Community Health Worker-Based Strategies for Hypertension Management in the Asian Context

Community Health Worker-Based Strategies for Hypertension Management in the Asian Context | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Community Health Worker-Based Strategies for Hypertension Management in the Asian Context Anna Porter, Prabhakaran Dorairaj, Vilma Irazola, Yin Cheng Lim, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6406093/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Low- and middle-income countries in Asia are experiencing a rapidly increasing prevalence of hypertension, yet they have some of the lowest rates of hypertension detection, treatment, and control in the world. Thus, the implementation of effective evidence-based interventions for hypertension is urgently needed. Focusing on four Asian countries – Bangladesh, China, India, and Nepal – this perspective article aims to: 1) Review evidence of the effectiveness of community health worker (CHW)-led interventions for hypertension control, 2) Highlight the key components of effective interventions, 3) Identify barriers to implementation, and 4) Select implementation strategies to overcome modifiable barriers. Our review suggests that CHW-led interventions have resulted in significant reduction in blood pressure in all countries and in varying context within these, as well as in reducing hypertension risk factors, including unhealthy diets, physical inactivity, and tobacco use, improving detection and linkage to care for newly diagnosed hypertension participants, and increasing medication uptake and blood pressure control in individuals with hypertension. Key components of effective interventions include blood pressure screening, linkage to primary care, and regular follow-up visits that incorporate blood pressure monitoring, health education, care follow-up, counseling, and support for medication adherence. Modifiable barriers to successful implementation of the intervention include CHWs’ high workload, CHWs’ low knowledge and skills for hypertension management, lack of supportive supervision, shortcomings of medical record system for hypertensive individuals, conflicting priorities in the health system for disease management, and patients’ lack of trust in the medical system. We selected five implementation strategies to address these barriers: conduct ongoing training for CHWs, modify incentive/allowance structures, conduct ongoing training for health care providers, audit and provide feedback, and use advisory boards and workgroups. There is a need for trials that test bundles of strategies for implementation of a CHW-led hypertension control program in these four countries and beyond. Hypertension Community Health Workers Global Health Asia Implementation Science Health Systems BACKGROUND The Public Health Importance of Hypertension Prevalence and impact of hypertension Hypertension (HTN) is a major preventable cause of cardiovascular disease and stroke 1–3 and is the leading risk factor for premature death and disability globally. 4,5 Despite global efforts to reduce the burden of HTN, low- and middle-income countries (LMICs), particularly Asian LMICs, are experiencing a rapid increase in HTN prevalence. 6 Approximately 78% of individuals with HTN live in LMICs. 7 Worldwide trends over the past 40 years indicate that mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) has steadily decreased in high-income Western countries but increased in LMICs, particularly East and Southeast Asia, South Asia, Oceania, and sub-Saharan Africa. 8 Similarly, the age-standardized prevalence of HTN has decreased in high-income countries (HICs) but remains unchanged or increased in many LMICs. 9 Notably, Asian countries have some of the lowest prevalences of HTN detection, treatment, and control in the world, with little improvement from 1990 to 2019. 9 In South and East Asian countries, HTN awareness is substantially lower than in HICs – 46% in South Asia and 58% in East Asia compared to >70% in Europe and North America. 10 Similarly, a smaller percent of the population with HTN in Asian countries are on medication - 13% in South Asia and 16.8% in East Asia versus 28.7% in the Americas. 10 Overall, only 24% of individuals with HTN in South Asia and 34.5% in East Asia have their HTN controlled, compared to 43% in North America. 10 Country-specific data shows similar findings, with South and East Asian countries having a much lower prevalence of HTN awareness, treatment, and control compared to the United States (Table 1). 11–15 These numbers emphasize that these Asian countries' implemented interventions in place at the present time are insufficient for HTN detection, treatment, and control. Table 1. Prevalence of hypertension, and prevalence of awareness, treatment, and control among people with hypertension in five Asian countries and the United States (U.S.), with years of data collection. National Prevalence Bangladesh 11 (2017-18) China 12 (2013-2014) India 13 (2019-2021) Nepal 14 (2013, 2019) Malaysia 15 (2015) U.S. 16 (2021-2023) Hypertension 26% 28% 28% 25% 35% 48% Awareness 37% 32% 37% 20% 38% 59% Treatment 31% 26% 18% 10% 31% 51% Control 13% 10% 9% 4% 11% 21% Consequences of uncontrolled hypertension HTN, often known as a silent disease, frequently goes undetected, putting individuals at increased risk for its consequences: chronic disease morbidity and mortality. As an example, at 30 years of age, individuals with HTN have a lifetime cardiovascular (CVD) risk of 63% as compared to 46% among people with normal blood pressure (BP) and develop CVD on an average 5 years earlier. 17 In addition to CVD, HTN significantly increases the risk for atrial fibrillation, chronic kidney disease, and dementia. 18 High SBP is the leading risk factor for disability-adjusted life years (DALYs) in individuals aged 50 years and older and the second leading risk factor in individuals aged 25-49 years. 4 HTN has been estimated to be responsible for 20% of global deaths, 10.8 million in 2019, more than any other behavioral, metabolic, or environmental risk factor. 4 The leading causes of death attributed to high BP include ischaemic heart disease (9%), stroke (6%), other cardiovascular disease (3%), and chronic kidney disease (2%). 4 An estimated 88% of these deaths occurred in LMICs, and individuals with high BP or HTN living in LMICs are more likely to die at younger ages. 19 Uncontrolled HTN imposes significant economic burdens on patients, their families, and national productivity. At the individual level, individuals with HTN incur substantial healthcare costs, with those living in LMICs spending 4-10% of household income on healthcare, compared to 3% in HIC. 20 Additionally, a larger percentage of individuals with HTN living in LMICs report refraining from care due to high costs. 20 At national levels, temporal trends indicate increased national spending over time, corresponding to increasing disease prevalence. 21 Indirect costs of HTN, such as loss of productivity, remain underexplored in LMICs, 22,23 but evidence from the U.S. indicates that work absenteeism accounts for over 20% of total HTN-associated medical expenditures. 24 Globally, indirect costs contribute to 45% of CVD expenses, including time lost from work, disability, and premature death. 25 Further, CVD-related expenses are projected to increase by 22% by 2030. 25 In European countries, €62 billion a year in lost earnings is estimated to result from CVD-related premature mortality. 26 Considering the substantial and rising HTN burden in LMICs and the associated years of life lost, particularly from deaths at younger ages, these countries will shoulder a significant share of this cost in the future, leading to broadening economic and health disparities. Importance of Community Health Workers (CHWs) in Hypertension Management Role of CHWs in healthcare delivery As defined by Naimoli and colleagues, 27 a community health worker (CHW) is “a health worker who receives standardized training outside the formal nursing or medical curricula to deliver a range of basic health, promotional, educational, and outreach services, and who has a defined role within the community system and larger health system.” The level of CHW employment and engagement with the health care system, place and scope of work, and depth of training varies by country and context. 28 CHWs are usually from the communities they serve and are vital in healthcare delivery, particularly in low-resource and rural settings with limited access to care. Essential to the CHW care model is the trust they build with their community, which supports positive patient interactions, care delivery, and in turn resilient community health systems. 29,30 CHW programs, which began over 100 years ago in China, have recently played a central role in reducing maternal and child mortality in LMICs, including those in Asia. 31 Evidence supporting CHW effectiveness in hypertension management In LMIC settings, CHWs have primarily supported maternal and child health, family planning, and communicable disease prevention, screening, and care, including for HIV/AIDS and tuberculosis. 31,32 However, with the rise in non-communicable diseases such as HTN, attention has turned to the potential role of CHWs in non-communicable disease (NCD) mitigation. 33–41 A recent systematic review of global evidence supports the effectiveness of CHW interventions in HTN control, including reducing BP, increasing linkage to care, enhancing treatment adherence, and reducing CVD risk. 42 In the Asian context, CHW interventions have led to significant improvements in BP in the populations considered, 43–53 as well as in reducing HTN risk factors - including unhealthy diet, physical inactivity, and tobacco use, 45,51,52 detection and linkage to care for newly diagnosed HTN participants, 54–56 and increased medication uptake and improved BP control in individuals with HTN. 43,44,47,50–52,57,58 A community-based CHW-led HTN intervention conducted in China among individuals with untreated high BP resulted in 14.6 mmHg greater reduction in SBP and a 7.0 mmHg greater reduction in DBP at 18 months compared to usual care. 47 This intervention also resulted in a 37% greater proportion of participants with BP control and 24% larger proportion of participants with adherence to anti-HTN medication as compared to usual care. 47 A community-based CHW-led HTN intervention conducted in Bangladesh, Pakistan, and Sri Lanka resulted in a 5.2mmHg greater reduction in SBP as compared to usual care, with a 8.32 mmHg greater reduction in participants with very poorly controlled BP at baseline. 44 In addition, the intervention groups had a 2.83 mmHg greater reduction in DBP, a 22% greater proportion of participants with BP control (SBP <140 mmHg and DBP <90 mmHg), and 11% greater use of anti-HTN medications. 44 Studies of community-based CHW-led interventions for BP reduction conducted in India 48,50 and Nepal 49 produced similar results, with approximately 5 mmHg greater reduction in SBP and a 2-3 mmHg greater reduction in DBP compared to usual care. KEY COMPONENTS OF COMMUNITY HEALTH WORKER-LED INTERVENTIONS IN HYPERTENSION CONTROL For this summary of key intervention components, we conducted a comprehensive review of the published evidence of CHW-led interventions for HTN control using a cluster-randomized design. To focus the search, we examined programs conducted in four Asian countries - Bangladesh, China, India, and Nepal. These four countries have similarly structured national healthcare programs that include CHWs. The prevalence of HTN is comparable across these four countries, and they face similar challenges in chronic disease prevention and control. We searched the literature that met our inclusion criteria in PubMed using the following terms in various combinations: “Community Health Worker”, “Female Community Health Volunteer”, CHW, “hypertension”, “blood pressure”, Bangladesh, China, India, Nepal. We additionally searched the articles listed under “similar articles” and “cited by” in PubMed as well as reviewing citations within the publications we identified as meeting our inclusion criteria. This search identified 14 publications. 43–45,47–54,57,59,60 The 14 identified CHW-led interventions designed to address HTN that we identified share several common intervention components. These include: Home or community-based BP screening. 43,47–54,57,59 CHWs measure BP in community members using community-based or home-based screening. This approach is designed to identify people with high BP and potentially undiagnosed HTN. In many of the programs we reviewed, screenings were conducted to identify individuals with high BP and eligible for further intervention, rather than screening being an explicit component of the intervention. Nonetheless, including screening is necessary for identifying those with undetected or uncontrolled HTN in the community. Facilitating linkage to primary care. 43,44,47,49,52,54,57 CHWs support individuals with high BP, including previously undiagnosed HTN or diagnosed but poorly controlled HTN, to connect with clinicians, determine diagnosis of HTN, and begin BP lowering medication as appropriate. Many times this occurs as part of the BP screening, where individuals who are identified as having high BP are referred to a clinician for follow-up and diagnosis confirmation. Follow-up visits. CHWs conduct follow-up visits focused on improving healthy lifestyle behaviors, screening, knowledge, and health-seeking behaviors of HTN patients. These visits may be conducted in individual homes with the patient or the patient and their family or in group settings. The frequency of these visits varied by study, with some occurring monthly, 45,47,50,52,53,60,61 every 2 months, 43,48,54,59 every 3 months, 62 or every 4 months. 49 Visits commonly included the following components: BP monitoring. 43–45,47–54,57,60 CHWs measure BP and report values back to the clinic. This allows for tracking changes in BP and BP control over time for patients and may indicate the need for further intervention by healthcare providers. Health Education. 43–45,47–54,59,60 CHWs provide culturally appropriate education on HTN and CVD risk and the importance of lifestyle changes, such as following a healthy diet, salt reduction, physical activity, tobacco cessation, and reducing alcohol consumption. Care follow-up. 43,47–53,57,60 CHWs monitor and encourage patient’s adherence to follow-up care with clinicians, including attending appointments and following healthcare provider recommendations. This may also include advising patients to follow up with providers based on BP monitoring. Counseling. 43,47,52,53 CHWs provide additional education and counseling on lifestyle changes tailored to patients’ needs. This may include discussing and troubleshooting barriers to care or lifestyle changes, accessing health insurance where available, and goal setting. Medication support. 