TY - JOUR
T1 - ASHA-Led Community-Based Groups to Support Control of Hypertension in Rural India Are Feasible and Potentially Scalable
AU - Riddell, Michaela A.
AU - Mini, G. K.
AU - Joshi, Rohina
AU - Thrift, Amanda G.
AU - Guggilla, Rama K.
AU - Evans, Roger G.
AU - Thankappan, Kavumpurathu R.
AU - Chalmers, Kate
AU - Chow, Clara K.
AU - Mahal, Ajay S.
AU - Kalyanram, Kartik
AU - Kartik, Kamakshi
AU - Suresh, Oduru
AU - Thomas, Nihal
AU - Maulik, Pallab K.
AU - Srikanth, Velandai K.
AU - Arabshahi, Simin
AU - Varma, Ravi P.
AU - D'Esposito, Fabrizio
AU - Oldenburg, Brian
N1 - Funding Information:
This study was funded by a research grant from the National Health and Medical Research Council (Australia) under the auspices of the Global Alliance for Chronic Diseases (GACD; GNT1040030) Hypertension Research Programme. RJ acknowledges the support of a National Heart Foundation Future Leader Fellowship (102059) and UNSW Scientia Fellowship. AT acknowledges support from the NHMRC for a research fellowship (GNT1042600). PM was supported by UKRI/MRC Grant MR/S023224/1—Adolescents’ Resilience and Treatment nEeds for Mental health in Indian Slums (ARTEMIS), and NHMRC/GACD Grant APP1143911—Systematic Medical Appraisal, Referral and Treatment for Common Mental Disorders in India—(SMART) Mental Health. RG is currently supported by a Marie Sklodowska-Curie Actions Research Fellowship (EU Grant Agreement ID 754432) outside this study.
Publisher Copyright:
Copyright © 2021 Riddell, Mini, Joshi, Thrift, Guggilla, Evans, Thankappan, Chalmers, Chow, Mahal, Kalyanram, Kartik, Suresh, Thomas, Maulik, Srikanth, Arabshahi, Varma, D'Esposito and Oldenburg.
PY - 2021/11/22
Y1 - 2021/11/22
N2 - Background: To improve the control of hypertension in low- and middle-income countries, we trialed a community-based group program co-designed with local policy makers to fit within the framework of India's health system. Trained accredited social health activists (ASHAs), delivered the program, in three economically and developmentally diverse settings in rural India. We evaluated the program's implementation and scalability. Methods: Our mixed methods process evaluation was guided by the United Kingdom Medical Research Council guidelines for complex interventions. Meeting attendance reports, as well as blood pressure and weight measures of attendees and adherence to meeting content and use of meeting tools were used to evaluate the implementation process. Thematic analysis of separate focus group discussions with participants and ASHAs as well as meeting reports and participant evaluation were used to investigate the mechanisms of impact. Results: Fifteen ASHAs led 32 community-based groups in three rural settings in the states of Kerala and Andhra Pradesh, Southern India. Overall, the fidelity of intervention delivery was high. Six meetings were delivered over a 3-month period to each of the intervention groups. The mean number of meetings attended by participants at each site varied significantly, with participants in Rishi Valley attending fewer meetings [mean (SD) = 2.83 (1.68)] than participants in West Godavari (Tukeys test, p = 0.009) and Trivandrum (Tukeys test, p < 0.001) and participants in West Godavari [mean (SD) = 3.48 (1.72)] attending significantly fewer meetings than participants in Trivandrum [mean (SD) = 4.29 (1.76), Tukeys test, p < 0.001]. Culturally appropriate intervention resources and the training of ASHAs, and supportive supervision of them during the program were critical enablers to program implementation. Although highly motivated during the implementation of the program ASHA reported historical issues with timely remuneration and lack of supportive supervision. Conclusions: Culturally appropriate community-based group programs run by trained and supported ASHAs are a successful and potentially scalable model for improving the control of hypertension in rural India. However, consideration of issues related to unreliable/insufficient remuneration for ASHAs, supportive supervision and their formal role in the wider health workforce in India will be important to address in future program scale up. Trial Registration: Clinical Trial Registry of India [CTRI/2016/02/006678, Registered prospectively].
AB - Background: To improve the control of hypertension in low- and middle-income countries, we trialed a community-based group program co-designed with local policy makers to fit within the framework of India's health system. Trained accredited social health activists (ASHAs), delivered the program, in three economically and developmentally diverse settings in rural India. We evaluated the program's implementation and scalability. Methods: Our mixed methods process evaluation was guided by the United Kingdom Medical Research Council guidelines for complex interventions. Meeting attendance reports, as well as blood pressure and weight measures of attendees and adherence to meeting content and use of meeting tools were used to evaluate the implementation process. Thematic analysis of separate focus group discussions with participants and ASHAs as well as meeting reports and participant evaluation were used to investigate the mechanisms of impact. Results: Fifteen ASHAs led 32 community-based groups in three rural settings in the states of Kerala and Andhra Pradesh, Southern India. Overall, the fidelity of intervention delivery was high. Six meetings were delivered over a 3-month period to each of the intervention groups. The mean number of meetings attended by participants at each site varied significantly, with participants in Rishi Valley attending fewer meetings [mean (SD) = 2.83 (1.68)] than participants in West Godavari (Tukeys test, p = 0.009) and Trivandrum (Tukeys test, p < 0.001) and participants in West Godavari [mean (SD) = 3.48 (1.72)] attending significantly fewer meetings than participants in Trivandrum [mean (SD) = 4.29 (1.76), Tukeys test, p < 0.001]. Culturally appropriate intervention resources and the training of ASHAs, and supportive supervision of them during the program were critical enablers to program implementation. Although highly motivated during the implementation of the program ASHA reported historical issues with timely remuneration and lack of supportive supervision. Conclusions: Culturally appropriate community-based group programs run by trained and supported ASHAs are a successful and potentially scalable model for improving the control of hypertension in rural India. However, consideration of issues related to unreliable/insufficient remuneration for ASHAs, supportive supervision and their formal role in the wider health workforce in India will be important to address in future program scale up. Trial Registration: Clinical Trial Registry of India [CTRI/2016/02/006678, Registered prospectively].
KW - accredited social health activist
KW - community-based
KW - hypertension control
KW - implementation evaluation
KW - India
KW - rural
KW - self-management
KW - task-shifting
UR - http://www.scopus.com/inward/record.url?scp=85120702409&partnerID=8YFLogxK
U2 - 10.3389/fmed.2021.771822
DO - 10.3389/fmed.2021.771822
M3 - Article
C2 - 34881267
AN - SCOPUS:85120702409
SN - 2296-858X
VL - 8
JO - Frontiers in Medicine
JF - Frontiers in Medicine
M1 - 771822
ER -