Abstract Body: Background Hypertension is the most important modifiable risk factor for stroke, a leading cause of death in China. Despite national efforts, stroke incidence and mortality rates remain high in China, with significant urban-rural disparities.

Objectives We aimed to examine the effectiveness of non-physician health worker-led antihypertensive interventions on the risk of stroke in rural China.

Methods We included 33,995 hypertensive participants from 326 villages in rural China using 48-month follow-up data from the China Rural Hypertension Control Project (CRHCP). In the CRHCP trial, non-physician healthcare workers initiated and titrated antihypertensive medications using a simple stepped-care protocol recommended by clinical guidelines. The primary outcome was total stroke during the 48-month follow-up period. Secondary outcomes included fatal and nonfatal strokes. We conducted a secondary analysis adjusted for pre-defined baseline covariates to examine the robustness of the intervention effect on stroke. Safety outcomes were also assessed at 48 months.

Results During a median of 48.2 months of follow-up, 1,151 strokes (1.7% yearly rate) occurred in participants in intervention villages compared to 1,484 strokes (2.4% yearly rate) in participants in usual care villages. The non-physician health worker-led intervention reduced stroke by 28% (hazard ratio = 0.72; 95% CI: 0.67, 0.77) in intervention compared to usual care participants. Similar reductions were also observed for fatal (hazard ratio = 0.74; 95% CI 0.63, 0.87) and nonfatal stroke (hazard ratio = 0.71; 95% CI 0.66, 0.78). Participants in intervention villages had a significantly lower rate of hospitalizations and deaths compared to usual care participants (risk ratio = 0.94; 95% CI 0.91, 0.98). There were no significant differences in rates of injurious falls, symptomatic hypotension, or syncope between the intervention and usual care villages.

Conclusion This study shows that a nonphysician health worker-led intensive BP control was effective at reducing stroke among rural residents in China. The non-physician community health worker-led intervention should be scaled up in China and other low- and middle-income countries to reduce the burden of stroke.