43,47,49,52–54,57 CHWs facilitate medication purchasing or access and track adherence. The level of medication support provided by CHWs varies by country. In China, for example, CHWs, called village doctors, have specialized training and can prescribe and titrate medications following a specific protocol. In other countries CHWs are not authorized to prescribe medication, so in this context, medication support was in the form of encouraging adherence. Barriers to implementation of CHW-led interventions in HTN Control Despite strong evidence of the effectiveness of CHW interventions in HTN control, several interrelated barriers hinder their implementation in our countries of interest. Note that here we are not considering barriers that patients experience to accessing or adhering to care, rather these are barriers to implementation at the CHW and health system level. Barriers we have identified as modifiable are listed by country in Table 2. Several studies indicate that CHWs already have high workloads and find it challenging to add new duties to their workloads. 46,62–65 One study in India highlighted the level of stress that local CHWs, called Accredited Social Health Activists (ASHAs), experience due to high work demands and low compensation. 65 Another study in China indicated that the current incentives for CHWs are insufficient for taking on or scaling-up new programming. 66 The high demands of a CHW’s position may prevent them from taking on the additional task of HTN control, especially if there is no financial or other compensation for their time and effort. CHWs often lack HTN knowledge, including risk factors and methods for control, skills for HTN detection and treatment, and self-efficacy for delivery. 63,64,66–69 CHWs are typically community members without basic education or training in general healthcare. Thus, they must be trained on the specific activities they are asked to carry out. Other barriers CHWs face include limited transportation options, making it difficult to travel the long distances required to reach patients, 62,66 patients’ negative attitudes towards CHWs, 70 and limitations of the health system, including a lack of supportive supervision and medications. 62 A lack of support from supervisors or the broader health system may undermine CHWs' ability to execute their responsibilities for HTN control. 54,63,69 Without supportive oversight that includes structured training and check-ins, CHWs are unlikely to succeed in an HTN control program where they might face challenges. In addition to the barriers faced by CHWs directly, there are barriers within the health system that may hinder the successful implementation of a CHW-led HTN control program. Studies reported concerns regarding insufficient health care providers (HCPs), including physicians, nurses, and other members of the primary care team, who are trained in NCDs to address the growing need for HTN prevention and control, 69,71,72 including taking the necessary steps required of task-shifting to CHWs and implementing new programming, such as training and supervision. 62,66 However, one study from Nepal highlighted more recent initiatives that are actively addressing workforce shortages. 69 In many LMICs, including the ones examined in detail here, the medical record system is insufficient, particularly for chronic conditions such as HTN that require continuous records for effective care. 68,71,73,74 Systems are needed to allow the CHWs to report BP monitoring and medication adherence back to the facilities, as well as an audit and feedback loop to assure the consistent high quality care delivery of CHWs. Broadly, health facilities often prioritize infectious diseases over chronic conditions such as HTN. 54,75,76 This is reflected in low funding allocation for CHW training for NCDs, CHW compensation, and essential BP lowering medications. 67,69 Finally, a lack of trust in health care providers or skepticism about the effectiveness of medicine may prevent patients from seeking care or participating in the CHW intervention. 54,61,63,68,70,74–76 One study in China found post-intervention that some participants remained resistant to Western medicines, primarily due to cultural beliefs or concerns about side effects. 66 Overall, however, studies reported positive feedback from patients, CHWs, and HCPs about the importance of the CHW intervention for HTN prevention, screening, and control, and its benefit on patients health care seeking behavior and adherence to prescribed therapies. 62 Table 2. Modifiable barriers to successful implementation of a CHW-led Hypertension Program by Country of Interest Bangladesh China India Nepal CHW high workload ✔ 46,62 ✔ 63 ✔ 65 ✔ 64 CHW low knowledge and skills for HTN management ✔ 68,69 ✔ 63 ✔ 64,67 Inadequate supervision of CHWs ✔ 63 ✔ 70 ✔ 64 Medical record system is insufficient for HTN ✔ 68,73 ✔ 71,77 ✔ 74 Patients’ lack of trust in the health system ✔ 68 ✔ 63 ✔ 54,70,75,76 ✔ 61,67 Conflicting priorities in health system for disease management ✔ 54,75,76 ✔ 67 CHW: Community Health Worker, HTN: Hypertension Implementation Strategy bundle We used an implementation science lens to evaluate the identified barriers and select potential implementation strategies to address these barriers, and the equity-based RE-AIM framework as a theoretical basis to drive the implementation. 78 The COM-B Model, a framework that outlines the capability, opportunity, and motivation for changing behaviors, was used to map out desired implementation outcomes, the modifiable barriers to implementation, potential implementation strategies to address these barriers, and targeted implementation outcomes (Supplemental Table 1). 79 The implementation strategies we chose align with the Expert Recommendations for Implementing Change (ERIC) list of strategies. 80 We thus recommend the following implementation strategies to address the known barriers to a CHW-led HTN control program: Conduct Ongoing Training for Community Health Workers: Several studies identified training as a necessary prerequisite to CHW intervention delivery, 62,67 and one specifically acknowledged the value of training for increasing self-efficacy. 62 We propose planning and delivering frequent rigorous education and training sessions, managed by health facilities using a train-the trainers approach, for CHWs to enhance their knowledge and skills in HTN management. This strategy was chosen to address the barriers of CHWs' insufficient knowledge and skills. Improved fidelity is the desired outcome, ensuring consistent and accurate application of HTN management techniques, such as blood pressure measurement and health education. Alter Incentive/Allowance Structures for Community Health Workers: One study conducted in Bangladesh, Pakistan, and Sri Lanka identified compensation for additional tasks as a potential facilitator, 46 while another study from China indicated that the current incentives are insufficient, 66 suggesting that an increase in compensation may improve implementation. We suggest working in collaboration with health facilities to incentivize CHWs to engage actively in the program, such as with additional financial compensation. By providing additional incentives, we aim to address the barriers of a high workload and conflicting priorities of CHWs. The implementation outcome aims for improved adoption of the intervention and fidelity of delivery, ensuring CHWs participate actively in the program. Conduct Ongoing Training for Health Care Providers: One study indicated that an intervention would be more effective if HCPs, such as physicians, nurses, pharmacists, and other members of the primary care team, provided public support of the programming and the work of the CHWs specifically to address skepticism and resistance of community members. 70 Training targeted to HCPs to enhance buy-in for adopting and championing the program, as well as training on providing support to CHWs working in the field is necessary. We recommend in-facility one-day training sessions for HCPs on HTN management and CHW programs, addressing the barrier of trust in the CHWs, the program, and the larger medical system. The implementation outcome sought is fidelity of the program, ensuring HCPs possess necessary skills and knowledge to support the CHWs effectively. Audit and provide feedback: One study identified a need for new referral pathways that support linking CHWs to HCWs to allow for improved record keeping for patients. 68 Health facilities are responsible for modifying health record systems to allow better monitoring of implementation and clinical outcomes. This addresses the barrier of a lack of sufficient healthcare records for HTN patients. Improved fidelity is the desired outcome, ensuring accurate and comprehensive data tracking to monitor and evaluate program effectiveness. Use Advisory Boards and Workgroups: Another way to address skepticism and resistance of community members, as well as buy-in from the health system is to engage stakeholders at multiple levels. We propose to leverage existing or create new formal stakeholder groups to provide input and advice on implementation efforts. This addresses the barrier of the health system's conflicting priorities. The desired outcome is adoption , ensuring stakeholders' involvement and commitment to program improvements. DISCUSSION AND CONCLUSION HTN is the leading cause of CVD and stroke, themselves the leading causes of mortality around the world. Currently, available programs have not been able to mitigate the burden, with HTN rates rising in low- and middle-income countries, especially in Asia. Community Health Workers (CHWs) have been known to play a critical role in Bangladesh, China, India, and Nepal, where limited resources constrain health systems. An evidence-based CHW intervention, if implemented effectively by reaching the target population, being adopted by the health system, and being delivered with high fidelity, is likely to improve HTN management, bring positive clinical changes in real-world settings, and has the potential for sustainable integration into the health system. The intervention and implementation strategies laid out here consist of multiple components. While the intervention and strategies have been independently identified as useful in the literature, no studies have investigated the most effective or cost-effective configuration of these components for a CHW-led HTN intervention. Optimization studies that focus on how these components can be combined and what strength of their delivery best balances benefits and costs needs further investigation in rigorous trials, using designs such as the Multiphase Optimization Strategy (MOST) 81,82 and Learn As You Go (LAGO). 83,84 Our team of investigators has diverse training and expertise and includes representation from multiple institutions and countries. This interdisciplinary perspective strengthens the potential applicability of the recommendations in this article. Unlike other reviews that focus solely on clinical outcomes, this article applies an implementation science lens, identifying modifiable barriers and proposing evidence-based strategies to enhance CHW-led interventions. This makes it particularly useful for policymakers and practitioners. Additionally, this article tailors its analysis to four Asian countries with similar healthcare structures, providing relevant, context-driven insights that can inform regional policies and adaptation in LMIC. We go beyond identifying challenges by offering concrete solutions, drawing from the COM-B model and ERIC framework to suggest five actionable implementation strategies. There are some limitations to highlight. First, we selected implementation strategies to address barriers that we identified as modifiable. Other barriers, such as cultural and social norms within the community may hinder patient engagement. Lack of trust in the medical system was discussed above, but additional factors include traditional gender roles and familial structures, social norms, dietary norms, and environmental concerns. In addition to engaging stakeholders at multiple levels, we suggest addressing this challenge by tailoring interventions to specific cultural contexts, with awareness that what works in one community may not be appropriate or acceptable in another. This article arises from the perspective of the authors and is based on our own experiences in these countries. Other scientists and practitioners with expertise in these or other country contexts may identify other interventions, barriers, or strategies to address HTN control. Additionally, our review is not systematic, and it is possible that we missed important published or unpublished literature that may have informed our perspective. However, we provide a thorough review of published CHW-led hypertension interventions, synthesizing evidence from multiple studies to highlight key components of interventions, packages likely to be successful. There is a need to conduct cross-country interdisciplinary research to address important contextual gaps in HTN detection and linkage to care, treatment, and control in Asia. A comprehensive research program should include (1) clear, specific, and measurable objectives to measure (a) implementation outcomes, (b) effectiveness outcomes, and (c) economic sustainability while ensuring harmonization through a central theme of community health worker (CHW)--led management and common scientific core, tied together through relevant implementation science theories, models, and frameworks; (2) pooling data to identify the most effective and efficient interventions and strategies to accelerate the translation of research findings into sustainable real-world applications; and (3) joint capacity building across countries. HTN is the number one risk factor for disability and death worldwide, 5 and is largely preventable and intervenable through known evidence-based interventions - implementation science is needed to put these interventions into practice. Abbreviations HTN Hypertension LMIC Low- and middle-income country SBP Systolic blood pressure DBP Diastolic blood pressure HIC High-income country CVD Cardiovascular disease BP Blood pressure DALY Disability-adjusted life year CHW Community health worker NCD Non-communicable disease ASHA Accredited social health activist HCP Health care provider ERIC Expert recommendations for implementing change MOST Multiphase optimization strategy LAGO Learn as you go Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and material Not applicable. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors’ contributions AS and DS conceived of the manuscript. AS drafted the outline. AKP conducted the literature search and drafted the manuscript. All authors reviewed the drafted manuscript and provided editorial feedback. All authors read and approved the final manuscript. Acknowledgements The authors would like to acknowledge the Center for Implementation and Prevention Science at Yale University and the Female Community Health Volunteers Led Hypertension Prevention and Control in Nepal project (NCT06163859). References Yusuf S, Joseph P, Rangarajan S, et al. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet. 2020;395(10226):795–808. 10.1016/S0140-6736(19)32008-2 . Birhanu MM, Zaman SB, Thrift AG, Evans RG, Zengin A. Risk factors for incident cardiovascular events among adults in low- and middle-income countries: A systematic review and meta-analysis of prospective cohort studies. Prev Med. 2022;158:107036. 