Impact factor (WEB OF SCIENCE - Clarivate)

2 year: 7.664 | 5 year: 7.127

Articles

A systematic review and meta-analysis of the effectiveness of hypertension interventions in faith-based organisation settings

Kit Yee Chan1,2*†, Noori Srivastava3*, Zhicheng Wang4*, Xiaoqian Xia5, Zhangziyue Huang6, Adrienne N Poon3,3, Daniel D Reidpath2,7

1 Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
2 School of Social Sciences, Monash University, Clayton, Victoria, Australia
3 Department of Medicine, School of Medicine & Health Sciences, George Washington University, Washington DC, USA
4 China Development Research Foundation, Beijing, China
5 London School of Hygiene & Tropical Medicine, London, UK
6 Milken Institute School of Public Health, George Washington University, Washington DC, USA
7 Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
* Joint first authorship.
† Joint senior authorship.

DOI: 10.7189/jogh.13.04075

Share:

Facebook
Twitter
LinkedIn
Print Friendly, PDF & Email

Hypertension or high blood pressure (BP) is the global, leading cause of mortality and the main modifiable risk factor for cardiovascular disease [13], dementia [4], decline in kidney function [5] and severe illness and death from coronavirus disease 2019 (COVID-19) [68]. All these outcomes are associated with substantial health and economic costs as well as personal suffering. Hypertension can be prevented or managed through a series of interrelated strategies: (i) effective population measures that reduce population risk factors, (ii) hypertension awareness raising, (iii) screening and proper diagnosis, (iv) individual behaviour modification (e.g. diet, physical activity and tobacco use) and (v) improved access and adherence to medication [9,10]. Unfortunately, these strategies have not, at scale, successfully reached socio-economically marginalised populations [1113]. Access barriers include (i) limited health budgets for NCD services that severely limit service availability, (ii) shortages of drugs and human resources (especially physicians) and (iii) a pervasive distrust of the health care system [1416]. Finding low-cost strategies to improve service provision has become even more critical, considering the rising global noncommunicable disease (NCD) burden and the rapidly rising global economic pressure that further threatens the already lean health service budgets.

One effective, cost-saving strategy, is to shift certain primary and secondary hypertension prevention tasks (e.g. blood pressure screening, monitoring, health education, behavioural coaching) from physicians to allied health professionals (e.g. nurses, pharmacists) and/or trained members of the community [1719]. Although various task-shifting models have emerged in the literature, much of the innovation relies on strategies for reaching diverse, underserved populations at locations where there is established trust between service providers and the populations [11,20]. The use of barbershops for hypertension intervention among African American males, in the US, is a case in point [21]. Other community sites for hypertension intervention include pharmacies [22] and community centres [23,24].

The potential of task-shifting has been illustrated in several recent systematic reviews and meta-analyses [18,25,26]. These reviews have shown significant mean BP reduction, in low-resource settings. With an estimated 84% of the world population being religiously affiliated [27] and with the long association of faith-based organisations (FBOs) with health care provision [28], FBOs stand out as potentially important partners for community-based BP intervention. In addition to their presence in some of the most socio-economically disadvantaged communities and their established trust within those communities, FBOs have resource advantages that may complement limited health sector resources [18,29]. These advantages include additional modes of financing and additional assets, such as human capital assets of paid staff and volunteers. Recent studies have shown the potential benefits of adapting community-based hypertension interventions to FBO settings [30,31]. However, the strength of the evidence has not been evaluated in aggregate, such as with meta-analyses [18,25,26].

Understanding the multi-faceted, complex factors and challenges or lessons-learned from FBO-based interventions would support development and evolution of models to guide future research and implementation of these interventions. This is best done using a systematic review of the literature. Thus, this systematic review aims to explore the state of the evidence of FBO-based interventions on BP management with a focus on randomised controlled trials (RCTs) and cluster randomised controlled trials (C-RCTs). In assessing the state of the literature, attention will be paid to the geographic spread of the studies, the nature of FBO involvement in the studies, and the factors that might have affected intervention success.

METHODS

The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework (Materials 1 in the Online Supplementary Document).

Databases and search strategies

We conducted an extended search of the published literature, in English and Chinese using PubMed, EMBASE, PsycINFO, CINAHL, CNKI, SinoMed, and Google Scholar (first 100 hits). We focused on these seven English and Chinese academic databases due to resource constraints and the fact that they cover the vast majority of health sciences publications. Grey literature was also searched using The World Bank DataBank research paper repository and Google (first 100 titles). Searches were conducted using various combinations of the following search terms: “faith”/“region”-based, “hypertension”, “blood pressure”, “diabetes”, “cardiometabolic”/“cardiovascular” disease, “prevention”, “intervention”, “program”, “screening”, “education”, “health promotion”. Search criteria did not restrict publication date or language. Searches were conducted initially in July 2021 and updated for English and Chinese databases in July 2022 and June 2022, respectively. Materials 2 in the Online Supplementary Document details the search strategies for each database. English academic databases were independently searched by two reviewers (NS and ZH), while the Chinese databases were searched by ZCW.

