title: A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol Development of a Smartphone‐Enabled Hypertension and Diabetes Mellitus Management Package to Facilitate Evidence‐Based Care Delivery in Primary Healthcare Facilities in India: The mPower Heart Project Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial. Effects of a nurse-led transitional care program on clinical outcomes, health-related knowledge, physical and mental health status among Chinese patients with coronary artery disease: A randomized controlled trial. Lifestyle interventions for hypertension treatment among Iranian women in primary health-care settings: Results of a randomized controlled trial Community health worker-based intervention for adherence to drugs and lifestyle change after acute coronary syndrome: a multicentre, open, randomised controlled trial. Short-term pilot feasibility study of a nurse-led intervention to improve blood pressure control after stroke in Nigeria Effect of a Community Health Worker–Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa Effect of pharmaceutical care on clinical outcomes of outpatients with type 2 diabetes mellitus Efficacy of an education course delivered to community health workers in diabetes control: A randomized clinical trial Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource-limited setting in South Africa: a randomised controlled trial. A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala The Nigerian antihypertensive adherence trial: a community-based randomized trial Pharmacist Involvement in Primary Care Improves Hypertensive Patient Clinical Outcomes A community programme to reduce salt intake and blood pressure in Ghana [ISRCTN88789643] The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. The impact of a disease management program (COACH) on the attainment of better cardiovascular risk control in dyslipidaemic patients at primary care centres (The DISSEMINATE Study): a randomised controlled trial Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana Economic analysis of a pragmatic randomised trial of home visits by a nurse to elderly people with hypertension in Mexico. The effect of community-based health management on the health of the elderly: a randomized controlled trial from China Lifestyle interventions reduce cardiovascular risk in patients with coronary artery disease: A randomized clinical trial Improved retention rates with low-cost interventions in hypertension and diabetes management in a rural African environment of nurse-led care: a cluster-randomised trial. Examination of a Nurse-led Community-based Education and Coaching Intervention for Coronary Heart Disease High-risk Individuals in China. Development and evaluation of a nurse-led hypertension management model in a community: a pilot randomized controlled trial. Effectiveness of a Multicomponent Quality Improvement Strategy to Improve Achievement of Diabetes Care Goals: A Randomized, Controlled Trial. Evaluation of the effect of motivational interviewing counselling on hypertension care. A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. Randomized Controlled Trial on Lifestyle Modification in Hypertensive Patients Cardiovascular disease risk management in a primary health care setting of north India. Beneficial effects of short-term nutritional counselling at the primary health-care level among Brazilian adults. Translational research for Diabetes Self-Management in Sri Lanka: A randomized controlled trial. Randomized controlled trial of clinical pharmacy management of patients with type 2 diabetes in an outpatient diabetes clinic in Jordan. Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka feasibility trial results Effect of a Nurse-Led Diabetes Self-Management Education Program on Glycosylated Hemoglobin among Adults with Type 2 Diabetes Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial Phone-based intervention for blood pressure control among Ghanaian stroke survivors: A pilot randomized controlled trial Cost-Effectiveness of a Comprehensive Approach for Hypertension Control in Low-Income Settings in Argentina: Trial-Based Analysis of the Hypertension Control Program in Argentina. Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial. The effect of patient education and home monitoring on medication compliance, hypertension management, healthy lifestyle behaviours and BMI in a primary health care setting. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015 Cost-effectiveness of a diabetes group education program delivered by health promoters with a guiding style in underserved communities in Cape Town, South Africa. A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India
abstract: Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Background The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide . The mPower Heart Project aim ed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task‐sharing with the use of a mobile phone – based clinical decision support system at Community Health Centers in Himachal Pradesh , India . Methods and Results The development of the intervention and mobile phone – based clinical decision support system was carried out using mixed methods in five Community Health Centers . The intervention was subsequently evaluated using pre – post evaluation design . During intervention , a nurse care coordinator screened , examined , and entered patient parameters into mobile phone – based clinical decision support system to generate a prescription , which was vetted by a physician . The change in systolic blood pressure , diastolic blood pressure , and fasting plasma glucose ( FPG ) over 18 months of intervention was quantified using generalized estimating equations models . During intervention , 6797 participants were enrolled . Six thous and sixteen participants had hypertension ( mean systolic blood pressure : 146.1 mm Hg , 95 % CI : 145.7 , 146.5 ; diastolic blood pressure : 89.52 mm Hg , 95 % CI : 89.33 , 89.72 ) , of which 3152 ( 52 % ) subjects were newly detected . Similarly , 1516 participants had diabetes mellitus ( mean FPG : 177.9 mg/dL , 95 % CI : 175.8 , 180.0 ) , of which 450 ( 30 % ) subjects were newly detected . The changes in systolic blood pressure , diastolic blood pressure , and FPG observed at 18 months of follow‐up were −14.6 mm Hg ( 95 % CI : −15.3 , −13.8 ) , −7.6 mm Hg ( CI : −8.0 , −7.2 ) , and −50.0 mg/dL ( 95 % CI : −54.6 , −45.5 ) , respectively , and were statistically significant even after adjusting for age , sex , and Community Health Center . Conclusions A nurse‐facilitated , mobile phone – based clinical decision support system‐enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale‐up in re source poor setting s. Clinical Trial Registration URL : https://www . clinical trials.gov . Unique identifiers : NCT01794052 . Clinical Trial Registry — India : CTRI/2013/02/003412 OBJECTIVE To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-re source setting s. METHODS Two geographically distant regions in two countries ( China and Nigeria ) were selected and 10 pairs of primary care facilities in each region were r and omly selected and matched . Regions were then r and omly assigned to a control group , which received usual care , or to an intervention group , which applied the cardiovascular risk management package . Each facility enrolled 60 consecutive patients with hypertension . Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event , according to a st and ardized treatment algorithm . Systolic blood pressure change from baseline to 12 months was the primary outcome measure . FINDINGS The study included 2397 patients with baseline hypertension : 1191 in 20 intervention facilities and 1206 in 20 control facilities .  Systolic and diastolic blood pressure decreased more in intervention patients than in controls . However , at 12 months more than half of patients still had uncontrolled hypertension ( systolic blood pressure > 140 mmHg and /or diastolic blood pressure > 90 mmHg ) . Behavioural risk factors had improved among intervention patients in Nigeria but not in China . Only about 2 % of hypertensive patients required referral to the next level of care . CONCLUSION Even in low-re source setting s , hypertensive patients can be effectively assessed and managed in primary care facilities BACKGROUND Coronary artery disease is a major cause of morbidity and mortality among adults worldwide , including China . After a hospital stay , transitional care could help to ensure improved patient care and outcomes , and reduce Medicare costs . Nevertheless , the results of the existing transitional care are not always satisfactory and our knowledge of how to perform effective transitional care for patients with coronary artery disease is limited in mainl and China . OBJECTIVES To examine the effectiveness of a nurse-led transitional care program on clinical outcomes , health-related knowledge , and physical and mental health status among Chinese patients with coronary artery disease . DESIGN R and omized controlled trial . METHODS The Omaha system and Pender 's health promoting model were employed in planning and implementing this nurse-led transitional care program . The sample was comprised of 199 Chinese patients with coronary artery disease . The experimental group ( n=100  ) received nurse-led transitional care intervention in addition to routine care . The nurse-led transitional care intervention included a structured assessment and health education , followed by 7 months of individual teaching and coaching ( home visits , telephone follow-up and group activity ) . The  control group ( n=99 ) received a comparable length routine care and follow-up contacts . Evaluations were conducted at baseline and completion of the interventions using the perceived knowledge scale for coronary heart disease , the medical outcomes study 36-item short-form health survey and clinical measures ( blood pressure , blood glucose , lipids , body mass index ) . Data were collected between March and October 2014 . RESULTS Compared with the control group , participants in the experimental group showed significant better clinical outcomes ( systolic blood pressure , t=5.762 , P=0.000 ; diastolic blood pressure , t=4.250 , P=0.000 ; fasting blood glucose , t=2.249 , P=0.027 ; total cholesterol , t=4.362 , P=0.000 ; triglyceride , t=3.147 , P=0.002 ; low density lipoprotein cholesterol , t=2.399 , P=0.018 ; and body mass index , t=3.166 , P=0.002 ) , higher knowledge scores for coronary artery disease ( total knowledge score , t=-7.099 , P=0.000 ) , better physical health status ( t=-2.503 , P=0.014 ) and mental health status ( t=-2.950 , P=0.004 ) . CONCLUSIONS This study provides evidence for the value of a  nurse-led transitional care program  using both the Omaha system and Pender 's health promoting model as its theoretical framework . The structured interventions in this nurse-led transitional care program facilitate the use of this program in other setting Background : Lifestyle factors such as weight , salt intake , and physical activity have shown to be important in treating hypertension . The object of this study was to describe feasibility and to assess the effectiveness of a multicomponent lifestyle intervention on high blood pressure ( BP ) of Iranian women . Material s and Methods : This r and omized controlled trial was conducted in four health centers by recruiting 161 women aged 35 - 65 years with high BP and r and omizing them to a 4-week lifestyle modification ( n = 80 ) or control group ( n = 81 ) . BP level and other health behavioral factors were assessed before and after the 4-week intervention and also after 6 months . Results : The mean systolic BP changed from 158.8 ( ±8.1 ) mmHg to 153.2 ( ±6.4 ) mmHg during 4-week and to 145.5 ( ±4.6 ) ) mmHg after 6 months in the intervention group ( P < 0.001 ) . There was a significant difference between two groups of study after 4-week mean = 5.6 ( confidence interval [ CI ] = 5.1 - 6.6 ) and 6 months follow mean ( CI = 12.3 - 14.6).