10.1016/j.ypmed.2022.107036 . Roth GA, Mensah GA, Johnson CO, et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019. J Am Coll Cardiol. 2020;76(25):2982–3021. 10.1016/j.jacc.2020.11.010 . Murray CJL, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1223–49. 10.1016/S0140-6736(20)30752-2 . Stanaway JD, Afshin A, Gakidou E, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1923–94. 10.1016/S0140-6736(18)32225-6 . Mills KT, Bundy JD, Kelly TN, et al. Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-Based Studies From 90 Countries. Circulation. 2016;134(6):441–50. 10.1161/CIRCULATIONAHA.115.018912 . World Health Organization. Global Report on Hypertension: The Race against a Silent Killer. World Health Organization; 2023. https://www.who.int/publications/i/item/9789240081062 . Zhou B, Bentham J, Di Cesare M, et al. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet. 2017;389(10064):37–55. 10.1016/S0140-6736(16)31919-5 . Zhou B, Carrillo-Larco RM, Danaei G, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398(10304):957–80. 10.1016/S0140-6736(21)01330-1 . Beaney T, Schutte AE, Stergiou GS, et al. May Measurement Month 2019: The Global Blood Pressure Screening Campaign of the International Society of Hypertension. Hypertension. 2020;76(2):333–41. 10.1161/HYPERTENSIONAHA.120.14874 . Khan MN, Oldroyd JC, Chowdhury EK, et al. Prevalence, awareness, treatment, and control of hypertension in Bangladesh: Findings from National Demographic and Health Survey, 2017–2018. J Clin Hypertens. 2021;23(10):1830–42. 10.1111/jch.14363 . Li Y, Yang L, Wang L, et al. Burden of hypertension in China: A nationally representative survey of 174,621 adults. Int J Cardiol. 2017;227:516–23. 10.1016/j.ijcard.2016.10.110 . Varghese JS, Venkateshmurthy NS, Sudharsanan N, et al. Hypertension Diagnosis, Treatment, and Control in India. JAMA Netw Open. 2023;6(10):e2339098. 10.1001/jamanetworkopen.2023.39098 . Dhungana RR, Pedisic Z, Dhimal M, Bista B, De Courten M. Hypertension screening, awareness, treatment, and control: a study of their prevalence and associated factors in a nationally representative sample from Nepal. Global Health Action. 2022;15(1):2000092. 10.1080/16549716.2021.2000092 . Ab Majid NL, Omar MA, Khoo YY, et al. Prevalence, Awareness, Treatment and Control of hypertension in the Malaysian population: findings from the National Health and Morbidity Survey 2006–2015. J Hum Hypertens. 2018;32(8–9):617–24. 10.1038/s41371-018-0082-x . Fryar C, Kit B, Carroll M, Afful J. Hypertension Prevalence, Awareness, Treatment, and Control among Adults Age 18 and Older: United States, August 2021–August 2023. National Center for Health Statistics (U.S.); 2024. 10.15620/cdc/164016 . Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people. Lancet. 2014;383(9932):1899–911. 10.1016/S0140-6736(14)60685-1 . Kokubo Y, Iwashima Y. Higher Blood Pressure as a Risk Factor for Diseases Other Than Stroke and Ischemic Heart Disease. Hypertension. 2015;66(2):254–9. 10.1161/HYPERTENSIONAHA.115.03480 . Zhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol. 2021;18(11):785–802. 10.1038/s41569-021-00559-8 . Murphy A, Palafox B, Walli-Attaei M, et al. The household economic burden of non-communicable diseases in 18 countries. BMJ Glob Health. 2020;5(2):e002040. 10.1136/bmjgh-2019-002040 . Zhang D, Wang G, Zhang P, Fang J, Ayala C. Medical Expenditures Associated With Hypertension in the U.S., 2000–2013. Am J Prev Med. 2017;53(6):S164–71. 10.1016/j.amepre.2017.05.014 . Gheorghe A, Griffiths U, Murphy A, Legido-Quigley H, Lamptey P, Perel P. The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review. BMC Public Health. 2018;18(1):975. 10.1186/s12889-018-5806-x . Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16(4):223–37. 10.1038/s41581-019-0244-2 . MacLeod KE, Ye Z, Donald B, Wang G. A Literature Review of Productivity Loss Associated with Hypertension in the United States. Popul Health Manage. 2022;25(3):297–308. 10.1089/pop.2021.0201 . Bloom DE, Cafiero ET, Jané-Llopis E et al. The Global Economic Burden of Non-Communicable Diseases .; 2011. Luengo-Fernandez R, Little M, Gray A, et al. Cardiovascular disease burden due to productivity losses in European Society of Cardiology countries. Eur Heart J - Qual Care Clin Outcomes. 2024;10(1):36–44. 10.1093/ehjqcco/qcad031 . Naimoli JF, Frymus DE, Wuliji T, Franco LM, Newsome MH. A Community Health Worker logic model: towards a theory of enhanced performance in low- and middle-income countries. Hum Resour Health. 2014;12(1):56. 10.1186/1478-4491-12-56 . Hodgins S, Lehmann U, Perry H et al. Comparing apples with apples: A proposed taxonomy for Community Health Workers and other front-line health workers for international comparisons. Probandari A, ed. PLOS Glob Public Health . 2025;5(2):e0004156. 10.1371/journal.pgph.0004156 Sripad P, Gottert A, Abuya T et al. Confirming—and testing—bonds of trust: A mixed methods study exploring community health workers’ experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya. Probandari A, ed. PLOS Glob Public Health . 2022;2(10):e0000595. 10.1371/journal.pgph.0000595 Mishra A. Trust and teamwork matter’: Community health workers’ experiences in integrated service delivery in India. Glob Public Health. 2014;9(8):960–74. 10.1080/17441692.2014.934877 . Perry HB, Zulliger R, Rogers MM. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness. Annu Rev Public Health. 2014;35(1):399–421. 10.1146/annurev-publhealth-032013-182354 . Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Hum Resour Health. 2016;14(1):65. 10.1186/s12960-016-0163-2 . Mishra SR, Neupane D, Preen D, Kallestrup P, Perry HB. Mitigation of non-communicable diseases in developing countries with community health workers. Global Health. 2015;11(1):43. 10.1186/s12992-015-0129-5 . Mishra SR, Lygidakis C, Neupane D, et al. Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature. Health Policy Plann. 2019;34(1):55–66. 10.1093/heapol/czy099 . Neupane D, Kallestrup P, McLachlan CS, Perry H. Community health workers for non-communicable diseases. Lancet Global Health. 2014;2(10):e567. 10.1016/S2214-109X(14)70303-1 . Joshi R, Alim M, Kengne AP et al. Task Shifting for Non-Communicable Disease Management in Low and Middle Income Countries – A Systematic Review. Moormann AM, ed. PLoS ONE . 2014;9(8):e103754. 10.1371/journal.pone.0103754 Jeet G, Thakur JS, Prinja S, Singh M. Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. Maulik PK. ed PLoS ONE. 2017;12(7):e0180640. 10.1371/journal.pone.0180640 . Widyasari V, Rahman FF, Lin KH, Wang JY. The Effectiveness of Health Services Delivered by Community Health Workers on Outcomes Related to Non-Communicable Diseases among Elderly People in Rural Areas: A Systematic Review. ijph . Published online June 15, 2021. 10.18502/ijph.v50i6.6408 Kim K, Choi JS, Choi E, et al. Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review. Am J Public Health. 2016;106(4):e3–28. 10.2105/AJPH.2015.302987 . Alaofè H, Asaolu I, Ehiri J, et al. Community Health Workers in Diabetes Prevention and Management in Developing Countries. Annals Global Health. 2017;83(3–4):661. 10.1016/j.aogh.2017.10.009 . Schutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in Low- and Middle-Income Countries. Circul Res. 2021;128(7):808–26. 10.1161/CIRCRESAHA.120.318729 . Mbuthia GW, Magutah K, Pellowski J. Approaches and outcomes of community health worker’s interventions for hypertension management and control in low-income and middle-income countries: systematic review. BMJ Open. 2022;12(4):e053455. 10.1136/bmjopen-2021-053455 . Joshi R, Agrawal T, Fathima F, et al. Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial. Am Heart J. 2019;216:9–19. 10.1016/j.ahj.2019.06.007 . Jafar TH, Gandhi M, De Silva HA, et al. A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med. 2020;382(8):717–26. 10.1056/NEJMoa1911965 . Jahan Y, Rahman MM, Faruque ASG, et al. Awareness Development and Usage of Mobile Health Technology Among Individuals With Hypertension in a Rural Community of Bangladesh: Randomized Controlled Trial. J Med Internet Res. 2020;22(12):e19137. 10.2196/19137 . Jafar TH, Silva AD, Naheed A, et al. Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka feasibility trial results. J Hypertens. 2016;34(9):1872–81. 10.1097/HJH.0000000000001014 . Sun Y, Mu J, Wang DW, et al. A village doctor-led multifaceted intervention for blood pressure control in rural China: an open, cluster randomised trial. Lancet. 2022;399(10339):1964–75. 10.1016/S0140-6736(22)00325-7 . Khetan A, Zullo M, Rani A et al. Effect of a Community Health Worker-Based Approach to Integrated Cardiovascular Risk Factor Control in India: A Cluster Randomized Controlled Trial. gh . 2019;14(4):355. 10.1016/j.gheart.2019.08.003 Neupane D, McLachlan CS, Mishra SR, et al. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. Lancet Global Health. 2018;6(1):e66–73. 10.1016/S2214-109X(17)30411-4 . Gamage DG, Riddell MA, Joshi R et al. Effectiveness of a scalable group-based education and monitoring program, delivered by health workers, to improve control of hypertension in rural India: A cluster randomised controlled trial. Neupane D, ed. PLoS Med . 2020;17(1):e1002997. 10.1371/journal.pmed.1002997 Bhattarai S, Skovlund E, Shrestha A, Mjølstad BP, Åsvold BO, Sen A. Impact of a community health worker led intervention for improved blood pressure control in urban Nepal: an open-label cluster randomised controlled trial. Lancet Reg Health - Southeast Asia. 2024;29:100461. 10.1016/j.lansea.2024.100461 . Suseela P, Ambika R, Mohandas RB. Effectiveness of a community-based education and peer support led by women’s self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial. BMJ Glob Health. 2022;7(11):e010296. 10.1136/bmjgh-2022-010296 . Tian M, Ajay VS, Dunzhu D, et al. A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India. Circulation. 2015;132(9):815–24. 10.1161/CIRCULATIONAHA.115.015373 . Pakhare A, Joshi A, Anwar R, et al. Linkage to primary-care public health facilities for cardiovascular disease prevention: a community-based cohort study from urban slums in India. BMJ Open. 2021;11(8):e045997. 10.1136/bmjopen-2020-045997 . Rajaa S, Sahu S, Thulasingam M. Contribution of community health care volunteers in facilitating mobilization for diabetes and hypertension screening among the general population residing in urban puducherry – An operational research study. J Family Med Prim Care. 2022;11(2):638. 10.4103/jfmpc.jfmpc_1316_21 . Ni Z, Atluri N, Shaw RJ, et al. Evaluating the Feasibility and Acceptability of a Mobile Health–Based Female Community Health Volunteer Program for Hypertension Control in Rural Nepal: Cross-Sectional Study. JMIR Mhealth Uhealth. 2020;8(3):e15419. 10.2196/15419 . Garg S, Dewangan M, Nanda P, et al. Impact of community health workers on improving identification and primary care of hypertension among the urban poor – findings from Chhattisgarh state of India. BMC Prim Care. 2023;24(1):272. 10.1186/s12875-023-02231-1 . Feng L, Jehan I, De Silva HA, et al. Effect of a Multicomponent Intervention on Antihypertensive Medication Intensification in Rural South Asia: Post Hoc Analysis of a Cluster RCT. Am J Hypertens. 2021;34(9):981–8. 10.1093/ajh/hpab072 . Kondal D, Jeemon P, Manimunda S, et al. Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study). J Am Heart Assoc. 2022;11(6):e023526. 10.1161/JAHA.121.023526 . Khanal MK, Bhandari P, Dhungana RR et al. Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial. Fukumoto Y, ed. PLoS ONE . 2021;16(10):e0258406. 10.1371/journal.pone.0258406 Bhattarai S, Bajracharya S, Shrestha A, et al. Facilitators and barriers to hypertension management in urban Nepal: findings from a qualitative study. Open Heart. 2023;10(2):e002394. 10.1136/openhrt-2023-002394 . Jafar TH, Tavajoh S, De Silva HA et al. Post-intervention acceptability of multicomponent intervention for management of hypertension in rural Bangladesh, Pakistan, and Sri Lanka- a qualitative study. Azmat SK, ed. PLoS ONE . 2023;18(1):e0280455. 10.1371/journal.pone.0280455 Long H, Huang W, Zheng P, et al. Barriers and Facilitators of Engaging Community Health Workers in Non-Communicable Disease (NCD) Prevention and Control in China: A Systematic Review (2006–2016). IJERPH. 2018;15(11):2378. 10.3390/ijerph15112378 . Rawal LB, Kharel C, Yadav UN, et al. Community health workers for non-communicable disease prevention and control in Nepal: a qualitative study. BMJ Open. 2020;10(12):e040350. 10.1136/bmjopen-2020-040350 . Shrivastava R, Sharma L, Jolly M, et al. We are everyone’s ASHAs but who’s there for us? a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India. Soc Sci Med. 2023;336:116234. 10.1016/j.socscimed.2023.116234 . Tian M, Yin X, Dunzhu D, et al. A qualitative evaluation of a simplified cardiovascular management program in Tibet, China. Global Health. 2018;14(1):24. 10.1186/s12992-018-0342-0 . Tan J, Xu H, Fan Q, et al. Hypertension Care Coordination and Feasibility of Involving Female Community Health Volunteers in Hypertension Management in Kavre District, Nepal: A Qualitative Study. Global Heart. 2020;15(1):73. 10.5334/gh.872 . Levitt NS, Puoane T, Denman CA, et al. Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa. Global Health Action. 2015;8(1):26318. 10.3402/gha.v8.26318 . Rawal L, Jubayer S, Choudhury SR, Islam SMS, Abdullah AS. Community health workers for non-communicable diseases prevention and control in Bangladesh: a qualitative study. glob health res policy. 2021;6(1):1. 10.1186/s41256-020-00182-z . Schierhout G, Praveen D, Patel B, et al. Why do strategies to strengthen primary health care succeed in some places and fail in others? Exploring local variation in the effectiveness of a community health worker managed digital health intervention in rural India. BMJ Glob Health. 2021;6(Suppl 5). 10.1136/bmjgh-2021-005003 . Lall D, Engel N, Devadasan N, Horstman K, Criel B. Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India. BMC Health Serv Res. 2019;19(1):44. 10.1186/s12913-019-3876-9 . Peters MA, Alonge O, Edward A, et al. Barriers to effective hypertension management in rural Bihar, India: A cross-sectional, linked supply- and demand-side study. PLOS Glob Public Health. 2022;2(10):e0000513. 10.1371/journal.pgph.0000513 . Islam MN, Karim MM, Inan TT, Islam AKMN. Investigating usability of mobile health applications in Bangladesh. BMC Med Inf Decis Mak. 2020;20(1):19. 10.1186/s12911-020-1033-3 . Bhandari B, Schutte AE, Jayasuriya R, Vaidya A, Subedi M, Narasimhan P. Acceptability of a mHealth strategy for hypertension management in a low-income and middle-income country setting: a formative qualitative study among patients and healthcare providers. BMJ Open. 2021;11(11):e052986. 10.1136/bmjopen-2021-052986 . Gupta S, Dhamija JP, Mohan I, Gupta R. Qualitative Study of Barriers to Adherence to Antihypertensive Medication among Rural Women in India. Int J Hypertens. 2019;2019:1–7. 10.1155/2019/5749648 . Dey S, Mukherjee A, Pati MK, et al. Socio-demographic, behavioural and clinical factors influencing control of diabetes and hypertension in urban Mysore, South India: a mixed-method study conducted in 2018. Arch Public Health. 2022;80(1):234. 