Implementation Of The World Health Organization Hearts Package Lowers Blood Pressure And Improves Hypertension Control In Rural Bangladesh: A Quasi Experimental Trial

Background: The World Health Organization (WHO) promotes the HEARTS technical package for improving hypertension control worldwide, but its effectiveness has not been evaluated. Methods: We conducted a quasi-experimental trial in primary healthcare facilities, Upazila Health Complexes (UHC), in rural Bangladesh. We enrolled a total of 3935 patients (mean age 52.3y, 70.5% female) with uncontrolled hypertension (blood pressure [BP] ≥140/90 mmHg): 1950 patients from 7 UHCs implementing HEARTS and 1985 patients from 7 matched usual care UHCs. The HEARTS package intervention components were 1) simplified treatment protocol, 2) reliable medication supply, 3) team-based care, 4) standardized follow-up, and 5) a mobile app to record BPs and medications. The primary outcome was systolic BP at 6 months measured at the patients' home; secondary outcomes were diastolic BP, hypertension control rate (<140/90 mmHg), and loss to follow-up. We ran multivariable mixed-effect linear and Poisson models. Results: At baseline, mean systolic BP was 158.4 mmHg in the intervention arm and 158.8 mmHg in the usual care arm. Follow-up was 95.5%. Compared to usual care, the intervention significantly lowered systolic and diastolic BP (Figure) and improved BP control (62.0% vs. 49.7%, p<0.001). Loss-to-follow-up was lower in the intervention arm (8.8% vs. 39.3%, p<0.001). Conclusions: The WHO HEARTS package implemented in rural Bangladesh significantly lowered BP and improved hypertension control. These results support use of the WHO HEARTS package to control hypertension in Bangladesh and provide a strong rationale for its implementation in other low and middle-income countries.