Inclusion and exclusion criteria

Included publications contain all of the following: (i) a NCD intervention that reported baseline and post-intervention BP measures (e.g. health promotion, risk factor screening, prevention, coaching, counselling to health promotion intervention/programmes), (ii) an intervention delivered in FBO settings and/or by trained FBO workers (e.g. FBO-based nurses, lay volunteers), (iii) cluster or individual randomised control trial (C-/RCT) design; and (iv) published in any languages. Excluded studies had the following characteristics: (i) were not original research (e.g. viewpoints, conference abstracts, reviews), (ii) were not trial studies, (iii) did not contain blood pressure as an outcome measure, or (iv) contained interventions that were purely based on faith-related practices (e.g. rituals, prayers).

Quality assessment

Study quality was assessed for potential bias from randomisation, blinding, and outcome assessment using the NIH Study Quality Assessment Tool for Controlled Intervention Studies [32].

Data extraction

Two reviewers independently extracted data from the retained studies (NS and KYC). Extracted data included first author, publication year, setting, religion, study population, objectives and design, sample size, follow-up time, key intervention components, intervention duration and intensity, training and roles assigned to FBO staff, and BP measures at baseline and follow-up. Where BP outcome data were available for two follow-up periods, the longer follow-up period was used. Task-shifting to FBO workers was categorised into one of three levels, using the team-based care conceptual framework adapted from Ogungbe et al. [18]. The categories were: (i) administrative tasks, (ii) basic intervention tasks (e.g. taking BP measures, health promotion, education, counselling), and (iii) advanced intervention tasks (diagnosis, treatment initiation and titration). Disagreements about extracted data were moderated by ZC and XQ.

Data analysis

Meta-analysis of the pooled data was conducted from the eleven retained, randomised controlled trials using STATA version 16.0. Net changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP) for the intervention and control groups were calculated separately based on the differences between the mean, respective measures at baseline and follow-up, and the standard deviation (SD). In nine of the 11 retained studies for SBP, and eight of the 10 retained studies for DBP, standard deviations were calculated from the reported confidence intervals and standard errors using the formulae outlined in Higgins et al. [33]. In the two remaining studies where this information was not reported [34,35], we imputed the values based on the mean standard deviation of the other eight (DBP) and nine (SBP) studies.

We estimated the effective sample size of each study to take into account the intra-class correlation (ICC) and design effect, as outlined in Killip et al. [36]. With one exception [37], ICCs were not reported. For the studies that did not report ICCs, the base cases were given fixed ICCs of 0.05. A sensitivity analysis was also conducted using lower and upper bounds of 0.02 and 0.09, respectively. These three values were based on reported ICCs in the literature for blood pressure studies in community settings. Studies were weighted using the inverse variance method. Study heterogeneity was quantified using I2 and Q statistics. A series of random effects models, using restricted maximum likelihood estimation (REML), were developed to estimate the population average mean change and 95% CI of both SBP and DBP. The significance of findings was set at P < 0.05. To assess each study’s contribution towards the overall heterogeneity, a sensitivity analysis was conducted by successively adding studies and recording changes in heterogeneity. Prediction intervals were generated to capture the spread of the pooled effect across study settings.

Because the studies’ populations reflected different levels of clinical severity in hypertension, subgroup analyses were conducted. Studies were categorised into three subgroups based on the mean baseline BP: (i)>140 / 90 mm Hg; (ii) 130-139 / 80-89 mm Hg; (iii)<130 / 80 mm Hg. The subgroup corresponds to the categories of stage two hypertension and above, stage one hypertension, and alleviated blood pressure and below the ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults [10]. Individual study effects and pooled effects were visualised with forest plots. Publication bias was assessed graphically through funnel plot asymmetry and statistically via Egger’s regression test.