10.1186/s13690-022-00996-y . Jindal D, Sharma H, Gupta Y, et al. Improving care for hypertension and diabetes in india by addition of clinical decision support system and task shifting in the national NCD program: I-TREC model of care. BMC Health Serv Res. 2022;22(1):688. 10.1186/s12913-022-08025-y . Shelton RC, Chambers DA, Glasgow RE. An Extension of RE-AIM to Enhance Sustainability: Addressing Dynamic Context and Promoting Health Equity Over Time. Front Public Health. 2020;8:134. 10.3389/fpubh.2020.00134 . Michie S, Van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. 10.1186/1748-5908-6-42 . Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21. 10.1186/s13012-015-0209-1 . Collins LM, Murphy SA, Strecher V. The Multiphase Optimization Strategy (MOST) and the Sequential Multiple Assignment Randomized Trial (SMART). Am J Prev Med. 2007;32(5):S112–8. 10.1016/j.amepre.2007.01.022 . Collins LM, Nahum-Shani I, Almirall D. Optimization of behavioral dynamic treatment regimens based on the sequential, multiple assignment, randomized trial (SMART). Clin Trails. 2014;11(4):426–34. 10.1177/1740774514536795 . Nevo D, Lok JJ, Spiegelman D. Analysis of learn-as-you-go (LAGO) studies. Ann Statist. 2021;49(2). 10.1214/20-AOS1978 . Bing A, Spiegelman D, Nevo D, Lok JJ. Learn-As-you-GO (LAGO) Trials: Optimizing Treatments and Preventing Trial Failure Through Ongoing Learning. Published online 2023. 10.48550/ARXIV.2307.06552 Supplementary Files SupplementalTable.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6406093","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456253739,"identity":"48d9ea63-031e-4d83-8ecf-4707f57960ab","order_by":0,"name":"Anna Porter","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYJADxgcMDBYghgFx6nkYGJiBSiVI08ImQZQW/tm9Bz8w7rDJt2fvfVbNUyMhx8DevE0CnxaJO+eSJRjPpFn28Bw3u81zTMKYgedYGV4tDDdyDCQY2w4b8Eiksd3mYZNIbJDIMcOrRf5GjvEPsBb5Z2zFPP8k6hvk3+DXYnADaCbEFjY2Zt42iQQGCR78WgyBWiwSz6QZ8JxJY5ac2ydh2MaTVmyBT4sc0GE3Pu6wMWBvP8b44c03G3l+9sMbb+DTAgaJDRCaCRg5DGwElYMAI1QL4w+ilI+CUTAKRsFIAwC4Fz2hNELdXQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-4353-5422","institution":"Yale University School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"","lastName":"Porter","suffix":""},{"id":456253740,"identity":"eac8fd94-ee53-4aef-965e-73a8618f225b","order_by":1,"name":"Prabhakaran Dorairaj","email":"","orcid":"","institution":"Centre for Chronic Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Prabhakaran","middleName":"","lastName":"Dorairaj","suffix":""},{"id":456253741,"identity":"19989ab5-8ee7-4197-8de5-2064633265f1","order_by":2,"name":"Vilma Irazola","email":"","orcid":"","institution":"Institute for Clinical Effectiveness and Health Policy: Instituto de Efectividad Clinica y Sanitaria","correspondingAuthor":false,"prefix":"","firstName":"Vilma","middleName":"","lastName":"Irazola","suffix":""},{"id":456253742,"identity":"ac94a837-3c75-40e6-81c0-4f86a00962ed","order_by":3,"name":"Yin Cheng Lim","email":"","orcid":"","institution":"University of Malaya Faculty of Medicine: Universiti Malaya Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yin","middleName":"Cheng","lastName":"Lim","suffix":""},{"id":456253743,"identity":"29e16d12-83bf-4600-b217-02dddc60076a","order_by":4,"name":"Malay Kanti Mridha","email":"","orcid":"","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Malay","middleName":"Kanti","lastName":"Mridha","suffix":""},{"id":456253744,"identity":"002d9753-1dbf-484c-9f63-23bbef7b9bf0","order_by":5,"name":"Sailesh Mohan","email":"","orcid":"","institution":"Centre for Chronic Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Sailesh","middleName":"","lastName":"Mohan","suffix":""},{"id":456253745,"identity":"90eec219-6bf9-4377-94c6-e08295c96739","order_by":6,"name":"Lisasha Poudel","email":"","orcid":"","institution":"Institute for Implementation Science and Health","correspondingAuthor":false,"prefix":"","firstName":"Lisasha","middleName":"","lastName":"Poudel","suffix":""},{"id":456253746,"identity":"aa57629c-d7da-4dcb-86e2-a6dadda17c12","order_by":7,"name":"Zahidul Quayyum","email":"","orcid":"","institution":"BRAC University James P Grant School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Zahidul","middleName":"","lastName":"Quayyum","suffix":""},{"id":456253747,"identity":"8fd6e876-2bbf-43a9-9b45-1325298461ec","order_by":8,"name":"Malabika Sarker","email":"","orcid":"","institution":"Brown University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Malabika","middleName":"","lastName":"Sarker","suffix":""},{"id":456253748,"identity":"a14739f0-1f68-41fb-88c4-997b061f1dfa","order_by":9,"name":"Nikhil Srinivasapura Venkateshmurthy","email":"","orcid":"","institution":"Centre for Chronic Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Nikhil","middleName":"Srinivasapura","lastName":"Venkateshmurthy","suffix":""},{"id":456253749,"identity":"72c7f388-2cf7-46ac-8fbb-f2db2f26fecb","order_by":10,"name":"Lijing L Yan","email":"","orcid":"","institution":"Duke Kunshan University","correspondingAuthor":false,"prefix":"","firstName":"Lijing","middleName":"L","lastName":"Yan","suffix":""},{"id":456253750,"identity":"f3670be8-8017-4a4b-adc3-8b39517e72be","order_by":11,"name":"Dong Roman Xu","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"Roman","lastName":"Xu","suffix":""},{"id":456253751,"identity":"3afe101f-5c07-42fe-a64b-115da7485280","order_by":12,"name":"Donna Spiegelman","email":"","orcid":"","institution":"Yale University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Donna","middleName":"","lastName":"Spiegelman","suffix":""},{"id":456253752,"identity":"8dbb452d-d855-44fd-9553-bc0f3e78b0c7","order_by":13,"name":"Archana Shrestha","email":"","orcid":"","institution":"Dhulikhel Hospital","correspondingAuthor":false,"prefix":"","firstName":"Archana","middleName":"","lastName":"Shrestha","suffix":""}],"badges":[],"createdAt":"2025-04-08 19:40:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6406093/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6406093/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98625264,"identity":"7540cb33-ebe6-414a-90bc-9b3078188815","added_by":"auto","created_at":"2025-12-19 17:09:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":877883,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6406093/v1/ed63fb7e-b7cf-44d3-a5a0-1b9f218aef94.pdf"},{"id":82924377,"identity":"f7ded301-8e0e-4c00-9674-d2d73b1afd9f","added_by":"auto","created_at":"2025-05-16 18:55:43","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":16865,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-6406093/v1/f6142ef0d83515ee58ae5c47.docx"}],"financialInterests":"","formattedTitle":"Community Health Worker-Based Strategies for Hypertension Management in the Asian Context","fulltext":[{"header":"BACKGROUND","content":"\u003ch5\u003e\u003cstrong\u003eThe Public Health Importance of Hypertension\u003c/strong\u003e\u003c/h5\u003e\n\u003cp\u003e\u003cem\u003ePrevalence and impact of hypertension\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHypertension (HTN) is a major preventable cause of cardiovascular disease and stroke\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e and is the leading risk factor for premature death and disability globally.\u003csup\u003e4,5\u003c/sup\u003e Despite global efforts to reduce the burden of HTN, low- and middle-income countries (LMICs), particularly Asian LMICs, are experiencing a rapid increase in HTN prevalence.\u003csup\u003e6\u003c/sup\u003e Approximately 78% of individuals with HTN live in LMICs.\u003csup\u003e7\u003c/sup\u003e Worldwide trends over the past 40 years indicate that mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) has steadily decreased in high-income Western countries but increased in LMICs, particularly East and Southeast Asia, South Asia, Oceania, and sub-Saharan Africa.\u003csup\u003e8\u003c/sup\u003e Similarly, the age-standardized prevalence of HTN has decreased in high-income countries (HICs) but remains unchanged or increased in many LMICs.\u003csup\u003e9\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNotably, Asian countries have some of the lowest prevalences of HTN detection, treatment, and control in the world, with little improvement from 1990 to 2019.\u003csup\u003e9\u003c/sup\u003e In South and East Asian countries, HTN awareness is substantially lower than in HICs \u0026ndash; 46% in South Asia and 58% in East Asia compared to \u0026gt;70% in Europe and North America.\u003csup\u003e10\u003c/sup\u003e Similarly, a smaller percent of the population with HTN in Asian countries are on medication - 13% in South Asia and 16.8% in East Asia versus 28.7% in the Americas.\u003csup\u003e10\u003c/sup\u003e Overall, only 24% of individuals with HTN in South Asia and 34.5% in East Asia have their HTN controlled, compared to 43% in North America.\u003csup\u003e10\u003c/sup\u003e Country-specific data shows similar findings, with South and East Asian countries having a much lower prevalence of HTN awareness, treatment, and control compared to the United States (Table 1).\u003csup\u003e11\u0026ndash;15\u003c/sup\u003e These numbers emphasize that these Asian countries\u0026apos; implemented interventions in place at the present time are insufficient for HTN detection, treatment, and control.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003eTable 1. Prevalence of hypertension, and prevalence of awareness, treatment, and control among people with hypertension in five Asian countries and the United States (U.S.), with years of data collection.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNational Prevalence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBangladesh\u003c/strong\u003e\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2017-18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChina\u003c/strong\u003e\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2013-2014)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndia\u003c/strong\u003e\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2019-2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNepal\u003c/strong\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2013, 2019)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalaysia\u003c/strong\u003e\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2015)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eU.S.\u003c/strong\u003e\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(2021-2023)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eAwareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e32%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eTreatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e31%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e18%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e31%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e51%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e13%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eConsequences of uncontrolled hypertension\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHTN, often known as a silent disease, frequently goes undetected, putting individuals at increased risk for its consequences: chronic disease morbidity and mortality. As an example, at 30 years of age, individuals with HTN have a lifetime cardiovascular (CVD) risk of 63% as compared to 46% among people with normal blood pressure (BP) and develop CVD on an average 5 years earlier.\u003csup\u003e17\u003c/sup\u003e In addition to CVD, HTN significantly increases the risk for atrial fibrillation, chronic kidney disease, and dementia.\u003csup\u003e18\u003c/sup\u003e High SBP is the leading risk factor for disability-adjusted life years (DALYs) in individuals aged 50 years and older and the second leading risk factor in individuals aged 25-49 years.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eHTN has been estimated to be responsible for 20% of global deaths, 10.8 million in 2019, more than any other behavioral, metabolic, or environmental risk factor.\u003csup\u003e4\u003c/sup\u003e The leading causes of death attributed to high BP include ischaemic heart disease (9%), stroke (6%), other cardiovascular disease (3%), and chronic kidney disease (2%).\u003csup\u003e4\u003c/sup\u003e An estimated 88% of these deaths occurred in LMICs, and individuals with high BP or HTN living in LMICs are more likely to die at younger ages.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eUncontrolled HTN imposes significant economic burdens on patients, their families, and national productivity. At the individual level, individuals with HTN incur substantial healthcare costs, with those living in LMICs spending 4-10% of household income on healthcare, compared to 3% in HIC.\u003csup\u003e20\u003c/sup\u003e Additionally, a larger percentage of individuals with HTN living in LMICs report refraining from care due to high costs.\u003csup\u003e20\u003c/sup\u003e At national levels, temporal trends indicate increased national spending over time, corresponding to increasing disease prevalence.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIndirect costs of HTN, such as loss of productivity, remain underexplored in LMICs,\u003csup\u003e22,23\u003c/sup\u003e but evidence from the U.S. indicates that work absenteeism accounts for over 20% of total HTN-associated medical expenditures.\u003csup\u003e24\u003c/sup\u003e Globally, indirect costs contribute to 45% of CVD expenses, including time lost from work, disability, and premature death.\u003csup\u003e25\u003c/sup\u003e Further, CVD-related expenses are projected to increase by 22% by 2030.\u003csup\u003e25\u003c/sup\u003e In European countries, \u0026euro;62 billion a year in lost earnings is estimated to result from CVD-related premature mortality.\u003csup\u003e26\u003c/sup\u003e Considering the substantial and rising HTN burden in LMICs and the associated years of life lost, particularly from deaths at younger ages, these countries will shoulder a significant share of this cost in the future, leading to broadening economic and health disparities.\u003c/p\u003e\n\u003ch5\u003e\u003cstrong\u003eImportance of Community Health Workers (CHWs) in Hypertension Management\u003c/strong\u003e\u003c/h5\u003e\n\u003cp\u003e\u003cem\u003eRole of CHWs in healthcare delivery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs defined by Naimoli and colleagues,\u003csup\u003e27\u003c/sup\u003e a community health worker (CHW) is \u0026ldquo;a health worker who receives standardized training outside the formal nursing or medical curricula to deliver a range of basic health, promotional, educational, and outreach services, and who has a defined role within the community system and larger health system.\u0026rdquo; The level of CHW employment and engagement with the health care system, place and scope of work, and depth of training varies by country and context.\u003csup\u003e28\u003c/sup\u003e CHWs are usually from the communities they serve and are vital in healthcare delivery, particularly in low-resource and rural settings with limited access to care. Essential to the CHW care model is the trust they build with their community, which supports positive patient interactions, care delivery, and in turn resilient community health systems.\u003csup\u003e29,30\u003c/sup\u003e CHW programs, which began over 100 years ago in China, have recently played a central role in reducing maternal and child mortality in LMICs, including those in Asia.