There are many important society-level drivers of this alarming increase in cardiovascular disease burden particularly in LMICs, but a key proximate cause of the cardiovascular disease epidemic is non-optimal blood pressure. Globally, it is estimated that approximately 20% of all deaths are attributable to non-optimal BP.

Unlike individual patient-based approaches that are focussed on effective medication, populationbased approaches such as reducing dietary sodium, increasing physical activity and decreasing unhealthy alcohol use are critical to achieving large, sustainable population-level benefits.

There is a paucity of information on effective and sustainable public health system strategies for managing hypertension in South Asian countries, including Sri Lanka. Many people in the rural communities of South Asian countries lack the correct perception of hypertension and have minimum knowledge on how to prevent hypertension or even manage existing hypertension. The main barriers to accessing health services are inadequate services and poor quality of existing facilities, shortage of medicine supplies, access to doctors due to high patient load, long travel distance to facilities, and long waiting times once facilities are reached.

COBRA-BPS or Control of Blood Pressure and Risk Attenuation – Bangladesh, Pakistan & Sri Lanka study, a community-based, stratified, cluster randomised, controlled trial was conducted over two years to evaluate the effectiveness of a scalable, multicomponent intervention (MCI) designed specifically for hypertension management in rural areas delivered by government community healthcare workers in addition to usual care.

The MCI consisted of five components: (1) Home health education by government community health workers (CHWs) (2) BP monitoring and stepped-up referral to a trained general practitioner using a checklist (3) Training public and private providers in management of hypertension and using a checklist (4) Designating hypertension triage counter and hypertension care coordinators in government clinics (5) A financing model to compensate for additional health services and provide subsidies to low income individuals with poorly controlled hypertension. Usual care comprised of existing services in the community without any additional training.

A total of 11,222 individuals aged over 40 years were screened in 30 randomly selected clusters from 15 rural districts in the three countries, and 2,645 with hypertension were enrolled to the study. The primary outcome was reduction in systolic blood pressure at 24 months. While 76% reported being on antihypertensive medications, 60% had uncontrolled blood pressure (>140 mmHg systolic or >90 mmHg diastolic) at enrolment.

Analysis of baseline data shows an alarmingly high burden of cardiometabolic multimorbidity affecting 1 in 4 individuals with hypertension from rural communities in Bangladesh, Pakistan, and Sri Lanka. Chronic Kidney Disease (CKD) was the most common comorbid condition, followed by diabetes, stroke, and heart disease. CKD and diabetes dominated all the morbidity pairs and were found in 10% of the population with hypertension. Individuals residing in Sri Lanka had higher odds of cardiometabolic multimorbidity regardless of lifestyles, sociodemographic and economic status.

Our findings add to the current knowledge on the epidemiology of cardiometabolic multimorbidity in rural South Asians, and underscore the importance to develop prevention and treatment strategies to target individuals at risk of or with cardiometabolic multimorbidity.

This complex community-based intervention study funded by a programme grant from the Wellcome Trust/MRC/DfiD (UK) and conducted in collaboration with public health specialists at the DukeNUS Graduate Medical School in Singapore has demonstrated the multi-component intervention centred on home visits by government CHWs with integration into the existing health system led to clinically meaningful reductions in BP among adults with hypertension at 24 months. If implemented, this cost-effective intervention delivered on top of usual care has the potential to reduce cardiovascular disease burden in South Asia through better control of blood pressure at community level.

The Sri Lankan cohort although more literate, wealthier, and having greater access to blood pressure lowering medication compared to those in Bangladesh and Pakistan had a higher percentage of patients with poorly controlled blood pressure (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) despite being on treatment at baseline.

COBRA-BPS: American Journal of Hypertension 2018; 31:1205–1214