RESULTS

Study characteristics and the state of the evidence

The searches yielded a total of 19 055 titles. After discarding duplicates, 4279 titles were screened. 3867 titles and 233 abstracts were excluded for failure to meet the inclusion criteria. Of the 179 full texts screened, 168 were excluded (Figure 1). Seventeen studies were kept as candidates for meta-analysis. Of these, four did not contain analysable data. Two studies were re-categorised as pre- and post-intervention design studies and discarded because identical BP interventions were provided to both the intervention and control groups while the experimental group received an additional faith component (e.g. prayer, gospel music). Noticeably, all studies that met the eligibility criteria were published in English. The inclusion of databases in the Chinese language did not yield additional studies. Our quality assessment indicates that the 11 retained studies are of fair to good quality (Materials 3 in the Online Supplementary Document).

Figure 1. PRISMA flowchart showing search results and article selection. BP – blood pressure, C/RCT – cluster/randomised control trial

Table 1 summarises the key characteristics of the 11 studies kept for meta-analysis. All 11 studies were published in the last two decades (nine since 2010). The median sample size was 373 participants (range = 71-1257; interquartile range (IQR) = 660). The median intervention and follow-up duration were eight months (range = 1.5-15 months; IQR = 6.5 months) and 12 months (range = 4.5-15 months; IQR = 6 months), respectively. Despite the relatively large sample sizes of some of the studies, most contain interventions that had not been previously implemented in FBO settings. The recency of the publications and the pilot nature of the intervention together indicates the infancy of the evidence base for FBO-based BP interventions. Only two studies employed an individual RCT design, while the majority were C-RCTs, where randomisation occurred at the level of FBO. In one C-RCT [38], FBOs were first grouped into geographical regions prior to randomisation.

Table 1. Summary of the characteristics of the cluster-/randomised controlled trials included in the meta-analysis

WordPress Data Table

BP – blood pressure, SBP – systolic blood pressure, DBP – diastolic blood pressure, A1C – glycosylated haemoglobin, BG – blood glucose, BMI – body mass index, HDL – high-density lipoprotein, LDL – low-density lipoprotein, MAP – mean arterial pressure, PA – physical activity, TC – total cholesterol, TG – triglyceride, WC – waist circumference, WHR – waist-to-hip ratio

*Task-shifting levels: 1. administrative tasks (e.g. participant recruitment); 2. simple intervention that can be performed independently with limited training and/or supervision support (e.g. health education, taking blood measures); 3. intervention tasks that require extended clinical training, supervision/support (e.g. diagnosis, prescription).

†Blood Pressure is inclusive of SBP and DBP.

Ten of the 11 studies were conducted in the US and were designed as community outreach interventions for high-risk, underserved, socioeconomically marginalised populations. All ten studies were based on FBOs of different Christian denominations. Nine studies targeted ethnic minorities (African American = 9, Hispanic/Latino = 2). Only one study was conducted outside the US in a non-Christian setting [39]. Intervention goals varied considerably between studies. Three studies targeted participants with one or more NCDs (hypertension [40], diabetes [38], diabetes mellitus, or congestive heart failure [41]). One study targeted pre-hypertensive populations [39]. The remaining seven studies targeted the more general patron populations and/or patrons with specific risk factors (e.g. physically inactive patrons). Noticeably, only two studies had baseline BP cut-offs in their participant selection criteria [39,40]. Furthermore, BP reduction was a primary outcome in less than half of the studies, amongst other more intermediate outcomes such as weight loss, increase in physical activity and dietary changes. However, heterogeneity in the selection of outcome measures and reporting means has ruled out meta-analysis based on risk factors.

Studies varied considerably in terms of intervention durations (median (mdn) = 6 months; range = 1.5-12 months) and follow-up time (mdn = 6 months; range = 4.5-15 months). Two studies had an intensive phase and a maintenance phase [35,40].

Intervention components and intensity also varied considerably between studies (Table 1). Most interventions also had multiple components delivered through two or more methods that ranged from individual and/or group sessions, telephone sessions, dedicated websites, and SMS reminders to print materials. The common component that appeared across all 11 studies was healthy behaviour or lifestyle education, counselling or coaching aimed at reducing NCD risks. However, the risk factor(s) of focus varied between studies. Some targeted multiple risk factors, while others a single risk factor. Some interventions also had components dedicated to the improvement of health advocacy and self-management of the targeted disease. Some interventions had a more hands-on approach and incorporated health-promoting activities into structured group sessions, e.g. physical exercise [35,40], healthy recipe tasting [42]. Others relied on a more self-directed and peer-supported approach [43].

Most of the interventions (n = 10) targeted individual patrons, though some studies also actively encouraged changes at the organisational level to support individual behavioural changes. For instance, the promotion of healthy food to be served at FBO-based events [37,38,44]) and/or the planning of physical activities by FBO staff, e.g. walking groups [38]. The outlier is Wilcox et al. [37], which focused solely on intervention at the organisational level – educating delegates to deliver healthy meals at the FBOs. This outlier also had the largest number of participants (n = 1257).