\u003csup\u003e31\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence supporting CHW effectiveness in hypertension management\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn LMIC settings, CHWs have primarily supported maternal and child health, family planning, and communicable disease prevention, screening, and care, including for HIV/AIDS and tuberculosis.\u003csup\u003e31,32\u003c/sup\u003e However, with the rise in non-communicable diseases such as HTN, attention has turned to the potential role of CHWs in non-communicable disease (NCD) mitigation.\u003csup\u003e33\u0026ndash;41\u003c/sup\u003e A recent systematic review of global evidence supports the effectiveness of CHW interventions in HTN control, including reducing BP, increasing linkage to care, enhancing treatment adherence, and reducing CVD risk.\u003csup\u003e42\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the Asian context, CHW interventions have led to significant improvements in BP in the populations considered,\u003csup\u003e43\u0026ndash;53\u003c/sup\u003e as well as in reducing HTN risk factors - including unhealthy diet, physical inactivity, and tobacco use,\u003csup\u003e45,51,52\u003c/sup\u003e detection and linkage to care for newly diagnosed HTN participants,\u003csup\u003e54\u0026ndash;56\u003c/sup\u003e and increased medication uptake and improved BP control in individuals with HTN.\u003csup\u003e43,44,47,50\u0026ndash;52,57,58\u003c/sup\u003e A community-based CHW-led HTN intervention conducted in China among individuals with untreated high BP resulted in 14.6 mmHg greater reduction in SBP and a 7.0 mmHg greater reduction in DBP at 18 months compared to usual care.\u003csup\u003e47\u003c/sup\u003e This intervention also resulted in a 37% greater proportion of participants with BP control and 24% larger proportion of participants with adherence to anti-HTN medication as compared to usual care.\u003csup\u003e47\u003c/sup\u003e A community-based CHW-led HTN intervention conducted in Bangladesh, Pakistan, and Sri Lanka resulted in a 5.2mmHg greater reduction in SBP as compared to usual care, with a 8.32 mmHg greater reduction in participants with very poorly controlled BP at baseline.\u003csup\u003e44\u003c/sup\u003e In addition, the intervention groups had a 2.83 mmHg greater reduction in DBP, a 22% greater proportion of participants with BP control (SBP \u0026lt;140 mmHg and DBP \u0026lt;90 mmHg), and 11% greater use of anti-HTN medications.\u003csup\u003e44\u003c/sup\u003e Studies of community-based CHW-led interventions for BP reduction conducted in India\u003csup\u003e48,50\u003c/sup\u003e and Nepal\u003csup\u003e49\u003c/sup\u003e produced similar results, with approximately 5 mmHg greater reduction in SBP and a 2-3 mmHg greater reduction in DBP compared to usual care.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eKEY COMPONENTS OF COMMUNITY HEALTH WORKER-LED INTERVENTIONS IN HYPERTENSION CONTROL\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eFor this summary of key intervention components, we conducted a comprehensive review of the published evidence of CHW-led interventions for HTN control using a cluster-randomized design. To focus the search, we examined programs conducted in four Asian countries - Bangladesh, China, India, and Nepal. These four countries have similarly structured national healthcare programs that include CHWs. The prevalence of HTN is comparable across these four countries, and they face similar challenges in chronic disease prevention and control.\u003c/p\u003e\n\u003cp\u003eWe searched the literature that met our inclusion criteria in PubMed using the following terms in various combinations: \u0026ldquo;Community Health Worker\u0026rdquo;, \u0026ldquo;Female Community Health Volunteer\u0026rdquo;, CHW, \u0026ldquo;hypertension\u0026rdquo;, \u0026ldquo;blood pressure\u0026rdquo;, Bangladesh, China, India, Nepal. We additionally searched the articles listed under \u0026ldquo;similar articles\u0026rdquo; and \u0026ldquo;cited by\u0026rdquo; in PubMed as well as reviewing citations within the publications we identified as meeting our inclusion criteria. This search identified 14 publications.\u003csup\u003e43\u0026ndash;45,47\u0026ndash;54,57,59,60\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe 14 identified CHW-led interventions designed to address HTN that we identified share several common intervention components. These include:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eHome or community-based BP screening.\u003c/strong\u003e\u003csup\u003e43,47\u0026ndash;54,57,59\u003c/sup\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCHWs measure BP in community members using community-based or home-based screening. This approach is designed to identify people with high BP and potentially undiagnosed HTN. In many of the programs we reviewed, screenings were conducted to identify individuals with high BP and eligible for further intervention, rather than screening being an explicit component of the intervention. Nonetheless, including screening is necessary for identifying those with undetected or uncontrolled HTN in the community.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFacilitating linkage to primary care.\u003c/strong\u003e\u003csup\u003e43,44,47,49,52,54,57\u003c/sup\u003e CHWs support individuals with high BP, including previously undiagnosed HTN or diagnosed but poorly controlled HTN, to connect with clinicians, determine diagnosis of HTN, and begin BP lowering medication as appropriate. Many times this occurs as part of the BP screening, where individuals who are identified as having high BP are referred to a clinician for follow-up and diagnosis confirmation.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFollow-up visits.\u0026nbsp;\u003c/strong\u003eCHWs conduct follow-up visits focused on improving healthy lifestyle behaviors, screening, knowledge, and health-seeking behaviors of HTN patients. These visits may be conducted in individual homes with the patient or the patient and their family or in group settings. The frequency of these visits varied by study, with some occurring monthly,\u003csup\u003e45,47,50,52,53,60,61\u003c/sup\u003e every 2 months,\u003csup\u003e43,48,54,59\u003c/sup\u003e every 3 months,\u003csup\u003e62\u003c/sup\u003e or every 4 months.\u003csup\u003e49\u003c/sup\u003eVisits commonly included the following components:\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eBP monitoring.\u003c/strong\u003e\u003csup\u003e43\u0026ndash;45,47\u0026ndash;54,57,60\u003c/sup\u003e CHWs measure BP and report values back to the clinic. This allows for tracking changes in BP and BP control over time for patients and may indicate the need for further intervention by healthcare providers.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHealth Education.\u003c/strong\u003e\u003csup\u003e43\u0026ndash;45,47\u0026ndash;54,59,60\u003c/sup\u003e CHWs provide culturally appropriate education on HTN and CVD risk and the importance of lifestyle changes, such as following a healthy diet, salt reduction, physical activity, tobacco cessation, and reducing alcohol consumption.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCare follow-up.\u003c/strong\u003e\u003csup\u003e43,47\u0026ndash;53,57,60\u003c/sup\u003e CHWs monitor and encourage patient\u0026rsquo;s adherence to follow-up care with clinicians, including attending appointments and following healthcare provider recommendations. This may also include advising patients to follow up with providers based on BP monitoring.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCounseling.\u003c/strong\u003e\u003csup\u003e43,47,52,53\u003c/sup\u003e CHWs provide additional education and counseling on lifestyle changes tailored to patients\u0026rsquo; needs. This may include discussing and troubleshooting barriers to care or lifestyle changes, accessing health insurance where available, and goal setting.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMedication support.\u003c/strong\u003e\u003csup\u003e43,47,49,52\u0026ndash;54,57\u003c/sup\u003e CHWs facilitate medication purchasing or access and track adherence. The level of medication support provided by CHWs varies by country. In China, for example, CHWs, called village doctors, have specialized training and can prescribe and titrate medications following a specific protocol. In other countries CHWs are not authorized to prescribe medication, so in this context, medication support was in the form of encouraging adherence.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers to implementation of CHW-led interventions in HTN Control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite strong evidence of the effectiveness of CHW interventions in HTN control, several interrelated barriers hinder their implementation in our countries of interest. Note that here we are not considering barriers that patients experience to accessing or adhering to care, rather these are barriers to implementation at the CHW and health system level. Barriers we have identified as modifiable are listed by country in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral studies indicate that CHWs already have high workloads and find it challenging to add new duties to their workloads.\u003csup\u003e46,62\u0026ndash;65\u003c/sup\u003e One study in India highlighted the level of stress that local CHWs, called Accredited Social Health Activists (ASHAs), experience due to high work demands and low compensation.\u003csup\u003e65\u003c/sup\u003e Another study in China indicated that the current incentives for CHWs are insufficient for taking on or scaling-up new programming.\u003csup\u003e66\u003c/sup\u003e The high demands of a CHW\u0026rsquo;s position may prevent them from taking on the additional task of HTN control, especially if there is no financial or other compensation for their time and effort.\u003c/p\u003e\n\u003cp\u003eCHWs often lack HTN knowledge, including risk factors and methods for control, skills for HTN detection and treatment, and self-efficacy for delivery.\u003csup\u003e63,64,66\u0026ndash;69\u003c/sup\u003e CHWs are typically community members without basic education or training in general healthcare. Thus, they must be trained on the specific activities they are asked to carry out. Other barriers CHWs face include limited transportation options, making it difficult to travel the long distances required to reach patients,\u003csup\u003e62,66\u003c/sup\u003e patients\u0026rsquo; negative attitudes towards CHWs,\u003csup\u003e70\u003c/sup\u003e and limitations of the health system, including a lack of supportive supervision and medications.\u003csup\u003e62\u003c/sup\u003e A lack of support from supervisors or the broader health system may undermine CHWs\u0026apos; ability to execute their responsibilities for HTN control.\u003csup\u003e54,63,69\u003c/sup\u003e Without supportive oversight that includes structured training and check-ins, CHWs are unlikely to succeed in an HTN control program where they might face challenges.\u003c/p\u003e\n\u003cp\u003eIn addition to the barriers faced by CHWs directly, there are barriers within the health system that may hinder the successful implementation of a CHW-led HTN control program. Studies reported concerns regarding insufficient health care providers (HCPs), including physicians, nurses, and other members of the primary care team, who are trained in NCDs to address the growing need for HTN prevention and control,\u003csup\u003e69,71,72\u003c/sup\u003e including taking the necessary steps required of task-shifting to CHWs and implementing new programming, such as training and supervision.\u003csup\u003e62,66\u003c/sup\u003e However, one study from Nepal highlighted more recent initiatives that are actively addressing workforce shortages.\u003csup\u003e69\u003c/sup\u003e In many LMICs, including the ones examined in detail here, the medical record system is insufficient, particularly for chronic conditions such as HTN that require continuous records for effective care.\u003csup\u003e68,71,73,74\u003c/sup\u003e Systems are needed to allow the CHWs to report BP monitoring and medication adherence back to the facilities, as well as an audit and feedback loop to assure the consistent high quality care delivery of CHWs. Broadly, health facilities often prioritize infectious diseases over chronic conditions such as HTN.\u003csup\u003e54,75,76\u003c/sup\u003e This is reflected in low funding allocation for CHW training for NCDs, CHW compensation, and essential BP lowering medications.\u003csup\u003e67,69\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, a lack of trust in health care providers or skepticism about the effectiveness of medicine may prevent patients from seeking care or participating in the CHW intervention.\u003csup\u003e54,61,63,68,70,74\u0026ndash;76\u003c/sup\u003e One study in China found post-intervention that some participants remained resistant to Western medicines, primarily due to cultural beliefs or concerns about side effects.\u003csup\u003e66\u003c/sup\u003e Overall, however, studies reported positive feedback from patients, CHWs, and HCPs about the importance of the CHW intervention for HTN prevention, screening, and control, and its benefit on patients health care seeking behavior and adherence to prescribed therapies.\u003csup\u003e62\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"585\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 585px;\"\u003e\n \u003cp\u003eTable 2. Modifiable barriers to successful implementation of a CHW-led Hypertension Program by Country of Interest\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBangladesh\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChina\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNepal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003eCHW high workload\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e46,62\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e63\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e65\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e64\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003eCHW low knowledge and skills for HTN management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e68,69\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e63\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e64,67\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003eInadequate supervision of CHWs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e63\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e70\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e64\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003eMedical record system is insufficient for HTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e68,73\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e71,77\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e74\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003ePatients\u0026rsquo; lack of trust in the health system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e68\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e63\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e54,70,75,76\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e61,67\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 202px;\"\u003e\n \u003cp\u003eConflicting priorities in health system for disease management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e54,75,76\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e✔\u003csup\u003e67\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 585px;\"\u003e\n \u003cp\u003eCHW: Community Health Worker, HTN: Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation Strategy bundle\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used an implementation science lens to evaluate the identified barriers and select potential implementation strategies to address these barriers, and the equity-based RE-AIM framework as a theoretical basis to drive the implementation.