%) knew about their HTN status at baseline, and 554 (47%) were newly detected during screening. At baseline, 301 (26%) individuals were optimally controlled, and at the end of two years their proportion increased to 442 (38%), an absolute increase of 12% (95%CI 10.2–13.9). [Figure 1] When we split these by status of HTN diagnosis, of the 623 previously known hypertensives, 48% were optimally controlled at baseline, which became 46% at the end of two years, and of the 554 newly detected hypertensives, and 29% were optimally controlled at the end of two years. There was a significant decline of 1.7 (95%CI −2.9 to −0.5) and 1.7 mm Hg (95%CI −2.4 to −1.1) in mean SBP and DBP respectively from baseline to follow up. This change can be largely attributed to a reduction in SBP among those with uncontrolled HTN. [Table 1], [Figure 2]
|Figure 1: “Study flow chart: Baseline survey and follow-up of hypertensive participants with blood pressure measurements and control status”|
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|Figure 2: “Change in Systolic Blood Pressure (SBP) from 2017 to 2019 among three baseline blood pressure groups: Newly detected uncontrolled, previously known controlled, and previously known uncontrolled hypertension”|
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|Table 1: Change in cardiovascular risk factors over two-year follow-up in the cohort (n=1177)|
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The proportion of individuals with uncontrolled blood pressure was progressively higher in each age band (55%, 63%, 67%, and 73% in those with baseline ages of 30–44, 45–59, 60–74, and above 75 years respectively). We observed a significant decline in SBP and DBP, across all age bands of individuals with uncontrolled HTN at baseline. About 65% of individuals who were sedentary at baseline, developed uncontrolled HTN, as compared to only 54% of those who were non-sedentary, that is, physically active. This difference was statistically significant. Individuals who were newly detected to have HTN, and those who had elevated blood pressure at baseline, were more likely to be uncontrolled on follow-up. [Table 2], [Figure 3]
|Figure 3: “Blood pressure trends from 2017 to 2019 stratified by baseline BP control status and age groups: Comparative analysis of systolic and diastolic blood pressure”|
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|Table 2: Distribution of status of BP control among various sociodemographic, behavioral, and biological variables|
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A total of 699 (59.4%) individuals were reported to be on antihypertensive drug therapy, 533 of these were linked to UPHC, and 166 to private-care providers. All these individuals received follow-up visits by ASHAs, and during these visits self-reported adherence to prescribed therapies was similar in both optimally controlled and uncontrolled individuals. (84.4% vs 85.8%; P = 0.842) An independent adherence assessment was also done at the end of one year in 263 of the UPHC attendees, and perceived adherence was lower in those subsequently found to be uncontrolled (69.5% vs 79.1%; P = 0.006). The proportion of individuals who were uncontrolled after two years was significantly higher amongst those who were linked to UPHC as compared to those linked to private providers (67% vs 61%; P = 0.009). Of those linked to UPHC, a median number of visits to the facility was similar in optimally controlled and uncontrolled subgroups (P = 0.436), and 116 (21.7%) individuals had one or more visits culminating in drug-escalation advice. While 24 (20.6%) of individuals who were advised drug escalation were optimally controlled, the remaining 92 (79%) were not. Of the 478 of 1177 individuals (40.6%), defaulted for initiation of drug therapy, and 276 (58%) had their blood pressures above 140/90 mm Hg at two-year follow-up. [Supplementary Table 2]
We performed multivariable logistic regression to identify risk factors for uncontrolled HTN. Hosmer-Lemeshow goodness-of-fit test was non-significant, there was no multi-collinearity, assumptions of homogeneity of variance, residual distribution, and absence of influential observations were met, however, the model's explanatory power was weak (Tjur's R2 = 0.06, RMSE = 0.46). After adjusting for age, and gender newly detected HTN (OR 2.42 (1.78–3.31)), and BMI (OR 1.04 (1.01–1.07)) were significant independent risk factors for uncontrolled HTN [Table 3].
