A South African clinical trial partly funded by the United States National Institutes of Health (NIH) – in which patients measured their own blood pressure – found that treating people at home rather than in clinics significantly improved their health and helped slash the burden on the public health system, writes Liezl Human for GroundUp.
Hypertension is described by the WHO as a “silent killer” because it’s often undiagnosed, and even once diagnosed, it’s often uncontrolled.
In the study comparing treating hypertension in clinics – the current standard of care – versus letting patients have more autonomy and treating the disease at home, the home-based care patients showed better outcomes.
The Africa Health Research Institute’s (AHRI) IMPACT-BP trial took place in rural KwaZulu-Natal and the results were published in The New England Journal of Medicine.
The trial looked at how patients with hypertension responded to treatment either at home or in clinics. Results showed that home-based hypertension treatment, with the help of community health workers (CHW), home visits and a mobile app, led to significantly lowered blood pressure at six and 12 months.
High blood pressure, which is often untreated, is one of the world’s leading risk factors for heart disease and premature death. Only about half of those with hypertension are diagnosed and only about one in five have their hypertension under control.
In the trial, about 774 patients with hypertension were split into three groups: one group was assigned home-based care for hypertension from a CHW, another received enhanced home-based care, and the third received standard care in a clinic.
In the home-based care group, participants received an automated blood-pressure machine to take BP measurements daily, and were trained by CHWs on how to use it.
The data were recorded into an app by CHWs on a monthly basis.
Nurses reviewed patient data monthly and entered prescription information. Prescriptions were sent to the community health workers who fetched and delivered the medication.
In the enhanced group, the participants received a BP machine that sent data directly to the app. CHWs visited participants to ensure their machines were working and to deliver medication.
Results showed that hypertension control rates were 32% in the standard-care group compared with about 60% in the home-based care groups.
Reduce public health load
Mark Siedner, infectious diseases specialist from AHRI and co-principal investigator of the trial, said that if the reduction in blood pressure seen in the home-based care groups were sustained over time, it would mean a significant reduction in heart attacks or strokes.
Travelling to clinics in rural KwaZulu-Natal is usually a whole-day affair, he said. It’s inconvenient, costs money, and it’s difficult for people who are older and have other illnesses or limited mobility. And when patients get there, they may have to queue for hours at a time, nurses may not have capacity to treat them, or the blood pressure machines may not work.
“There are multiple features of hypertension which make it difficult for patients potentially to engage in their care. What we offered them was not to spend four hours in a clinic, but to measure their own blood pressure, to understand their own health, and to be able to receive care especially in the comfort of their own home, where the community health worker would deliver their medicines for them.”
Siedner said they also heard from nurses and managers in the clinic that patient loads had reduced and that pressure lessened in the clinics.
Nsika Sithole, the trial’s project manager from AHRI, said the study shows that “community-based care is actually feasible” and that the model they used is “scaleable”.
The only thing they brought that was not already established in the Health department was the mobile health app, he added. Otherwise, the trial was done in partnership with Health department clinics and nurses. The CHWs were from the community.
“It’s an easy scaleable model because it’s got a system that is already established within the community,” said Sithole.
The biggest challenge was network connections. Internet access was needed for the health workers to input data into the app. To manage this, each staff member had two or three sim cards. If they couldn’t connect to Vodacom, they would switch to MTN, for instance.
Otherwise, they would input the data when they were on wi-fi at the clinics.
Siedner said that other challenges included load-shedding, drug stockouts, or in one case, where a clinic they were working at was damaged by weather.
Study details
Home-Based Care for Hypertension in Rural SA
Mark Siedner, Nombulelo Magula, Lusanda Mazibuko, Nsika Sithole, Alison Castle, Siyabonga Nxumalo, Thabang Manyaapelo, Thomas Gaziano et al.
Published in The New England Journal of Medicine on 1 September 2025
Abstract
Background
Poorly controlled hypertension is a common problem worldwide, particularly in low-resource settings.
Methods
We conducted an open-label, randomised, controlled trial of a home-based model of hypertension care in South Africa. Adults with hypertension were assigned to receive home-based care, which consisted of patient monitoring of blood pressure, home visits from a community health worker (CHW) for data collection and medication delivery, and remote nurse-led decision making supported by a mobile application (CHW group); enhanced home-based care, which consisted of the same intervention but with blood-pressure machines transmitting readings automatically (enhanced CHW group); or standard care with clinic-based management (standard-care group). The primary outcome was the systolic blood pressure at 6 months. Secondary outcomes were the systolic blood pressure at 12 months and hypertension control at 6 and 12 months. Safety outcomes included adverse events, deaths, and retention in care.
Results
A total of 774 adults underwent randomisation. The mean age was 62 years; 76.0% of the participants were women, 13.6% had diabetes mellitus, and 46.5% had human immunodeficiency virus infection. The mean systolic blood pressure at 6 months was lower in the CHW group than in the standard-care group (difference, –7.9 mm Hg; 95% confidence interval [CI], −10.5 to −5.3; P<0.001) and was also lower in the enhanced CHW group than in the standard-care group (difference, −9.1 mm Hg; 95% CI, −11.7 to −6.4; P<0.001). The percentage of participants with hypertension control at 6 months was 57.6% in the standard-care group, as compared with 76.9% in the CHW group (relative risk, 1.33; 95% CI, 1.18 to 1.51) and 82.8% in the enhanced CHW group (relative risk, 1.44; 95% CI, 1.28 to 1.62). The improvements in systolic blood pressure and hypertension control with home-based care appeared to persist at 12 months. Severe adverse events and deaths occurred in 2.7% and 1.0% of the participants, respectively, and occurred in a similar percentage of participants across trial groups. Retention in care was observed in more than 95% of the participants in the CHW and enhanced CHW groups.
Conclusions
In South Africa, home-based hypertension care led to a significantly lower mean systolic blood pressure at 6 months than standard, clinic-based care. (Supported by the National Institutes of Health and others; IMPACT-BP ClinicalTrials).
New England Journal of Medicine article – Home-Based Care for Hypertension in Rural SA (Open access)
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Can SA reach targets to reduce hypertension?
Home-based BP control programme proves efficient
Telemonitoring may cut heart attack, stroke by 50% — 5-year study