(P < 0.001 ) A significant correlation was detected between systolic BP ( SBP ) and diastolic BP ( DBP ) with weight , body mass index , waist circumference , salt intake , and physical activity level ( P < 0.001 ) . Stepwise regression analyses indicated that the weight , dietary salt intake , and physical activity level were significant predictors of SBP and DBP . Conclusion : The results of this study suggest that lifestyle modification program is associated with improvements in BP level in Iranian women BACKGROUND Adherence to drugs and healthy lifestyles is low after acute coronary syndrome . We assessed whether trained community health workers could improve adherence to drugs , lifestyle changes , and clinical risk markers in patients with acute coronary syndrome in India . METHODS In this study done at 14 hospitals in India we r and omly assigned ( 1:1 ) patients with acute coronary syndrome 1 or 2 days before discharge from hospital to a community health worker-based intervention group or a st and ard care group . Patients were r and omly assigned with a telephone r and omisation service . In the intervention group , during four in-hospital and two home visits , community health workers used unstructured discussion s , visual methods , and patient diaries to educate patients on healthy lifestyle and drugs , and measures to enhance adherence . The primary outcome was adherence to proven secondary prevention drugs ( antiplatelet drugs , β blockers , angiotensin-converting enzyme inhibitors or angiotensin receptor blockers , and statins )  estimated using a Composite Medication Adherence Scale at 1 year . The secondary outcomes were difference in lifestyle factors ( diet , exercise , and tobacco and alcohol use ) , and clinical risk markers ( blood pressure , bodyweight , BMI , heart rate , and lipids ) . All analyses were by intention to treat . This trial is registered with the Clinical Trial Registry of India , number REF/2013/03/004737 , and Clinical Trials.gov , number NCT01207700 . RESULTS Between Aug 23 , 2011 , and June 25 , 2012 , 806 participants were r and omly assigned ( 405 to a community health worker-based intervention group and 401 to a st and ard care group ) . At 1 year , 40 patients had died and 15 had discontinued or been lost to follow-up , so 750 ( 93 % ) were included in the analyses ( 375 in each group ) . Secondary prevention drugs prescribed at discharge were 98 % ( 786/803 ) for any antiplatelet drug , 79 % ( 638/803 ) for dual antiplatelet drugs , 69 % ( 555/803 ) for β blockers , 69 % ( 552/803 ) for angiotensin-converting enzyme inhibitors and angiotensin receptor blockers , and 95 % ( 762/803 ) for statins  . At one year , overall adherence ( ≥80 % ) to prescribed evidence -based drugs was higher in the intervention group than in the control group ( 97 % vs 92 % , odds ratio [ OR ] 2·62 , 95 % CI 1·32 - 5·19 ; p=0·006 ) . For individual drugs , we recorded significant differences for angiotensin-converting enzyme inhibitors and angiotensin receptor blockers ( 97 % [ 233/240 ] in the intervention group vs 93 % [ 223/240 ] in the control group ; p=0·036 ) and statins ( 97 % [ 346/356 ] vs 93 % [ 321/345 ] ; p=0·011 ) . The intervention group had significantly greater adherence to smoking cessation  ( 85 % [ 110/129 ] vs 52 % [ 71/138 ] , OR 5·46 , 95 % CI 3·03 - 9·86 ; p<0·0001 ) , regular physical activity ( 89 % [ 333/375 ] vs 60 % [ 226/375 ] , OR 5·23 , 95 % CI 3·57 - 7·66 ; p<0·0001 ) , and healthy diet  ( score 5·0 vs 3·0 , OR 2·47 , 95 % CI 1·88 - 3·25 ; p<0·0001 ) . More patients in the intervention group had stopped alcohol use at 1 year ( 87 % [ 64/74 ] vs 46 % [ 46/67 ] , OR 2·92 , 95 % CI 1·26 - 6·79 ; p = 0·010 ) . At 1 year , the mean systolic blood pressure ( 124·4 mm Hg [ SD 13·5 ] vs 128·0 mm Hg [ 15·9 ] ; p=0·002 ) , weight ( 65·0 kg [ 11·0 ] vs 66·5 kg [ 11·5 ] ; p<0·0001 ) , cholesterol ( 157·0 [ 40·2 ] vs 166·9 [ 48·4 ] ; p=0·184 ) , LDL ( 81·0 [ 20·6 ] vs 87·3 [ 29·9 ] ; p=0·191 ) , HDL ( 42·0 [ 11·4 ] vs 38·2 [ 6·5 ] ; p=0·042 ) , and BMI ( 24·4 kg/m(2 ) [ SD 3·7 ] vs 25·0 kg/m(2 ) [ 3·8 ] ; p<0·0001 ) were lower in the intervention group than in the control group . However , we noted no significant difference in diastolic blood pressure and heart rate . INTERPRETATION A community health worker-based personalised intervention strategy in patients with acute coronary syndrome  improved adherence to evidence -based drugs and healthy lifestyles , and result ed in an improvement in clinical risk markers . Integration of trained community health workers can improve secondary prevention in coronary artery disease . FUNDING US National Heart , Lung , and Blood Institute ( NHLBI ) , National Institutes of Health , Department of Health and Human Services , and the UnitedHealth group , USA BACKGROUND Given the paucity of neurologists in Sub-Saharan Africa ( SSA ) , task-shifting post-stroke care to nurses could be a viable avenue for enhancing post-stroke outcomes . This pilot study assessed the feasibility and short-term impact of a nurse-led intervention to manage blood pressure ( BP ) control in recent stroke survivors in Nigeria . METHODS A r and omized pilot trial allocated patients within one month of an index stroke from two participating hospitals in Nigeria to either nurse-led group clinic or st and ard care for 14days  . Key study endpoints were successful execution of the protocol , subject retention , and short-term BP effects . RESULTS There were no significant differences between the intervention ( n=17 ) and control ( n=18 ) groups at baseline . At the post-intervention clinic , patient retention rate was 100 % . In the intervention group , both the systolic and diastolic BPs measured at home were lower than the clinic BPs post-intervention ( 127±12.88/78.13±19.26mmHg versus 137.50±23.05/84.06±9.67mmHg ; p=0.05 ) . However , there was no significant change in clinic blood pressure ( BP ) recordings in both the intervention and control groups . CONCLUSION It is possible to initiate a nurse-led group clinic intervention to address BP management  among stroke survivors in SSA with good early retention of participants . A larger and longer-term trial is being planned Importance Despite extensive knowledge of hypertension treatment , the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries . Objective To test whether a community health worker – led multicomponent intervention would improve blood pressure ( BP ) control among low-income patients with hypertension . Design , Setting , and Participants A cluster r and omized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina . A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016 . Interventions Nine centers ( 743 patients ) were r and omized to the multicomponent intervention , which included a community health worker – led home intervention ( health coaching , home BP monitoring , and BP audit and feedback ) , a physician intervention , and a text-messaging intervention over 18 months .  Nine centers ( 689 patients ) were r and omized to usual care . Main Outcomes and Measures The co primary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension . Secondary outcomes included the proportion of patients with controlled hypertension ( BP < 140/90 mm Hg ) . Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a st and ard protocol , the means of which were used for analyses . Results Of 1432 participants ( mean age , 55.8 years [ SD , 13.3 ] ; 772 women [ 53.0 % ] ) , 1357 ( 94.8 % ) completed the trial . Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group ; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care  group . Systolic BP reduction from baseline to month 18 was 19.3 mm Hg ( 95 % CI , 17.9 - 20.8 mm Hg ) for the intervention group and 12.7 mm Hg ( 95 % CI , 11.3 - 14.2 mm Hg ) for the usual care group ; the difference in the reduction was 6.6 mm Hg ( 95 % CI , 4.6 - 8.6 ; P < .001 ) . Diastolic BP decreased by 12.2 mm Hg ( 95 % CI , 11.2 - 13.2 mm Hg ) in the intervention group and 6.9 mm Hg ( 95 % CI , 5.9 - 7.8 mm Hg ) in the control group ; the difference in the reduction was 5.4 mm Hg ( 95 % CI , 4.0 - 6.8 mm Hg ; P < .001 ) . The proportion of patients with controlled hypertension increased from 17.0 % at baseline to 72.9 % at 18 months in the intervention group and from 17.6 % to 52.2 % in the usual care group ; the difference in the increase was 20.6 % ( 95 % CI , 15.4%-25.9 % ; P < .001 ) . No adverse events were reported . Conclusions and Relevance Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker – led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months . Further research is needed to assess generalizability and cost-effectiveness of this intervention and to underst and which components may have contributed most to the outcome . Trial Registration clinical trials.gov Identifier : 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 r and omised 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 st and ards of equipment in clinics . Trial registration number IS RCT N12128227 Background In the People ’s Republic of China , out patients have limited time with their physicians . Thus , compared to in patients , out patients have lower medication adherence and are less knowledgeable about their disease . Objective The objective of this study was to evaluate the effect of pharmaceutical care on clinical outcomes of out patients with type 2 diabetes mellitus ( T2DM ) . Patients and methods A r and omized , controlled , prospect i ve clinical trial was conducted recruiting a total of 240 T2DM out patients from Zhongda Hospital , Southeast University . The control group ( CG ) received only common care from medical staff , whereas the inter vention group ( IG ) received extra pharmaceutical care from clinical pharmacists . Biochemical data such as  blood pressure ( BP ) , fasting blood glucose ( FBG ) , glycosylated hemoglobin A1 ( HbA1c ) , and blood lipid  were collected before and after 6-month intervention . The primary end points in this study were FBG and HbA1c . Results After the intervention , most of the baseline clinical outcomes of the patients in IG significantly improved , while only body mass index , diastolic BP , low-density lipoprotein cholesterol , and total cholesterol ( TC ) improved significantly in patients in the CG . Compared to CG , in IG , there were significant improvements in FBG , HbA1c , TC , the target attainment rates of HbA1c , and BP . Conclusion Pharmaceutical care provided by clinical pharmacists could improve the control of diabetes of out patients , and clinical pharmacists could play an important role in diabetes management Background Community health workers are community members who provide education and care for patients for a broad range of health issues , including diabetes mellitus . However , few community health workers are trained for diabetes education and little is known about the effectiveness of their interventions . The aim of this study is to evaluate the effect of a diabetes education program delivered to community health workers in improving the metabolic control of patients with type 2 diabetes mellitus . Methods Eight community health