Implementation of Evidence-based Hypertension Control Interventions in Low- and Middle-income Countries: What Does It Take to Scale-up?

Hypertension (HTN) is highly prevalent globally among low- and middle-income countries (LMICs). By 2020, cardiovascular disease (CVD) deaths related to HTN in LMICs are projected to increase by 75%. HTN control in LMICs is hindered by an acute shortage of physicians, limited diagnostic medical equipment, and a dearth of disease management resources. Despite the increasing prevalence of HTN in LMICs, scalable, evidence-based interventions to reduce morbidity and mortality attributed to HTN are rarely applied in these settings. The TAsk-Shifting Strategy for Hypertension (TASSH), a 5-year cluster-randomized controlled trial that has been implemented in community health centers in the Ashanti region of Ghana, is an evidence-based example of a scalable intervention strategy for LMICs that can effectively control HTN. The aims of this study were to: (a) conduct a systematic review of interventions for HTN control implemented in LMICs and assess the effect on blood pressure control as demonstrated in RCTs that stated “scale-up”; (b) identify the WHO/ExpandNet scale-up components (i.e., Inputs, Outputs, Outcomes, Impact, Cost effectiveness, Equity, Embedded within current health organization policy, Monitoring and evaluation, Sustainability); and (c) investigate the community health nurse stakeholders’ (n = 27) perceptions of the evidence-based TASSH cluster-randomized controlled trial in Ghana. Twenty-nine randomized-controlled trials describing potentially scalable HTN control intervention strategies and WHO/ExpandNet components were identified. Studies reported clinically significant differences in blood pressure, with 16 studies reporting statistically significant mean differences in BP (p < 0.05). Multicomponent interventions, including drug therapy and health education, provided the most benefit to participants. However, there was limited reporting on translation into existing institutional policy, cost effectiveness, stakeholder engagement, and sustainability. Patient goal setting, leadership engagement, and availability of resources, all of which were mentioned by TASSH nurses as important for successful implementation and eventual TASSH scale-up, emerged as major themes. LMICs need context-specific metrics and indicators to effectively evaluate and standardize the reporting of scale-up components and processes. In addition, infrastructure development, including capacity building at the individual, institutional, and systems levels, as well as stakeholder engagement (i.e., leadership), are necessary to address HTN-related morbidity and mortality and other diseases.