\u003csup\u003e78\u003c/sup\u003e The COM-B Model, a framework that outlines the capability, opportunity, and motivation for changing behaviors, was used to map out desired implementation outcomes, the modifiable barriers to implementation, potential implementation strategies to address these barriers, and targeted implementation outcomes (Supplemental Table 1).\u003csup\u003e79\u003c/sup\u003e The implementation strategies we chose align with the Expert Recommendations for Implementing Change (ERIC) list of strategies.\u003csup\u003e80\u003c/sup\u003e We thus recommend the following implementation strategies to address the known barriers to a CHW-led HTN control program:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eConduct Ongoing Training for Community Health Workers:\u003c/strong\u003e\u0026nbsp; Several studies identified training as a necessary prerequisite to CHW intervention delivery,\u003csup\u003e62,67\u003c/sup\u003e and one specifically acknowledged the value of training for increasing self-efficacy.\u003csup\u003e62\u003c/sup\u003e We propose planning and delivering frequent rigorous education and training sessions, managed by health facilities using a train-the trainers approach, for CHWs to enhance their knowledge and skills in HTN management. This strategy was chosen to address the barriers of CHWs\u0026apos; insufficient knowledge and skills. Improved \u003cem\u003efidelity\u003c/em\u003e is the desired outcome, ensuring consistent and accurate application of HTN management techniques, such as blood pressure measurement and health education.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAlter Incentive/Allowance Structures for Community Health Workers:\u003c/strong\u003e One study conducted in Bangladesh, Pakistan, and Sri Lanka identified compensation for additional tasks as a potential facilitator,\u003csup\u003e46\u003c/sup\u003e while another study from China indicated that the current incentives are insufficient,\u003csup\u003e66\u003c/sup\u003e suggesting that an increase in compensation may improve implementation. We suggest working in collaboration with health facilities to incentivize CHWs to engage actively in the program, such as with additional financial compensation. By providing additional incentives, we aim to address the barriers of a high workload and conflicting priorities of CHWs. The implementation outcome aims for improved \u003cem\u003eadoption\u0026nbsp;\u003c/em\u003eof the intervention and \u003cem\u003efidelity\u003c/em\u003e of delivery, ensuring CHWs participate actively in the program.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConduct Ongoing Training for Health Care Providers:\u003c/strong\u003e One study indicated that an intervention would be more effective if HCPs, such as physicians, nurses, pharmacists, and other members of the primary care team, provided public support of the programming and the work of the CHWs specifically to address skepticism and resistance of community members.\u003csup\u003e70\u003c/sup\u003e Training targeted to HCPs to enhance buy-in for adopting and championing the program, as well as training on providing support to CHWs working in the field is necessary. We recommend in-facility one-day training sessions for HCPs on HTN management and CHW programs, addressing the barrier of trust in the CHWs, the program, and the larger medical system. The implementation outcome sought is \u003cem\u003efidelity\u0026nbsp;\u003c/em\u003eof the program, ensuring HCPs possess necessary skills and knowledge to support the CHWs effectively.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAudit and provide feedback: \u0026nbsp;\u003c/strong\u003eOne study identified a need for new referral pathways that support linking CHWs to HCWs to allow for improved record keeping for patients.\u003csup\u003e68\u003c/sup\u003e Health facilities are responsible for modifying health record systems to allow better monitoring of implementation and clinical outcomes. This addresses the barrier of a lack of sufficient healthcare records for HTN patients. Improved\u003cem\u003e\u0026nbsp;fidelity\u003c/em\u003e is the desired outcome, ensuring accurate and comprehensive data tracking to monitor and evaluate program effectiveness.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eUse Advisory Boards and Workgroups:\u003c/strong\u003e Another way to address skepticism and resistance of community members, as well as buy-in from the health system is to engage stakeholders at multiple levels. We propose to leverage existing or create new formal stakeholder groups to provide input and advice on implementation efforts. This addresses the barrier of the health system\u0026apos;s conflicting priorities. The desired outcome is \u003cem\u003eadoption\u003c/em\u003e, ensuring stakeholders\u0026apos; involvement and commitment to program improvements.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"DISCUSSION AND CONCLUSION","content":"\u003cp\u003eHTN is the leading cause of CVD and stroke, themselves the leading causes of mortality around the world. Currently, available programs have not been able to mitigate the burden, with HTN rates rising in low- and middle-income countries, especially in Asia. Community Health Workers (CHWs) have been known to play a critical role in Bangladesh, China, India, and Nepal, where limited resources constrain health systems. An evidence-based CHW intervention, if implemented effectively by reaching the target population, being adopted by the health system, and being delivered with high fidelity, is likely to improve HTN management, bring positive clinical changes in real-world settings, and has the potential for sustainable integration into the health system.\u003c/p\u003e\n\u003cp\u003eThe intervention and implementation strategies laid out here consist of multiple components. While the intervention and strategies have been independently identified as useful in the literature, no studies have investigated the most effective or cost-effective configuration of these components for a CHW-led HTN intervention. Optimization studies that focus on how these components can be combined and what strength of their delivery best balances benefits and costs needs further investigation in rigorous trials, using designs such as the Multiphase Optimization Strategy (MOST)\u003csup\u003e81,82\u003c/sup\u003e and Learn As You Go (LAGO).\u003csup\u003e83,84\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur team of investigators has diverse training and expertise and includes representation from multiple institutions and countries. This interdisciplinary perspective strengthens the potential applicability of the recommendations in this article. Unlike other reviews that focus solely on clinical outcomes, this article applies an implementation science lens, identifying modifiable barriers and proposing evidence-based strategies to enhance CHW-led interventions. This makes it particularly useful for policymakers and practitioners. Additionally, this article tailors its analysis to four Asian countries with similar healthcare structures, providing relevant, context-driven insights that can inform regional policies and adaptation in LMIC. We go beyond identifying challenges by offering concrete solutions, drawing from the COM-B model and ERIC framework to suggest five actionable implementation strategies.\u003c/p\u003e\n\u003cp\u003eThere are some limitations to highlight. First, we selected implementation strategies to address barriers that we identified as modifiable. Other barriers, such as cultural and social norms within the community may hinder patient engagement. Lack of trust in the medical system was discussed above, but additional factors include traditional gender roles and familial structures, social norms, dietary norms, and environmental concerns. In addition to engaging stakeholders at multiple levels, we suggest addressing this challenge by tailoring interventions to specific cultural contexts, with awareness that what works in one community may not be appropriate or acceptable in another.\u003c/p\u003e\n\u003cp\u003eThis article arises from the perspective of the authors and is based on our own experiences in these countries. Other scientists and practitioners with expertise in these or other country contexts may identify other interventions, barriers, or strategies to address HTN control. Additionally, our review is not systematic, and it is possible that we missed important published or unpublished literature that may have informed our perspective. However, we provide a thorough review of published CHW-led hypertension interventions, synthesizing evidence from multiple studies to highlight key components of interventions, packages likely to be successful.\u003c/p\u003e\n\u003cp\u003eThere is a need to conduct cross-country interdisciplinary research to address important contextual gaps in HTN detection and linkage to care, treatment, and control in Asia. A comprehensive research program should include (1) clear, specific, and measurable objectives to measure (a) implementation outcomes, (b) effectiveness outcomes, and (c) economic sustainability while ensuring harmonization through a central theme of community health worker (CHW)--led management and common scientific core, tied together through relevant implementation science theories, models, and frameworks; (2) pooling data to identify the most effective and efficient interventions and strategies to accelerate the translation of research findings into sustainable real-world applications; and (3) joint capacity building across countries. HTN is the number one risk factor for disability and death worldwide,\u003csup\u003e5\u003c/sup\u003e and is largely preventable and intervenable through known evidence-based interventions - implementation science is needed to put these interventions into practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHTN\u0026nbsp; \u0026nbsp; \u0026nbsp;Hypertension\u003c/p\u003e\n\u003cp\u003eLMIC\u0026nbsp; \u0026nbsp;Low- and middle-income country\u003c/p\u003e\n\u003cp\u003eSBP\u0026nbsp; \u0026nbsp; \u0026nbsp;Systolic blood pressure\u003c/p\u003e\n\u003cp\u003eDBP\u0026nbsp; \u0026nbsp;\u0026nbsp;Diastolic blood pressure\u003c/p\u003e\n\u003cp\u003eHIC\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;High-income country\u003c/p\u003e\n\u003cp\u003eCVD\u0026nbsp; \u0026nbsp;\u0026nbsp;Cardiovascular disease\u003c/p\u003e\n\u003cp\u003eBP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Blood pressure\u003c/p\u003e\n\u003cp\u003eDALY\u0026nbsp;\u0026nbsp;Disability-adjusted life year\u003c/p\u003e\n\u003cp\u003eCHW\u0026nbsp; \u0026nbsp;Community health worker\u003c/p\u003e\n\u003cp\u003eNCD\u0026nbsp; \u0026nbsp;\u0026nbsp;Non-communicable disease\u003c/p\u003e\n\u003cp\u003eASHA\u0026nbsp;\u0026nbsp;Accredited social health activist\u003c/p\u003e\n\u003cp\u003eHCP\u0026nbsp; \u0026nbsp;\u0026nbsp;Health care provider\u003c/p\u003e\n\u003cp\u003eERIC\u0026nbsp; \u0026nbsp;Expert recommendations for implementing change\u003c/p\u003e\n\u003cp\u003eMOST\u0026nbsp;\u0026nbsp;Multiphase optimization strategy\u003c/p\u003e\n\u003cp\u003eLAGO\u0026nbsp;\u0026nbsp;Learn as you go\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and material\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAS and DS conceived of the manuscript. AS drafted the outline. AKP conducted the literature search and drafted the manuscript. All authors reviewed the drafted manuscript and provided editorial feedback. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the Center for Implementation and Prevention Science at Yale University and the Female Community Health Volunteers Led Hypertension Prevention and Control in Nepal project (NCT06163859).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYusuf S, Joseph P, Rangarajan S, et al. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet. 2020;395(10226):795\u0026ndash;808. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(19)32008-2\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(19)32008-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirhanu MM, Zaman SB, Thrift AG, Evans RG, Zengin A. Risk factors for incident cardiovascular events among adults in low- and middle-income countries: A systematic review and meta-analysis of prospective cohort studies. Prev Med. 2022;158:107036. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ypmed.2022.107036\u003c/span\u003e\u003cspan address=\"10.1016/j.ypmed.2022.107036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoth GA, Mensah GA, Johnson CO, et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990\u0026ndash;2019. J Am Coll Cardiol. 2020;76(25):2982\u0026ndash;3021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacc.2020.11.010\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2020.11.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray CJL, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1223\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(20)30752-2\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(20)30752-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStanaway JD, Afshin A, Gakidou E, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990\u0026ndash;2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1923\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(18)32225-6\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(18)32225-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMills KT, Bundy JD, Kelly TN, et al. Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-Based Studies From 90 Countries. Circulation. 2016;134(6):441\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIRCULATIONAHA.115.018912\u003c/span\u003e\u003cspan address=\"10.1161/CIRCULATIONAHA.115.018912\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Report on Hypertension: The Race against a Silent Killer. World Health Organization; 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240081062\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240081062\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou B, Bentham J, Di Cesare M, et al. Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19\u0026middot;1 million participants. Lancet. 