workers , providing care for 118 patients , were r and omized in two groups to receive a 1-month diabetes education program ( intervention , patients n = 62 ) or an education course in other health issues ( control , patients n = 56 ) . Each community health worker was responsible for transmitting the acquired knowledge to patients . Primary outcome was changed in HbA1C 3 months after the intervention . Results : participants Mean age was 61 ± 11 years , 35 % were men and 62 % were whites . HbA1c levels reduced in both groups ( intervention : 9.1 ± 2.2 vs. 7.9 ± 1.9 % ; control : 9.1 ± 2.1 vs. 8.4 ± 2.5 % , p < 0.001 ) , but no statistically significant differences were observed between groups ( p between groups = 0.13 ) . Total cholesterol ( intervention : 192 ± 43 vs. 182 ± 39 mg/dl ; control : 197 ± 44 vs. 191 ± 45 mg/dl , p between groups = 0.035 ) and triglycerides ( intervention : 158 [ 106–218 ] vs. 135 [ 106–215 ] ; control : 128 [ 100–215 ] mg/dl vs. 146 [ 102–203 ] mg/dl , p between groups = 0.03 ) reduced overtime only in intervention group . Conclusions In this study , a significant decrease in HbA1c was observed during patients ' follow-up , but it was similar in intervention and control groups . The diabetes mellitus education course delivered to community health workers was able to improve patients ’ lipid profile INTRODUCTION Elevated blood pressure greatly contributes to cardiovascular deaths in low-income and middle-income countries . We aim ed to investigate the effectiveness of a population -level intervention led by existing community health workers in reducing the burden of hypertension in a low-income population . METHODS We did a community-based , open-label , two-group , cluster-r and omised controlled trial in Nepal . Using computer-generated codes , we r and omly assigned ( 1:1 ) 14 clusters to a lifestyle intervention led by female community health volunteers ( FCHVs ) or usual care ( control group )  . In the intervention group , 43 FCHVs provided  home visits  every 4 months for lifestyle counselling and blood pressure monitoring .  Eligible participants had been involved in a previous population -based survey , were aged 25 - 65 years , did not have plans to migrate outside the study area , and were not severely ill or pregnant . The primary outcome was mean systolic blood pressure at 1 year . We included all participants who remained in the trial at 1 year in the primary analysis . This trial is registered with Clinical Trials.gov , number NCT02428075 . FINDINGS Between April 1 , 2015 , and Dec 31 , 2015 , we recruited 1638 participants ( 939 assigned to intervention ; 699 assigned to control ) . At 1 year , 855 participants remained in the intervention group ( 425 were normotensive , 175 were prehypertensive , and 255 had hypertension ) and 613 remained in the control group ( 305 were normotensive , 128 were prehypertensive , and 180 had hypertension ) . The mean systolic blood pressure at 1 year was significantly lower in the intervention group than in the control group for all cohorts : the difference was -2·28 mm Hg ( 95 % CI -3·77 to -0·79 , p=0·003 ) for participants who were normotensive , -3·08 mm Hg ( -5·58 to -0·59 , p=0·015 ) for participants who were prehypertensive , and -4·90 mm Hg ( -7·78 to -2·00 , p=0·001 ) for participants who were hypertensive . INTERPRETATION A simple , FCHV-led lifestyle intervention coupled with monitoring of blood pressure is effective for reduction of blood pressure in individuals with hypertension and ameliorates age-related increases in blood pressure in adults without hypertension in the general population of Nepal . FUNDING Aarhus University , Jayanti Memorial Trust Background In many low-income countries , care for patients with non-communicable diseases ( NCDs ) and mental health conditions is provided by nurses . The benefits of nurse substitution and supplementation in NCD care in high-income setting s are well recognised , but evidence from low- and middle-income countries is limited . Primary Care 101 ( PC101 ) is a programme design ed to support and exp and nurses ’ role in NCD care , comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions . We evaluated the effect of the programme on primary care nurses ’ capacity to manage NCDs . Methods and Findings In a cluster r and omised controlled trial design , 38 public sector primary care clinics in the Western Cape Province , South Africa , were r and omised . Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an exp and ed range of drugs for several NCDs . Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa ( PALSA PLUS ) management tool and usual training . Patients attending these clinics with one or more of hypertension ( 3,227 ) , diabetes ( 1,842 ) , chronic respiratory disease ( 1,157 ) or who screened positive for depression ( 2,466 ) , totalling 4,393 patients , were enrolled between 28 March 2011 and 10 November 2011 . Primary outcomes were treatment intensification in the hypertension , diabetes , and chronic respiratory disease cohorts , defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo , and case detection in the depression cohort . Primary outcome data were analysed for 2,110 ( 97 % ) intervention and 2,170 ( 97 % ) control group patients . Treatment intensification rates in intervention clinics were not superior to those in the control clinics ( hypertension : 44 % in the intervention group versus 40 % in the control group , risk ratio [ RR ] 1.08 [ 95 % CI 0.94 to 1.24 ; p = 0.252 ] ; diabetes : 57 % versus 50 % , RR 1.10 [ 0.97 to 1.24 ; p = 0.126 ] ; chronic respiratory disease : 14 % versus 12 % , RR 1.08 [ 0.75 to 1.55 ; p = 0.674 ] ) , nor was case detection of depression ( 18 % versus 24 % , RR 0.76 [ 0.53 to 1.10 ; p = 0.142 ] ) . No adverse effects of the nurses ’ exp and ed scope of practice were observed . Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts , limited data on uptake of PC101 by users , reliance on process outcomes , and insufficient re sources to measure important health outcomes , such as HbA1c , at follow-up . Conclusions Educational outreach to primary care nurses to train them in the use of a management tool involving an exp and ed role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases . This notwithst and ing , the intervention , with adjustments to improve its effectiveness , has been adopted for implementation in primary care clinics throughout South Africa . Trial Registration The trial is registered with Current Controlled Trials ( IS RCT N20283604 OBJECTIVE To evaluate the effect of a participant-customised nutrition education programme on glycated Hb ( HbA(1c ) ) , blood lipids , blood pressure , BMI and dietary behaviours in patients with type 2 diabetes mellitus . DESIGN A r and omised controlled trial . The control group ( n 41 ) received education material s. The intervention group ( n 41 ) received the same education material s and participated in eight weekly ( 2 - 2·5 h ) group nutrition education sessions and follow-up sessions . Outcomes were assessed at 6 and 12 months . An intention-to-treat analysis was conducted . ANCOVA compared the groups ( adjustments for baseline values , age , sex and clinic ) . SETTING Two community health centres , Moretele sub-district ( North West Province ) , South Africa . SUBJECTS Adults ( aged 40 - 70 years ) with type 2 diabetes , HbA(1c ) ≥8 % .  RESULTS Differences in HbA(1c ) ( primary outcome ) were -0·64 % ( P=0·15 ) at 6 months and -0·63 % ( P=0·16 ) at 12 months in favour of the intervention group . Starchy-food intake was significantly lower in the intervention group , 9·3 v. 10·8 servings/d ( P=0·005 ) at 6 months and 9·9 v. 11·9 servings/d ( P=0·017 ) at 12 months . Median energy intake was significantly lower in the intervention group at 12 months ( 5988 v. 6946 kJ/d , P=0·017 ) . No significant group differences in BMI , lipid profile , blood pressure and intakes of macronutrients , vegetables and fruits were observed . CONCLUSIONS Nutrition education was not efficacious on HbA(1c ) ; however , it improved specific dietary behaviours . Group education and h and s-on activities appeared to contribute to the improvement . Optimal goal setting and self-efficacy training/ assessment could benefit future nutrition education programmes for people with type 2 diabetes mellitus in re source -limited setting Introduction Diabetes self-management education ( DSME ) is a fundamental element of type 2 diabetes care . Although 75 % of adults with diabetes worldwide live in low-income and middle-income countries ( LMICs ) , limited DSME research has been conducted in LMICs . The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala . Methods We conducted a prospect i ve study of a DSME intervention using a quasi-experimental , single-group pretest – posttest design . We enrolled 90 participants in the intervention , which consisted of 6 home visits ( May 2014–July 2016 ) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan population s. Primary outcomes were changes in mean hemoglobin A1c ( HbA1c ) and mean systolic and diastolic blood pressure at baseline and at 12 months . Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion . Results HbA1c decreased significantly from baseline to 12 months ( absolute mean change , −1.5 % ; 95 % confidence interval [ CI ] , −1.9 % to −1.0 % ; P < .001 ) . Systolic blood pressure also improved significantly at 12 months ( −6.2 mm Hg ; 95 % CI , −10.1 to −2.2 mm Hg ; P = .002 ) ; changes in diastolic blood pressure were not significant ( −1.6 mm Hg ; 95 % CI , −3.9 to −0.7 mm Hg ; P = .17 ) . We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion . Conclusion DSME interventions can be successfully delivered in a setting with an underre source d health system , high poverty rate , and unique cultural characteristics like Mayan Guatemala . Our findings point to the need for more DSME research in re source -limited setting s globally Background : Research in industrialized countries has demonstrated that a key factor limiting the control of hypertension is poor patient adherence and that the most successful interventions for long-term adherence employ multiple strategies . Very little data exist on this question in low-income countries , wherein medication-taking behavior may be less well developed . Method : We conducted a treatment adherence trial of 544 patients [ mean age ∼63 years , mean blood pressure ( BP ) ∼168/92 mmHg ] with previously untreated hypertension in urban and rural Nigeria . Eligible participants were r and omized to one of two arms : clinic management only , or clinic management and home visits . Both interventions included three elements : a community based , nurse-led treatment program with physician backup ; facilitation of clinic visits and health education ; and the use of diuretics and a & bgr ; blocker as needed . After initial diagnosis , the management protocol was implemented by a nurse with physician backup . Participants were evaluated monthly for 6 months . Results : Medication adherence was assessed with pill count and urine testing . Drop-out rates , by treatment group , ranged from 12 to 28 % . Among participants who completed the 6-month trial , overall adherence was high ( ∼77 % of participants took > 98 % of prescribed pills ) . Adherence did not differ by treatment arm , but was better at the rural than the urban site and among those with higher baseline BP . Hypertension control ( BP < 140/90 mmHg ) was achieved in approximately 66 % of participants at 6 months . Conclusion : This community-based intervention confirms relatively modest