Figure 1
Description of key terminologies.
Figure 2
Description of the study selection processes.
Table 1
Study characteristics of studies assessing community-based strategies to improve hypertension outcomes.
| AUTHORS, (YEAR), COUNTRY | STUDY DESIGN | SETTING | SAMPLE SIZE | STUDY PARTICIPANTS | MAIN OUTCOME | SECONDARY OUTCOME | RISK OF BIAS | |||
|---|---|---|---|---|---|---|---|---|---|---|
| INTERVENTION | CONTROL/COMPARATOR | |||||||||
| NO. OF PARTICIPANTS | MEAN AGE | NO. OF PARTICIPANTS | MEAN AGE | |||||||
| Jafar et al., (2009) [38], Pakistan | Cluster-randomized, controlled trial | NA | 1341 | 1015 (3 different groups of intervention) | 53.8–55.3 | 326 | 53.3 | Change in systolic blood pressure | The proportion of people with controlled hypertension (BP < 140/90 mm Hg) | Some concern |
| Nguyen et al., (2018) [39], Vietnam | Cluster-randomized controlled feasibility trial | Rural | 160 | 80 | 66 | 80 | 66.9 | Patient’s levels of Systolic and diastolic blood pressure | The proportion of patients with controlled hypertension | Some concern |
| Nuepane et al., (2018) [34], Nepal | Open-label, cluster-randomized trial | Urban | 435 | 255 | 50.1 | 180 | 50.3 | Mean systolic blood pressure at 1 year | Change in mean diastolic blood pressure | Low |
| Vedanthan et al., (2019) [33], Kenya | Cluster-randomized trial | Rural | 1460 | 500 and 469 | 53.7, 54.3 | 491 | 54.6 | Linkage to care | Change in SBP | High |
| Li et al., (2019) [24], China | Cluster-randomized control trial | NA | 462 | 186 | 61.7 | 276 | 61.3 | SBP change between baseline and follow-up | DBP, BP control | High |
| Gamage et al., (2020) [31], India | Cluster-randomized controlled trial | Rural | 1734 | 637 | 56.6 | 1097 | 56.9 | The proportion of people with controlled hypertension (BP < 140/90 mm Hg) | Change in SBP and DBP | High |
| Jafar et al., (2020) [41], Bangladesh, Pakistan and Sri Lanka | Cluster-randomized, controlled trial | Rural | 2645 | 1330 | 58.5 | 1315 | 59.0 | Mean change in systolic Blood pressure from baseline to 24 months | Diastolic blood pressure and % of participants with blood pressure control | Some concern |
| Khanal et al., (2021) [35], Nepal | Cluster-Randomized Controlled Trial | Rural | 125 | 63 | 56.6 | 62 | 56.6 | Normalized SBP | Controlled DBP, mean difference of SBP, waist circumference and Knowledge score | Some concern |
| Suseela et al., (2022) [30], India | Cluster-randomized Controlled pragmatic Trial | Urban slums | 1952 | 968 | 56.8 | 984 | 55.7 | Change in mean SBP | Proportion of patients on antihypertensive medication, change in self-reported medication adherence scores, change in BMI, self-reported tobacco uses and per capita monthly consumption of salt | Some concern |
| Thapa et al., (2023) [36], Nepal | Open-label, cluster-randomized trial | Rural | 1638 | 939 | 45.4 | 699 | 45.3 | Mean change SBP | Mean change in DBP, the proportion of participants with new diagnosis of hypertension, the proportion of those who were aware of their hypertension status, Change in use of antihypertensive medication use. | Some concern |
| Adeyemo et al., (2013) [37], Nigeria | Randomized controlled trial | Rural and Urban | 668 | 668 | 63 | - | - | Pill count and biological assay with a urinary riboflavin tracer | Mean BP level | High |
| Lu et al., (2015) [26], China | Randomized, non-blinded trial | NA | 360 | 233 | 53.8 | 114 | 55.9 | Change in the proportion of subjects with normalized BP | - | Some concern |
