Community Health Workers Improve Linkage to Hypertension Care in Western Kenya
Key result
A smartphone-based behavioral communication strategy for community health workers did not significantly reduce systolic blood pressure compared to usual care (difference -2.13 mmHg, 95% CI -4.89 to 0.42).
Why the study?
Elevated blood pressure is the leading global mortality risk factor, and delayed hypertension care is associated with increased mortality.
Does a smartphone-based behavioral communication strategy for community health workers improve linkage to care and reduce systolic blood pressure in adults with elevated blood pressure?
Study Design
Type
RCT (n=1,460)
Blinding
Open-label
Randomization
Cluster randomized
Multicenter
Yes
Structured PICO
Does a smartphone-based behavioral communication strategy for community health workers improve linkage to care and reduce systolic blood pressure in adults with elevated blood pressure?
P
Population
1,460 adults with elevated blood pressure in western Kenya, 58% female, followed for 15 months.
I
Intervention
Community health workers equipped with tailored behavioral communication strategies and smartphone technology (mHealth) with real-time decision support.
C
Comparator
Usual care (community health workers with standard training referring individuals to health facility).
O
Outcome
Co-primary outcomes: documented linkage to care and change in systolic blood pressure at 15 months.surrogate
Main Result
Mean Difference: -2.13 (95% CI -4.89–0.42)
Absolute Event Rate: -13.1% vs -9.7%
Limitations
- Reliance on self-reported linkage data due to electronic medical record shortcomings
- Missing data at baseline and follow-up
- Significant baseline differences across trial arms
- Differential time to follow-up across arms
- Lack of access to medication prescribing data
- Screening participants may not be fully representative of the general population
- Reliance on self-reported linkage data
- Baseline differences across trial arms
- Differential time to follow-up
- Lack of medication prescribing data
- Screening participants may not be representative
Ask about this paper
Answers are grounded in this paper and cite their sources.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“What we found was that the smartphone-based arm did improve linkage to care and improved BP a modest amount, although the BP results in the end were not statistically significant. The conclusion is that community health workers have a role and quite likely can improve linkage and BP if they're equipped with smartphones and behavioral communication.”
Implication
Equipping community health workers with smartphone technology improved linkage to care but did not significantly reduce blood pressure compared to usual care in a low-resource setting.
Abstract
Background: Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay seeking hypertension care is associated with increased mortality. Objective: We investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP. Methods: We conducted a cluster randomized trial with three arms: 1) usual care (standard training); 2) “paper-based” (tailored behavioral communication, using paper-based tools); and 3) “smartphone” (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care, and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data. Results: 1460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mmHg. Follow-up measures of linkage were available for 1128 (77%) and BP for 1106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms. Average overall follow-up SBP was 149.9 mmHg. Participants in the smartphone arm experienced a modestly greater reduction in SBP vs. usual care (−13.1 mmHg vs. −9.7), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change. Conclusions: A strategy combining tailored behavioral communication and mHealth for CHWs led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. Trial Registration: Registered as on www.clinicaltrials.gov.
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Cite This Study
Vedanthan et al. (2019) conducted an RCT in Elevated blood pressure (n=1,460). Smartphone-based tailored behavioral communication by community health workers vs. Usual care (community health workers with standard training) was evaluated on Change in systolic blood pressure (SBP) at 15 months (MD -2.13, 95% CI -4.89, 0.42). A smartphone-based behavioral communication strategy for community health workers did not significantly reduce systolic blood pressure compared to usual care (difference -2.13 mmHg, 95% CI -4.89 to 0.42).