Introduction In low/middle-income countries with substantial HIV and tuberculosis epidemics, health services often neglect other highly prevalent chronic conditions, such as hypertension, which as a result are poorly managed. This paper reports on a study to assess the effect on hypertension management of lay health workers (LHW) working in South African rural primary healthcare clinics to support the provision of integrated chronic care.
Methods A pragmatic cluster randomised trial with a process evaluation in eight rural clinics assessed the effect of adding two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months. Control clinics continued with usual care. The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure (BP) before and after the intervention, as measured by two cross-sectional population surveys.
Results There was no improvement in BP control among users of intervention clinics as compared with control clinics. However, the LHWs improved clinic functioning, including overall attendance, and attendance on the correct day. All clinics faced numerous challenges, including rapidly increasing number of users of chronic care, unreliable BP machines and cuffs, intermittent drug shortages and insufficient space.
Conclusion LHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients, the dominance of the vertically funded HIV programme and the poor standards of equipment in clinics.
Trial registration number ISRCTN12128227.
- cluster randomised trial
- South Africa
- lay health workers
- chronic care
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Handling editor Valery Ridde
Contributors JG, MT: conceptualisation, overall oversight of the research, interpretation and analysis of data, drafting and revising the manuscript, and approval of final version. TC, SE, EM: interpretation and analysis of data, contributed to the drafting of the manuscript and approval of final version. FXFGO, CK: oversight of data collection, interpretation and analysis of data, contributed to the drafting of the manuscript and approval of final version. FL: management of data collection and implementation of research, interpretation and analysis of data, contributed to the drafting of the manuscript and approval of final version.
Funding The Nkateko study was funded by the UK Medical Research Council under the Global Alliance for Chronic Diseases (GACD) Programme.
Competing interests None declared.
Patient consent Obtained.
Ethics approval University of the Witwatersrand Human Research Ethics Committee (Medical), the University of Warwick Biomedical and Scientific Research Ethics Committee, and the Mpumalanga’s Provincial Research and Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The Stata dataset containing the baseline and end of intervention surveys are available in the Warwick Research Archive Portal (WRAP) repository,
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