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Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study

Summary Background Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population le... Full description

Journal Title: The Lancet (British edition) 2012, Vol.379 (9810), p.47-54
Main Author: Farzadfar, Farshad, MD
Other Authors: Murray, Christopher JL, Prof , Gakidou, Emmanuela, PhD , Bossert, Thomas, PhD , Namdaritabar, Hengameh, MD , Alikhani, Siamak, MD , Moradi, Ghobad, MD , Delavari, Alireza, MD , Jamshidi, Hamidreza, PhD , Ezzati, Majid, Prof
Format: Electronic Article Electronic Article
Language: English
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Quelle: Alma/SFX Local Collection
Publisher: Kidlington: Elsevier Ltd
ID: ISSN: 0140-6736
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title: Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study
format: Article
creator:
  • Farzadfar, Farshad, MD
  • Murray, Christopher JL, Prof
  • Gakidou, Emmanuela, PhD
  • Bossert, Thomas, PhD
  • Namdaritabar, Hengameh, MD
  • Alikhani, Siamak, MD
  • Moradi, Ghobad, MD
  • Delavari, Alireza, MD
  • Jamshidi, Hamidreza, PhD
  • Ezzati, Majid, Prof
subjects:
  • Abridged Index Medicus
  • Adult
  • Arterial hypertension. Arterial hypotension
  • Biological and medical sciences
  • Blood and lymphatic vessels
  • Blood Glucose - analysis
  • Blood Pressure
  • Cardiology. Vascular system
  • Cardiovascular disease
  • Community Health Workers - supply & distribution
  • Diabetes
  • Diabetes Mellitus - blood
  • Diabetes Mellitus - diagnosis
  • Diabetes Mellitus - epidemiology
  • Diabetes Mellitus - therapy
  • Diabetes. Impaired glucose tolerance
  • Diagnosis
  • Diseases
  • Endocrine pancreas. Apud cells (diseases)
  • Endocrinopathies
  • Etiopathogenesis. Screening. Investigations. Target tissue resistance
  • Female
  • General aspects
  • Health facilities
  • Humans
  • Hypertension - diagnosis
  • Hypertension - epidemiology
  • Hypertension - physiopathology
  • Hypertension - therapy
  • Internal Medicine
  • Iran
  • Iran - epidemiology
  • Male
  • Medical research
  • Medical sciences
  • Mortality
  • Primary Health Care
  • Risk factors
  • Rural Health Services
  • Rural Population
ispartof: The Lancet (British edition), 2012, Vol.379 (9810), p.47-54
description: Summary Background Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community. Methods We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching. Results NCDSS had data for 65 619 individuals aged 25 years or older (11 686 of whom in rural areas); of these, 64 694 (11 521 in rural areas) had data for SBP and 50 202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (−0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (−0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method. Interpretation Primary care systems with trained community health-care workers and wel
language: eng
source: Alma/SFX Local Collection
identifier: ISSN: 0140-6736
fulltext: fulltext
issn:
  • 0140-6736
  • 1474-547X
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titleEffectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study
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creatorFarzadfar, Farshad, MD ; Murray, Christopher JL, Prof ; Gakidou, Emmanuela, PhD ; Bossert, Thomas, PhD ; Namdaritabar, Hengameh, MD ; Alikhani, Siamak, MD ; Moradi, Ghobad, MD ; Delavari, Alireza, MD ; Jamshidi, Hamidreza, PhD ; Ezzati, Majid, Prof
creatorcontribFarzadfar, Farshad, MD ; Murray, Christopher JL, Prof ; Gakidou, Emmanuela, PhD ; Bossert, Thomas, PhD ; Namdaritabar, Hengameh, MD ; Alikhani, Siamak, MD ; Moradi, Ghobad, MD ; Delavari, Alireza, MD ; Jamshidi, Hamidreza, PhD ; Ezzati, Majid, Prof
descriptionSummary Background Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community. Methods We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching. Results NCDSS had data for 65 619 individuals aged 25 years or older (11 686 of whom in rural areas); of these, 64 694 (11 521 in rural areas) had data for SBP and 50 202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (−0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (−0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method. Interpretation Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel. Funding None.
