Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials

Abstract

ObjectiveTo evaluate evidence from published randomised controlled trials (RCTs) for the use of task-shifting strategies for cardiovascular disease (CVD) risk reduction in low-income and middle-income countries (LMICs).DesignSystematic review of RCTs that utilised a task-shifting strategy in the management of CVD in LMICs.Data SourcesWe searched the following databases for relevant RCTs: PubMed from the 1940s, EMBASE from 1974, Global Health from 1910, Ovid Health Star from 1966, Web of Knowledge from 1900, Scopus from 1823, CINAHL from 1937 and RCTs from ClinicalTrials.gov.Eligibility criteria for selecting studiesWe focused on RCTs published in English, but without publication year. We included RCTs in which the intervention used task shifting (non-physician healthcare workers involved in prescribing of medications, treatment and/or medical testing) and non-physician healthcare providers in the management of CV risk factors and diseases (hypertension, diabetes, hyperlipidaemia, stroke, coronary artery disease or heart failure), as well as RCTs that were conducted in LMICs. We excluded studies that are not RCTs.ResultsOf the 2771 articles identified, only three met the predefined criteria. All three trials were conducted in practice-based settings among patients with hypertension (2 studies) and diabetes (1 study), with one study also incorporating home visits. The duration of the studies ranged from 3 to 12 months, and the task-shifting strategies included provision of medication prescriptions by nurses, community health workers and pharmacists and telephone follow-up posthospital discharge. Both hypertension studies reported a significant mean blood pressure reduction (2/1 mm Hg and 30/15 mm Hg), and the diabetes trial reported a reduction in the glycated haemoglobin levels of 1.87%.ConclusionsThere is a dearth of evidence on the implementation of task-shifting strategies to reduce the burden of CVD in LMICs. Effective task-shifting interventions targeted at reducing the global CVD epidemic in LMICs are urgently needed.

Maintenance Dialysis throughout the World in Years 1990 and 2010

“…Recent advances in treating and preventing communicable diseases coupled with the dramatic rise in the prevalence of diabetes and hypertension have initiated a shift in focus to the relationship between NCDs and morbidity, most recently in developing regions of the world. [1][2][3][4] This is exemplified by the United Nations 2012 Summit 2025 Initiative, which focuses on decreasing the burden of premature mortality to NCDs by 25% by year 2025.…”

Shining a Light on Task-Shifting Policy: Exploring opportunities for adaptability in non-communicable disease management programmes in Uganda

“…30 Ugandan nurses are among those envisioned to take up the task-shifting role in the detection and management of NCDs; as a result, these nurses will require additional training in NCD management as well as supportive supervision, mirroring the use of NPHWs in the detection and management of HIV. 9,14,15,18,26,29 Unfortunately, the scope of practice for nurses and midwives often limits their roles. At present, only midwives in Uganda are allowed to administer drugs during obstetric care.…”

“…7 In 2008, the WHO noted a regional critical shortage of more than four million trained health workers. 5,8,9 In 2015, 31 countries in sub-Saharan Africa reported an increased need for trained health personnel. 10 As there is a direct relationship between the health worker-to-population ratio and NCD health outcomes, this is a serious concern.…”

“…8,10,13,20 Trained 7 Task-shifting interventions by nurses and nursing assistants in LMICs have reportedly helped to reduce the burden of CVDs and there is considerable evidence supporting the effectiveness of task-shifting implementation for chronic disease management. 9,19 The WHO recommends task-shifting as a strategy for LMICs to address the global human resource crisis. 8 Without a policy on task-shifting, Uganda may not attain the benefits and viability of NCD programme implementation reported by other countries.…”

Capsule Commentary on Margolis et al., A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why did it Work?

“…3 Despite these limitations, the current findings are consistent with previous studies which suggest that task-shifting is a viable method of improving BP management. 4,5 Future work should investigate the effectiveness of this treatment model with patients who have sleep apnea or resistant hypertension.…”