Table 7. Description and summary of findings of studies evaluating complex national or regional interventions incorporating components from more than one health system building block.

Study, Setting and Sample Size	Study Design	Summary of Intervention	Health System Building Blocks Included	Summary of Findings	Risk of Bias Assessment
Nissinen et al. 1983 [31]North Karelia – Finlandn = 3,002	Cohort study with control area – 5-y follow-up from 1972–1977	Introduction of systematic HT care within the existing primary health care structure.The program featured public health education, training of health personnel, reorganization of primary care services, and creation of an information system.	1. Human resources2. Physical resources3. Delivery and governance.	BP levels fell further in both hypertensive men and women in intervention region compared to control region (p<0.001)	High risk of selection biasHigh risk of confounding.
Labhardt et al. 2010 [28]Central Region, Cameroon.n = 493	Cohort study – before and after intervention, no control group.Median follow up 102 d.	Integration of care for HT and type 2 diabetes into the existing primary health care system by task shifting from physicians in hospitals to non-physician clinicians in health centers.The intervention included training, equipment and regional supervision and monitoring. Local treatment protocols were adapted from international guidance.	1. Human resources2. Physical resources3. Intellectual resources4. Delivery and governance.	Fall in BP from baseline to follow up: Systolic BP fell by −26.5 mmHg (95% CI −12.5 to −40.5). Diastolic BP fell by 17.2 mmHg (95% CI −7.1 to −27.3)	High risk of selection bias and differential misclassification bias.
Khosravi et al. 2010 [38].Iran, Intervention areas Ifsahan and Najaf-Abadn = 12,514/9,572 (pre-/post- intervention survey)	Ecological study – surveys performed before and after intervention. (6-y follow-up) Reference area included.	Ifsahan Healthy Heart Program:Complex regional intervention incorporating 3 strategies1. Educating health professionals in HT management (includes publication of local guidelines).2. Public education.3. Occasional free BP measurement and cardiovascular risk assessment services.	1. Human resources2. Intellectual resources3. Delivery and governance.	Improvement in BP awareness, treatment and control in intervention area (p<0.001 for all outcomes).Improvements also seen in reference area. (p<0.05 for all outcomes)	High risk of confounding.
Gulliford et al. 1999 [39].Trinidad and Tobago.n = 690/1,597 (pre-/post intervention survey)	Ecological study – surveys performed before and after intervention. (5-y follow-up)	National intervention to improve diabetes care in Trinidad and Tobago. Intervention included:1. Evaluation of diabetes care and feedback of findings.2. Training workshops for doctors.3. Publication and dissemination of guidelines.	1. Human resources2. Intellectual resources3. Delivery and governance.	Adjusted OR for BP control amongst diabetics post intervention versus pre-intervention = 1.24 (95% CI 0.84–1.85)	High risk of selection bias. High risk of non-differential misclassification.