Most studies (n = 9) assigned some basic intervention tasks to trained FBO staff (e.g. health education, coaching, counselling, BP measures; i.e. level 2 tasks under the team-based care conceptual framework). However, the extent of task-shifting and the specific tasks designated to FBO workers varied between studies. The level of support offered to FBO staff also varied. Several of these studies involved FBO staff in the development and adaptation of the interventions [38,44]. Two studies gave no indications of involving FBO members in the development and delivery of the interventions [35,39]. However, in one of the two studies, FBOs workers assisted in participant recruitment [35]. Information on the adequacy of training and support was not available in most papers.

Meta-analysis

For SBP, a non-significant average mean difference was found of -0.78 mm Hg (95% CI = -2.11 to 0.55), between baseline and follow-up for the intervention and control groups (Figure 2). The 95% prediction interval for the SBP pooled estimate was -2.32 to 0.76. There was no measurable study heterogeneity. Asymmetry was not detected in the funnel plots (Materials 4a in the Online Supplementary Document). In addition, Egger’s regression test did not indicate evidence of publication bias (t = 1.63; degrees of freedom (df) = 11; P = 0.139).

Figure 2. Estimates of the population average mean change and 95% confidence interval (CI) of systolic blood pressure (SBP) between intervention and control groups.

For DBP, a non-significant average mean difference was found of -0.20 mm Hg (95% CI = -1.16 to 0.75), between baseline and follow-up for the intervention and control groups (Figure 3). The 95% prediction interval for the DBP pooled estimate was -2.56 to 2.15. There was non-significant study heterogeneity (I2 = 42.2%; τ2 = 0.8; Q-statistic (Q) (9) = 14.07; P = 0.12). Asymmetry was not detected in the funnel plots (Materials 4b in the Online Supplementary Document). In addition, Egger’s regression test did not indicate evidence of publication bias (t = 0.71; df = 11; P = 0.495).

Figure 3. Estimates of the population average mean change and 95% confidence interval (CI) of diastolic blood pressure (DBP) between intervention and control groups.

Subgroup analyses of the SBP and DBP results were conducted. For SBP, the overall intervention effect was largely attributable to studies where the mean baseline SBP was greater than 140 mm Hg (-6.23 mm Hg; 95% CI = -11.21 to -1.25; I2 = 0.0%; P = 0.46) (Figure 4). Very little reduction in SBP was observed for studies where the mean SBP was less than 140 mgHg (-0.12 mm Hg; 95% CI = -2.08 to 1.84; I2 = 0.0%; P = 0.19), for studies with a mean baseline SBP measure of 130-139 mm Hg, (-0.60 mm Hg; 95% CI = -2.55 to 1.35; I2 = 0.0%; P = 0.75), and for studies with a mean baseline SBP measures under 130 mm Hg. No significant intervention effect was observed in any of the DBP subgroups (Figure 5).

Figure 4. Subgroup analyses based on baseline population mean systolic blood pressure of: (1)>140 mm Hg; (2) 130-139 mm Hg; (3)<130 mm Hg. mmHg – millimetres of mercury

Figure 5. Subgroup analyses based on baseline population mean diastolic blood pressure of: (1)>90 mm Hg; (2) 80-89 mm Hg; (3) 80 mm Hg. mmHg – millimetres of mercury

DISCUSSION

To our knowledge, this is the first systematic review and meta-analysis of the effect of interventions based in FBO settings on BP reduction. Our study did not find significant overall decreases in SBP or DBP levels. Although, a significant reduction in SBP was found in a subset of studies with a mean baseline population SBP level of ≥140 mm Hg (i.e. in those with clinical hypertension). Despite the non-significant overall effects, the direction of the findings is consistent with recent systematic reviews and meta-analyses on the effects of community-based interventions beyond FBO settings [18,25,26]. The weaker effect on BP reduction may be attributable to the lower mean baseline BP of the studies included in this current analysis, compared to previous meta-analyses. Previous studies have suggested that, especially with shorter-term interventions, intervention effects are often unstable for participants with baseline BP at the lower end of the spectrum [31]. Whilst only 18% of studies in the current review had a mean population SBP level of ≥140 mm Hg at baseline, 65% of the CHW-led interventions in the review by Anand et al. had a baseline population mean SBP of ≥140 mm Hg [25]. The proportion of studies with baseline population mean SBP level in the lower end of the BP spectrum was also much higher in our study (≥130 mm Hg = 36%; 120-129 mm Hg = 40%; >120 mm Hg = 5%), compared to the studies included in the aforementioned review (130-139 mm Hg = 13%; 120-129 mm Hg = 20%; <120 mm Hg = 2%).

