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

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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.