Community-Based Interventions to Promote Blood Pressure Control in a Developing Country A Cluster Randomized Trial Tazeen H. Jafar, MD, MPH; Juanita Hatcher, PhD; Neil Poulter, MD; Muhammad Islam, MSc; Shiraz Hashmi, MD; Zeeshan Qadri, MSc; Rasool Bux, MSc; Ayesha Khan, MSc; Fahim H. Jafary, MD; Aamir Hameed, MD; Ata Khan, MD; Salma H. Badruddin, PhD; and Nish Chaturvedi, MD, for the Hypertension Research Group Background: Despite convincing evidence that lowering blood pressure decreases cardiovascular morbidity and mortality, the hy- pertension burden remains high and control rates are poor in de- veloping countries. Objective: To assess the effectiveness of 2 community-based interventions on blood pressure in hypertensive adults. Design: Cluster randomized, 2  2 factorial, controlled trial. (Clini- calTrials.gov registration number: NCT00327574) Setting: 12 randomly selected communities in Karachi, Pakistan. Patients: 1341 patients 40 years or older with hypertension (sys- tolic blood pressure 140 mm Hg, diastolic blood pressure 90 mm Hg, or already receiving treatment). Measurements: Reduction in systolic blood pressure from baseline to end of follow-up at 2 years. Intervention: Family-based home health education (HHE) from lay health workers every 3 months and annual training of general practitioners (GPs) in hypertension management. Results: The age, sex, and baseline blood pressure–adjusted decrease in systolic blood pressure was significantly greater in the HHE and GP group (10.8 mm Hg [95% CI, 8.9 to 12.8 mm Hg]) than in the GP-only, HHE-only, or no intervention groups (5.8 mm Hg [CI, 3.9 to 7.7 mm Hg] in each; P  0.001). The interaction between the main effects of GP train- ing and HHE on the primary outcome approached significance (interaction P = 0.004 in intention-to-treat analysis and P = 0.044 in per-protocol analysis). Limitations: Follow-up blood pressure measurements were missing for 22% of patients. No mechanism was detected by which inter- ventions lowered blood pressure. Conclusion: Family-based HHE delivered by trained lay health workers, coupled with educating GPs on hypertension, can lead to significant blood pressure reductions among patients with hyper- tension in Pakistan. Both strategies in combination may be feasible for upscaling within the existing health care systems of Indo-Asian countries. Primary Funding Source: Wellcome Trust. Ann Intern Med. 2009;151:593-601. www.annals.org For author affiliations, see end of text. C ardiovascular disease has, in just a few decades, be- come the leading cause of death in adults worldwide, accounting for 1 in 5 deaths. Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease (1, 2). Despite the demonstrated benefits of effective drug treatment (3, 4) and the existence of many clinical practice guidelines (5), hypertension prevention, treatment, and control rates remain suboptimal worldwide (6). The situa- tion is particularly acute in developing countries, such as Pakistan, India, and China, where hypertension has reached epidemic proportions—affecting more than 20% of the adult population (7)—yet control rates are less than 6% (8). Poor health literacy and unhealthy lifestyles, com- pounded by lack of awareness of hypertension (7), are part of the cause. In addition, the health systems in these coun- tries are often dysfunctional: More than 80% of the expen- diture for chronic disease care is out-of-pocket; private care general practitioners (GPs), who primarily treat acute con- ditions, are the front-line service providers; and national programs for preventing and controlling hypertension are inadequate. Serious deficiencies in management of hyper- tension also have been identified in the knowledge and practice of health care providers. (9) However, evidence for public health interventions to improve hypertension con- trol rates through patient or physician education in Indo- Asian countries is lacking. We conducted the COBRA-1 (Control of Blood Pres- sure and Risk Attenuation-1) trial in Karachi, Pakistan, to test the effectiveness of 2 community-based strategies: family-based home health education (HHE), delivered by trained community health workers, to improve population- level health literacy and behaviors, and hypertension man- agement training for GPs. We tested the effect of these interventions, alone and in combination, on blood pressure in adults with hypertension. We hypothesized that HHE See also: Print Editors’ Notes ............................. 594 Summary for Patients ....................... I-24 Web-Only Appendixes Appendix Tables Conversion of graphics into slides Annals of Internal Medicine Article © 2009 American College of Physicians 593