A potential contributor to the low average population baseline BP of the studies retained in our review could be that most of these studies were primarily aimed at reducing risk factors in the general adult patrons rather than BP reduction in hypertensive patrons. Given the cumulative nature of NCD risks over the life course, the value of organisation-based interventions capable of altering members’ risk trajectories prior to the emergence of the disease cannot be understated. To enable a more informative meta-analysis of BP outcomes from such interventions, breakdowns of BP outcomes by participants’ baseline BP ranges would be required but are absent in the publications used in this review. Moreover, evaluations of interventions that target non-hypertensive patrons should not rely on BP outcomes alone but in conjunction with intermediate outcome measures, such as changes in risk factors (e.g. weights, dietary changes), disease knowledge, and self-advocacy in health-seeking. Unfortunately, even though most of the studies we identified had included such measures, heterogeneity in the selection and reporting of outcome measures prevented further analyses. For a more complete understanding of the potential of FBO-based intervention on NCD prevention, separate reviews on the effects on some of the more commonly used intermediate outcomes will be required.

Consistent with previous reviews, the tasks delegated to lay-FBO workers were mostly basic intervention tasks that did not require substantial training (e.g. health education, counselling, BP measures). Previous research has shown that while interventions assisted or led by trained community workers can lead to effective BP reduction, their effectiveness might be inferior to interventions led by allied health workers (e.g. dietitians, pharmacists) [18,25]. Most studies identified in our review have multiple components and involved a mix of trained FBO workers and allied health workers in the delivery of interventions. Further research will be needed to provide insights into which intervention components might be best delivered by trained FBO workers vs. allied health workers. To be truly effective, community-based interventions must be integrated within the wider health system, allowing participants with high BP to have easy access to medical consultation for diagnosis and prescriptions [17,18,25]. Unfortunately, most studies identified in our review appeared to be standalone interventions with no mentions of wider health system linkages – an issue that perhaps requires consideration in future studies.

Several other limitations of the evidence base and methodological issues require further elaboration. First, despite the comprehensiveness of our search strategies and databases, only eleven publications were identified globally. Aside from one study conducted in Thai Buddhist temples, all the other studies were conducted in Christian FBOs in a single high-income country – the US. The absence of FBO-based studies from China is understandable, considering China already has a three-tier health care delivery system with a well-established history of incorporating lower-order health professionals and trained community health workers (formerly known as “barefoot doctors”) into health promotion and disease prevention strategies [45]. The challenge for China has largely been the strengthening and transitioning of the already established system to NCD prevention and management, which has been a focus of recent NCD intervention strategies and intervention research [4648]. Furthermore, the insignificant roles of organised religions in the daily lives of ordinary Han Chinese (who make up 91.1% of the Chinese population) [49] also make FBOs less suitable for community-based NCD interventions. The potential for FBOs as partners in health promotion might be of higher value in ethnic minority populations, where organised religions have a greater presence.

More surprising, however, is the absence of studies from countries, besides the US, in which organised religions have much greater prominence (e.g. South Asian, African and Middle Eastern countries). The omission of academic databases in languages besides English and Chinese (e.g. LILACS) from the current review could have led to the oversight of studies published in other languages. However, what is evident is the lack of research in even English-speaking countries where there is a prominent FBO presence, such as in sub-Saharan Africa. Given the reach and resources available to the FBO sector and health budget shortages, especially in low- and middle-income countries (LMICs), the lack of health-religion cooperation in health research and service delivery could represent a missed opportunity for health outcome improvement [50].

Relative to previous reviews, the samples sizes of the studies identified in our review were considerably smaller – 30% (range = 71-1257) had ≥750 participants (range = 118-2397) compared to, for example, 90% of the CHW-led studies in Anand et al. [25]. Intervention duration and follow-up intervals were on average shorter in the studies used in our meta-analysis than those reported in previous reviews. While our quality assessment indicates the studies in our analyses to be of fair to good standards, the strength of our analysis was negatively affected by potential bias resulting from issues including unclear treatment allocation, concealment, drop-out rates and protocol adherence, and insufficient analysis and reporting in C-RCTs.