| He et al., (2017) [23], Argentina | Randomized clinical trial | Urban | 1432 | 1432 | 55.8 | - | - | Differences between the intervention and control groups in mean systolic and diastolic BP changes | Proportion of patients who had controlled hypertension | Some concern |
| Qi, Qiu, and Zhang., (2017) [25], China | Prospective, double-blind, randomized study | NA | 1183 | 533 | 63.5 | 499 | 64.5 | Reduction in systolic and diastolic BP | - | Some concern |
| Pan et al., (2018) [27], China | Randomized control trial | Urban | 107 | 52 | 56.6 | 55 | 57.8 | Average changes in blood pressure | Post-interventional control rate | Some concern |
| Sany et al., (2018) [32], Iran | Randomized controlled trial | NA | 240 | 240 | 54.8 | - | - | Changes in SBP and DBP | Medication Adherence | Some concern |
| Sheilini et al., (2019) [29], India | Randomized controlled study | NA | 160 | 64 | - | 60 | - | Medication adherence level | Changes in SBP and DBP | Low |
| Khetan et al., (2019) [28], India | Randomized controlled trial | Urban | 3556 | 736 | 52.1 | 506 | 51.7 | Change in SBP from visit 1 to post-intervention | Mean reduction in diastolic blood pressure | Some concern |
| Hickey et al., (2022) [40], Kenya and Uganda | Randomized controlled trial | Rural | 199 | 99 | 56 | 100 | 56 | Linkage to care | Blood pressure control | Some concern |
Figure 3
Overall Risk of bias.
Table 2
Intervention characteristics of studies assessing community-based strategies to improve hypertension outcomes.
| AUTHORS, (YEAR), COUNTRY | INTERVENTION CHARACTERISTICS | CONTROL GROUP/COMPARATOR DESCRIPTION | |||
|---|---|---|---|---|---|
| INTERVENTION SETTING | DURATION OF INTERVENTION | INDIVIDUALS DELIVERING INTERVENTION | INTERVENTION COMPONENTS | ||
| Jafar et al., (2009) [37], Pakistan | Community-based | 24 months | Community health workers/general practitioners | Family-based home health education (HHE) from trained lay health workers every 3 months. Annual training of General Practitioners in hypertension management. | Usual Care |
| Adeyemo et al., (2013) [36], Nigeria | Facility-based and community based | 6 months | Nurses | Multicomponent Intervention: Clinic-based treatment; provision of free antihypertensive medications; and Reimbursement of transportation costs for a monthly clinic visit | Home visit and routine clinic care |
| Lu et al., (2015) [25], China | Community-based | 24 months | General practitioners | Multicomponent Intervention: Self-reading learning; regular lecture and Interactive workshop | Regular lecture and interactive lecture |
| He et al., (2017) [22], Argentina | Community-based | 18 months | Community health worker | Multicomponent Intervention: 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 | Usual care with no intervention |
| Qi, Qiu, and Zhang., (2017) [24], China | Community-based | 60 months | Patients/participants | Non-multicomponent intervention: Home Blood Pressure Monitoring | Measured and recorded BP in the community |
| Nguyen et al., (2018) [38], Vietnam | Facility-based and community based | 12 months | Community health worker | Multicomponent Intervention: Storytelling intervention (DVDs); didactic “Learn More” content (DVDs) | Received a single DVD |
| Neupane et al., (2018) [33], Nepal | Community-based | 12 months | Female community health volunteers (FCHVs) | Multicomponent Intervention: Home visits every 4 months for lifestyle counseling and blood pressure monitoring. | Usual care about current practices for HTN management at the community level. |
