101
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Vedanthan R, Bernabe-Ortiz A, Herasme OI, Joshi R, Lopez-Jaramillo P, Thrift AG, Webster J, Webster R, Yeates K, Gyamfi J, Ieremia M, Johnson C, Kamano JH, Lazo-Porras M, Limbani F, Liu P, McCready T, Miranda JJ, Mohan S, Ogedegbe O, Oldenburg B, Ovbiagele B, Owolabi M, Peiris D, Ponce-Lucero V, Praveen D, Pillay A, Schwalm JD, Tobe SW, Trieu K, Yusoff K, Fuster V. Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries. Cardiol Clin 2017; 35:99-115. [PMID: 27886793 PMCID: PMC5131527 DOI: 10.1016/j.ccl.2016.08.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control.
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Affiliation(s)
- Rajesh Vedanthan
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
| | - Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Omarys I Herasme
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Rohina Joshi
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | | | - Amanda G Thrift
- School of Clinical Sciences at Monash Health, Monash University, Wellington Road and Blackburn Road, Clayton, VIC 3800, Australia
| | - Jacqui Webster
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Ruth Webster
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Karen Yeates
- School of Medicine, Queens University, 15 Arch Street, Kingston, ON K7L 3N6, Canada
| | - Joyce Gyamfi
- School of Medicine, New York University, 550 1st Avenue, New York, NY 10016, USA
| | - Merina Ieremia
- Samoan Ministry of Health, Motootua, Ifiifi street, Apia, Samoa
| | - Claire Johnson
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Jemima H Kamano
- College of Health Sciences, School of Medicine, Moi University, PO Box 3900, Eldoret 30100, Kenya
| | - Maria Lazo-Porras
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Felix Limbani
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg 2000, South Africa
| | - Peter Liu
- University of Ottawa, 75 Laurier Avenue East, Ottawa, ON K1N 6N5, Canada
| | - Tara McCready
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Sailesh Mohan
- Public Health Foundation of India, Plot No. 47, Sector 44, New Delhi, India
| | - Olugbenga Ogedegbe
- School of Medicine, New York University, 550 1st Avenue, New York, NY 10016, USA
| | - Brian Oldenburg
- School of Population and Global Health, University of Melbourne, Parkville, VC 3010, Australia
| | - Bruce Ovbiagele
- Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | | | - David Peiris
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Vilarmina Ponce-Lucero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Peru
| | - Devarsetty Praveen
- The George Institute for Global Health, 301 ANR Centre, Road No 1, Banjara Hills, Hyderabad 500034, India
| | - Arti Pillay
- Pacific Research Centre for the Prevention of Obesity and Non-Communicable Diseases, Fiji National University, Suva, Fiji
| | - Jon-David Schwalm
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Sheldon W Tobe
- University of Toronto, 27 King's College Circle, Toronto, ON M5S 1A1, Canada
| | - Kathy Trieu
- The George Institute for Global Health, University of Sydney, 50 Bridge Street, Sydney, NSW 2000, Australia
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selangor and UCSI University, Kuala Lumpur, Malaysia
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
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102
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Gaziano T, Cho S, Sy S, Pandya A, Levitt NS, Steyn K. Increasing Prescription Length Could Cut Cardiovascular Disease Burden And Produce Savings In South Africa. Health Aff (Millwood) 2017; 34:1578-85. [PMID: 26355061 DOI: 10.1377/hlthaff.2015.0351] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
South Africa's rates of statin use are among the world's lowest, despite statins' demonstrated effectiveness for people with a high blood cholesterol level or history of cardiovascular disease. Almost 5 percent of the country's total mortality has been attributed to high cholesterol levels, fueled in part by low levels of statin adherence. Drawing upon experience elsewhere, we used a microsimulation model of cardiovascular disease to investigate the health and economic impacts of increasing prescription length from the standard thirty days to either sixty or ninety days, for South African adults on a stable statin regimen. Increasing prescription length to sixty or ninety days could save 1,694 or 2,553 lives per million adults, respectively. In addition, annual per patient costs related to cardiovascular disease would decrease by $152.41 and $210.29, respectively. Savings would largely accrue to patients in the form of time savings and reduced transportation costs, as a result of less frequent trips to the pharmacy. Increasing statin prescription length would both save resources and improve health outcomes in South Africa.
