Task Strengthening in Primary Care for Hypertension Control: impact in a low-resource setting

Abstract

Background: Hypertension continues to be a significant public health issue in low- and middle-income countries (LMICs), where access to ongoing care and blood pressure (BP) management is restricted. Community-based strategies, especially those integrated within primary healthcare systems, offer a promising way to enhance detection, treatment, and control. This study combines evidence from a systematic review, mixed-methods implementation research, and a stepped-wedge cluster-randomized trial conducted within Ghana’s Community-based Health Planning and Services (CHPS) system. Methods: A systematic review and meta-analysis assessed community-based hypertension interventions in LMICs. Qualitative interviews and stakeholder prioritization exercises were guided by the Consolidated Framework for Implementation Research (CFIR). A stepped-wedge cluster randomized trial compared a task-strengthening/practice facilitation (TSF/PF) approach with usual care across CHPS zones in rural Ghana, evaluating changes in mean systolic and diastolic BP over 24 months. Results: Nineteen studies in the systematic review demonstrated that multicomponent, community-based interventions, delivered mainly by community health workers, significantly improved BP control, though technology-enabled approaches were infrequently used. Qualitative findings identified key facilitators to hypertension management, including availability of BP monitors, workforce motivation, and supportive policies. At the same time, barriers included medication supply and transport costs, equipment shortages, and limited capacity building. Stakeholders prioritized 46 implementation strategies across six domains, with equipment availability rated most important and capacity building most feasible. In the trial, CHPS zones screened over 12,000 community members and referred nearly 5,400 for further care. After 24 months, mean systolic BP declined by 12.3 mmHg in the intervention arm and 13.6 mmHg in usual care, with no statistically significant between-group difference; diastolic BP reductions were slightly greater in the usual care arm. Conclusions: Community-based hypertension care delivered through primary health systems can achieve substantial reductions in BP in rural LMIC settings. However, incremental gains beyond strengthened usual care may be challenging to demonstrate, particularly amid health system disruptions such as COVID-19. Sustainable improvements will require investments in equipment, workforce capacity, financing, and integration of scalable digital innovations.