Treating hypertension in rural South Africa: Comparative effectiveness of two different patient outreach models.

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The South African Department of Health is currently reorganising the health system to improve care of chronic conditions. The Department of Health has recognised that chronic conditions, including hypertension, are poorly managed in rural, low-resource areas of South Africa. Hypertension is a very common chronic condition, affecting as much as 46% of the adult population, but many people with hypertension remain undiagnosed, are not taking treatment, or do not take their medication consistently. Part of the plan of the Department of Health is for a new cadre of Community Health Workers, six per team with one nurse, making visits to households and responsible for around 270 households. In some areas, including the area where this research will take place, they will also be responsible for delivering medication to people's homes, monitoring clinical indicators, encouraging people with chronic conditions, including hypertension, to take their medication. However, there is concern that this model may prove both too impracticable in rural areas because of the large distances, among other things. We propose to develop and test the effectiveness of a lower resource model in which there is more emphasis on educating and empowering patients to manage their condition. Two lay health workers will be based in a clinic and will support patients with chronic conditions, providing patient education, support to encourage adherence to medication, and texted reminders about clinic appointments and repeat prescriptions. In addition the lay health workers will encourage and support patients to set up self-help groups, which will provide social support but will also provide practical support in fetching medication from the clinics, which are often a long distance from homes. We will carry out a randomised trial comparing the two models of care in 8 clinics in north eastern South Africa, which is a low resource rural area with widely scattered villages. Because we are basing this research in a Health and Demographic Surveillance System site where an annual census is carried out and there is an extensive database of information on the people living on the site, we will be able to identify the people using the clinics so that we can see patterns of use of the clinics and how they change during the trial. This will also mean that we can examine the effects of the two interventions by factors such as how far the household is from the nearest clinic. The census database will also provide a sampling frame for two surveys which will measure the prevalence and control of hypertension in the community before and after the trial.During the trial we will also be using in-depth interviews to study patients, health workers and community members perceptions and experience of the interventions and what are the factors that encourage or discourage either attendance at clinics or adherence to medication.