TASSH is a 5-year cluster-randomized trial currently in its fifth year and designed to evaluate the comparative effectiveness of the implementation of the WHO-PEN [
18] targeted at cardiovascular risk assessment (intervention group) versus provision of health insurance coverage (control group) on blood pressure reduction at 12 months and blood pressure control at 24 months post-intervention. A full description of the TASSH protocol has been published elsewhere [
16], but briefly, a total of 32 CHCs and district hospitals in the Ashanti Region of Ghana, were randomly assigned to either the intervention group (
n = 16) or the control group (
n = 16). Both patients in the intervention and control group received health insurance and follow-up care every three months. However, patients in the intervention condition received care from community-health nurses who had been trained in blood pressure measurement, hypertension diagnosis, treatment and management, in addition to the WHO Package of Essential Noncommunicable diseases (WHO-PEN) Patients in the intervention group received “usual care,” which varied based on the clinic they attended. Blood pressure outcomes are evaluated at baseline, 12 months, and 24 months. To date, the trial has enrolled 757 patients, of which 86% of all the patients have completed the primary outcome of the study at 12 months. A total of 64 nurses (2 from each of the 32 study sites) were trained in the delivery of the TASSH protocol. Nurses were recruited from each of the 32 clinics involved in the study, and trained in theWHO-PEN CVD Package. The WHO-PEN involved fours steps: 1) inquiry about the patient’s history (e.g., heart attack, stroke, lifestyle behaviors, diabetes); 2) physical and laboratory experiments (including BP measurements, fasting glucose, cholesterol); 3) estimation of cardiovascular disease risk based on risk charts provided by WHO (categorized as low, medium, or high); 4) initiation of drug therapy, lifestyle counseling, and follow-up visits [
19,
20]. Nurses working at the intervention clinics implemented these protocols immediately after training, while those working in the control clinics delivered “care as usual” until the end of the intervention, when they provided a delayed intervention, implementing the WHO-PEN training. Treatment received by patients attending the control clinics varied based on clinic procedures; however patients were treated by physicians and not community health nurses. Prior to implementing the TASSH program, nurses’ roles in the clinics included checking and recording vital signs, dressing wounds, taking blood samples to the lab, making beds, dusting or general upkeep of wards, etc.. In the control clinics, nurses maintained these duties until the end of the intervention period, in which they began to implement TASSH.