|Table 3: Logistic regression analysis for determinants of uncontrolled hypertension|
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| Discussion|| |
In this study, we aimed to evaluate the degree of blood pressure control among individuals with HTN in the context of NPCDCS. Our results showed that, out of every ten individuals with HTN, six were on treatment, and only four were optimally controlled after two years of follow-up. Furthermore, the modest increase in the overall proportion of individuals with optimally controlled blood pressure was due to blood pressure control in less than a third of newly detected hypertensives, while the majority of newly detected and previously known hypertensives remained uncontrolled. Our findings highlight the challenges of achieving blood pressure control in vulnerable communities, especially in older individuals with higher BMI who are newly detected with HTN. These results provide a benchmark for the NPCDCS program, suggesting that achieving optimal blood pressure control within short periods of follow-up is feasible but challenging.
A recent systematic review reported that in India only 13% of all individuals with HTN are treated, and a meager eight percent are controlled. Our baseline screening bridged the awareness gap, and CHW-based adherence reinforcement improved the proportion of on-treatment and control individuals from 43% and 29% to 60% and 38% respectively. While these numbers are encouraging, and approach and even exceed proportions for control achieved in previous studies in high-income settings,, they bring forth challenges of initiating antihypertensive drugs in all who need them, improving adherence in those initiated, and appropriate dosing requirements. In the current study education, wealth, or gender did not increase the risk of uncontrolled HTN. These socioeconomic characteristics are perceived as proxy indicators for awareness, access, or empowerment. It is likely that more complex behavioral phenomena such as fear, reluctance, and the adverse impact of being labeled with an illness, affected both initiation and adherence to prescribed drug therapies. We found that the risk of being uncontrolled was consistently higher with increasing age, a factor that contributes to therapeutic inertia. Further, the presence of fixed-dose combinations in the drug formulary in UPHCs could have helped reduce inertia, as the use of combination treatment in newly detected hypertensives is likely to achieve a faster blood-pressure control.
Similar findings were reported in recent studies on predictors of HTN control in primary healthcare settings.[29–31] These studies have reported age, gender, race, waist-hip ratio, BMI, presence of diabetes mellitus, intake of multiple drugs, and lack of knowledge as predictors.[29–31]
Physical activity is important to achieve blood-pressure control and is an important component of various population-based programs. Self-reported physical activity levels correlate well with reduced blood pressure levels. In the current study, hypertensive individuals who reported themselves to be sedentary at baseline were more likely to be uncontrolled two years later. This is due to various reasons, including the fact that physical inactivity leads to increased vascular resistance, decreased nitric oxide production, and reduced arterial compliance, all of which are associated with elevated blood pressure levels.[34–36] Moreover, sedentary individuals are more likely to have a higher BMI and a higher waist circumference, which are both associated with higher blood pressure levels. While this effect observed on univariate analysis, was not significant when adjusted for age and gender, it is an important lifestyle measure that has a strong legacy effect. A sedentary lifestyle also leads to higher BMI, which was an independent predictor of blood-pressure control in our study. While some studies, such as the SPRINT trial have found no relationship between BMI and blood-pressure control, another large study from China found a significant lowering effect. While the mean BMI of participants in the SPRINT trial was 29 kg/m2, it was 24.4 kg/m2 in the Chinese study. The mean BMI of our participants was 25.8 kg/m2, closer to that of the Chinese study. It is likely that blood-pressure control in population subgroups with a lower BMI is more feasible, as compared to those with obesity.
