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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 3, May/June 2020

AFRICA

e5

participant had been sitting for five minutes. SBP and DBP were

measured three times at one- to two-minute intervals with the

average of the last two readings taken as the mean clinic reading.

Participants were randomly assigned in a 1:1:1 fashion (to

receive community health worker support, home blood pressure

monitoring or usual care) by simple ballot conducted by health

records officers in each of the two health centres.

Study personnel were instructed to treat participants with SBP

140 mmHg and

<

159 mmHg and/or DBP

90 mmHg and

<

100 mmHg who had not previously been on blood pressure-

lowering therapy with amlodipine 5 mg. All other patients were

recommended to be treated with fixed-dose combinations of

amlodipine 5 mg/ ramipril 5 mg or amlodipine 5 mg/losartan

50 mg for those intolerant of ramipril, according to local practice.

Community healthworker support consisted of four structural

education sessions and eight home visits over four weeks for

tailored counselling related to health behaviours, medication

adherence and clinic follow up. Home blood pressure monitoring

included training and provision of an automated home blood

pressure-monitoring device for daily monitoring.

At baseline, we collected data on demographics, medical

and social history, anthropometry and laboratory studies. Four

weeks after randomisation, participants returned to the clinical

site for an evaluation of change in SBP and hypertension control

(co-primary outcomes). Secondary outcomes included self-

reported blood pressure-lowering medication adherence and side

effects.

Statistical analysis

We reported baseline data using means (standard deviation)

or medians (interquartile range) as appropriate for continuous

variables, and proportions for categorical variables. We used

analysis of variance (ANOVA) and Pearson’s chi-squared test

to compare baseline continuous and categorical data. We

calculated the mean change in SBP from baseline to follow up

and compared these results across groups using analysis of

covariance (ANCOVA), adjusting for baseline SBP. We defined

statistical significance as a two-sided

p

<

0.05 and used SAS v9.4

(Cary, North Carolina) for analyses.

Results

Table 1 summarises the baseline data and co-primary and

secondary results. Among the 60 participants recruited, mean

(SD) age was 41 (11), 46 (8) and 42 (7) years in the community

health worker-supported, home blood pressure-monitoring,

and usual-care groups, respectively (

p

=

0.18). Overall, 35% of

participants were male with a higher proportion in the home

blood pressure-monitoring group (65%) compared with other

groups.

Most (75%) participants had been diagnosed with

hypertension for five to 10 years. Baseline mean (SD) SBP

were 159 (11), 151 (13) and 155 (12) mmHg in the community

health worker-supported, home blood pressure-monitoring and

usual-care groups, respectively (

p

=

0.12). Baseline mean (SD)

DBP were 99 (11), 91 (8) and 98 (8) mmHg in the same groups,

respectively (

p

=

0.86).

At the four-week follow up, the mean SBP differences were

–31 (12), –27 (14) and –21 (8) mmHg in the community health

worker-supported, home blood pressure-monitoring and usual-

care groups, respectively (

p

=

0.02). There were no differences

in DBP at the four-week follow up. Only one adverse event

(dizziness) occurred in one participant in the home blood

pressure-monitoring group and no adverse events occurred in

the other groups. Self-reported

use of

two BP-lowering drugs

at the four-week follow up was

higher in the community health

worker-supported (80%) and home blood pressure-monitoring

(70%) groups compared with the usual-care group (65%), but

these differences were not statistically significant (

p

=

0.12).

Discussion

Our study demonstrates that community health worker support

and home blood pressure monitoring are feasible and may

be effective in primary care settings in Nigeria. However,

Table 1. Baseline characteristics and outomes of

participants by intervention group

Parameters

Commu-

nity health

worker

support

(

n

=

20)

Home

blood pres-

sure moni-

toring

(

n

=

20)

Usual care

(

n

=

20)

p

-value

a

Baseline characteristics

Age, mean (SD), years

42 (11)

46 (8)

42 (7)

0.18

Male,

n

(%)

5 (25)

13 (65)

3 (15)

<

0.01

Height, mean (SD), cm

161 (12) 168 (12)

163 (10)

0.17

Weight, mean (SD), kg

73 (13)

77 (11)

69 (9)

0.06

Duration of hypertension,

n

(%)

0.86

<

5 years

14 (70)

15 (75)

16 (80)

5–10 years

5 (25)

4 (20)

4 (20)

>

10 years

1 (5)

1 (5)

0 (0)

Occupation,

n

(%)

0.04

Caterer

1 (5)

0 (0)

0 (0)

Clergy

0 (0)

1 (5)

0 (0)

Driver

0 (0)

0 (0)

1 (5)

Farming

1 (5)

0 (0)

1 (5)

Housewife

1 (5)

0 (0)

2 (10)

Lecturer

0 (0)

1 (5)

0 (0)

Public servant

1 (5)

11 (55)

3 (15)

Retired

1 (5)

0 (0)

0 (0)

Trader

15 (75)

7 (35)

13 (65)

Baseline medication,

n

(%)

0.29

None

5 (25)

5 (25)

11 (55)

CCB

7 (35)

7 (35)

6 (30)

ACE-I

6 (30)

6 (30)

1 (5)

BB

2 (10)

2 (10)

2 (10)

Baseline SBP, mean (SD), mmHg

159 (11) 151 (13)

155 (12)

0.12

Baseline DBP, mean (SD), mmHg

99 (11)

97 (8)

98 (8)

0.86

Follow up characteristics

Follow up medication,

n

(%)

0.12

CCB

4 (20)

6 (30)

7 (35)

CCB and ACE-I

6 (30)

3 (15)

0 (0)

CCB and ARB

10 (50)

11 (55)

13 (65)

4-week SBP, mean (SD), mmHg

128 (5)

125 (5)

133 (11)

<

0.01

4-week DBP, mean (SD), mmHg

81 (8)

80 (5)

82 (6)

0.51

Decrease in SBP, mean (SD), mmHg

b

31 (12)

27 (14)

21 (8)

0.02

Decrease in DBP, mean (SD), mmHg

b

18 (9)

17 (9)

16 (6)

0.88

Adverse events,

n

(%)

0 (0)

1 (5)

0 (0)

0.36

Non-adherence to study medication,

n

(%)

0 (0)

1 (5)

1 (5)

0.60

CCB, calcium channel blocker; DBP, diastolic blood pressure; SBP, systolic blood

pressure; SD standard deviation;

a

ANOVA or chi-squared test;

b

Decrease

=

baseline

– 4-week follow up.