Key takeaways 

  • Hypertension is the primary risk factor for stroke and heart disease, which are leading causes of death in South Africa. Hypertension control rates remain low globally, especially in low-resource settings
  • A clinical trial in KwaZulu-Natal found that a home-based and tech-supported model of care significantly improved hypertension control rates in rural South Africa
  • Similar approaches of care could be used to improve hypertension control in other remote and resource-constrained settings

Bringing blood pressure care into people’s homes significantly improved hypertension control in rural South Africa. This is according to the results of a clinical trial, presented at the European Society of Cardiology Congress 2025 in Madrid, Spain and simultaneously published in the New England Journal of Medicine.

Hypertension is the primary risk factor for stroke, heart disease, and kidney disease which are leading causes of death in South Africa. Despite the wide availability of low-cost, effective therapies, hypertension control remains extremely poor in the country. The ‘IMPACT-BP’ clinical trial tested whether a simple, home-based model of care – combining blood pressure self-monitoring, community health worker support, and nurse-led, tech-supported clinical care – could improve blood pressure control.

The results show significantly improved hypertension control rates (from around 58% to more than 80%), indicating that patients can safely and effectively manage their own chronic conditions in their own homes when supported to do so.

“We need new and better models of chronic disease care to address the multiple causes of poor hypertension care, which include clinics with long wait times, the cost of transport to clinics, and lack of engagement with patients to help manage their own care,” explained the IMPACT-BP trial’s co-principal investigator, Professor Mark Siedner from Africa Health Research Institute (AHRI), South Africa. “Our trial aimed to get at the heart of these issues, by testing whether transferring care from the clinic to patient’s homes, teaching them to monitor their own disease, partnering with community health workers and empowering nurses with decision-support technology could improve blood pressure control in a low-resourced area of rural South Africa.”

Study design

IMPACT-BP was an open-label, randomised controlled trial conducted at the Africa Health Research Institute in KwaZulu-Natal, in which patients were recruited from two public-sector primary healthcare clinics. The study was designed with co-principal investigator, Dr Thomas Gaziano, from MGB and Harvard Medical School, and Professor Nombulelo Magula of the University of KwaZulu-Natal, and in partnership with the KwaZulu-Natal Provincial Department of Health.

Adults were eligible if they had uncontrolled hypertension as defined by the South African Department of Health guidelines: two measurements of SBP >140 mmHg and/or diastolic BP (DBP) >90 mmHg taken at least six months apart. People seeking services at public sector primary health care clinics in rural KZN were invited to participate.

Three strategies were assessed: 1) standard-of-care (SOC), clinic-based management; 2) home-based BP self-monitoring supported by the provision of BP machines, community health workers (CHWs) who conducted home visits for data collection and medication delivery, and remote nurse-led care aided by a mobile application with decision support; and 3) an enhanced CHW arm in which BP machines included cellular technology to automatically transmit BP readings to a mobile app.

Study results

A total of 774 patients were enrolled. The average age was 62 years, with 76% being women, 14% having diabetes, and 47% living with HIV. At six months, the CHW and enhanced CHW arms had 8-10 mmHg lower average SBP compared to the SOC arm. The SOC group had hypertension control of 57.6%, compared to 76.9% in the CHW arm and 82.8% in the improved CHW arm. Retention in care remained more than 95% in both intervention arms, with patients reporting that they appreciated the opportunity to manage their own hypertension and be supported by community health workers.

“This study is an important example of how making models of chronic disease care more convenient – taking it from the clinic to patients’ homes and letting them play a major role in their own care – can substantially improve hypertension outcomes,” said Dr Gaziano.

Of particular value was that the programme was successful in a community that has historically had low access to care. “Achieving hypertension control in over 80% of people in rural South Africa is a clear example that equitable health care access can be achieved in under-resourced communities. Similar models of care that address structural barriers could be considered to improve hypertension control in other remote and resource-limited settings. Expansion of the model to include the care of people with multiple comorbidities may also be valuable,” said Professor Magula.

Read the full article here: https://www.nejm.org/doi/full/10.1056/NEJMoa2509958