Elsevier

The Lancet

Volume 379, Issue 9810, 7–13 January 2012, Pages 47-54
The Lancet

Articles
Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study

https://doi.org/10.1016/S0140-6736(11)61349-4Get rights and content

Summary

Background

Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community.

Methods

We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching.

Results

NCDSS had data for 65 619 individuals aged 25 years or older (11 686 of whom in rural areas); of these, 64 694 (11 521 in rural areas) had data for SBP and 50 202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (−0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (−0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method.

Interpretation

Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel.

Funding

None.

Introduction

Non-communicable diseases are important contributors to the burden of disease in countries at all stages of economic development. Although population growth and ageing have led to a rise in the absolute burden of such diseases, age-specific mortality and incidence of cardiovascular diseases and some other non-communicable diseases have decreased in high-income countries.1, 2 This success is at least partly attributable to the decrease in major risk factors, including smoking and high blood pressure and cholesterol.2, 3, 4, 5 However, the prevalence of these risk factors has increased or remained unchanged in many low-income and middle-income countries.3, 4, 5

Dietary, lifestyle, regulatory, and pharmacological interventions can lower major risk factors for cardiovascular disease, and are probably the reason behind population-level decreases in high-income settings.6, 7 However, the ability to identify people at high risk for cardiovascular disease, to deliver interventions, and to ensure compliance to these interventions is constrained by the number and cost of physicians and health facilities. Primary care might provide a cost-effective mechanism for the management of risk factors for cardiovascular disease in low-income and middle-income countries.8 However, little evidence exists for whether health systems with low-to-medium budgets can use primary care for the management of risk factors for cardiovascular disease, especially in places where much of the population live in rural areas.9 Also unclear is how the number of primary health-care workers—an important constraint in low-income and middle-income countries—can affect the effectiveness of the primary care system in the management of non-communicable disease and their risk factors. This absence of evidence is a major obstacle to the formulation of specific policies and plans for the control of non-communicable diseases, which are an important global health priority following the 2011 High-level Meeting of the UN General Assembly.

In this paper, we assessed how the Iranian rural primary health-care system, known as the Behvarz system, has contributed to the management of two major non-communicable diseases—hypertension and diabetes, which are both important risk factors for mortality and burden of disease in low-income and middle-income countries.3, 10 Cardiovascular disease and diabetes caused 53% of all adult deaths in Iran in 2006.11 High blood pressure (which caused 80 000 annual deaths in 2005) and hyperglycaemia (which caused 34 000 annual deaths in 2005) are the leading metabolic risk factors for mortality in Iran.11

The Behvarz system uses community health workers to provide primary health care in rural Iran—areas with populations generally less than 5000 people and those with agriculture as the main economic activity. Community members with at least primary education are recruited into the Behvarz programme on the basis on their performance in an entrance examination. Newly appointed Behvarz workers undergo 2 years of classroom and practical training before beginning work in their own local community. Behvarz workers receive regular training throughout their career, a fixed salary that is about a sixth of that of physicians, and a performance-based bonus of no more than 5% of their salary. Between 1996 and 2002, the programme was expanded to incorporate diabetes prevention and control.12 As a part of the protocol established by the National Plan for Prevention and Control of Diabetes, Behvarz workers are trained to identify high-risk groups—those aged 30 years or older who are pregnant, have a family history of diabetes, or are overweight. High-risk individuals are referred to physicians who visit the local community in so-called health houses for diabetes testing and, as required, treatment. Diagnosis, treatment, and lifestyle advice, as well as the date of the subsequent physician visit, are recorded by a Behvarz worker. Diagnosed patients obtain their subsidised drugs from the medical team visiting the health house. Behvarz workers then follow up patients with diabetes monthly to check that they are adhering to their treatment, to arrange for new drug supply, to examine them for symptoms of hyperglycaemia (eg, diabetic wounds and ulcers), and to refer patients with symptoms such as ulceration, painful limbs, and blurred vision to physicians at the rural health centres. The physicians to whom the patients are referred are expected to treat on the basis of well developed guidelines,13 with patients advised by their local Behvarz worker to visit physicians at least once every 3 months. Behvarz workers are also responsible for holding training sessions on healthy diet and lifestyle for, among others, individuals who are at high risk for diabetes.14 Although Iran has a programme for the management of hypertension, at the time of this study the programme did not have a specific role for Behvarz workers or detailed guidelines for physicians.

Section snippets

Data sources

We used data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS)11, 15 to measure the coverage of treatment for diabetes and hypertension, and to estimate the effectiveness of treatment in the reduction of fasting plasma glucose (FPG) and systolic blood pressure (SBP). We also combined NCDSS data and data for the density of Behvarz workers to examine whether a higher density of workers is associated with improved district-level outcomes—ie, lower mean FPG and SBP.

We used data for

Results

Diabetes prevalence was higher in urban areas than it was in rural areas, whereas the difference between rural and urban areas for hypertension was small (table 1). The prevalence of both disorders was higher in women than it was in men (table 1).

About half of individuals with diabetes or hypertension had been diagnosed (table 2). Nationally, 39·2% (95% CI 37·7–40·7%) of those with diabetes and 35·7% (34·9–36·5%) of those with hypertension received medication, with higher treatment coverage in

Discussion

In our nationally representative analysis, treatment of diabetes in Iran was more effective in rural areas than it was in urban areas. The diabetes treatment effect in rural and urban areas were, respectively, about 67% and 11% of the 2·0 mmol/L treatment effect in randomised trials.22 The estimated hypertension treatment effects are less than half of that recorded in trials.23 The difference between rural and urban areas was substantially smaller for hypertension treatment, with urban

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