| Pan et al., (2018) [26], China | Community-based | 12 months | GP, a hypertension specialist, a general nurse, and an information manager. | Non-multicomponent intervention: Home telemonitoring for blood pressure | Usual care (no automated BP device for home monitoring) |
| Sany et al., (2018) [31], Iran | Community-based | NA | Health providers | Non-multicomponent intervention: communication skills intervention | Usual Care (no definition of usual care) |
| Sheilini et al., (2019) [28], India | Facility-based and community based | 6 months | Nurses | Multicomponent Intervention: Individualized teaching on mediation adherence and healthy lifestyle practices; information leaflet on medication adherence and healthy lifestyle practices; weekly medication-reminder boxes; and telephonic reminder for follow-up. | Routine care |
| Khetan et al., (2019) [28], India | Community-based | 24 months | Community health worker | Multicomponent Intervention: Training of Community Health Workers; Community Health Worker led home-based counseling; Physician examination | Usual Care in the community |
| Vedanthan et al., (2019) [32], Kenya | Community-based | 15 months | Community health workers | Multicomponent Intervention: “Paper-based” (tailored behavioral communication, using paper-based tools); and “smartphone” (tailored behavioral communication, using smartphone technology). | Usual Care (Standard Training) |
| Li et al., (2019) [23], China | Community-based | 6 months | Family doctors | Multicomponent Intervention: Health education; health promotion, group chat, and BP monitoring | Usual community health care services (Health lectures and one chronic disease follow-up) |
| Gamage et al., (2020) [30], India | Community-based | 3 months | Community health workers | Multicomponent Intervention: Monitoring of BP, education about hypertension, and support for a healthy lifestyle change | Usual care |
| Jafar et al., (2020) [40], Bangladesh, Pakistan and Sri Lanka | Community-based | 24 months | Community health workers | Multicomponent Intervention: Blood pressure monitoring and the use of a checklist to guide monitoring and referral to Physicians. | Usual care (Existing services in the community and routine home visits) |
| Khanal et al., (2021) [34], Nepal | Community-based | 6 months | Medical school graduate and registered nurses | Multicomponent Intervention: Four health education sessions and home visit and usual care | Usual care |
| Suseela et al., (2022) [29], India | Community-based | 6 months | Women’s self-help groups members | Multicomponent Intervention: Assistance in daily hypertension management, social and emotional support to encourage healthy behaviours and referral to the primary health care system | Standard care |
| Hickey et al., (2022) [39], Kenya and Uganda | Community-based | 3 months | Community health workers | Multicomponent Intervention: Linkage incentive - provision of transportation vouchers (worth $5.00) and follow up phone calls | Usual care (No linkage incentive and No follow up phone calls) |
| Thapa et al., (2023) [35], Nepal | Community-based | 12 months | Female community health volunteers | Multicomponent Intervention: Home visits lifestyle counselling and blood pressure measurement | Usual care |
Table 3
Key findings of studies assessing community-based strategies to improve hypertension outcomes.
