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

摘要 在尼泊尔，HTN在成年人中的患病率为25%，与全球患病率相似。然而，在尼泊尔，一个 相对较大比例的成年人(44%)不知道自己的HTN状态，33%的HTN患者 接受治疗，只有12%的患者血压得到控制。尽管有经过验证的 有效的生活方式改变和低成本的抗HTN治疗预防重大血管事件和总 在死亡率方面，这些建议尚未付诸实践。在尼泊尔，基本的一揽子计划 通过了非传染性疾病(PEN) 包括 检测和管理HTN的协议 然而，基本保健设施在多个层面上存在主要执行障碍：(A)个人层面：低 感知易感性、低健康素养、误解；(B)人际层面：同辈压力；(C) 社区一级：支持不健康饮食和低服药依从性的规范；以及(D)组织 职等：人力资源职位空缺，卫生工作人员负担过重，医疗用品供应中断 药品；记录和报告效率低下，以及提供者与患者之间的互动不足。在回应这些问题时 多层次实施障碍，我们建议实施和评估一个新的任务转移策略，以 社区卫生工作者(CHW)，领导改进HTN的预防和控制。社区卫生工作者将：(A)参与 更频繁地、更长时间地在客户家中与客户进行沟通和教育，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，提高保健系统的效率； 监测血压；及。(三)社区卫生服务中心会直接把HTN患者与医护人员接驳。 通过时间转介卫生设施。我们会进行第三类混合成效--实施研究，以 实施和评估CHW主导的HTN预防和控制(CHPC)实施战略，以交付 增加对健康饮食、体力活动和抗高血压药物使用的摄取和维持； 导致血压下降。AIM 1将评估CHPC实施的简化结果 在患者、提供者和卫生系统层面使用RE-AIM框架的战略。我们将使用混合的 衡量范围、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 通过整群随机对照试验，比较基于设备的PEN对收缩压的影响。我们将招募2432人 171个地理分组中患有高血压的参与者随机评估CHPC的收缩压 (主要结果)。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中的有效性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 尼泊尔和其他小岛屿发展中国家政府制定了HTN预防和控制战略，以减轻#年HTN的负担 资源设置较低。

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.