Hypertension — commonly known as high blood pressure — is poorly managed in SA, but findings from a study in rural KwaZulu-Natal suggest a compelling alternative to the current model of clinic-based care: using community healthcare workers to monitor people’s blood pressure in their own homes.
Hypertension is a major contributor to SA’s growing burden of non-communicable diseases because of the many complications that can come with it, including cardiovascular and kidney disease, heart failure, heart attacks and stroke.
Some good news is that findings from a new study point to how healthcare providers might improve hypertension control among adults with high blood pressure — by using community healthcare workers to take the management of blood pressure out of clinics and into people’s homes.
The researchers split 774 adults in KwaZulu-Natal into three groups. One group of 257 was cared for at home by community health workers, the other group of 258 got enhanced care at home by community health workers and the last group of 259 got standard care at a clinic.
All participants were seen by a nurse when they were enrolled so they could be started on the appropriate antihypertensive medicines available in the public sector. They were then randomised to the three study arms.
In the standard of care arm, participants had to go to the clinic every month to have their blood pressure measured by a nurse, their blood pressure medications adjusted as needed and then collect those meds from the pharmacy at the clinic.
In the community health worker group, participants were given an automated blood-pressure machine and trained to use it by the healthcare workers.
They had to take their blood pressure every day and the healthcare workers visited about once a month to check on the participants and to record the readings into a mobile application.
The data was then sent to the nurses at the clinics to be reviewed and they then entered a prescription for the appropriate medicine and dosage based on the average blood pressure readings.
The community healthcare workers then got a prompt to pick up the medicine and deliver it to the participants.
In the enhanced community healthcare workers group, participants got a blood pressure machine with mobile connectivity. The daily readings (of between six and ten readings a week) were sent directly to the mobile app used by the nurses.
Community healthcare workers would visit the participants about once a month to check on them, to ensure that the machines were working and to deliver the medicines. With the exception of the blood pressure readings getting sent straight to the nurses, everything was done in a similar way to the previous group.
The results showed that, after six months of care, both groups of participants who were cared for at home by community healthcare workers had a greater reduction in blood pressure than those getting the standard of care at clinics.
In the standard of care arm, the average blood pressure of participants did not really change much compared to what it was at the start of the study.
In the community care arms, the average blood pressure for participants was strikingly lower than at the outset. In the standard of care group, 32.5% of people had their blood pressure under control at six months, compared with 57.4% in the community health worker group and 61.3% in the enhanced community health worker group.
“We basically moved chronic disease care from the clinic, which is inconvenient and costly, to the patient’s home,” said Prof Mark Seidner, the study’s principal investigator.
We basically moved chronic disease care from the clinic, which is inconvenient and costly, to the patient’s home
— Prof Mark Seidner, the study’s principal investigator.
Seidner is a health systems researcher and a clinical trialist working at the Africa Health Research Institute in KwaZulu-Natal and a professor of medicine at Harvard Medical School in Boston.
Some of the challenges with how hypertension care is currently delivered, Seidner said, include the inconvenience of going to a clinic for a blood pressure reading, blood pressure machines not working, long clinic waiting times, the expense of travelling to the clinic and nurses being overwhelmed by the long queues of patients waiting for care.
Apart from the substantial improvements seen with home-based care, another striking aspect of the study is how little improvement was seen in patients receiving clinic-based care.
”That just says to me our system is not working,” said Seidner.
Prof Brian Rayner, a senior research scholar specialising in nephrology and hypertension at the University of Cape Town, concurred that “an awful finding” coming out of the study is that broadly the standard of care for people with hypertension isn’t necessarily helping them keep their blood pressure under control.
“I think people [receiving home care from community health workers] really appreciated that they could take control of their health; they could measure their blood pressure. They certainly appreciate that they didn’t have to come to a clinic,” said Rayner.
The study team presented their findings at a workshop with officials from the national and KZN departments of health.
The next step for the researchers is to do a cost-effectiveness analysis to determine whether it would be feasible to implement home-based care, Seidner said. They are hoping to have these results in the next few months.
- This article was first published by Spotlight — health journalism in the public interest.