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Affiliation(s)
- Thomas Gaziano
- Thomas Gaziano is an assistant professor in the Cardiovascular Division of Brigham and Women's Hospital, in Boston, Massachusetts
| | - Sylvia Cho
- Sylvia Cho is a research assistant in the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston
| | - Stephen Sy
- Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health
| | - Ankur Pandya
- Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health
| | - Naomi S Levitt
- Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital, in Cape Town, South Africa
| | - Krisela Steyn
- Krisela Steyn is associate director of the Chronic Diseases Initiative for Africa, at Old Groote Schuur Hospital
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103
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Gaziano T, Abrahams-Gessel S, Surka S, Sy S, Pandya A, Denman CA, Mendoza C, Puoane T, Levitt NS. Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries. Health Aff (Millwood) 2017; 34:1538-45. [PMID: 26355056 DOI: 10.1377/hlthaff.2015.0349] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In low-resource settings, a physician is not always available. We recently demonstrated that community health workers-instead of physicians or nurses-can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone-based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.
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Affiliation(s)
- Thomas Gaziano
- Thomas Gaziano is an assistant professor in the Cardiovascular Division of Brigham and Women's Hospital, in Boston, Massachusetts
| | - Shafika Abrahams-Gessel
- Shafika Abrahams-Gessel is a research manager at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston
| | - Sam Surka
- Sam Surka is a researcher in the Chronic Diseases Initiative for Africa at Old Groote Schuur Hospital, in Cape Town, South Africa
| | - Stephen Sy
- Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health
| | - Ankur Pandya
- Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health
| | - Catalina A Denman
- Catalina A. Denman is a professor in the Centro de Estudios en Salud y Sociedad at El Colegio de Sonora, in Hermosillo, Mexico
| | - Carlos Mendoza
- Carlos Mendoza is a coinvestigator at the Instituto de Nutricion de Centro America y Panama, in Guatemala City, Guatemala
| | - Thandi Puoane
- Thandi Puoane is a professor in the School of Public Health at the University of the Western Cape, in Bellville, South Africa
| | - Naomi S Levitt
- Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital
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104
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Comparison of Nonblood-Based and Blood-Based Total CV Risk Scores in Global Populations. Glob Heart 2017; 11:37-46.e2. [PMID: 27102021 DOI: 10.1016/j.gheart.2015.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Cost-effective primary prevention of cardiovascular disease (CVD) in low- and middle-income countries requires accurate risk assessment. Laboratory-based risk tools currently used in high-income countries are relatively expensive and impractical in many settings due to lack of facilities. OBJECTIVES This study sought to assess the correlation between a non-laboratory-based risk tool and 4 commonly used, laboratory-based risk scores in 7 countries representing nearly one-half of the world's population. METHODS We calculated 10-year CVD risk scores for 47,466 persons with cross-sectional data collected from 16 different cohorts in 9 countries. The performance of the non-laboratory-based risk score was compared with 4 laboratory-based risk scores: Pooled Cohort Risk Equations (ASCVD [Atherosclerotic Cardiovascular Disease]), Framingham, and SCORE (Systematic Coronary Risk Evaluation) for high- and low-risk countries. Rankings of each score were compared using Spearman rank correlations. Based on these correlations, we measured concordance between individual absolute CVD risk as measured by the Harvard NHANES (National Health and Nutrition Examination Survey) risk score, and the 4 laboratory-based risk scores, using both the conventional Framingham risk thresholds of >20% and the recent ASCVD guideline threshold of >7.5%. RESULTS The aggregate Spearman rank correlations between the non-laboratory-based risk score and the laboratory-based scores ranged from 0.915 to 0.979 for women and from 0.923 to 0.970 for men. When applying the conventional Framingham risk threshold of >20% over 10 years, 92.7% to 96.0% of women and 88.3% to 92.8% of men were equivalently characterized as "high" or "low" risk. Applying the recent ASCVD guidelines risk threshold of >7.5% resulted in risk characterization agreement for women ranging from 88.1% to 94.4% and from 89.0% to 93.7% for men. CONCLUSIONS The correlation between non-laboratory-based and laboratory-based risk scores is very high for both men and women. Potentially large numbers of high-risk individuals could be detected with relatively simple tools.