As mentioned earlier, the studies identified by our review varied considerably in intervention components, intensity, duration, follow-up intervals as well as the involvement, training, and support for FBO workers. To better understand the potential of FBOs as partners for community-based hypertension interventions, more research will be needed across more FBO settings, especially in countries with strong FBO presence. More research will also be required on the longer-term effects of successful FBO-based interventions as well as how some of the aforementioned factors affect hypertension and other intermittent intervention outcomes. Finally, this review only included evidence at the highest level (i.e. C/RCT). The inclusion of studies with other designs (e.g. quasi-experimental design) might have interesting insights into FBO-based intervention, or at the very least, provide additional data to supplement those identified in the current review.

CONCLUSIONS

This review provided support for the potential of FBO-based intervention in reducing blood pressure in hypertensive populations in the short term. However, more research is needed to understand the effects of such interventions in producing clinically meaningful long-term effects and the factors that affect their success. The current evidence base is inadequate for evaluating the potential of FBO-based interventions on hypertension prevention in non-hypertensive populations because intervention effects might be better reflected through intermediate outcomes.

Additional material

Online Supplementary Document

Acknowledgements

We thank Dr Jacob Nasser for his initial contribution to the quality assessment of the retained studies.

Ethics statement: Ethic approval is not required as the manuscript used only data from the published literature.

[1] Financial disclosure Funding: We did not receive funding for this study.

[2] Authorship contributions: KYC, DDR and ANP conceptualised the study. KYC oversaw the review, moderated the data extraction and quality assessment, and drafted the manuscript. DDR oversaw the statistical analysis. NS conducted the review of the English literature, initial data extraction, and helped prepare the manuscript. ZCW conducted the Chinese literature review and statistical analyses. ZZH parallel reviewed the English literature. XQX conducted parallel data extraction and quality assessment and prepared the data for statistical analysis. ANP drafted sections of the manuscript. All authors have contributed to the final version of the manuscript.

[3] Conflicts of interest Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.

references

1 

P BovetF PaccaudCommentary: Alcohol, coronary heart disease and public health: Which evidence-based policy? Int J Epidemiol. 2001;30:734-7. 10.1093/ije/30.4.73411511594

2 

GBD 2017 Risk Factor CollaboratorsGlobal, 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;392:1923-94. 10.1016/S0140-6736(18)32225-630496105

3 

E RapsomanikiA TimmisJ GeorgeM Pujades-RodriguezAD ShahS DenaxasBlood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet. 2014;383:1899-911. 10.1016/S0140-6736(14)60685-124881994

4 

YN OuCC TanXN ShenW XuXH HouQ DongBlood Pressure and Risks of Cognitive Impairment and Dementia: A Systematic Review and Meta-Analysis of 209 Prospective Studies. Hypertension. 2020;76:217-25. 10.1161/HYPERTENSIONAHA.120.1499332450739

5 

B VaesE BekeC TruyersS ElliF BuntinxJY VerbakelThe correlation between blood pressure and kidney function decline in older people: a registry-based cohort study. BMJ Open. 2015;5:e007571. 10.1136/bmjopen-2015-00757126129635

6 

F ZhouT YuR DuG FanY LiuZ LiuClinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054-62. 10.1016/S0140-6736(20)30566-332171076

7 

G OnderG RezzaS BrusaferroCase-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. 2020;323:1775-76. 10.1001/jama.2020.468332203977

8 

LQ LiT HuangYQ WangZP WangY LiangTB HuangCOVID-19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J Med Virol. 2020;92:577-83. 10.1002/jmv.2575732162702

9 

P VerdecchiaG ReboldiF AngeliThe 2020 International Society of Hypertension global hypertension practice guidelines – key messages and clinical considerations. Eur J Intern Med. 2020;82:1-6. 10.1016/j.ejim.2020.09.00132972800

10 

PK WheltonRM CareyWS AronowDE CaseyKJ CollinsC Dennison Himmelfarb2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:1269-324. 10.1161/HYP.000000000000006629133354

11 

M PashaLC BrewerS SennhauserM AlsawasMH MuradHealth Care Delivery Interventions for Hypertension Management in Underserved Populations in the United States: A Systematic Review. Hypertension. 2021;78:955-65. 10.1161/HYPERTENSIONAHA.120.1594634397275

12 

D BannM FluhartyR HardyS ScholesSocioeconomic inequalities in blood pressure: co-ordinated analysis of 147,775 participants from repeated birth cohort and cross-sectional datasets, 1989 to 2016. BMC Med. 2020;18:338. 10.1186/s12916-020-01800-w33203396

13 

B LengY JinG LiL ChenN JinSocioeconomic status and hypertension: a meta-analysis. J Hypertens. 2015;33:221-9. 10.1097/HJH.000000000000042825479029

14 

A KabirMN KarimRM IslamL RomeroB BillahHealth system readiness for non-communicable diseases at the primary care level: a systematic review. BMJ Open. 2022;12:e060387. 10.1136/bmjopen-2021-06038735140165