default rates compared with industrialized societies , and suggests that medication adherence can be high in developing world setting s in clinic attenders BACKGROUND The practice of pharmaceutical care in primary care setting s in Thail and is currently not generally accepted . OBJECTIVE To evaluate the effect of pharmacist involvement in treatment with hypertensive patients in primary care setting s. METHODS The treatment objective was to stabilize the blood pressure ( BP ) of hypertensive patients in accordance with the Joint National Committee on Prevention , Detection , Evaluation and Treatment of High Blood Pressure guidelines . Patients were r and omly assigned to a pharmacist-involved group ( treatment ) or a group with no pharmacist involvement ( control ) . Pre- and post-test BPs , tablet counts , lifestyle modifications , and pharmacists ’ recommendations were recorded . The 6-month study was carried out in Mahasarakham University pharmacy and 2 primary care units . Patients were monitored monthly by review ing their medications and supported by providing pharmaceutical care and counseling . RESULTS From a total of 235 patients , the treatment group ( n = 118 ) had a significant reduction in both systolic ( S ) and diastolic ( D ) BP compared with the 117 patients of the control group ( p = 0.037 , 0.027 , respectively ) . The 158 patients ( 76 treatment , 82 control ) with BPs 140/90 mm Hg at the beginning of the study showed significant BP reductions ( p = 0.002 SBP , 0.008 DBP ) . The proportion of 158 patients whose BP became stabilized was higher in the treatment group ( p = 0.017 ) . The treatment group showed significantly better adherence ( p = 0.014 ) and exercise control ( p = 0.012 ) at the end of the study . Physicians accepted 42.72 % of medication modifications and 5.34 % of the suggestions for additional investigations . CONCLUSIONS Hypertensive patients who received pharmacist input  achieved a significantly greater benefit in BP reduction , BP control , and improvement in adherence rate and lifestyle modification Background In Africa hypertension is common and stroke is increasing . Detection , treatment and control of high blood pressure ( BP ) is limited . BP can be lowered by reducing salt intake . In Africa salt is added to the food by the consumer , as processed food is rare . A population -wide approach with programmes based on health education and promotion is thus possible . Methods We carried out a community-based cluster r and omised trial of health promotion in 1,013 participants from 12 villages ( 628 women , 481 rural dwellers ) ; mean age 55 years to reduce salt intake and BP .  Average BP was 125/74 mmHg and urinary sodium ( UNa ) 101 mmol/day . A health promotion intervention was provided over 6 months to all villages . Assessment s were made at 3 and 6 months . Primary end-points were urinary sodium excretion and BP levels . Results There was a significant positive relationship between salt intake and both systolic ( 2.17 mmHg [ 95 % CI 0.44 to 3.91 ] per 50 mmol of UNa per day , p < 0.001 ) and diastolic BP ( 1.10 mmHg [ 0.08 to 1.94 ] , p < 0.001 ) at baseline . At six months the intervention group showed a reduction in systolic ( 2.54 mmHg [ -1.45 to 6.54 ] ) and diastolic ( 3.95 mmHg [ 0.78 to 7.11 ] , p = 0.015 ) BP when compared to control . There was no significant change in UNa . Smaller villages showed greater reductions in UNa than larger villages ( p = 0.042 ) . Irrespective of r and omisation , there was a consistent and significant relationship between change in UNa and change in systolic BP , when adjusted for confounders . A difference in 24-hour UNa of 50 mmol was associated with a lower systolic BP of 2.12 mmHg ( 1.03 to 3.21 ) at 3 months and 1.34 mmHg ( 0.08 to 2.60 ) at 6 months ( both p < 0.001 ) . Conclusion In West Africa the lower the salt intake , the lower the BP . It would appear that a reduction in the average salt intake in the whole community may lead to a small but significant reduction in population systolic BP Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more OBJECTIVE The prevalence of type 2 diabetes , especially in developing countries , has grown over the past decades . We performed a controlled clinical study to determine whether a community-based , group-centered public health intervention addressing nutrition and exercise can ameliorate glycemic control and associated cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica . RESEARCH DESIGN AND METHODS A total of 75 adults with type 2 diabetes , mean age 59 years , were r and omly assigned to the intervention group or the control group . All participants received basic diabetes education . The subjects in the intervention group participated in 11 weekly nutrition classes ( 90 min each session ) . Subjects for whom exercise was deemed safe also participated in triweekly walking groups ( 60 min each session ) . Glycosylated hemoglobin , fasting plasma glucose , total cholesterol , triglycerides , HDL and LDL cholesterol , height , weight , BMI , and blood pressure were measured at baseline and the end of the study ( after 12 weeks ) . RESULTS The intervention group lost 1.0 + /- 2.2 kg compared with a weight gain in the control group of 0.4 + /- 2.3 kg ( P = 0.028 ) . Fasting plasma glucose decreased 19 + /- 55 mg/dl in the intervention group and increased 16 + /- 78 mg/dl in the control group ( P = 0.048 ) . Glycosylated hemoglobin decreased 1.8 + /- 2.3 % in the intervention group and 0.4 + /- 2.3 % in the control group ( P = 0.028 ) . CONCLUSIONS Glycemic control of type 2 diabetic patients can be improved through community-based , group-centered public health interventions addressing nutrition and exercise . This pilot study provides an economically feasible model for programs that aim to improve the health status of people with type 2 diabetes Background To evaluate the efficacy of Counselling and Advisory Care for Health ( COACH ) programme in managing dyslipidaemia among primary care practice s in Malaysia . This open-label , parallel , r and omised controlled trial compared the COACH programme delivered by primary care physicians alone ( PCP arm ) and primary care physicians assisted by nurse educators ( PCP-NE arm ) . Methods This was a multi-centre , open label , r and omised trial of a disease management programme ( COACH ) among dyslipidaemic patients in 21 Malaysia primary care practice s. The participating centres enrolled 297 treatment naïve subjects who had the primary diagnosis of dyslipidaemia ; 149 were r and omised to the COACH programme delivered by primary care physicians assisted by nurse educators ( PCP-NE ) and 148 to care provided by primary care physicians ( PCP ) alone .  The primary efficacy endpoint was the mean percentage change from baseline LDL-C at week 24 between the 2 study arms . Secondary endpoints included mean percentage change from baseline of lipid profile ( TC , LDL-C , HDL-C , TG , TC : HDL ratio ) , Framingham Cardiovascular Health Risk Score and absolute risk change from baseline in blood pressure parameters at week 24 . The study also assessed the sustainability of programme efficacy at week 36 . Results Both study arms demonstrated improvement in LDL-C from baseline . The least squares ( LS ) mean change from baseline LDL-C were −30.09 % and −27.54 % for PCP-NE and PCP respectively . The difference in mean change between groups was 2.55 % ( p=0.288 ) , with a greater change seen in the PCP-NE arm . Similar observations were made between the study groups in relation to total cholesterol change at week 24 . Significant difference in percentage change from baseline of HDL-C were observed between the PCP-NE and PCP groups , 3.01 % , 95 % CI 0.12 - 5.90 , p=0.041 , at week 24 . There was no significant difference in lipid outcomes between 2 study groups at week 36 ( 12 weeks after the programme had ended ) . Conclusion Patients who received coaching and advice from primary care physicians ( with or without the assistance by nurse educators ) showed improvement in LDL-cholesterol . Disease management services delivered by PCP-NE demonstrated a trend towards add-on improvements in cholesterol control compared to care delivered by physicians alone ; however , the improvements were not maintained when the services were withdrawn . Trial registration National Medical Research Registration ( NMRR ) Number : NMRR-08 - 287 - 1442Trial Registration Number ( Clinical Trials.gov Identifier ) : Background Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa . Implementation of evidence -based systems-level strategies targeted at these barriers are lacking . We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage ( HIC ) alone versus a nurse-led task shifting strategy for hypertension control ( TASSH ) plus HIC on systolic blood pressure ( SBP ) reduction among patients with uncontrolled hypertension in Ghana . Methods and findings Using a pragmatic cluster r and omized trial , 32 community health centers within Ghana ’s public healthcare system were r and omly assigned to either HIC alone or TASSH + HIC .  A total of 757 patients with uncontrolled hypertension were recruited between November 28 , 2012 , and June 11 , 2014 , and followed up to October 7 , 2016 . Both intervention groups received health insurance coverage plus scheduled nurse visits , while TASSH + HIC comprised cardiovascular risk assessment , lifestyle counseling , and initiation/titration of antihypertensive medications for 12 months , delivered by trained nurses within the healthcare system . The primary outcome was change in SBP from baseline to 12 months . Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months . Of the 757 patients ( 389 in the HIC group and 368 in the TASSH + HIC group ) , 85 % had 12-month data available ( 60 % women , mean BP 155.9/89.6 mm Hg ) . In intention-to-treat analyses adjusted for clustering , the TASSH + HIC group had a greater SBP reduction ( −20.4 mm Hg ; 95 % CI −25.2 to −15.6 ) than the HIC group ( −16.8 mm Hg ; 95 % CI −19.2 to −15.6 ) , with a statistically significant between-group difference of −3.6 mm Hg ( 95 % CI −6.1 to −0.5 ; p = 0.021 ) . Blood pressure control improved significantly in both groups ( 55.2 % , 95 % CI 50.0 % to 60.3 % , for the TASSH + HIC group versus 49.9 % , 95 % CI 44.9 % to 54.9 % , for the HIC group ) , with a non-significant between-group difference of 5.2 % ( 95 % CI −1.8 % to 12.4 % ; p = 0.29 ) . Lifestyle behaviors did not change appreciably in either group . Twenty-one adverse events were reported ( 9 and 12 in the TASSH + HIC and HIC groups , respectively ) . The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits , if any , of the TASSH + HIC group . Conclusions Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone , among patients with uncontrolled hypertension in Ghana . Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost – benefit analysis . Trial registration Clinical Trials.gov OBJECTIVE To analyse the costs and the effectiveness of an intervention of home visits made by nurses to elderly people versus usual care given by the family medicine units . MATERIAL AND METHODS A sample of 4,777 subjects aged 60 years and over covered by the Mexican Institute of Social Security ( Instituto Mexicano del Seguro Social , IMSS ) were screened . Those with a systolic and /or diastolic blood pressure level higher or equal than 160/90 mm Hg were r and omly allocated to the intervention or control groups . The intervention consisted of visits at home by nurses who gave health and lifestyle advice to the participants . The economic evaluation was considered from a health services and patient perspective . Direct and indirect costs were calculated as incremental . Effectiveness was measured in terms of cost per millimetre of mercury reduced . RESULTS Three hundred and forty five participants were allocated to the intervention group and compared with 338 controls . At the end of the intervention period the difference in the mean change in systolic blood pressure was 3.31 mm Hg ( 95 % CI 6.32 , 0.29 ; p = 0.03 ) comparing with the control group . In diastolic blood pressure the difference was 3.67 ( 95 % CI 5.22 , 2.12 ; p < 0.001 ) . The total cost of the intervention was 101 901.66 pesos . The intervention cost per patient was 34.61 pesos ( US$ 3.78 ) , ( CI 95 % 34.44 , 35.46 ) . The cost-effectiveness ratios was 10.46 pesos ( US$ 1.14 ) for systolic ( CI 95 % 129.31 , 5.51 ) and 9.43 ( US$ 1.03 ) for diastolic ( CI 95 % 19.90 , 2.49 ) . CONCLUSIONS The reduction in blood pressure obtained may well justify the small incremental cost of the intervention Background An aging population poses significant challenges to health care in China .  Health management has been implemented to reduce the costs of care , raise health service utilization , increase health knowledge and improve quality of life . Several studies have tried to verify the effectiveness of health management in achieving these goals worldwide . However , there have been insufficient r and omized control trials ( RCTs ) to draw reliable conclusions . The few small-scale studies conducted in China include mostly the general population rather than the elderly . Our study is design ed to evaluate the impact of community-based health management on the health of the elderly through an RCT in Nanjing , China . Methods Two thous and four hundred participants , aged 60 or older and who gave informed consent , were r and omly allocated 1:1 into management and control groups , the r and omization schedule was concealed from community health service center staff until allocation . Community-based health management was applied in the former while the latter was only given usual care . After 18 months , three categories of variables ( subjective grading health indices , objective health indices and health service utilization ) were measured based on a question naire , clinical monitoring and diagnostic measurements . Differences between the two groups were assessed before and after the intervention and analyzed with t-test , χ2-test , and multiple regression analysis . Results Compared with the control group , the management group demonstrated improvement on the following variables ( P<0.01 ) : health knowledge score , self-evaluated psychological conditions , overall self-evaluated health conditions , diet score , physical activity duration per week , regular blood pressure monitoring , waist-to-hip ratio , systolic blood pressure and fasting blood sugar . The number of outpatient clinic visits did not differ significantly ( P=0.60 ) between the two groups before intervention , while after intervention it was smaller in the management group than in the control group ( P<0.01 ) . However , the number of hospital admissions in the preceding 6 months was not different between the two groups even after intervention ( P=0.36 ) . Multiple regression analysis showed that gender , age , education level , chronic disease status and self-evaluated psychological conditions were important factors affecting health knowledge score , BMI , and waist-to-hip ratio .  Conclusion Community-based health management improved both subjective grading health indices , objective health indices and decreased the number of outpatient clinic visits , demonstrating effectiveness in improving elderly health . Trial registration Background : Nurse-led interventions have proven beneficial to reduce estimated cardiovascular risk . Aim : The purpose of this study was to evaluate the effect of systematic , nurse-led individual lifestyle counseling sessions on the reduction of 10-year cardiovascular risk scores in patients with coronary artery disease ( CAD ) . Methods : This was a r and omized clinical trial of CAD patients treated at a tertiary referral hospital . The intervention group received nurse-led guidance by means of five face-to-face sessions and telephone contact over the course of one year , starting three months after hospital discharge . Exercise and dietary goals were set for each patient and monitored at each session . The control group received st and ard medical advice . Patients were stratified by Framingham risk score and compared at the end of the follow-up period . Results : The final sample comprised 74 patients , 38 in the intervention group and 36 in the control group . Mean age was 58±9 years ; 74 % of patients were male . A 1.7 point ( −13.6 % ) reduction in risk score was recorded in the intervention group , vs a 1.2 point increase in risk score ( + 11 % ) in the control group ( p=0.011 ) . Significant between-group differences were detected for weight ( intervention , 78±14 kg at baseline vs 77±14 kg at study end ; control , 78±15 kg vs 79±15 kg ; p=0.04 ) , systolic blood pressure ( intervention , 136±22 mm Hg vs 124±15 mm Hg ; control , 126±15 mm Hg vs 129±16 mm Hg ; p=0.005 ) , and diastolic blood pressure ( intervention , 82±10 mm Hg vs 77±09 mm Hg ; control , 79±09 mm Hg vs 80±10 mm Hg ; p=0.02 ) . Conclusion : Structured and systematic nurse-led lifestyle counseling effectively reduced cardiovascular risk score OBJECTIVE To compare the effects of low-level facility-based interventions on patient retention rates for cardiovascular ( CV ) disease in an environment of task shifting and nurse-led care in rural health districts in Central Cameroon . METHODS This study is an open-label , three-arm , cluster-r and omised trial in nurse-led facilities . All three groups implemented a treatment contract . The control group ( group 1 ) had no additional intervention , group 2 received the incentive of 1 month of free treatment every forth month of regularly respected visits , and group 3 received reminder letters in case of a missed follow-up visit . The primary outcome was patient retention at 1 year . Secondary outcomes were adherence to follow-up visit schemes and changes in blood pressure ( BP ) and blood glucose levels . Patients ' monthly spending for drugs and transport was calculated retrospectively . RESULTS A total of 33 centres and 221 patients were included . After 1 year , 109 patients ( 49.3 % ) remained in the programme . Retention rates in groups 2 and 3 were 60 % and 65 % , respectively , against 29 % in the control group . The differences between the intervention groups and the control group were significant ( P < 0.001 ) , but differences between the two intervention groups were not ( P = 0.719 ) . There were no significant differences in BP or fasting plasma glucose trends between retained patients in the study groups . Average monthly cost to patients for antihypertensive medication was € 1.1 ± 0.9 and for diabetics € 1.2 ± 1.1 . Transport costs to the centres were on average € 1.1 ± 1.0 for hypertensive patients and € 1.1 ± 1.6 for patients with diabetes . CONCLUSIONS Low-cost interventions suited to an environment of task shifting and nurse-led care and needing minimal additional re sources can significantly improve retention rates in CV disease management in rural Africa . The combination of a treatment contract and reminder letters in case of missed appointments was an effective measure to retain patients in care PURPOSE Early detection and management of coronary heart disease ( CHD ) are embedded into many community health service and primary care practice s in western countries . The Framingham CHD risk score has been used to predict CHD and mortality for nearly 20 years , and it has predicted CHD event risk accurately in multiethnic population s. The aim of this study was to access the effect of a 6-month community-based intervention on CHD risk in individuals at high risk . METHODS A r and omized controlled trial of individuals with a high 10-year CHD risk were recruited from two communities in China . Individuals in the intervention group ( n = 53 ) received a 3-month group education and a 3-month coaching session . Physical examination and self-report question naires were used to collect both pre- and postintervention data on blood pressure , glucose , cholesterol , body mass index , smoking , depression , and health-related quality of life ( HRQoL ) . RESULTS A total of 102 participants ( 85.0 % ) completed the 6-month study . Compared with the usual care group , the intervention group had a 5 mmHg greater reduction in systolic blood pressure ( t = 2.01 , p = .047 ) , larger declines in glucose ( t = -2.49 , p = .015 ) , cholesterol ( t = -2.44 , p = .017 ) , body mass index ( t = -2.58 , p = .011 ) , and depression ( t = -2.05 , p = .043 ) , and better reports of HRQoL ( t = 3.36 , p = .001 ) . No significant group differences in smoking behaviors were reported . CONCLUSION A 6-month  community-based intervention in a CHD high-risk population improved disease-related risk factors , depression , and HRQoL. Results provide preliminary evidence for primary prevention of cardiovascular disease risk in a community high-risk population This study aims to develop a nurse-led hypertension management model in the community setting and pilot it to an experimental trial . A total of 73 recruited participants were r and omly allocated into two groups . The study group received a home visit and 2 - 4 telephone follow-ups from the trained community nurses assisted by nursing student volunteers . The control group received doctor-led hypertension management . Data was collected at recruitment and immediately after the 8-week program . Outcome measures included blood pressure readings , self-care adherence , self-efficacy , quality of life , and patient satisfaction . Participants from the study group led by nurses had significant improvement in self-care adherence , patient satisfaction post-intervention than those from the control group led by doctors . However , there were no statistical significant differences in blood pressure readings , quality of life and self-efficacy between the two groups . The findings show that the nurse-led hypertension management appears to be a promising way to manage hypertensive patients at the community level , particularly when the healthcare system is better integrated BACKGROUND Achievement of diabetes care goals is suboptimal globally . Diabetes-focused quality improvement ( QI ) is effective but remains untested in South Asia . OBJECTIVE To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes . DESIGN Parallel , open-label , pragmatic r and omized , controlled trial . ( Clinical Trials.gov : NCT01212328 ) . SETTING Diabetes clinics in India and Pakistan . PATIENTS 1146 patients ( 575 in the intervention group and 571 in the usual care group ) with type 2 diabetes and poor cardiometabolic profiles ( glycated hemoglobin [ HbA1c ] level ≥8 % plus systolic blood pressure [ BP ] ≥140 mm Hg and /or low-density lipoprotein cholesterol [ LDLc ] level ≥130 mg/dL ) .  