Chronic diseases including hypertension, diabetes, cardiovascular and kidney disease have become major public health problems worldwide. Despite a high prevalence of hypertension (one in three adults), and diabetes (one in five adults), blood pressure control remains poor in Pakistan (<3%). Further, population based data on the burden of cardiovascular and kidney disease from this region are lacking. Population Based Strategies for Effective control of High Blood Pressure is a community based, factorial design, cluster randomized controlled intervention study being conducted on about 20,000 subjects from 12 randomly selected low and middle-income communities in Karachi. This study includes 1) a population survey to estimate the burden of cardiovascular disease and kidney disease, and, 2) a randomized intervention trial to assess the impacts of a Population Approach and a High Risk Approach on control of high blood pressure. The Population Approach consists of home health education (HHE) delivered by trained community health workers (CHW) to children, women and men versus no HHE. Screening for chronic diseases was done in all communities. Health messages include information on the deleterious effects of hypertension, and non-pharmacological interventions for preventing and controlling hypertension and cardiovascular disease, along with advice on weight loss strategies, exercise, smoking cessation, low salt and saturated fat intake, and high fruit and vegetable intake. Special advice is designed for children to ensure adequate caloric and nutrient intake for optimum growth. The CHWs made appointments for the first two sessions, each lasting one and one-half hours within one month of each other, at times which were convenient to most occupants in the house. The messages are being reinforced during subsequent 3-monthly visits of one hour each. This frequency of visit by CHW is consistent with other government sponsored home-based preventive services in Pakistan, thus, ensuring sustainability. The High Risk Approach comprises of targeted training of general practitioners
(GP). These GPs were intensively trained in standard treatment algorithms
for management of hypertension using non-pharmacologic (diet, weight loss,
exercise, smoking cessation) and low cost generic drug intervention. Hypertensive
adults identified in the population survey were randomized to care by
specially trained GP or usual care in the community. Among subjects aged 40 years or over, the prevalence of hypertension
(systolic pressure ｳ 140 mmHg, or diastolic ｳ 90 mmHg based on mean of
two readings from two separate occasions or on antihypertensive therapy)
was 44%, diabetes was 21%, and ECG changes suggestive of ischemia was
22.8% (29.4% in women and 15.6 % in men), and albuminuria was 8.6%. The prevalence (95% CI) of reduced Cockcroft Gault (CG) eGFR was 30.2%
(26.7-34.0%) in women and 21.6% (18.5-25.2%) in men (p<0.001). The
prevalence (95% CI) of reduced MDRD Study eGFR was 10.6 (8.4-13.3) in
women and 8.9 (6.8-11.5) in men (p<0.001). Tracking of outcomes including changes in blood pressure levels, albuminuria, estimated GFR, CVD morbidity and mortality over five years is ongoing. Further, cost effectiveness of the strategies would be assessed by in-depth economic analysis.
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