Nurses Treating High Blood Pressure in Ghana: A Clinical Trial

Primary Research Aim

Countries in sub-Saharan Africa are experiencing an epidemic of cardiovascular disease propelled by rapidly increasing rates of hypertension. Barriers to hypertension control in sub-Saharan Africa include poor access to care and high out-of-pocket costs.

Although sub-Saharan Africa bears 24 percent of the global disease burden, it has only 3 percent of the global health workforce. Given such limited resources, cost-effective strategies, such as task shifting, are needed to mitigate the rising cardiovascular disease epidemic in sub-Saharan Africa. Ghana, a country in sub-Saharan Africa 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.

Our study evaluates the comparative effectiveness of the implementation of the WHO cardiovascular disease management strategy versus provision of health insurance coverage, on blood pressure reduction. The study runs from 2012 – 2017 and is funded by the U.S. National Institutes of Health’s  National Heart, Lung, and Blood Institute. See trial registration information on ClinicalTrials.gov.

Research Objectives and Methodology

Using a cluster randomized design, 32 community health centers and district hospitals in Ghana were randomly assigned, with 16 assigned to the intervention group, and the other half assigned to the control group. A total of 757 patients with uncomplicated hypertension, meaning blood pressure of 140-179/90-99 mmHg and absence of target organ damage, were enrolled in this study, with at least 20 patients enrolled per site.

The intervention consists of the WHO’s cardiovascular disease management strategy, including assessment, patient education, initiation and titration of antihypertensive medications, and behavioral counseling on lifestyle behaviors and medication adherence every three months for a total of 12 months.

The primary outcome is the mean change in systolic blood pressure from baseline to 12 months. The secondary outcomes are rates of blood pressure 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 delivered the intervention as part of Ghana’s community-based health planning and services program. Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive cardiovascular risk reduction and hypertension control in resource-poor settings.

Current Status

We have recruited and assigned all 32 health facilities into four cohorts. We have recruited 757 patients from 32 health facilities—16 district hospitals, 16 health centers. Twelve-months follow-up is complete, and 24–month follow-up is still underway. Nurses refer complicated cases of hypertension, where systolic blood pressure is over 180 and there are other cardiovascular disease outcomes, to a hypertension specialist. The study is in its fifth year, and we expect to have completed data collection by the end of 2016 and data analyses in 2017. 

Project contact: Joyce Gyamfi - joyce.gyamfi@nyumc.org

Research Team

Our research team represents collaboration between universities in the U.S. and in Ghana.

  • Gbenga Ogedegbe, MD, MPH, FAHA, FACP, principle investigator, NYU School of Medicine
  • Richard Cooper, MD, co-investigator, Loyola University Chicago Stritch School of Medicine
  • Jacob Plange-Rhule, MD, co-investigator, Kwame Nkrumah School of Science and Technology,Ghana
  • Joyce Gyamfi, MS, senior research coordinator, NYU School of Medicine
  • Michael Ntim, MSc, lead project coordinator, Kwame Nkrumah School of Science and Technology
  • Kingsley Apusiga, BS, project coordinator, Kwame Nkrumah School of Science and Technology

Selected Publications

A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol. Implementation Science, 2014.

Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials. BMJ Open, 2014.