Improving blood pressure control is a challenging task, especially in community-based HTN management programs. There are several reasons why regular follow-up with intensive pharmacotherapy is crucial to achieving this goal. Firstly, HTN is a chronic condition that requires long-term management, and patients may struggle with adherence to medication and lifestyle changes. Regular follow-up and monitoring can help identify and address barriers to adherence and provide support to patients. Secondly, HTN is often asymptomatic, and patients may not realize the importance of blood pressure control. Follow-up visits provide an opportunity to educate patients about the risks of uncontrolled HTN and the benefits of treatment. Thirdly, HTN management requires individualized care, and regular follow-up allows healthcare providers to tailor treatment plans based on patient response to medication and other factors. Lastly, community-based HTN management programs often involve patients from diverse backgrounds with varying levels of health literacy, cultural beliefs, and social determinants of health. Regular follow-up can help providers understand these factors and develop patient-centered care plans that address patients' unique needs and challenges. In a Cochrane review of 56 randomized control trials, other measures such as self-monitoring, appointment reminders, and health education had little independent effects and were less useful. The feasibility of achieving even lower targets than envisaged in NPCDCS was demonstrated in the intensive blood-pressure control arm in the SPRINT trial. Similar intensive management is also possible through CHWs in low-income settings. Two recent trials have demonstrated this effect. First, the HOPE4 study demonstrated that CHW-based intensive blood pressure control can improve the proportion of optimally controlled individuals to 69% as compared to 30% in the standard care arm. Second, in another randomized control trial from Argentina, CHW-led multi-dimensional care that involved intensive health coaching, home BP monitoring, audits, and feedback optimally controlled 72% of individuals. When CHWs are provided with intensive supportive supervision, and empowered to obtain quick feedback on treatment decisions, it can help improve therapeutic inertia and achieve better control levels.
Our study provides important insights into the challenges of HTN management in the community and the potential of CHW-based follow-up systems to improve blood pressure control outcomes. However, further research is needed to explore related areas that complement the findings of the current study. Investigating the impact of lifestyle interventions, the effectiveness of different treatment regimens, and the influence of social and cultural factors on medication adherence could provide a more complete understanding of HTN management in the community. This could inform the development of strategies to further improve outcomes and support the implementation of NPCDCS.
The study design has several strengths. The study used a community-based cohort design, which allows for a better understanding of the health status of the population being studied. The study also used a door-to-door survey, which helped ensure a representative sample of the population. The use of ASHAs helped to facilitate follow-up visits and improve the accuracy of the data collected. The study also included a one-year adherence assessment, which helped to ensure that the study participants were adhering to their prescribed drug therapy. However, the study also has some limitations. The study was conducted in a single city in India, which may limit the generalizability of the findings to other populations. We could follow up only three-fourths of our intended cohort, mostly due to migration, and limited availability at home due to the long working hours of many participants. The proportion of individuals on treatment was modest, reflecting the real-world apprehensions many individuals with HTN have, regarding the initiation of drug therapy. Also, the study did not assess the long-term outcomes of the program, which may limit the ability to conclude the sustainability of the intervention.
| Conclusion|| |
In this study, six out of every ten individuals with HTN were on treatment, and four of them were optimally controlled. The findings provide a benchmark for NPCDCS in terms of achievable goals within short periods of follow-up. Newly detected individuals with HTN and those who are obese require more intensive monitoring and follow-up to improve optimal control levels in the community. CHW-based follow-ups are feasible, but more intensive treatments and follow-up systems are needed for better blood pressure control outcomes.
Ethics Approval and Consent to Participate
The study was conducted in accordance with ethical principles and guidelines, and approval was obtained from the Institutional Human Ethics Committee (Ref: IHEC-LOP/2017/EF00045). Written informed consent was obtained from all participants before they participated in the study.
Investigators would like to acknowledge the efforts of all community health workers (ASHAs) and their officials affiliated with the Urban Public Health system in implementing this study.
Consent for Publication
We have not presented any identifiable information of the individual and therefore individual's consent for publication is not applicable.
Financial Support and Sponsorship
Indian Council of Medical Research extramural project grant (Grant – PI- Dr. Rajnish Joshi, IRIS-2014-0976).
Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]