INTERVENTION Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records . MEASUREMENTS Proportions achieving HbA1c level less than 7 % plus BP less than 130/80 mm Hg and /or LDLc level less than 100 mg/dL ( primary outcome ) ; mean risk factor reductions , health-related quality of life ( HRQL ) , and treatment satisfaction ( secondary outcomes ) . RESULTS Baseline characteristics were similar between groups . Median diabetes duration was 7.0 years ; 6.8 % and 39.4 % of participants had preexisting cardiovascular and microvascular disease , respectively ; mean HbA1c level was 9.9 % ; mean BP was 143.3/81.7 mm Hg ; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months , a greater percentage of intervention participants achieved the primary outcome ( 18.2 % vs. 8.1 % ; relative risk , 2.24 [ 95 % CI , 1.71 to 2.92 ] ) . Compared with usual care , intervention participants achieved larger reductions in HbA1c level ( -0.50 % [ CI , -0.69 % to -0.32 % ] ) , systolic BP ( -4.04 mm Hg [ CI , -5.85 to -2.22 mm Hg ] ) , diastolic BP ( -2.03 mm Hg [ CI , -3.00 to -1.05 mm Hg ] ) , and LDLc level ( -7.86 mg/dL [ CI , -10.90 to -4.81 mg/dL ] ) and reported higher HRQL and treatment satisfaction . LIMITATION Findings were confined to urban specialist diabetes clinics . CONCLUSION Multicomponent QI improves achievement of diabetes care goals , even in re source -challenged clinics . PRIMARY FUNDING SOURCE National Heart , Lung , and Blood Institute and UnitedHealth Group OBJECTIVE This study tests the effectiveness of motivational interviewing compared with the usual care for Chinese hypertensive patients . METHODS A r and omised controlled trial was used . One hundred and twenty eligible participants were r and omly assigned to either the control group ( usual care group ) or the intervention group ( motivational interviewing group ) . RESULTS The results of this study demonstrated that the total scores and the mean scores for each dimension of the adherence question naire were increased in the intervention group ( P<0.05 ) , and the systolic blood pressure and diastolic blood pressure of the hypertensive patients greatly decreased in the intervention group during the six months of the motivational interviewing counselling ( P<0.05 ) . CONCLUSION The application of motivational interviewing for hypertensive patients is a promising approach for sustaining the clinical benefits of adherence behaviour . PRACTICE IMPLICATION S Motivational interviewing should be provided to hypertensive patients at hospitals and community health centres to assist patients in controlling their BP and to enhance treatment adherence . A series of training courses on the motivational interviewing technique should be provided to nurses AIM The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu , China . BACKGROUND Epidemiological studies indicate a dose- , level- and duration -dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality . Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes . DESIGN METHODS A r and omized controlled trial was conducted . Coronary heart disease patients ( n = 167 ) who met the sampling criteria in two tertiary medical centres in Chengdu , south-west China , were r and omly assigned to either an intervention group ( the cardiac rehabilitation programme ) or control group ( the routine care ) . The change of health behaviours ( walking performance , step II diet adherence , medication adherence , smoking cessation ) and physiological risk parameters ( serum lipids , blood pressure , body weight ) were assessed to evaluate the programme effect . RESULTS Patients in the intervention group demonstrated a significantly better performance in walking , step II diet adherence , medication adherence ; a significantly greater reduction in serum lipids including triglyceride , total cholesterol , low-density lipoprotein ; and significantly better control of systolic and diastolic blood pressure at three months . The majority of these positive impacts were maintained at six months . The effect of the programme on smoking cessation , body weight , serum high-density lipoprotein , was not confirmed . CONCLUSIONS A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients . Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease . RELEVANCE TO CLINICAL PRACTICE This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients . Furthermore , the hospital-home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care The authors examined the effects of a comprehensive lifestyle modification intervention on blood pressure ( BP ) and other  cardiovascular risk factors in hypertensive patients . A total of 70 participants were r and omly placed into either a lifestyle intervention or a control group . Four education classes and individual counseling sessions were held for the intervention group . Participants in the control group were provided with routine outpatient services and were asked to maintain their usual lifestyle . Data were gathered at baseline and at the end of 6 months . At the end of 6 months , BP , body weight , body mass index , waist circumference , and fasting lipids , apart from high-density lipoprotein cholesterol , significantly declined in the intervention group . Healthpromoting lifestyle scores of the intervention group had increased significantly compared to those of the control group . In conclusion , the results demonstrate the feasibility of comprehensive lifestyle modification and show its beneficial effects OBJECTIVE This study was primarily carried out to assess the feasibility of an adapted WHO CVD risk management package in a primary care setting . METHODS A community intervention trial was conducted in eight health posts located in rural , urban , and slum areas of northern India . After a 4 day training , eight health workers implemented the package among 1010 adults > or = 30 years of age from a r and omly chosen cluster of households . Locally adapted scenario 1 WHO protocol was used for the assessment of CVD risks . The health workers inquired about smoking , alcohol , diet , physical activity , symptoms of angina , and transient ischaemic attacks ; and measured systolic blood pressure ( SBP7 ) , height , and weight . Those with a risk were counseled and referred to a physician . Hypertensives were followed at 1 , 3 , and 5-month interval to reinforce risk prevention and adherence to treatment . In a 20 % r and om sub sample , in the study and control area before and after the intervention , WHO STEPS instrument was used to evaluate effectiveness of the package . FINDINGS After training , the knowledge of health workers regarding risk factors and symptoms of CVDs increased from 47 % to 92.5 % , and their performance in detection of risks was comparable to the investigator . All health workers could pay scheduled home visits regularly . They referred 279 ( 27.6 % ) individuals having raised systolic blood pressure ( SBP )  , and 74.5 % contacted the doctor . Significant decrease in mean SBP ( 8.8 mm Hg ) was observed during follow-up . Significantly higher reports of intention to quit tobacco ( 60.3 % vs 25.5 % ) and regular intake of anti-hypertensive medication ( 58.3 % vs 34.8 % ) were observed in the intervention area compared to the control area . CONCLUSION Adapted WHO CVD risk management package can be implemented through primary care system OBJECTIVE To evaluate the impact of a low-cost nutritional intervention in changing the lifestyle of adults . DESIGN R and omised clinical trial . SETTING Primary health-care centre in São José do Rio Preto , São Paulo State , Brazil . SUBJECTS We r and omly assigned 104 adults ( 83 women and 21 men aged 30 - 65 years , body mass index 24 - 35 kg m(-2 ) , non-diabetic ) into two groups : nutrition counselling and control . Each subject in the intervention group received three individualised nutritional counselling sessions during the first 6 months aim ed at increasing intakes of fruits , vegetables and olive oil , reducing saturated fat and improving physical activity .  Body composition , biochemical indicators and lifestyle were assessed at baseline and at 6 months and 1 year in both groups . RESULTS After 6 months of follow-up , body weight , waist circumference , diastolic blood pressure , fasting blood glucose , total and low-density lipoprotein cholesterol , total and saturated fat , and dietary energy and cholesterol levels showed a more significant decrease among subjects in the intervention group than in the control group ( P < 0.05 ) . Moreover , the intervention group showed significantly greater improvement in each intervention goal , such as reduced intake of saturated fat and increased intakes of fruits , vegetables , fibre and olive oil ( P < 0.05 ) . After 12 months of follow-up , most of the outcomes were maintained . CONCLUSIONS The low-cost nutritional intervention programme improved serum lipids profile and weight control , and appeared to be feasible for use at a primary health-care centre in a developing country AIMS The study tested the hypothesis that a theory driven Diabetes Self-Management ( DSM ) intervention delivered by trained nurses would result in a clinical ly significant improvement in glycaemic control . METHODS Patients with an HbA1c > 7.5 % ( 58mmol/mol ) and free of diabetes complications were enrolled into a r and omized controlled trial ( n=85 ) . Intervention consisted of four sessions and monthly follow up for 6 months . Biochemical tests , and diet and physical activity assessment  s were done in both groups . Analysis of covariance was used to test the effectiveness of the intervention . RESULTS At 6 months , there was a significant difference ( P=0.001 ) in HbA1c between the groups controlling for baseline values and other variables . Based on the primary outcome , 28 % in the intervention group achieved the target value of 6.5 % HbA1c , compared to 8 % in the " usual care " group ( P<0.001 ; η(2)=0.65 ) . The reduction in total energy intake and increase in physical activity was significant in the intervention group between baseline and follow up . CONCLUSIONS The DSM intervention has result ed in a clinical ly significant impact on glycaemia , change in diet and physical activity , and has demonstrated the feasibility of using it within existing care arrangements in a developing country setting BACKGROUND Glycemic goals ( hemoglobin A1c < 7 % ) are often not achieved in patients with type 2 diabetes despite the availability of many effective treatments and the documented benefits of glycemic control in the reduction of long-term microvascular and macrovascular complications . Several studies have established the important positive effects of pharmacist-led management on achieving glycemic control and other clinical outcomes in patients with diabetes . Diabetes prevalence and mortality are increasing rapidly in Jordan . Nevertheless , clinical pharmacists in Jordan do not typically provide pharmaceutical care ; instead , the principal responsibilities of pharmacists in Jordan are dispensing and marketing of medical products to physicians . OBJECTIVE To assess the primary clinical outcome of glycemic control ( A1c ) and secondary outcomes , including blood pressure , lipid values , self-reported medication adherence , and self-care activities for patients with type 2 diabetes in an outpatient diabetes clinic r and omly assigned to either usual care or a pharmacist-led pharmaceutical care intervention program . METHODS Patients with type 2 diabetes attending an outpatient diabetes clinic of a large teaching hospital were recruited over a 4-month period from January through April 2011 and r and omly assigned to intervention and usual care groups using the Minim software technique . The intervention group at baseline received face-to-face objective -directed education from a clinical pharmacist about type 2 diabetes , prescription medications , and necessary lifestyle changes , followed by 8 weekly telephone follow-up calls to discuss and review the prescribed treatment plan and to resolve any patient