| AUTHORS, (YEAR), COUNTRY | KEY FINDINGS | |||
|---|---|---|---|---|
| MAIN OUTCOME | SECONDARY OUTCOME | |||
| INTERVENTION | CONTROL/COMPARATOR | INTERVENTION | CONTROL/COMPARATOR | |
| Jafar et al., (2009) [37], Pakistan | Mean systolic blood pressure fell by 9.0 mm Hg in the intervention group | Mean systolic blood pressure fell by 3.9 mm Hg in the control group | Blood-pressure control (<140/90 mm Hg) was achieved in 53.2% of those in the intervention group | Blood-pressure control (<140/90 mm Hg) was 43.7% of those in the control group (relative risk, 1.22; 95% CI, 1.10 to 1.35). |
| Adeyemo et al., (2013) [36], Nigeria | ~77% of participants took > 98% of prescribed pills | – | Hypertension control (BP < 140/90 mmHg) was achieved in ~66% of participants | – |
| Lu et al., (2015) [25], China | Normalized BP increased significantly (from 41.2% to 63.2%, p < 0.001) increased more substantially in Group 3 (from 40.2% to 86.3%, p < 0.001) | – | – | – |
| He et al., (2017) [22], Argentina | Systolic BP reduction from baseline to month 18 was 19.3 mmHg (95%CI, 17.9–20.8 mmHg) | 12.7 mmHg (95%CI, 11.3–14.2 mmHg) for the usual care group | Patients with controlled hypertension increased from 17.0% (baseline) to 72.9% at 18 months in the intervention group | Increased from 17.6% (baseline) to 52.2% at 18 months in the usual care group |
| Qi, Qiu, and Zhang., (2017) [24], China | Decrease in the systolic pressure by (4.3 ± 3.2) mmHg (P < 0.05) | Decrease in the systolic pressure by (3.9 ± 3.1) mmHg (P < 0.05) | Decrease in diastolic pressure by (3.5 ± 2.5) mmHg (P < 0.05). | Diastolic pressure decreased by (3.0 ± 2.5) mmHg (P < 0.05). |
| Pan et al., (2017) [26], China | Reduction in blood pressure systolic blood pressure was 16.4 (12.3–18.3) | Reduction in blood pressure systolic blood pressure was 9.8 (6.2–13.5) | Blood pressure control was achieved for 63.6% | Blood pressure control was achieved for 41.80 |
| Sany et al., (2018) [31], Iran | Reduction SBP from 145.6 ± 13.8 to 124.2 ± 7.2 Reduction DBP from 91.50 ± 9.6 to 78.16 ± 6.3 | Reduction SBP from 146.1 ± 15.0 to 143.8 ± 13.0 The was reduction DBP from 89.53 ± 9.6 to 87.16 ± 10.0 | Increased from 84.08 ± 9.09 to 102.22 ± 12.13 | Increased from 82.20 ± 10.0 to 83.18 ± 8.0 |
| Nguyen et al., (2018) [38], Vietnam | Patient’s mean systolic blood pressure declined by 10.7 mmHg (95% CI: 6.5–14.9 mmHg) in the storytelling intervention | Patient’s mean systolic blood pressure declined by 5.8 mmHg (95% CI: 1.6–10.0 mmHg) in the didactic intervention group. | Proportion of patients with controlled hypertension was 31.4 (18.4–44.3) for the storytelling Group | Proportion of patients with controlled hypertension was 20.5 (7.2–33.7) for the Didactic Group |
| Neupane et al., (2018) [33], Nepal | Change in mean SBP = –6·47 | Change in mean SBP = –2.85 | Change in mean DBP = –2·90 | Change in mean DBP = –1.11 |
| Li et al., (2019) [23], China | Mean difference in SBP from baseline was –5.3 (–8.2, –2.4). | The mean difference in SBP from baseline was 1.6 (–1.2, 4.5) | The mean difference in DBP from baseline was –1.1 (–2.7, 0.6) | Mean difference in DBP from baseline was 2.0 (0.6, 3.7) |
| Vedanthan et al., (2019) [32], Kenya | Linkage to care for the paper-based and Smartphone was 43% and 54% | Linkage to care for the usual care group was 50% | Change in SBP for the Paper-based and smartphone was –8.4 ± 24.0 and –13.1 ± 20.5 respectively | Change in SBP for the usual care group was –9.7 ± 25.1 |