15 

DJ HellerA KumarSP KishoreCR HorowitzR JoshiR VedanthanAssessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis. JAMA Netw Open. 2019;2:e1916545. 10.1001/jamanetworkopen.2019.1654531790570

16 

S ArakelyanK JailobaevaA DakessianK DiaconuL CaperonA StrangThe role of trust in health-seeking for non-communicable disease services in fragile contexts: A cross-country comparative study. Soc Sci Med. 2021;291:114473. 10.1016/j.socscimed.2021.11447334662762

17 

Organization WH. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva, Switzerland: World Health Organization. 2007. Available: https://apps.who.int/iris/handle/10665/43821. Accessed: 24 July 2023.

18 

O OgungbeD CazabonA AjenikokoP JeemonAE MoranY Commodore-MensahDetermining the frequency and level of task-sharing for hypertension management in LMICs: A systematic review and meta-analysis. EClinicalMedicine. 2022;47:101388. 10.1016/j.eclinm.2022.10138835480075

19 

R JoshiD PeirisTask-sharing for the prevention and control of non-communicable diseases. Lancet Glob Health. 2019;7:e686-7. 10.1016/S2214-109X(19)30161-531097265

20 

OA UthmanL HartleyK ReesF TaylorS EbrahimA ClarkeMultiple risk factor interventions for primary prevention of cardiovascular disease in low- and middle-income countries. Cochrane Database Syst Rev. 2015;2015:CD011163. 10.1002/14651858.CD011163.pub226272648

21 

J EbingerCA BlylerJ BrettlerF RaderBarbershop Management of Hypertension in the African American Population: Pitfalls and Opportunities for Extension to Other Underserved Communities. Curr Cardiol Rep. 2020;22:64. 10.1007/s11886-020-01319-932562103

22 

J HeV IrazolaKT MillsR PoggioA BeratarrecheaJ DolanEffect of a Community Health Worker–Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial. JAMA. 2017;318:1016-25. 10.1001/jama.2017.1135828975305

23 

P ZhaiK HayatW JiQ LiL ShiN AtifEfficacy of Text Messaging and Personal Consultation by Pharmacy Students Among Adults With Hypertension: Randomized Controlled Trial. J Med Internet Res. 2020;22:e16019. 10.2196/1601932432556

24 

JD SchwalmT McCreadyP Lopez-JaramilloK YusoffA AttaranP LamelasA community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster-randomised controlled trial. Lancet. 2019;394:1231-42. 10.1016/S0140-6736(19)31949-X31488369

25 

TN AnandLM JosephAV GeethaD PrabhakaranP JeemonTask sharing with non-physician health-care workers for management of blood pressure in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 2019;7:e761-71. 10.1016/S2214-109X(19)30077-431097278

26 

G JeetJS ThakurS PrinjaM SinghCommunity health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. PLoS One. 2017;12:e0180640. 10.1371/journal.pone.018064028704405

27 

Hackett C, Grim B, Stonawski M, Skirbekk V, Potančoková M, Abel G. The Global Religious Landscape A Report on the Size and Distribution of the World’s Major Religious Groups as of 2010. Pew Research Center’s Forum on Religion & Public Life. 2012. Available: https://assets.pewresearch.org/wp-content/uploads/sites/11/2014/01/global-religion-full.pdf. Accessed: 24 July 2023.

28 

Levin J, Post SG. Religion and Medicine: A History of the Encounter Between Humanity’s Two Greatest Institutions. Oxford University Press. 2020.

29 

JF DuffWW BuckinghamStrengthening of partnerships between the public sector and faith-based groups. Lancet. 2015;386:1786-94. 10.1016/S0140-6736(15)60250-126159394

30 

MM CraneJL WilliamsCK GarciaK JonesIN CallawayCC TangneyA Small-Changes Weight Loss Programfor African-American Church Members. Health Behav Policy Rev. 2020;7:279-91.32864386

31 

SS YiLC WyattS PatelC ChoyR DharJM ZanowiakA Faith-Based Intervention to Reduce Blood Pressure in Underserved Metropolitan New York Immigrant Communities. Prev Chronic Dis. 2019;16:E106. 10.5888/pcd16.18061831400096

32 

National Heart, Lung, and Blood Institute. Quality Assessment of Controlled Intervention Studies. Available: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed: 1 November 2022.

33 

Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.3. Cochrane. 2022. Available: https://training.cochrane.org/handbook/current. Accessed: 24 July 2022.

