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Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa
  1. Jane Goudge1,
  2. Tobias Chirwa2,
  3. Sandra Eldridge3,
  4. Francesc Xavier F Gómez-Olivé4,
  5. Chodziwadziwa Kabudula4,
  6. Felix Limbani1,
  7. Eustasius Musenge6,
  8. Margaret Thorogood2,5
  1. 1 Centre for Health Policy, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  2. 2 Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  3. 3 Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  4. 4 MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  5. 6 Division of Epidemiology and Biostatistics, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
  6. 5 Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
  1. Correspondence to Professor Jane Goudge; Jane.goudge{at}gmail.com

Abstract

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
  • hypertension

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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Footnotes

  • 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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