Project HOPE (Hypertension Outreach Through Partnership and Engagement)

This pilot uses a quasi-experimental, hybrid type 1 effectiveness-implementation design to assess both the clinical effectiveness and implementation outcomes of a nurse-led, community-based hypertension intervention in an urban Liberian setting. The intervention is embedded within the Ministry of Health's (MOH) National Community Health Strategy 2023-2032 and operationalizes the MOH's new Community Health hypertension management protocols, which adapt WHO pharmacologic and non-pharmacologic guidelines to the local context.

Care is delivered by community health nurses (CHNs) operating out of community-based mobile clinics (CBMCs) sited in five contiguous, high-thoroughfare communities (Zubah Town, King Gray, Barchue, Kpelle Town, and Congo Town Back Rd). The communities are within 15-20 minutes of each other to support shared logistics and continuity of care across mobile clinic visits. Recruitment occurs over the first 3 months of the 7-month pilot period; each enrolled participant is then followed for 3 months.

CHNs complete a multi-day, competency-based training program led by the Johns Hopkins Center for Health Equity (JHCHE) in partnership with the Liberian implementation team. Training covers standardized BP measurement using a "screen and confirm" protocol (including a 5-minute pre-measurement rest and automated triplicate readings), WHO-aligned pharmacologic step-up algorithm adapted to local formulary and context, and structured non-pharmacologic counseling using a patient-facing Options Tool adapted from the RICH LIFE trial (covering diet, physical activity, smoking cessation, adherence support, danger-sign recognition, and social drivers of hypertension). Motivational interviewing techniques and simplified treatment protocols under physician oversight follow the Addressing Hypertension Care in Africa (ADHINCRA) model. Ongoing technical assistance and remote protocol-fidelity monitoring are provided by the JHCHE team.

The study is being conducted under a dual-Institutional Review Board (IRB) structure: the Liberian team holds local IRB approval for the patient-care component, while Johns Hopkins Medicine (JHM) IRB approval covers all CHN-facing research activities and a secondary evaluation of patient outcomes using the limited data set. The work is intended to generate real-world evidence to inform scale-up of equitable, nurse-led chronic disease care across urban and peri-urban communities in Liberia and comparable health systems.

Patient Participant Inclusion Criteria:

• Adults aged ≥25 years
• Stage 2 hypertension defined as either:

• Systolic Blood Pressure (SBP) ≥160 mmHg at screening (Group A); OR
• SBP 140-159 mmHg at screening with either documented elevation on more than one visit or a known history of hypertension (e.g., prior clinician diagnosis or current use of antihypertensive medication) (Group B)

Patient Participant Exclusion Criteria:

• <25 years of age
• Hypertensive emergency with SBP ≥180 mmHg at screening (these patients will be referred to the nearest health center per local protocol; they may be re-screened for eligibility at a subsequent visit if SBP meets the inclusion criteria above)
• Diagnosis of end-stage renal disease (ESRD)
• Condition which interferes with outcome measurement (e.g., dialysis)
• Serious medical condition which either limits life expectancy or requires active management (e.g., certain cancers)
• Cognitive impairment or other condition preventing participation in the intervention
• Active alcohol or substance use disorder (i.e., not sober/abstinent for ≥30 days), screened using the NIAAA Single Alcohol Screening Question
• Pregnant or planning pregnancy in the next 24 months
• Currently nursing a child
• Current participation in another research study focused on reducing blood pressure
• Current participation in a care management program related to health conditions (e.g., weight reduction, smoking cessation)
• Planning to move out of the geographic area within 7 months
• Unwillingness to provide informed consent

Community Health Nurse (CHN) Participant Inclusion Criteria:

• CHNs who were directly involved in delivering the nurse-led community-based hypertension intervention
• Willing to provide oral informed consent for participation in pre/post-training surveys and semi-structured interviews

Community Health Nurse (CHN) Participant Exclusion Criteria:

• CHNs who were not directly involved in the delivery of the intervention