Health system interventions for hypertension: evidence to inform policy in two Indian states

PROJECT ABSTRACT / SUMMARY Noncommunicable diseases (NCDs), including cardiovascular diseases (CVD), now represent the leading cause of death and disability in India. Between 1990 and 2021, the proportion of deaths attributable to CVD increased from 15.2% to 24.5%. Hypertension, a central risk factor for CVD, has also increased in prevalence in recent decades. As of 2021, an estimated 28.1% of Indian adults had hypertension. Management of high blood pressure through pharmacotherapy and modifications to diet and physical activity can prevent CVD. However, most Indians with hypertension do not receive effective treatment. Among adults with hypertension, only 16.5% are on treatment and only 8.7% have achieved control of their blood pressure. Reported barriers to management of hypertension occur at multiple levels, including low uptake of screening by patients, insufficient time and knowledge of health workers, and poor geographic access to facilities. Improving hypertension management in public sector facilities will require new strategies to address these barriers, and supportive health system policies. Two examples of such strategies that have yet to be evaluated are the Andhra Pradesh Family Doctor Programme and the Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I- TREC) study (U01HL138635, PI: Tandon). To have impact on the population need, effective strategies must be coupled with translation of evidence into policies to support implementation at scale. However, poor understanding by researchers of the policy process and information needs limits uptake of research findings to inform policy. This F31 proposal leverages existing research partnerships with two state governments to evaluate health system interventions for hypertension management and the role of research in policy in Andhra Pradesh and Punjab states. We will use the RE-AIM framework to assess the reach, effectiveness, and implementation fidelity of hypertension services delivered through the Andhra Pradesh Family Doctor Programme, a statewide health system initiative to screen and refer people with hypertension to village health clinics (Aim 1). In Aim 2, we will develop a Markov model to estimate the cost-effectiveness of the I-TREC model of hypertension care in primary health facilities in Punjab state in terms of lifetime health outcomes. Finally, we will disseminate findings of these evaluations to officials in Andhra Pradesh and Punjab and solicit feedback on how to improve the relevance and utility of these findings to inform future decisions (Aim 3). This dissertation will leverage innovative implementation science and mixed-methods approaches to evaluate population-wide hypertension programs and produce evidence that is tailored to the needs of the state government decision makers who shape health system policy in India. We expect findings from these evaluations to be primed for uptake to inform the scale up of these programs in Andhra Pradesh and Punjab and may be applicable to other Indian states and South Asian nations.