Hypertension, which occurs when someone’s blood pressure is higher than normal, causes a range of life threatening complications. (Photo: Shutterstock)News & Features
10th November 2025 | Elri Voigt
Hypertension – a condition where blood pressure is consistently higher than normal – is poorly managed in South Africa. Remarkable findings from a study in rural KwaZulu-Natal suggest a compelling alternative to the current model of clinic-based care – using community healthcare workers to monitor people’s blood pressure in their own homes.
Often described as a “silent killer”, high blood pressure – also called hypertension – is a major contributor to South Africa’s growing burden of non-communicable diseases. This is because of the many complications that could come with it, including cardiovascular disease, kidney disease, heart failure, heart attack, and stroke.
The recently published Global Burden of Disease 2023 report explained that non-communicable disease rates are rising rapidly in low-and-middle income countries. High blood pressure was ranked as the fifth highest risk factor driving the most death and disability combined in South Africa in 2023, according to the report. The top risk factor was unsafe sex, followed by malnutrition.
Yet, as Spotlight has previously reported, South Africa is falling short of the targets set out in the country’s National Strategic Plan (NSP) for the prevention and control of NCDs (2022-2027). The hypertension targets are that 90% of people over 18 will know whether they have raised blood pressure; 60% of people with raised blood pressure will receive interventions; and 50% of people receiving interventions for hypertension will have controlled blood pressure levels. The available data suggests South Africa is falling particularly far short on the first target, with cascading effects for the other two.
On this #WorldHypertensionDay, Spotlight asks: Can SA reach its #hypertension targets as set in the National Strategic Plan for #NCDs? @SECTION27news @HealthZA @FosterMohale @PublicHealthSA @UCTHealthSci @WitsHealthFac @FrancoisVenter3 @russ421 https://t.co/cVc8KHRiH5
— Spotlight (@SpotlightNSP) May 17, 2023
Some good news is that findings from a new study point to how we might improve hypertension control among adults who know they have high blood pressure (the second target in the NSP). The innovation is not a new pill or injection, but simply to use community healthcare workers to take the management of blood pressure out of clinics and into people’s homes.
How the study was conducted
The researchers split 774 adults in KwaZulu-Natal into three groups. One group (257 people) was cared for at home by community health workers, the other group (258 people) got enhanced care at home by community health workers, and the last group (259 people) got the standard of care at the clinic. Almost all of the study participants stayed in the study for the full six months of follow-up.
The participants were screened for high blood pressure – defined as two readings of at least 140 millimetres of mercury (mm Hg) systolic and/or 90 mm Hg diastolic, taken at least six months apart. Systolic pressure is the upper number you’ll see on a blood pressure monitor and diastolic is the lower number. Systolic blood pressure is the pressure in the arteries when the heart beats, and diastolic blood pressure is the pressure in the arteries when the heart rests between beats.
All participants were seen by a nurse when they were enrolled so they could be started on the appropriate antihypertensive medicines available in the public sector. These were either hydrochlorothiazide, lisinopril, amlodipine, or a combination of these drugs. They were then randomised to the three study arms.
In the standard of care arm, participants had to go to the clinic every month to have their blood pressure measured by a nurse, have their blood pressure medications adjusted as needed, and then collect those meds from the pharmacy at the clinic.
In the community health worker group, participants were given an automated blood-pressure machine and were trained to use it by the community healthcare workers. They had to take their blood pressure every day (or six to ten times per week), and the community healthcare workers visited about once a month to check on the participants and to record the readings into a mobile application. The data was then sent to the nurses at the clinics to be reviewed and they then entered a prescription for the appropriate medicine and dosage based on the average blood pressure readings. The community healthcare workers then got a prompt to pick up the medicine and deliver it to the participants.
In the enhanced community healthcare workers group, participants got a blood pressure machine with mobile connectivity. The daily readings (or between six and ten readings per week) were sent directly to the mobile app used by the nurses. Community healthcare workers would visit the participants about once a month to check the machines are working, check on the participants and to deliver the medicines. With the exception of the blood pressure readings getting sent straight to the nurses, everything was done in a similar way to the previous group.
Remarkable findings
The result showed that, after six months of care, both groups of participants who were cared for at home by community healthcare workers had a greater reduction in blood pressure than those getting the standard of care at clinics.
In the standard of care arm, the average systolic blood pressure of participants did not really change much compared to what it was at the start of the study, going down by about 1.9 mm Hg. In the community care arms, the average systolic blood pressure for participants was strikingly different than at the outset. It was about 9.1 mm Hg lower in the community healthcare group and 10.5 mm Hg lower in the enhanced community healthcare group.
If you compared the groups with each other, the average systolic blood pressure of the community healthcare group was 7.9 mm Hg lower than in the standard of care group after six months. The participants in the enhanced community healthcare group had an average systolic blood pressure that was 9.1 mm Hg lower than the standard of care group after six months.
In the standard of care group, 32.5% of people had their blood pressure under control at six months, compared with 57.4% in the community health worker group, and 61.3% in the enhanced community health worker group.