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languageeng
publisherKidlington: Elsevier Ltd
subjectAbridged Index Medicus ; Adult ; Arterial hypertension. Arterial hypotension ; Biological and medical sciences ; Blood and lymphatic vessels ; Blood Glucose - analysis ; Blood Pressure ; Cardiology. Vascular system ; Cardiovascular disease ; Community Health Workers - supply & distribution ; Diabetes ; Diabetes Mellitus - blood ; Diabetes Mellitus - diagnosis ; Diabetes Mellitus - epidemiology ; Diabetes Mellitus - therapy ; Diabetes. Impaired glucose tolerance ; Diagnosis ; Diseases ; Endocrine pancreas. Apud cells (diseases) ; Endocrinopathies ; Etiopathogenesis. Screening. Investigations. Target tissue resistance ; Female ; General aspects ; Health facilities ; Humans ; Hypertension - diagnosis ; Hypertension - epidemiology ; Hypertension - physiopathology ; Hypertension - therapy ; Internal Medicine ; Iran ; Iran - epidemiology ; Male ; Medical research ; Medical sciences ; Mortality ; Primary Health Care ; Risk factors ; Rural Health Services ; Rural Population
ispartofThe Lancet (British edition), 2012, Vol.379 (9810), p.47-54
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0Farzadfar, Farshad, MD
1Murray, Christopher JL, Prof
2Gakidou, Emmanuela, PhD
3Bossert, Thomas, PhD
4Namdaritabar, Hengameh, MD
5Alikhani, Siamak, MD
6Moradi, Ghobad, MD
7Delavari, Alireza, MD
8Jamshidi, Hamidreza, PhD
9Ezzati, Majid, Prof
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0Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study
1The Lancet (British edition)
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descriptionSummary Background Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community. Methods We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching. Results NCDSS had data for 65 619 individuals aged 25 years or older (11 686 of whom in rural areas); of these, 64 694 (11 521 in rural areas) had data for SBP and 50 202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (−0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (−0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method. Interpretation Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel. Funding None.
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0Abridged Index Medicus
1Adult
2Arterial hypertension. Arterial hypotension
3Biological and medical sciences
4Blood and lymphatic vessels
5Blood Glucose - analysis
6Blood Pressure
7Cardiology. Vascular system
8Cardiovascular disease
9Community Health Workers - supply & distribution
10Diabetes
11Diabetes Mellitus - blood
12Diabetes Mellitus - diagnosis
13Diabetes Mellitus - epidemiology
14Diabetes Mellitus - therapy
15Diabetes. Impaired glucose tolerance
16Diagnosis
17Diseases
18Endocrine pancreas. Apud cells (diseases)
19Endocrinopathies
20Etiopathogenesis. Screening. Investigations. Target tissue resistance
21Female
22General aspects
23Health facilities
24Humans
25Hypertension - diagnosis
26Hypertension - epidemiology
27Hypertension - physiopathology
28Hypertension - therapy
29Internal Medicine
30Iran
31Iran - epidemiology
32Male
33Medical research
34Medical sciences
35Mortality
36Primary Health Care
37Risk factors
38Rural Health Services
39Rural Population
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5Alikhani, Siamak, MD
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titleEffectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study
authorFarzadfar, Farshad, MD ; Murray, Christopher JL, Prof ; Gakidou, Emmanuela, PhD ; Bossert, Thomas, PhD ; Namdaritabar, Hengameh, MD ; Alikhani, Siamak, MD ; Moradi, Ghobad, MD ; Delavari, Alireza, MD ; Jamshidi, Hamidreza, PhD ; Ezzati, Majid, Prof
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1Adult
2Arterial hypertension. Arterial hypotension
3Biological and medical sciences
4Blood and lymphatic vessels
5Blood Glucose - analysis
6Blood Pressure
7Cardiology. Vascular system
8Cardiovascular disease
9Community Health Workers - supply & distribution
10Diabetes
11Diabetes Mellitus - blood
12Diabetes Mellitus - diagnosis
13Diabetes Mellitus - epidemiology
14Diabetes Mellitus - therapy
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16Diagnosis
17Diseases
18Endocrine pancreas. Apud cells (diseases)
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26Hypertension - epidemiology
27Hypertension - physiopathology
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29Internal Medicine
30Iran
31Iran - epidemiology
32Male
33Medical research
34Medical sciences
35Mortality
36Primary Health Care
37Risk factors
38Rural Health Services
39Rural Population
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eissn1474-547X
codenLANCAO
abstractSummary Background Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community. Methods We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching. Results NCDSS had data for 65 619 individuals aged 25 years or older (11 686 of whom in rural areas); of these, 64 694 (11 521 in rural areas) had data for SBP and 50 202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (−0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (−0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method. Interpretation Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel. Funding None.
copKidlington
pubElsevier Ltd
pmid22169105
doi10.1016/S0140-6736(11)61349-4