Community Health Worker Led Hypertension Prevention and Control (CHPC) in Nepal: An Implementation Trial

摘要 在尼泊尔，成人HTN的患病率为25%，与全球患病率相似。然而，在尼泊尔， 相对较大比例的成年人（44%）不知道他们的HTN状态，33%的HTN患者 只有12%的患者的血压得到控制。尽管已经证明 有效的生活方式改变和低成本的抗HTN治疗在预防主要血管事件和总 然而，这些建议尚未付诸实践。在尼泊尔， 非传染性疾病（PEN）是指 包括 协议检测和管理HTN在 然而，在多个层面上存在着重大的执行障碍：（a）个人层面：低 感知的易感性，健康知识水平低，误解;（B）人际层面：同伴压力;（c） 社区一级：支持不健康饮食和坚持服药率低的规范; 职等：人力资源职位空缺，保健工作人员负担过重，医疗用品中断， 药物;记录和报告效率低下，以及提供者与患者之间的互动不足。针对这些 由于存在多层次的实施障碍，我们建议实施和评估一种新的任务转移策略， 社区卫生工作者（CHW），从而改善HTN预防和控制。CHW将：（a）参与 更频繁地与客户进行更长时间的教育，并在他们的家中，从而建立客户的自我， 功效;（B）通过提供优质提供者-客户时间来改变生活方式， （c）社区卫生工作者会直接把高血压病人与医护服务提供者接驳， 通过及时转诊提供保健设施。我们将进行第三类混合有效性-实施研究， 实施和评估CHW领导的HTN预防和控制（CHPC）实施战略， 增加健康饮食、体力活动和抗高血压药物使用的摄取和维持; 目标1将评估CHPC实施的实施结果 在患者、提供者和卫生系统层面使用RE-AIM框架的战略。我们将利用混合 衡量覆盖范围、有效性、采用、实施和维护结果的方法， 持续实施CHPC。目标2将评估CHPC实施战略的有效性 通过一项群集随机对照试验，将其与基于机构的PEN对收缩压的影响进行比较。我们将招募2432人 在171个地理集群中随机分配的高血压参与者，以评估CHPC对收缩压的影响 （主要成果）。目标3将评估CHPC的经济可持续性。我们将收集主要成本数据 并使用目标2的成效估计来模拟成本和成本- 有效性和家庭自付支出的影响。如果成功，这项研究将提供 尼泊尔政府和其他低收入国家政府制定了一项HTN预防和控制战略， 低资源设置。

ABSTRACT In Nepal, the prevalence of HTN among adults is 25% is similar to the global prevalence. In Nepal, however, a comparatively larger proportion of adults (44%) are unaware of their HTN status, 33% of HTN patients are receiving treatment, and only 12% of the patients have their BP under control. Despite the availability of proven effective lifestyle changes and low-cost anti-HTN treatment in preventing major vascular events and total mortality, these recommendations have not been translated into practice. In Nepal, the Package of Essential Non Communicable Diseases (PEN) was adopted that includes protocols to detect and manage HTN at the basic health facilities However, major implementation barriers at multiple levels exists: (a) Individual level: low perceived susceptibility, low health literacy, misconceptions; (b) Interpersonal level: peer pressure; (c) Community level: norms supporting unhealthy eating and low medication adherence; and (d) Organizational level: unfilled human resource positions, overburdened health staff, interrupted medical supplies and medicines; inefficient recording and reporting, and inadequate provider-patient interaction. In response to these multi-level implementation barriers, we propose to implement and evaluate a new task-shifting strategy to community health workers (CHW), leading to improved HTN prevention and control. CHWs will : (a) engage with and educate clients more frequently, for longer periods, and in their homes, hence building clients' self- efficacy; (b) improve health system efficiency by providing quality provider-client time to modify lifestyle, monitor blood pressure; and (c) CHWs will directly connect the HTN patients with health care providers at health facilities through time referral. We will conduct a type III hybrid effectiveness-implementation study to implement and evaluate a CHW led HTN prevention and control (CHPC) implementation strategy to deliver increased uptake and sustainment of healthy diet, physical activity, and antihypertensive medication use; leading to lowering of blood pressure.Aim 1 will assessimplementation outcomes of CHPC implementation strategy using the RE-AIM framework at the patient, provider and health system levels. We will utilize mixed methods to measure the Reach, Effectiveness, Adoption, Implementation and Maintenance outcomes for sustained implementation of CHPC. Aim 2 will assess the effectiveness of the CHPC implementation strategy compared to facility-based PEN on systolic BP via a cluster randomized controlled trial. We will recruit 2432 participants with high blood pressure in 171 geographic clusters randomized to assess CHPC on systolic BP (primary outcome). Aim 3 will evaluate the economic sustainability of CHPC. We will collect primary cost data from facilities and participants and use the effectiveness estimate from aim 2 to model the costs and cost- effectiveness and household out of pocket expenditure impacts. If successful, this study will provide the governments of Nepal and other LMICs a HTN prevention and control strategy to mitigate the burden of HTN in low resource settings.