concerns . The primary outcome measure was glycemic control ( A1c ) , and secondary measures included systolic and diastolic blood pressure , complete lipid profile ( i.e. , total cholesterol , low-density lipoprotein cholesterol [ LDL-C ] , high-density lipoprotein cholesterol [ HDL-C ] , serum triglycerides ) , and self-reported medication adherence ( 4-item Morisky Scale ) and self-care activities ( Summary of Diabetes Self-Care Activities question naire ) . Data were collected at baseline and at 6 months follow-up . Changes from baseline to follow-up were calculated for biomarker values , and between-group differences in the change amounts were tested using the t test for independent sample s. A P value of < 0.05 was considered statistically significant . RESULTS A total of 77 of 85 patients ( 90.6 % ) r and omly assigned to the intervention group and 79 of 86 patients ( 91.9 % ) assigned to usual care had baseline and 6-month follow-up values . Compared with baseline values , patients in the intervention group had a mean reduction of 0.8 % in A1c versus a mean increase of 0.1 % from baseline in the usual care group ( P = 0.019 ) . The intervention group compared with the usual care group had small but statistically significant improvements in the secondary measures of fasting blood glucose , systolic and diastolic blood pressure , total cholesterol , LDL-C , serum triglycerides , self-reported medication adherence , and self-care activities . Between-group differences in changes in the secondary measures of HDL-C and body mass index were not significant . CONCLUSIONS Patients with type 2 diabetes who received pharmacist-led pharmaceutical care in an outpatient diabetes clinic experienced reduction in A1c at 6 months compared with essentially no change in the usual care group . Six of 8 secondary biomarkers were improved in the intervention group compared with usual care Background : High blood pressure ( BP ) is the leading attributable risk for cardiovascular disease globally . There is little information on effective and sustainable public health system strategies for managing hypertension in South Asian countries . We conducted a feasibility study to gather preliminary data to optimize BP-lowering strategies for a public health intervention in rural communities in Bangladesh , Pakistan , and Sri Lanka . Methods : A mixed method feasibility study comprised a 3-month pre and postevaluation of a multicomponent intervention ( MCI ) , including BP screening and home health education by trained government community health worker ( CHW ) ; providers trained in hypertension management , and compensation of CHW for additional services . Checklists were used to document care . Stakeholder interviews were also conducted . Individuals aged 40 years and above with high BP ( systolic ≥140 mmHg or diastolic ≥90 mmHg based on two readings from 2 separate days , or receiving antihypertensive medications ) were enrolled from rural communities in Bangladesh , Pakistan , and Sri Lanka . BP was measured at baseline and 3 months postintervention . Results : A total of 412 ( 90 % ) of the 454 eligible individuals were recruited . Of those recruited , 90 % received home health education session by trained CHWs , 80 % were referred to trained providers , of whom 83 % completed the management checklist . A follow-up rate of 95.6 % was achieved . The mean SBP declined significantly by 4.5 mmHg 95 % confidence interval ( 2.3 , 6.7 ) mmHg ( P < 0.001 ) in the overall pooled analysis in three countries ; however , it varied among countries . BP decline was 10.5 mmHg ( 8.1 , 13.0 mmHg ) ( P < 0.001 ) in the pooled analysis of individuals with uncontrolled hypertension at baseline , and was also significant each of the three countries . All 98 stakeholders strongly supported upscaling the proposed MCI strategies . Conclusion : The proposed MCI is feasible for implementation and requires long-term , large-scale evaluation in the rural public health infrastructure in South Asian countries to determine sustainability of health system changes and BP control . If these long-term effects are confirmed , MCI may be a long-term strategy for tackling rising rates of cardiovascular disease in low-re source d countries . Clintrial.gov In recent years , great emphasis has been placed on the role of nonpharmacological self-management in the care of patients with diabetes . Studies have reported that nurses , compared to other healthcare professionals , are more likely to promote preventive healthcare seeking behaviors . The aim of this study was to investigate the effectiveness of a nurse-led diabetes self-management education on glycosylated hemoglobin . A two-arm parallel-group r and omized controlled trial with the blinded outcome assessors was design ed . One hundred forty-two adults with type 2 diabetes were r and omized to receive either usual diabetes care ( control group ) or usual care plus a nurse-led diabetes self-management education ( intervention group ) . Duration of the intervention was 12 weeks . The primary outcome was glycosylated hemoglobin ( HbA1c values ) . Secondary outcomes were changes in blood pressure , body weight , lipid profiles , self-efficacy ( efficacy expectation and outcome expectation ) , self-management behaviors , quality of life , social support , and depression . Outcome measures were assessed at baseline and at 12-week and 24-week postr and omizations . Patients in the intervention group showed significant improvement in HbA1c , blood pressure , body weight , efficacy expectation , outcome expectation , and diabetes self-management behaviors . The beneficial effect of a nurse-led intervention continued to accrue beyond the end of the trial result ing in sustained improvements in clinical , lifestyle , and psychosocial outcomes . This trial is registered with I RCT 2016062528627N1 Abstract Background Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33 % have been recorded in Cape Town . Previous studies show that quality of care and health outcomes are poor . The development of an effective education programme should impact on self-care , lifestyle change and adherence to medication ; and lead to better control of diabetes , fewer complications and better quality of life . Methods Trial design : Pragmatic cluster r and omized controlled trial Participants : Type 2 diabetic patients attending 45 public sector community health centres in Cape Town Interventions : The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style . The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room . Objective : To evaluate the effectiveness of the group diabetes education programme Outcomes : Primary outcomes : diabetes self-care activities , 5 % weight loss , 1 % reduction in HbA1c . Secondary outcomes : self-efficacy , locus of control , mean blood pressure , mean weight loss , mean waist circumference , mean HbA1c , mean total cholesterol , quality of life R and omisation : Computer generated r and om numbers Blinding : Patients , health promoters and research assistants could not be blinded to the health centre ’s allocation Numbers r and omized : Seventeen health centres ( 34 in total ) will be r and omly assigned to either control or intervention groups . A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80 % to detect the primary outcomes with 5 % precision . Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570 . Discussion The study will inform policy makers and managers of the district health system , particularly in low to middle income countries , if this programme can be implemented more widely . Trial registerPan African Clinical Trial Registry Background The potential of mobile-health ( mHealth ) technology for the management of hypertension among stroke survivors in Africa remains unexplored . We assessed whether an mHealth technology-enabled , nurse-guided intervention initiated among stroke patients within one month of symptom onset is effective in improving their blood pressure ( BP ) control . Methods A two-arm pilot cluster r and omized controlled trial involving 60 stroke survivors , ≥18 years , with BP ≥140/90 mmHg at screening/enrollment visit at a medical center in Ghana . Participants in the intervention arm ( n = 30 ) received a Blue-toothed BP device and smartphone with an App for monitoring BP measurements and medication intake under nurse guidance for three months after which intervention was withdrawn . Control arm ( n = 30 ) received usual care . Primary outcome measure was proportion with clinic BP < 140/90 mmHg at month 9 ; secondary outcomes included medication adherence . Findings Mean ± SD age was 55 ± 13 years , 65 % males . Two participants on intervention and three in control group were lost to follow-up . At month 9 , proportion on the intervention versus controls with BP < 140/90 mmHg was 14/30 ( 46.7 % ) versus 12/30 ( 40.0 % ) , p = 0.79 by intention-to-treat ; systolic BP < 140 mmHg was 22/30 ( 73.3 % ) versus 13/30 ( 43.3 % ) , p = 0.035 . Mean ± SD medication possession ratio was 0.95 ± 0.16 on intervention versus 0.98 ± 0.24 in the control arm , p = 0.56 . Interpretation We demonstrate feasibility and signal of improvement in BP control  among stroke survivors in a re source -limited setting via an mHealth intervention . Larger scale studies are warranted . Trial registration NCT02568137 . Registered on 13 July 2015 at Clinical Trials.gov BACKGROUND A recent cluster r and omized trial evaluating a multicomponent intervention showed significant reductions in blood pressure in low-income hypertensive subjects in Argentina . OBJECTIVES To assess the cost-effectiveness of this intervention . METHODS A total of 1432 hypertensive participants were recruited from 18 primary health care centers . The intervention included home visits led by community health workers , physician education , and text messaging . Re source use and quality of life data using the three-level EuroQol five-dimensional question naire were prospect ively collected . The study perspective was that of the public health care system , and the time horizon was 18 months . Intention-to-treat analysis was used to analyze cost and health outcomes ( systolic blood pressure [ SBP ] change and quality -adjusted life-years [ QALYs ] ) . A 1 time gross domestic product per capita per QALY was used as the cost-effectiveness threshold ( US $ 14,062 ) . RESULTS Baseline characteristics were similar in the two arms . QALYs significantly increased by 0.06 ( 95 % confidence interval [ CI ] 0.04 - 0.09 ) in the intervention group , and SBP net difference favored the intervention group : 5.3 mm Hg ( 95 % CI 0.27 - 10.34 ) . Mean total costs per participant were higher in the intervention arm : US $ 304 in the intervention group and US $ 154 in the control group ( adjusted difference of US $ 140.18 ; 95 % CI US $ 75.41-US $ 204.94 ) . The incremental cost-effectiveness ratio was $ 3299 per QALY ( 95 % credible interval 1635 - 6099 ) and US $ 26 per mm Hg of SBP ( 95 % credible interval 13 - 46 ) . Subgroup analysis showed that the intervention was cost-effective in all prespecified subgroups ( age , sex , cardiovascular risk , and body mass index ) . CONCLUSIONS The multicomponent intervention was cost-effective for blood pressure control among low-income hypertensive patients Background : The burden of noncommunicable diseases and their risk factors has rapidly increased worldwide , including in India .  