2017;389(10064):37\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(16)31919-5\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(16)31919-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou B, Carrillo-Larco RM, Danaei G, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398(10304):957\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(21)01330-1\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(21)01330-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeaney T, Schutte AE, Stergiou GS, et al. May Measurement Month 2019: The Global Blood Pressure Screening Campaign of the International Society of Hypertension. Hypertension. 2020;76(2):333\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/HYPERTENSIONAHA.120.14874\u003c/span\u003e\u003cspan address=\"10.1161/HYPERTENSIONAHA.120.14874\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan MN, Oldroyd JC, Chowdhury EK, et al. Prevalence, awareness, treatment, and control of hypertension in Bangladesh: Findings from National Demographic and Health Survey, 2017\u0026ndash;2018. J Clin Hypertens. 2021;23(10):1830\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jch.14363\u003c/span\u003e\u003cspan address=\"10.1111/jch.14363\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Yang L, Wang L, et al. Burden of hypertension in China: A nationally representative survey of 174,621 adults. Int J Cardiol. 2017;227:516\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijcard.2016.10.110\u003c/span\u003e\u003cspan address=\"10.1016/j.ijcard.2016.10.110\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarghese JS, Venkateshmurthy NS, Sudharsanan N, et al. Hypertension Diagnosis, Treatment, and Control in India. JAMA Netw Open. 2023;6(10):e2339098. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2023.39098\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2023.39098\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhungana RR, Pedisic Z, Dhimal M, Bista B, De Courten M. Hypertension screening, awareness, treatment, and control: a study of their prevalence and associated factors in a nationally representative sample from Nepal. Global Health Action. 2022;15(1):2000092. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/16549716.2021.2000092\u003c/span\u003e\u003cspan address=\"10.1080/16549716.2021.2000092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAb Majid NL, Omar MA, Khoo YY, et al. Prevalence, Awareness, Treatment and Control of hypertension in the Malaysian population: findings from the National Health and Morbidity Survey 2006\u0026ndash;2015. J Hum Hypertens. 2018;32(8\u0026ndash;9):617\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41371-018-0082-x\u003c/span\u003e\u003cspan address=\"10.1038/s41371-018-0082-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFryar C, Kit B, Carroll M, Afful J. Hypertension Prevalence, Awareness, Treatment, and Control among Adults Age 18 and Older: United States, August 2021\u0026ndash;August 2023. National Center for Health Statistics (U.S.); 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15620/cdc/164016\u003c/span\u003e\u003cspan address=\"10.15620/cdc/164016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1\u0026middot;25 million people. Lancet. 2014;383(9932):1899\u0026ndash;911. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(14)60685-1\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(14)60685-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKokubo Y, Iwashima Y. Higher Blood Pressure as a Risk Factor for Diseases Other Than Stroke and Ischemic Heart Disease. Hypertension. 2015;66(2):254\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/HYPERTENSIONAHA.115.03480\u003c/span\u003e\u003cspan address=\"10.1161/HYPERTENSIONAHA.115.03480\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol. 2021;18(11):785\u0026ndash;802. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41569-021-00559-8\u003c/span\u003e\u003cspan address=\"10.1038/s41569-021-00559-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy A, Palafox B, Walli-Attaei M, et al. The household economic burden of non-communicable diseases in 18 countries. BMJ Glob Health. 2020;5(2):e002040. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjgh-2019-002040\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2019-002040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang D, Wang G, Zhang P, Fang J, Ayala C. Medical Expenditures Associated With Hypertension in the U.S., 2000\u0026ndash;2013. Am J Prev Med. 2017;53(6):S164\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amepre.2017.05.014\u003c/span\u003e\u003cspan address=\"10.1016/j.amepre.2017.05.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGheorghe A, Griffiths U, Murphy A, Legido-Quigley H, Lamptey P, Perel P. The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review. BMC Public Health. 2018;18(1):975. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-018-5806-x\u003c/span\u003e\u003cspan address=\"10.1186/s12889-018-5806-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16(4):223\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41581-019-0244-2\u003c/span\u003e\u003cspan address=\"10.1038/s41581-019-0244-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLeod KE, Ye Z, Donald B, Wang G. A Literature Review of Productivity Loss Associated with Hypertension in the United States. Popul Health Manage. 2022;25(3):297\u0026ndash;308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/pop.2021.0201\u003c/span\u003e\u003cspan address=\"10.1089/pop.2021.0201\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloom DE, Cafiero ET, Jan\u0026eacute;-Llopis E et al. \u003cem\u003eThe Global Economic Burden of Non-Communicable Diseases\u003c/em\u003e.; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuengo-Fernandez R, Little M, Gray A, et al. Cardiovascular disease burden due to productivity losses in European Society of Cardiology countries. Eur Heart J - Qual Care Clin Outcomes. 2024;10(1):36\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ehjqcco/qcad031\u003c/span\u003e\u003cspan address=\"10.1093/ehjqcco/qcad031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaimoli JF, Frymus DE, Wuliji T, Franco LM, Newsome MH. A Community Health Worker logic model: towards a theory of enhanced performance in low- and middle-income countries. Hum Resour Health. 2014;12(1):56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1478-4491-12-56\u003c/span\u003e\u003cspan address=\"10.1186/1478-4491-12-56\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodgins S, Lehmann U, Perry H et al. Comparing apples with apples: A proposed taxonomy for Community Health Workers and other front-line health workers for international comparisons. Probandari A, ed. \u003cem\u003ePLOS Glob Public Health\u003c/em\u003e. 2025;5(2):e0004156. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgph.0004156\u003c/span\u003e\u003cspan address=\"10.1371/journal.pgph.0004156\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSripad P, Gottert A, Abuya T et al. Confirming\u0026mdash;and testing\u0026mdash;bonds of trust: A mixed methods study exploring community health workers\u0026rsquo; experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya. Probandari A, ed. \u003cem\u003ePLOS Glob Public Health\u003c/em\u003e. 2022;2(10):e0000595. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgph.0000595\u003c/span\u003e\u003cspan address=\"10.1371/journal.pgph.0000595\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra A. Trust and teamwork matter\u0026rsquo;: Community health workers\u0026rsquo; experiences in integrated service delivery in India. Glob Public Health. 2014;9(8):960\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17441692.2014.934877\u003c/span\u003e\u003cspan address=\"10.1080/17441692.2014.934877\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry HB, Zulliger R, Rogers MM. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness. Annu Rev Public Health. 2014;35(1):399\u0026ndash;421. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1146/annurev-publhealth-032013-182354\u003c/span\u003e\u003cspan address=\"10.1146/annurev-publhealth-032013-182354\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Hum Resour Health. 2016;14(1):65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12960-016-0163-2\u003c/span\u003e\u003cspan address=\"10.1186/s12960-016-0163-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra SR, Neupane D, Preen D, Kallestrup P, Perry HB. Mitigation of non-communicable diseases in developing countries with community health workers. Global Health. 2015;11(1):43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12992-015-0129-5\u003c/span\u003e\u003cspan address=\"10.1186/s12992-015-0129-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra SR, Lygidakis C, Neupane D, et al. Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature. Health Policy Plann. 2019;34(1):55\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/heapol/czy099\u003c/span\u003e\u003cspan address=\"10.1093/heapol/czy099\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeupane D, Kallestrup P, McLachlan CS, Perry H. Community health workers for non-communicable diseases. Lancet Global Health. 2014;2(10):e567. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(14)70303-1\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(14)70303-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshi R, Alim M, Kengne AP et al. Task Shifting for Non-Communicable Disease Management in Low and Middle Income Countries \u0026ndash; A Systematic Review. Moormann AM, ed. \u003cem\u003ePLoS ONE\u003c/em\u003e. 2014;9(8):e103754. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0103754\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0103754\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeet G, Thakur JS, Prinja S, Singh M. Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. Maulik PK. ed PLoS ONE. 2017;12(7):e0180640. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0180640\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0180640\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWidyasari V, Rahman FF, Lin KH, Wang JY. The Effectiveness of Health Services Delivered by Community Health Workers on Outcomes Related to Non-Communicable Diseases among Elderly People in Rural Areas: A Systematic Review. \u003cem\u003eijph\u003c/em\u003e. Published online June 15, 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18502/ijph.v50i6.6408\u003c/span\u003e\u003cspan address=\"10.18502/ijph.v50i6.6408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim K, Choi JS, Choi E, et al. Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review. Am J Public Health. 2016;106(4):e3\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2015.302987\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2015.302987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlaof\u0026egrave; H, Asaolu I, Ehiri J, et al. Community Health Workers in Diabetes Prevention and Management in Developing Countries. Annals Global Health. 2017;83(3\u0026ndash;4):661. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.aogh.2017.10.009\u003c/span\u003e\u003cspan address=\"10.1016/j.aogh.2017.10.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in Low- and Middle-Income Countries. Circul Res. 2021;128(7):808\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIRCRESAHA.120.318729\u003c/span\u003e\u003cspan address=\"10.1161/CIRCRESAHA.120.318729\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMbuthia GW, Magutah K, Pellowski J. Approaches and outcomes of community health worker\u0026rsquo;s interventions for hypertension management and control in low-income and middle-income countries: systematic review. BMJ Open. 2022;12(4):e053455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2021-053455\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021-053455\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshi R, Agrawal T, Fathima F, et al. Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial. Am Heart J. 2019;216:9\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ahj.2019.06.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ahj.2019.06.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJafar TH, Gandhi M, De Silva HA, et al. A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med. 2020;382(8):717\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa1911965\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1911965\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJahan Y, Rahman MM, Faruque ASG, et al. Awareness Development and Usage of Mobile Health Technology Among Individuals With Hypertension in a Rural Community of Bangladesh: Randomized Controlled Trial. J Med Internet Res. 2020;22(12):e19137. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2196/19137\u003c/span\u003e\u003cspan address=\"10.2196/19137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJafar TH, Silva AD, Naheed A, et al. Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka feasibility trial results. J Hypertens. 2016;34(9):1872\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/HJH.0000000000001014\u003c/span\u003e\u003cspan address=\"10.1097/HJH.0000000000001014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun Y, Mu J, Wang DW, et al. A village doctor-led multifaceted intervention for blood pressure control in rural China: an open, cluster randomised trial. Lancet. 2022;399(10339):1964\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(22)00325-7\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(22)00325-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhetan A, Zullo M, Rani A et al. Effect of a Community Health Worker-Based Approach to Integrated Cardiovascular Risk Factor Control in India: A Cluster Randomized Controlled Trial. \u003cem\u003egh\u003c/em\u003e. 2019;14(4):355. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gheart.2019.08.003\u003c/span\u003e\u003cspan address=\"10.1016/j.gheart.2019.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeupane D, McLachlan CS, Mishra SR, et al. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. Lancet Global Health. 2018;6(1):e66\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(17)30411-4\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(17)30411-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGamage DG, Riddell MA, Joshi R et al. Effectiveness of a scalable group-based education and monitoring program, delivered by health workers, to improve control of hypertension in rural India: A cluster randomised controlled trial. Neupane D, ed. \u003cem\u003ePLoS Med\u003c/em\u003e. 2020;17(1):e1002997. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.1002997\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.1002997\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhattarai S, Skovlund E, Shrestha A, Mj\u0026oslash;lstad BP, \u0026Aring;svold BO, Sen A. Impact of a community health worker led intervention for improved blood pressure control in urban Nepal: an open-label cluster randomised controlled trial. Lancet Reg Health - Southeast Asia. 2024;29:100461. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.lansea.2024.100461\u003c/span\u003e\u003cspan address=\"10.1016/j.lansea.2024.100461\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuseela P, Ambika R, Mohandas RB. Effectiveness of a community-based education and peer support led by women\u0026rsquo;s self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial. BMJ Glob Health. 