The study findings were published in September in the New England Journal of Medicine, one of the world’s top medical journals.
‘The amount you really want to get’
“We basically moved chronic disease care from the clinic, which we think is inconvenient and costly, to the patient’s home,” Professor Mark Seidner, the study’s principal investigator, told Spotlight. Seidner is a health systems researcher and a clinical trialist working at the Africa Health Research Institute in KwaZulu-Natal, and professor of medicine at Harvard Medical School in Boston.
Some of the challenges with how hypertension care is currently delivered, Seidner said, include the inconvenience of going to the clinic for a blood pressure reading, blood pressure machines not working, long clinic waiting times, the expense of travelling to the clinic, and nurses being overwhelmed by the long queues of patients waiting for care.
He said reducing someone’s blood pressure at the levels that were seen in the home-based care arms is on par with the ideal “amount you really want to get” as a healthcare system and are “clinically significant”.
Seidner said that lowering the blood pressure of people with hypertension by between 5- and 10-mm Hg is associated with a 25% reduction in their risk of heart attack, stroke, or kidney damage. “Those numbers are really impactful over the life course of people with hypertension,” he said.
Apart from the substantial improvements seen with home-based care, another striking aspect of the study is how little improvement was seen in patients receiving clinic-based care.
“[I]f you look at the blood pressure in the control arm; it didn’t really change much over time. One or two points. That just says to me our system is not working,” said Seidner.
Professor Brian Rayner, a senior research scholar specialising in nephrology and hypertension at the University of Cape Town, concurred that “an awful finding” coming out of the study is that broadly the standard of care for people with hypertension isn’t necessarily helping people keep their blood pressure under control. Rayner is also a past president of the South African Hypertension Society.
He told Spotlight that hypertension control is “pretty poor in both the private and public sector, so we’ve got a lot of work to do”.
“We’re going to work with the Department of Health to think about how this study may have implications for policy in South Africa,” Seidner said.
Potential integration
The study team presented their findings at a workshop with officials from the KwaZulu-Natal health department and the national department of health, Foster Mohale, spokesperson for the national health department, told Spotlight. (You can find his full response here).
“The department is engaging with the research team to explore the potential integration of the IMPACT-BP model into existing national initiatives,” he said. The study’s use of community health workers (CHWs) to deliver home-based hypertension care, Mohale said, aligns with the department’s community-based screening and linkage to care campaign launched in KwaZulu-Natal in March 2024.
“This national campaign mobilises CHWs and Traditional Health Practitioners (THPs) to screen for blood pressure and diabetes at household level as part of the first phase. Both CHWs and THPs have been trained and equipped with point-of-care testing devices, including blood pressure monitors and glucometers,” said Mohale. This campaign, he said, has already been rolled out in six of the country’s nine provinces, and is expected to be operational in all 52 districts in South Africa by 2029.
“The department is using the lessons from the IMPACT-BP study to strengthen monitoring, referral pathways, and patient follow-up mechanisms within this community-based model of care,” Mohale added.
Positive feedback
Interviews of participants, the nurses and the community healthcare workers involved in the study is still being analysed, but Seidner said so far, the feedback has been tremendously positive.
“I think people really appreciated the fact that …they could take control of their own health; they could measure their own blood pressure. They certainly appreciate the fact that they didn’t have to come to clinic,” he added.
The next step for the researchers is to do a cost-effectiveness analysis to determine whether it would be feasible to implement home-based care, Seidner said. They are hoping to have these results in the next few months.
This will include calculating how much it costs to run a programme like this, Seidner said, and what the health benefits of the programme are, like the impact of people living longer, reducing strokes, heart attacks and kidney failure.
“Our job now is to say…what is that ratio of cost-to-benefit? And is it something that is affordable, and efficient, and effective within the South African health sector?” he added.
Another aspect that still needs to be investigated, said Seidner, is how well this type of home-based care would perform in an urban setting.
The future of hypertension care
When asked what the future of hypertension care in the country should look like, Rayner said that for the average patient, care should be much more accessible, with more nurse-based care and care protocols. He suggested a tiered approach where care for primary hypertension is mainly offered by nurses either in clinics or in patient’s homes. For more complicated cases as well as secondary hypertension, there should be a referral structure where patients can be cared for at a secondary or tertiary level.
“There has to be a big investment in nurse-based hypertension care because there’s not enough doctors in the public health system,” he said. “[E]ven with the budgets we have, I think you can, with these types of studies, implement, get more nurses involved, get home-based care going.”
Other changes include to reduce salt and sugar content in foods, making medication more accessible to patients by bringing it closer to their homes, reducing medicine stockouts, more high blood pressure screening programmes, and offering blood pressure medications as combination pills (rather than multiple pills).
Ultimately, Seidner said that while their results on home-based care are compelling “there’s really important questions about costs and benefits that we still need to hash out”. And he is adamant that those questions must in fact be hashed out. “We really need to push the envelope, think outside the box, and really ask ourselves, is clinic-based care the best way of delivering chronic disease care in 2025?” he said.