34 

CM TuckerS KangNA UkonuGS LinnCS DiSangroTM ArthurA Culturally Sensitive Church-Based Health-Smart Intervention for Increasing Health Literacy and Health-Promoting Behaviors among Black Adult Churchgoers. J Health Care Poor Underserved. 2019;30:80-101. 10.1353/hpu.2019.000930827971

35 

OK DuruCA SarkisianM LengCM MangioneSisters in motion: A randomized controlled trial of a faith-based physical activity intervention. J Am Geriatr Soc. 2010;58:1863-9. 10.1111/j.1532-5415.2010.03082.x20929464

36 

S KillipMahfoudZPearceK. What Is an Intracluster Correlation Coefficient? Crucial Concepts for Primary Care Researchers. Ann Fam Med. 2004;2:204-8. 10.1370/afm.14115209195

37 

S WilcoxA ParrottM BaruthM LakenM CondraskyR SaundersThe Faith, Activity, and Nutrition program: a randomized controlled trial in African-American churches. Am J Prev Med. 2013;44:122-31. 10.1016/j.amepre.2012.09.06223332327

38 

ED PaskettRD BalticGS YoungML KatzSM LeskoKH WebberA group randomized trial to reduce obesity among Appalachian church members: The walk by faith study. Cancer Epidemiol Biomarkers Prev. 2018;27:1289-97. 10.1158/1055-9965.EPI-17-108530337343

39 

S PengpidK PeltzerA PuckpinyoIJ ChantarasongsukEffectiveness of a cluster-randomized controlled trial community-based lifestyle intervention program to control prehypertension and/or prediabetes in Thailand. Int J Diabetes Dev Ctries. 2019;39:123-31. 10.1007/s13410-018-0641-2

40 

AM SchoenthalerKJ LancasterW ChaplinM ButlerJ ForsythG OgedegbeCluster Randomized Clinical Trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks. Circ Cardiovasc Qual Outcomes. 2018;11:e004691. 10.1161/CIRCOUTCOMES.118.00469130354579

41 

LR YanekDM BeckerTF MoyJ GittelsohnDM KoffmanProject Joy: faith based cardiovascular health promotion for African American women. Public Health Rep. 2001;116:68-81. 10.1093/phr/116.S1.6811889276

42 

CD Samuel-HodgeTC KeyserlingS ParkLF JohnstonZ GizliceSI BangdiwalaA randomized trial of a church-based diabetes self-management program for African Americans with type 2 diabetes. Diabetes Educ. 2009;35:439-54. 10.1177/014572170933327019383882

43 

DL BrownKM ConleyBN SánchezK ResnicowJE CowderyE SaisA multicomponent behavioral intervention to reduce stroke risk factor behaviors: The stroke health and risk education cluster-randomized controlled trial. Stroke. 2015;46:2861-7. 10.1161/STROKEAHA.115.01067826374480

44 

RL NewtonLA CarterW JohnsonD ZhangS LarriveeBM KennedyA Church-Based Weight Loss Intervention in African American Adults using Text Messages (LEAN Study): Cluster Randomized Controlled Trial. J Med Internet Res. 2018;20:e256. 10.2196/jmir.981630143478

45 

D ZhangPU UnschuldChina’s barefoot doctor: past, present, and future. Lancet. 2008;372:1865-7. 10.1016/S0140-6736(08)61355-018930539

46 

Committee HCAP. Action for a Healthy China (2019-2030) 2018. Available: http://www.gov.cn/xinwen/2019-07/15/content_5409694.htm. Accessed: 28 November 2022.

47 

G HaoZ ChenX WangL ZhangY KangC ZhengEvaluation of the Community-Based Hypertension Management Programs in China. Front Public Health. 2022;10:896603. 10.3389/fpubh.2022.89660335712306

48 

M TianVS AjayD DunzhuSS HameedX LiZ LiuA 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;132:815-24. 10.1161/CIRCULATIONAHA.115.01537326187183

49 

Ning J. Main Data of the Seventh National Population Census. China: National Bureau of Statistics; 2021. Available: http://www.stats.gov.cn/english/PressRelease/202105/t20210510_1817185.html. Accessed: 11 May 2021.

50 

J OlivierC TsimpoR GemignaniM ShojoH CoulombeF DimmockUnderstanding the roles of faith-based health-care providers in Africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction. Lancet. 2015;386:1765-75. 10.1016/S0140-6736(15)60251-326159398

Correspondence to:
Kit Yee Chan
Centre for Global Health, University of Edinburgh,
Old Medical School, Teviot Place, Edinburgh EH8 9AG
Scotland
UK
[email protected]