| Sheilini et al., (2019) [28], India | At 6 months the mean medication adherence was 8.00 ± 0.00 compared to the mean medication adherence at baseline of 5.59 ± 0.49 | At 6 months the mean medication adherence score was 7.70 ± 0.72 compared to the mean medication adherence score at baseline of 5.93 ± 0.44 | SBP post 6-months was 153.28 ± 12.85 compared to a baseline SBP of 154.34 ± 10.34. DBP post 6-months was 84.96 ± 6.89 compared to a baseline DBP of 86.28 ± 7.01. | SBP post 6-months was 154.83 ± 11.57 compared to a baseline SBP of 154.66 ± 11.26. DBP post 6-months was 87.30 ± 7.99 compared to a baseline DBP of 85.73 ± 6.58. |
| Khetan et al., (2019) [27], India | Mean ± SD change in systolic blood pressure at 2 years was –12.2 ± 19.5 mm Hg | Mean ± SD change in systolic blood pressure at 2 years was –6.4 ± 26.1 mm Hg | Mean ± SD change in diastolic blood pressure at 2 years was –5.1 ± 13.5 | Mean ± SD change in diastolic blood pressure at 2 years was –3.0 ± 14.7 |
| Gamage et al., (2020) [30], India | Control of BP improved from baseline to follow-up from 49.5% to 69.7% of the intervention group | Control of BP improved from baseline to follow-up from 52.2% to 61.7% of the usual care group | Decline in systolic BP in the intervention group was 8.2 mmHg. Decline in diastolic BP in the intervention group was (4.2 mm Hg) | Decline in systolic BP in the usual care group was 2.1 mmHg. Decline in diastolic BP in the usual care group was 2.2 mmHg. |
| Jafar et al., (2020) [40], Bangladesh, Pakistan and Sri Lanka | Mean systolic blood pressure fell by 9.0 mm Hg in the intervention group. | Mean systolic blood pressure fell by 3.9 mm Hg in the control group | The mean diastolic blood pressure fell by –6.07 (–6.85 to –5.29) Blood-pressure control (<140/90 mm Hg) was achieved in 53.2% of the participants in the intervention group | The mean diastolic blood pressure fell by –3.24 (–4.03 to –2.45) Blood-pressure control (<140/90 mmHg) was achieved in 43.7% of the participants in the control group |
| Khanal et al., (2021) [34], Nepal | Proportion of controlled SBP was 58.3% | Proportion of controlled SBP was 40% | Proportion of controlled DBP was 30% Mean change in SBP was 18.8 mmHg. | Proportion of controlled DBP was 20% Mean change in SBP was 11.2 mmHg |
| Suseela et al., (2022) [29], India | Mean reduction in SBP was 6.3 mmHg | Mean reduction in SBP was 2.2 mmHg | Percentage change in patient using antihypertensive was 14.2% Change in self-reported medication adherence was 1.44. Change in Self-reported tobacco use was –1.5 | Percentage change in patient using antihypertensive 8.8% Change in self-reported medication adherence was 0.58. Change in Self-reported tobacco use was –0.3 |
| Hickey et al., (2022) [39], Kenya and Uganda | Linkage to care was 96% | Linkage to care was 66% | Blood-pressure control (<140/90 mm Hg) was achieved in 51% of the participants in the intervention group | Blood-pressure control (<140/90 mmHg) was achieved in 41% of the participants in the control group |
| Thapa et al., (2023) [35], Nepal | Increase in mean SBP was 10.4 mmHg | Increase in mean SBP was systolic 6.3 mmHg | Increase in mean DBP was systolic 5.7 mmHg | Increase in mean DBP was systolic 3.2 mmHg |
Figure 4
Forest plot for all studies highlighting the effect of the intervention on blood pressure control.
Figure 5
Highlights of the risk of bias domains.
| Abbreviation | Meaning |
| BP | Blood Pressure |
| CHW | Community Health Worker |
| cluster RCT | Cluster Randomized Controlled Trial |
| DBP | Diastolic Blood Pressure |
| JNC-7 | The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure |
| LMICs | Low- and Middle-Income Countries |
| MESH | Medical Subject Headings |
| PRISMA | Preferred Reporting Items for Systematic Reviews and Meta-Analyses |
| RCT | Randomized Controlled Trial |
| REDCap | Research Electronic Data Capture |
| ROBS 2 | Risk of Bias 2 |
| RR | Relative Risk |
| SBP | Systolic Blood Pressure |