Primary Care Strategies to Reduce High Blood Pressure: A Cluster Randomized Trial in Rural Bangladesh, Pakistan and Sri Lanka

Principal Investigator: Dr. Aliya Naheed

Funded by: MRC/Wellcome Trust/DfiD, UK


Project Brief

This study examined primary care strategies to reduce high blood pressure among rural hypertensive patients. It explored the determinants of uncontrolled hypertension among rural South Asia. Among hypertensive individuals, 58.0% had uncontrolled BP, off them highest found in Pakistan, and then Sri Lanka and Bangladesh. It suggested improving access and adherence to antihypertensive medications in disadvantaged populations in rural South Asia. The study also explored prevalence of Chronic Kidney Disease (CKD) and cardiometabolic multimorbidity were found very high among the rural South Asian hypertensive individuals.

The study also revealed three major care pathways of hypertension treatment, management and control in rural Bangladesh. Seek specialized hospitals for acute care, private hospitals/local pharmacy for nonacute symptoms, and incidental hypertension identification while being treated for another condition. It also revealed patients experiences on accessing healthcare services for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka. Patients reported low knowledge on how to prevent or treat hypertension and also reported some barriers to accessing health services, such as- inadequate services, poor quality of existing facilities, shortage of medicine supplies, busyness of doctors due to high patient load, long travel distance to facilities, and long waiting times, and costs.

This series of evidences helped government in strengthening primary healthcare facilities for the hypertension care service. The Directorate General of Health Services (DGHS) already established a corner for NCD services at the sub-district hospitals and increased supplies of antihypertensive and lipid lowering drugs. In some sub-districts hospitals, the government deployed a trained nurse in the NCD corner for helping Physicians in measuring blood pressure and diabetes. Now patients are getting antihypertensive and anti lipid drugs for longer duration without cost.


  1. Jafar TH, Gandhi M, De Silva HA, Jehan I, Naheed A, Finkelstein EA, Turner EL, Morisky D, Kasturiratne A, Khan AH, Clemens JD. A community-based intervention for managing hypertension in rural South Asia. New England Journal of Medicine. 2020 Feb 20;382(8):717-26.      

  2. Jafar TH, Jehan I, de Silva HA, Naheed A, Gandhi M, Assam P, Finkelstein EA, Quigley HL, Bilger M, Khan AH, Clemens JD, Ebrahim S, Turner EL; for COBRA-BPS Study Group, Kasturiratne A. Multicomponent intervention versus usual care for management of  hypertension in rural Bangladesh, Pakistan and Sri Lanka: study protocol for a cluster randomized controlled trial.Trials. 2017 Jun 12;18(1):272. doi: 10.1186/s13063-017-2018-0.        

  3. Jafar TH, Silva Ad, Naheed A, Jehan I, Liang F, Assam PN, Legido-Quigley H, Finkelstein EA, Ebrahim S, Wickremasinghe R, Alam D, Khan AH; COBRA-BPS Study Group. Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka: feasibility trial results.J Hypertens. 2016 Sep;34(9):1872-81.

  4. Feng L, de Silva HA, Jehan I, Naheed A, Kasturiratne A, Himani G, Hasnat MA, Jafar TH. Regional variation in chronic kidney disease and associated factors in hypertensive individuals in rural South Asia: findings from control of blood pressure and risk attenuation—Bangladesh, Pakistan and Sri Lanka. Nephrology Dialysis Transplantation. 2019 Oct 1;34(10):1723-30.

  5. Jafar TH, Gandhi M, Jehan I, Naheed A, de Silva HA, Shahab H, Alam D, Luke N, Wee Lim C, COBRA-BPS Study Group. Determinants of uncontrolled hypertension in rural communities in South Asia—Bangladesh, Pakistan, and Sri Lanka. American journal of hypertension. 2018 Oct 15;31(11):1205-14.

  6. Naheed A, Haldane V, Jafar TH, Chakma N, Legido-Quigley H. Patient pathways and perceptions of hypertension treatment, management, and control in rural Bangladesh: a qualitative study. Patient preference and adherence. 2018;12:1437.

  7. Legido-Quigley H, Naheed A, de Silva HA, Jehan I, Haldane V, Cobb B, Tavajoh S, Chakma N, Kasturiratne A, Siddiqui S, Jafar TH. Patients’ experiences on accessing health care services for management of hypertension in  rural Bangladesh, Pakistan and Sri Lanka: A qualitative study. PLoS One. 2019 Jan 25;14(1):e0211100.

  8. Feng L, Jehan I, de Silva HA, Naheed A, Farazdaq H, Hirani S, Kasturiratne A, Ranasinha CD, Islam MT, Siddiquee AT, Jafar TH. Prevalence and correlates of cardiometabolic multimorbidity among hypertensive individuals: a cross-sectional study in rural South Asia—Bangladesh, Pakistan and Sri Lanka. BMJ open. 2019 Sep 1;9(9):e030584.


Policy Forum on Hypertension and Cardiometabolic Diseases- Impact on Health Systems Sri Lanka, Bangladesh, Pakistan, and Regional Countries. Held on 1 October

Developed by Shawkat Jahangir NCD icddr,b © 2019                                                                         Information provided by Dr. Noshin Farzana NCD icddr,b