2022;7(11):e010296. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjgh-2022-010296\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2022-010296\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian M, Ajay VS, Dunzhu D, et al. A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, India. Circulation. 2015;132(9):815\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIRCULATIONAHA.115.015373\u003c/span\u003e\u003cspan address=\"10.1161/CIRCULATIONAHA.115.015373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePakhare A, Joshi A, Anwar R, et al. Linkage to primary-care public health facilities for cardiovascular disease prevention: a community-based cohort study from urban slums in India. BMJ Open. 2021;11(8):e045997. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2020-045997\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2020-045997\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajaa S, Sahu S, Thulasingam M. Contribution of community health care volunteers in facilitating mobilization for diabetes and hypertension screening among the general population residing in urban puducherry \u0026ndash; An operational research study. J Family Med Prim Care. 2022;11(2):638. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/jfmpc.jfmpc_1316_21\u003c/span\u003e\u003cspan address=\"10.4103/jfmpc.jfmpc_1316_21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNi Z, Atluri N, Shaw RJ, et al. Evaluating the Feasibility and Acceptability of a Mobile Health\u0026ndash;Based Female Community Health Volunteer Program for Hypertension Control in Rural Nepal: Cross-Sectional Study. JMIR Mhealth Uhealth. 2020;8(3):e15419. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2196/15419\u003c/span\u003e\u003cspan address=\"10.2196/15419\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg S, Dewangan M, Nanda P, et al. Impact of community health workers on improving identification and primary care of hypertension among the urban poor \u0026ndash; findings from Chhattisgarh state of India. BMC Prim Care. 2023;24(1):272. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12875-023-02231-1\u003c/span\u003e\u003cspan address=\"10.1186/s12875-023-02231-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng L, Jehan I, De Silva HA, et al. Effect of a Multicomponent Intervention on Antihypertensive Medication Intensification in Rural South Asia: \u003cem\u003ePost Hoc\u003c/em\u003e Analysis of a Cluster RCT. Am J Hypertens. 2021;34(9):981\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ajh/hpab072\u003c/span\u003e\u003cspan address=\"10.1093/ajh/hpab072\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKondal D, Jeemon P, Manimunda S, et al. Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study). J Am Heart Assoc. 2022;11(6):e023526. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/JAHA.121.023526\u003c/span\u003e\u003cspan address=\"10.1161/JAHA.121.023526\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhanal MK, Bhandari P, Dhungana RR et al. Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial. Fukumoto Y, ed. \u003cem\u003ePLoS ONE\u003c/em\u003e. 2021;16(10):e0258406. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0258406\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0258406\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhattarai S, Bajracharya S, Shrestha A, et al. Facilitators and barriers to hypertension management in urban Nepal: findings from a qualitative study. Open Heart. 2023;10(2):e002394. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/openhrt-2023-002394\u003c/span\u003e\u003cspan address=\"10.1136/openhrt-2023-002394\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJafar TH, Tavajoh S, De Silva HA et al. Post-intervention acceptability of multicomponent intervention for management of hypertension in rural Bangladesh, Pakistan, and Sri Lanka- a qualitative study. Azmat SK, ed. \u003cem\u003ePLoS ONE\u003c/em\u003e. 2023;18(1):e0280455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0280455\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0280455\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong H, Huang W, Zheng P, et al. Barriers and Facilitators of Engaging Community Health Workers in Non-Communicable Disease (NCD) Prevention and Control in China: A Systematic Review (2006\u0026ndash;2016). IJERPH. 2018;15(11):2378. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph15112378\u003c/span\u003e\u003cspan address=\"10.3390/ijerph15112378\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRawal LB, Kharel C, Yadav UN, et al. Community health workers for non-communicable disease prevention and control in Nepal: a qualitative study. BMJ Open. 2020;10(12):e040350. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2020-040350\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2020-040350\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShrivastava R, Sharma L, Jolly M, et al. We are everyone\u0026rsquo;s ASHAs but who\u0026rsquo;s there for us? a qualitative exploration of perceptions of work stress and coping among rural frontline workers in Madhya Pradesh, India. Soc Sci Med. 2023;336:116234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2023.116234\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2023.116234\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian M, Yin X, Dunzhu D, et al. A qualitative evaluation of a simplified cardiovascular management program in Tibet, China. Global Health. 2018;14(1):24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12992-018-0342-0\u003c/span\u003e\u003cspan address=\"10.1186/s12992-018-0342-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan J, Xu H, Fan Q, et al. Hypertension Care Coordination and Feasibility of Involving Female Community Health Volunteers in Hypertension Management in Kavre District, Nepal: A Qualitative Study. Global Heart. 2020;15(1):73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5334/gh.872\u003c/span\u003e\u003cspan address=\"10.5334/gh.872\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevitt NS, Puoane T, Denman CA, et al. Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa. Global Health Action. 2015;8(1):26318. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3402/gha.v8.26318\u003c/span\u003e\u003cspan address=\"10.3402/gha.v8.26318\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRawal L, Jubayer S, Choudhury SR, Islam SMS, Abdullah AS. Community health workers for non-communicable diseases prevention and control in Bangladesh: a qualitative study. glob health res policy. 2021;6(1):1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s41256-020-00182-z\u003c/span\u003e\u003cspan address=\"10.1186/s41256-020-00182-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchierhout G, Praveen D, Patel B, et al. Why do strategies to strengthen primary health care succeed in some places and fail in others? Exploring local variation in the effectiveness of a community health worker managed digital health intervention in rural India. BMJ Glob Health. 2021;6(Suppl 5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjgh-2021-005003\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2021-005003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLall D, Engel N, Devadasan N, Horstman K, Criel B. Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India. BMC Health Serv Res. 2019;19(1):44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-019-3876-9\u003c/span\u003e\u003cspan address=\"10.1186/s12913-019-3876-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeters MA, Alonge O, Edward A, et al. Barriers to effective hypertension management in rural Bihar, India: A cross-sectional, linked supply- and demand-side study. PLOS Glob Public Health. 2022;2(10):e0000513. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgph.0000513\u003c/span\u003e\u003cspan address=\"10.1371/journal.pgph.0000513\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIslam MN, Karim MM, Inan TT, Islam AKMN. Investigating usability of mobile health applications in Bangladesh. BMC Med Inf Decis Mak. 2020;20(1):19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12911-020-1033-3\u003c/span\u003e\u003cspan address=\"10.1186/s12911-020-1033-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhandari B, Schutte AE, Jayasuriya R, Vaidya A, Subedi M, Narasimhan P. Acceptability of a mHealth strategy for hypertension management in a low-income and middle-income country setting: a formative qualitative study among patients and healthcare providers. BMJ Open. 2021;11(11):e052986. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2021-052986\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021-052986\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta S, Dhamija JP, Mohan I, Gupta R. Qualitative Study of Barriers to Adherence to Antihypertensive Medication among Rural Women in India. Int J Hypertens. 2019;2019:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2019/5749648\u003c/span\u003e\u003cspan address=\"10.1155/2019/5749648\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDey S, Mukherjee A, Pati MK, et al. Socio-demographic, behavioural and clinical factors influencing control of diabetes and hypertension in urban Mysore, South India: a mixed-method study conducted in 2018. Arch Public Health. 2022;80(1):234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13690-022-00996-y\u003c/span\u003e\u003cspan address=\"10.1186/s13690-022-00996-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJindal D, Sharma H, Gupta Y, et al. Improving care for hypertension and diabetes in india by addition of clinical decision support system and task shifting in the national NCD program: I-TREC model of care. BMC Health Serv Res. 2022;22(1):688. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12913-022-08025-y\u003c/span\u003e\u003cspan address=\"10.1186/s12913-022-08025-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShelton RC, Chambers DA, Glasgow RE. An Extension of RE-AIM to Enhance Sustainability: Addressing Dynamic Context and Promoting Health Equity Over Time. Front Public Health. 2020;8:134. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2020.00134\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2020.00134\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichie S, Van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1748-5908-6-42\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-6-42\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10(1):21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13012-015-0209-1\u003c/span\u003e\u003cspan address=\"10.1186/s13012-015-0209-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollins LM, Murphy SA, Strecher V. The Multiphase Optimization Strategy (MOST) and the Sequential Multiple Assignment Randomized Trial (SMART). Am J Prev Med. 2007;32(5):S112\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amepre.2007.01.022\u003c/span\u003e\u003cspan address=\"10.1016/j.amepre.2007.01.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollins LM, Nahum-Shani I, Almirall D. Optimization of behavioral dynamic treatment regimens based on the sequential, multiple assignment, randomized trial (SMART). Clin Trails. 2014;11(4):426\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1740774514536795\u003c/span\u003e\u003cspan address=\"10.1177/1740774514536795\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNevo D, Lok JJ, Spiegelman D. Analysis of learn-as-you-go (LAGO) studies. Ann Statist. 2021;49(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1214/20-AOS1978\u003c/span\u003e\u003cspan address=\"10.1214/20-AOS1978\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBing A, Spiegelman D, Nevo D, Lok JJ. Learn-As-you-GO (LAGO) Trials: Optimizing Treatments and Preventing Trial Failure Through Ongoing Learning. Published online 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.48550/ARXIV.2307.06552\u003c/span\u003e\u003cspan address=\"10.48550/ARXIV.2307.06552\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Community Health Workers, Global Health, Asia, Implementation Science, Health Systems","lastPublishedDoi":"10.21203/rs.3.rs-6406093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6406093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLow- and middle-income countries in Asia are experiencing a rapidly increasing prevalence of hypertension, yet they have some of the lowest rates of hypertension detection, treatment, and control in the world. Thus, the implementation of effective evidence-based interventions for hypertension is urgently needed. Focusing on four Asian countries \u0026ndash; Bangladesh, China, India, and Nepal \u0026ndash; this perspective article aims to: 1) Review evidence of the effectiveness of community health worker (CHW)-led interventions for hypertension control, 2) Highlight the key components of effective interventions, 3) Identify barriers to implementation, and 4) Select implementation strategies to overcome modifiable barriers. Our review suggests that CHW-led interventions have resulted in significant reduction in blood pressure in all countries and in varying context within these, as well as in reducing hypertension risk factors, including unhealthy diets, physical inactivity, and tobacco use, improving detection and linkage to care for newly diagnosed hypertension participants, and increasing medication uptake and blood pressure control in individuals with hypertension. Key components of effective interventions include blood pressure screening, linkage to primary care, and regular follow-up visits that incorporate blood pressure monitoring, health education, care follow-up, counseling, and support for medication adherence. Modifiable barriers to successful implementation of the intervention include CHWs\u0026rsquo; high workload, CHWs\u0026rsquo; low knowledge and skills for hypertension management, lack of supportive supervision, shortcomings of medical record system for hypertensive individuals, conflicting priorities in the health system for disease management, and patients\u0026rsquo; lack of trust in the medical system. We selected five implementation strategies to address these barriers: conduct ongoing training for CHWs, modify incentive/allowance structures, conduct ongoing training for health care providers, audit and provide feedback, and use advisory boards and workgroups. There is a need for trials that test bundles of strategies for implementation of a CHW-led hypertension control program in these four countries and beyond.\u003c/p\u003e","manuscriptTitle":"Community Health Worker-Based Strategies for Hypertension Management in the Asian Context","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 18:55:38","doi":"10.21203/rs.3.rs-6406093/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a1dacc7-3a35-4ab8-b15f-0b685869bdb7","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-18T09:41:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 18:55:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6406093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6406093","identity":"rs-6406093","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}