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Study finds front line health workers can drive effective control of blood pressure in the rural communities in Bangladesh

Dhaka, Bangladesh, 20 February, 2020 – A multi country research has found promising results in controlling high blood pressure among hypertensive patients through a low-cost health intervention carried out by community health workers in rural settings in South Asia.

The COBRA-BPS trial, co-conducted by icddr,b, Aga Khan University, Pakistan, the University of Kelanyia, Sri Lanka, and coordinated by Duke-National University of Singapore reveals that regular home visits by community healthcare workers to monitor patients’ blood pressure (BP)  along with lifestyle coaching to them could effectively control high blood pressure. The findings of the tri-nation study are published in the prestigious New England Journal of Medicine today.

The multi-country Control of Blood Pressure and Risk Attenuation – Bangladesh, Pakistan, Sri Lanka (COBRA-BPS) study is a cluster randomised trial that evaluated the effectiveness of the multi-component intervention among 2,550 individuals with hypertension living in 30 rural communities in Bangladesh, Pakistan and Sri Lanka between 2016 and 2019.

In Bangladesh the trial was implemented by icddr,b in Munshiganj and Tangail districts among 895 hypertensive individuals  in close collaborations with the NCD Control Programme, DGHS, MoHFW. In the COBRA intervention areas six Health Assistants (HAs) measured blood pressure of 447 study patients at homes using a digital blood pressure machine and provided education for promotion of lifestyle. The HAs referred patients with uncontrolled blood pressure to selected sub district hospital where doctors treated those patients following a treatment protocol and mobilized supplies of anti-hypertensive drugs for the patients.

Dr Aliya Naheed, study’s principal investigator in Bangladesh and the country lead, said, “It was quite satisfying to observe that the hypertensive individuals who received COBRA care had at least 5mm Hg (millimetres of mercury) reduction in their systolic blood pressure in a year that  sustained up to two years. Overall deaths due to heart attack or stroke was lower  in patients receiving intervention suggesting that COBRA intervention can be a potential solution for controlling blood pressure and preventing  deaths from heart attack and stroke the leading causes of premature deaths  in Bangladesh”.

Professor Dr AHM  Enayet Hussain, Director General of Medical Education, and Chair of the COBRA Advisory Committee in Bangladesh commented that “COBRA intervention helped us to identify a large bulk of  patients suffering from hypertension in rural areas, women in particular,  and provide high quality treatment. We have taken into account the learning of COBRA for prevention and control of non-communicable diseases in Bangladesh”

Professor Tazeen H. Jafar, lead investigator from the Health Services and Systems Research Programme at Duke-NUS Medical School, Singapore, says “Community health workers are an integral part of the primary care infrastructure for the successful door to door delivery of maternal and child healthcare in South Asia – as well as China, Mexico, and Africa,” Prof Jafar added. “Our findings show that community health workers can have an equally important role in managing hypertension.”

COBRA-BPS strategy is a service model introduced on top of the existing services provided from the government rural primary healthcare facilities, and its success has demonstrated a potential pathway of quality of services for hypertension and other noncommunicable diseases in Bangladesh. Data suggests that programme delivery cost for scaling up the COBRA intervention in Bangladesh would be only 0.60 US dollar or equivalent to ~51.00 Taka per patient annually.

Dr. John David Clemens, iccdr,b’s Executive Director and Co-country lead in Bangladesh, said, “The implemented strategies in the COBRA-BPS trial have the potential to offer sustainable and low cost solutions for effective blood pressure lowering that can be integrated in the public healthcare systems in Bangladesh and other South Asian countries, and could save thousands of lives.”

This is the first multi-country trial of its kind that sets a credible example of South-South research collaboration. While there are differences in the health systems and some population characteristics in the countries involved, BP control rates are uniformly poor in all of them. Nonetheless, similar results were achieved in all three countries with COBRA intervention suggesting that the intervention has validity across South Asian settings.

"We look forward to obtaining all out support from the government for scaling up this low cost strategy for effective control of blood pressure in rural areas in Bangladesh.” Dr Aliya Naheed further added.

The study is funded by the Joint Global Health Trials scheme, which includes the Medical Research Council, the UK Department for International Development (DFID), the National Institute for Health Research (NIHR) and the Wellcome Trust. The COBRA-BPS study is led by Prof Jafar and her team at Duke-NUS Medical School.


Access to the article: Jafar TH, Gandhi M, de Silva AH, Jehan I, Naheed A, Finkelstein EA, Turner E, et al (2020). A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med; 382: 717-26. DOI:10.1056/NEJMoa1911965.

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