Innovative management strategies with electronic decision support and task sharing have been assessed for hypertension , diabetes mellitus , and depression individually , but an integrated package for multiple chronic condition management in primary care has not been evaluated . Methods : In a prospect i ve , multicenter , open-label , cluster-r and omized controlled trial involving 40 community health centers , using hypertension and diabetes mellitus as entry points , we evaluated the effectiveness of mWellcare , an mHealth system consisting of electronic health record storage and an electronic decision support for the integrated management of 5 chronic conditions ( hypertension , diabetes mellitus , current tobacco and alcohol use , and depression ) versus enhanced usual care among patients with hypertension and diabetes mellitus in India . At trial end ( 12-month follow-up ) , using intention-to-treat analysis , we examined the mean difference between arms in change in systolic blood pressure and glycated hemoglobin as primary outcomes and fasting blood glucose , total cholesterol , predicted 10-year risk of cardiovascular disease , depression score , and proportions reporting tobacco and alcohol use as secondary outcomes . Mixed-effects regression models were used to account for clustering and other confounding variables . Results : Among 3698 enrolled participants across 40 clusters ( mean age , 55.1 years ; SD , 11 years ; 55.2 % men ) , 3324 completed the trial . There was no evidence of difference between the 2 arms for systolic blood pressure ( & Dgr;=−0.98 ; 95 % CI , −4.64 to 2.67 ) and glycated hemoglobin ( & Dgr;=0.11 ; 95 % CI , −0.24 to 0.45 ) even after adjustment of several key variables ( adjusted differences for systolic blood pressure : – 0.31 [ 95 % CI , −3.91 to 3.29 ] ; for glycated hemoglobin : 0.08 [ 95 % CI , −0.27 to 0.44 ] ) . The mean within-group changes in systolic blood pressure in mWellcare and enhanced usual care were −13.65 mm Hg versus −12.66 mm Hg , respectively , and for glycated hemoglobin were −0.48 % and −0.58 % , respectively . Similarly , there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes . Conclusions : We did not find an incremental benefit of mWellcare over enhanced usual care in the management of the chronic conditions studied . Clinical Trial Registration : URL : https://www . clinical trials.gov . Unique identifier : NCT02480062 BACKGROUND The hypertension prevalence rate is increasing but the control rate is unsatisfactory . Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level . OBJECTIVE This study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level . DESIGN A single-blind , r and omized controlled trial was performed in an urban community healthcare center in China . Hypertensive patients with uncontrolled blood pressure ( systolic blood pressure ≥140mmHg and /or diastolic blood pressure ≥90mmHg ) were r and omly allocated into two groups : the study group ( n=67 ) and the control  group ( n=67 ) . The nurse-led hypertension management model included four components ( delivery system design , decision support , clinical information system and self-management support ) . Patients in the control group received usual care . Patients in the study group received a 12-week period of hypertension management . The patient outcomes , which involved blood pressure , self-care behaviors , self-efficacy , quality of life and satisfaction , were assessed at three time points : the baseline , immediately after the intervention and 4 weeks after the intervention . RESULTS After the intervention , the blood pressure of patients in the study group decreased significantly compared to those in the control group , and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43mmHg and 5.10/2.69mmHg , respectively ( p<0.01 ) . In addition , patients in the study group had significantly greater improvement in self-care behaviors than those in the control group ( p<0.01 ) . The study group had a higher level of satisfaction with hypertensive care than the control group ( p<0.01 ) . No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention . CONCLUSIONS The nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level AIM The aim of this study was to determine the effect of anti-hypertensive patient-oriented education and in-home monitoring for medication adherence and management of hypertension in a primary care setting , by providing education on healthy lifestyle behaviours and medication adherence . BACKGROUND Hypertension is the third most common cause of death worldwide . Prevalence of hypertension in Turkey is approximately 30 % in the general population and 45 - 50 % in population over 50 . DESIGN R and omised controlled study . METHODS This study conducted in Turkey used a study group comprised of 120 subjects ( 40 Group A , 40 Group B , 40 controls ) , all previously diagnosed with hypertension and who started medication therapy at least one year prior to start of study . The study was conducted between February-November 2006 at public primary health care facilities and homes of the study participants . Participants in Group A and B received a total of six monthly education sessions , four times during clinic visits and two home visits . Medication adherence education for Groups A and B and education about healthy lifestyle behaviours for Group B were administered in a structured and individualised format . The control group was routinely monitored in health care facilities . RESULTS Healthy lifestyle behaviours and perception of self-efficacy regarding medication adherence showed improvement after education sessions in Groups A and B. Systolic and diastolic blood pressures of subjects in Group A and B showed a significant decrease compared with those of the control group ; the blood pressure decrease in Group B was greater than in Group A. CONCLUSION Nurses play an important role in uncontrolled hypertension detection and can improve medication adherence and healthy lifestyle behaviours . RELEVANCE TO CLINICAL PRACTICE Patient education medication adherence alone and in combination with healthy lifestyle behaviour teaching is an effective tool for blood pressure reduction in the hypertensive population in primary health care setting Background The burden of cardiovascular diseases ( CVDs ) remains unclear in many regions of the world . Objectives The GBD ( Global Burden of Disease ) 2015 study integrated data on disease incidence , prevalence , and mortality to produce consistent , up-to- date estimates for cardiovascular burden . Methods CVD mortality was estimated from vital registration and verbal autopsy data . CVD prevalence was estimated using modeling software and data from health surveys , prospect i ve cohorts , health system administrative data , and registries . Years lived with disability ( YLD ) were estimated by multiplying prevalence by disability weights . Years of life lost ( YLL ) were estimated by multiplying age-specific CVD deaths by a reference life expectancy . A sociodemographic index ( SDI ) was created for each location based on income per capita , educational attainment , and fertility . Results In 2015 , there were an estimated 422.7 million cases of CVD ( 95 % uncertainty interval : 415.53 to 427.87 million cases ) and 17.92 million CVD deaths ( 95 % uncertainty interval : 17.59 to 18.28 million CVD deaths ) . Declines in the age-st and ardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries . Ischemic heart disease was the leading cause of CVD health lost globally , as well as in each world region , followed by stroke . As SDI increased beyond 0.25 , the highest CVD mortality shifted from women to men . CVD mortality decreased sharply for both sexes in countries with an SDI > 0.75 . Conclusions CVDs remain a major cause of health loss for all regions of the world . Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI , but only a gradual decrease or no change in most regions . Future up date s of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets for CVD OBJECTIVE This study aim ed to evaluate the cost-effectiveness of a group diabetes education program delivered by health promoters in community health centers in the Western Cape , South Africa . METHODS The effectiveness of the education program was derived from the outcomes of a pragmatic cluster r and omized controlled trial ( RCT ) . Incremental operational costs of the intervention , as implemented in the trial , were calculated . All these data were entered into a Markov micro-simulation model to simulate clinical outcomes and health costs that were expressed as an Incremental Cost Effectiveness Ratio ( ICER ) . RESULTS The only significant effect from the RCT at one year was a reduction in blood pressure ( systolic blood pressure -4.65 mmHg ( 95%CI:-9.18 to -0.12 ) and diastolic blood pressure -3.30 mmHg ( 95%CI:-5.35 to -1.26 ) ) . The ICER for the intervention , based on the assumption that the costs would recur every year and the effect could be maintained , was 1862 $ /QALY gained . CONCLUSION A structured group education program performed by mid-level trained healthcare workers at community health centers , for the management of Type II diabetes in the Western Cape , South Africa is therefore cost-effective . PRACTICE IMPLICATION S This cost-effectiveness analysis supports the more widespread implementation of this intervention in primary care within South Africa Background — In rural areas in China and India , the cardiovascular disease burden is high but economic and healthcare re sources are limited . This study ( the Simplified Cardiovascular Management Study [ SimCard ] ) aims to develop and evaluate a simplified cardiovascular management program delivered by community health workers with the aid of a smartphone-based electronic decision support system . Methods and Results — The SimCard study was a yearlong cluster-r and omized , controlled trial conducted in 47 villages ( 27 in China and 20 in India ) . Recruited for the study were 2086 individuals with high cardiovascular risk ( aged ≥40 years with self-reported history of coronary heart disease , stroke , diabetes mellitus , and /or measured systolic blood pressure ≥160 mm Hg ) . Participants in the intervention villages were managed by community health workers through an And roid-powered app on a monthly basis focusing on 2 medication use and 2 lifestyle modifications . In comparison with the control group , the intervention group had a 25.5 % ( P<0.001 ) higher net increase in the primary outcome of the proportion of patient-reported antihypertensive medication use pre- and post-intervention . There were also significant differences in certain secondary outcomes : aspirin use ( net difference : 17.1 % ; P<0.001 ) and systolic blood pressure ( –2.7 mm Hg ; P=0.04 ) . However , no significant changes were observed in the lifestyle factors . The intervention was culturally tailored , and country-specific results revealed important differences between the regions . Conclusions — The results indicate that the simplified cardiovascular management program improved quality of primary care and clinical outcomes in re source -poor setting s in China and India . Larger trials in more places are needed to ascertain the potential impacts on mortality and morbidity outcomes . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01503814
target: The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure , but low for diastolic blood pressure .
  INTERPRETATION Task-sharing interventions are effective in reducing blood pressure .
background: BACKGROUND Task sharing for the management of hypertension could be useful for understaffed and re source -poor health systems .
  We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries .