基于社区的南亚农村地区高血压管理干预措施。

A Community-Based Intervention for Managing Hypertension in Rural South Asia.

机构信息

From the Program in Health Services and Systems Research (T.H.J., E.A.F., L.F.) and the Center for Quantitative Medicine (M.G.), Duke-NUS Medical School, the Department of Renal Medicine, Singapore General Hospital (T.H.J.), and the Department of Biostatistics, Singapore Clinical Research Institute (M.G., P.N.A.) - all in Singapore; the Duke Global Health Institute (T.H.J., E.A.F., E.L.T.) and the Department of Biostatistics and Bioinformatics, Duke University (E.L.T.) - both in Durham, NC; the Center for Child Health Research, Tampere University, Tampere, Finland (M.G.); the Clinical Trials Unit, Department of Pharmacology (H.A.S.), and the Department of Public Health (A.K.), Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka; the Department of Community Health Sciences (I.J.) and the Section of Cardiology, Department of Medicine (A.H.K.), Aga Khan University, Karachi, Pakistan; the International Center for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh (A.N., J.D.C.); the UCLA Fielding School of Public Health, Department of Community Health Sciences, Los Angeles (D.M.); and the London School of Hygiene and Tropical Medicine, London (S.E.).

出版信息

N Engl J Med. 2020 Feb 20;382(8):717-726. doi: 10.1056/NEJMoa1911965.

DOI:10.1056/NEJMoa1911965

PMID:32074419

Abstract

BACKGROUND

The burden of hypertension is escalating, and control rates are poor in low- and middle-income countries. Cardiovascular mortality is high in rural areas.

METHODS

We conducted a cluster-randomized, controlled trial in rural districts in Bangladesh, Pakistan, and Sri Lanka. A total of 30 communities were randomly assigned to either a multicomponent intervention (intervention group) or usual care (control group). The intervention involved home visits by trained government community health workers for blood-pressure monitoring and counseling, training of physicians, and care coordination in the public sector. A total of 2645 adults with hypertension were enrolled. The primary outcome was reduction in systolic blood pressure at 24 months. Follow-up at 24 months was completed for more than 90% of the participants.

RESULTS

At baseline, the mean systolic blood pressure was 146.7 mm Hg in the intervention group and 144.7 mm Hg in the control group. At 24 months, the mean systolic blood pressure fell by 9.0 mm Hg in the intervention group and by 3.9 mm Hg in the control group; the mean reduction was 5.2 mm Hg greater with the intervention (95% confidence interval [CI], 3.2 to 7.1; P<0.001). The mean reduction in diastolic blood pressure was 2.8 mm Hg greater in the intervention group than in the control group (95% CI, 1.7 to 3.9). Blood-pressure control (<140/90 mm Hg) was achieved in 53.2% of the participants in the intervention group, as compared with 43.7% of those in the control group (relative risk, 1.22; 95% CI, 1.10 to 1.35). All-cause mortality was 2.9% in the intervention group and 4.3% in the control group.

CONCLUSIONS

In rural communities in Bangladesh, Pakistan, and Sri Lanka, a multicomponent intervention that was centered on proactive home visits by trained government community health workers who were linked with existing public health care infrastructure led to a greater reduction in blood pressure than usual care among adults with hypertension. (Funded by the Joint Global Health Trials scheme; COBRA-BPS ClinicalTrials.gov number, NCT02657746.).

摘要

背景

高血压负担日益加重，中低收入国家的控制率较差。农村地区心血管死亡率较高。

方法

我们在孟加拉国、巴基斯坦和斯里兰卡的农村地区进行了一项集群随机对照试验。总共 30 个社区被随机分配到多组分干预组（干预组）或常规护理组（对照组）。干预措施包括经过培训的政府社区卫生工作者进行家庭访视以监测血压和提供咨询、培训医生以及协调公共部门的护理。共有 2645 名高血压成年人入组。主要结局是 24 个月时收缩压降低。超过 90%的参与者完成了 24 个月的随访。

结果

在基线时，干预组的平均收缩压为 146.7mmHg，对照组为 144.7mmHg。在 24 个月时，干预组的平均收缩压下降了 9.0mmHg，对照组下降了 3.9mmHg；干预组的平均降幅为 5.2mmHg（95%置信区间[CI]，3.2 至 7.1；P<0.001）。干预组的舒张压平均降低了 2.8mmHg（95%CI，1.7 至 3.9）。干预组中有 53.2%的参与者血压控制在<140/90mmHg，而对照组为 43.7%（相对风险，1.22；95%CI，1.10 至 1.35）。干预组的全因死亡率为 2.9%，对照组为 4.3%。

结论

在孟加拉国、巴基斯坦和斯里兰卡的农村社区，以受过培训的政府社区卫生工作者主动上门为中心的多组分干预措施，这些工作者与现有的公共卫生保健基础设施相联系，与常规护理相比，可使高血压成年人的血压降低更多。（由联合全球卫生试验计划资助；COBRA-BPS ClinicalTrials.gov 编号，NCT02657746）。