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105
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Khetan AK, Purushothaman R, Chami T, Hejjaji V, Madan Mohan SK, Josephson RA, Webel AR. The Effectiveness of Community Health Workers for CVD Prevention in LMIC. Glob Heart 2016; 12:233-243.e6. [PMID: 27993594 DOI: 10.1016/j.gheart.2016.07.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 06/27/2016] [Accepted: 07/19/2016] [Indexed: 11/29/2022] Open
Abstract
Community health workers (CHW) may be effective in tackling the burden of cardiovascular diseases in low- and middle-income countries (LMIC). This review examines whether CHWs can improve the identification and control of cardiovascular risk factors in LMIC. We searched for studies that used CHW as a basis for cardiovascular risk factor management. Our search yielded 11 articles that targeted cardiovascular risk factor assessment, hypertension, diabetes, smoking, diet and physical activity. There were 4 randomized controlled trials, 3 quasi-experimental studies, 3 cross-sectional studies, and 1 retrospective analysis. Eight studies reported positive results with CHW being able to effectively screen for cardiovascular risk factors, decrease systolic blood pressure, decrease fasting blood glucose, increase quit rates of smoking, decrease weight, and improve diet and physical activity. Our review demonstrates that CHW may be effective in helping tackle the burden of cardiovascular disease in LMIC.
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Affiliation(s)
- Aditya K Khetan
- Department of Medicine, University Hospitals Health System, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | - Tarek Chami
- Department of Medicine, University Hospitals Health System, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vittal Hejjaji
- Department of Medicine, University Hospitals Health System, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sri Krishna Madan Mohan
- Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Health System, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Richard A Josephson
- Department of Medicine, Harrington Heart and Vascular Institute, University Hospitals Health System, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
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106
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Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, Damasceno A, Delles C, Gimenez-Roqueplo AP, Hering D, López-Jaramillo P, Martinez F, Perkovic V, Rietzschel ER, Schillaci G, Schutte AE, Scuteri A, Sharman JE, Wachtell K, Wang JG. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. Lancet 2016; 388:2665-2712. [PMID: 27671667 DOI: 10.1016/s0140-6736(16)31134-5] [Citation(s) in RCA: 586] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Michael H Olsen
- Department of Internal Medicine, Holbæk Hospital and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Odense, Denmark; Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.
| | - Sonia Y Angell
- Division of Prevention and Primary Care, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Samira Asma
- Global NCD Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pierre Boutouyrie
- Department of Pharmacology and INSERM U 970, Georges Pompidou Hospital, Paris Descartes University, Paris, France
| | - Dylan Burger
- Kidney Research Centre, Ottawa Hospital Research Institute, Department of Cellular and Molecular Medicine, University of Ottawa, ON, Canada
| | - Julio A Chirinos
- Department of Medicine at University Hospital of Pennsylvania and Veteran's Administration, PA, USA
| | | | - Christian Delles
- Christian Delles: Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne-Paule Gimenez-Roqueplo
- INSERM, UMR970, Paris-Cardiovascular Research Center, F-75015, Paris, France; Paris Descartes University, F-75006, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Genetics, F-75015, Paris, France
| | - Dagmara Hering
- The University of Western Australia-Royal Perth Hospital, Perth, WA, Australia
| | - Patricio López-Jaramillo
- Direccion de Investigaciones, FOSCAL and Instituto de Investigaciones MASIRA, Facultad de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Fernando Martinez
- Hypertension Clinic, Internal Medicine, Hospital Clinico, University of Valencia, Valencia, Spain
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Ernst R Rietzschel
- Department of Cardiology, Ghent University and Biobanking & Cardiovascular Epidemiology, Ghent University Hospital, Ghent, Belgium
| | - Giuseppe Schillaci
- Department of Internal Medicine, University of Perugia, Terni University Hospital, Terni, Italy
| | - Aletta E Schutte
- Medical Research Council Unit on Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
| | - Angelo Scuteri
- Hypertension Center, Hypertension and Nephrology Unit, Department of Medicien, Policlinico Tor Vergata, Rome, Italy
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Kristian Wachtell
- Department of Cardiology, Division of Cardiovascular and Pulmonary Diseases Oslo University Hospital, Oslo, Norway
| | - Ji Guang Wang
- The Shanghai Institute of Hypertension, RuiJin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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107
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Rheeder P, Muthembe T, Lawson S, Brink J. Diabetes and hypertension screening in Zandspruit, Johannesburg 2012–2014. S Afr Fam Pract (2004) 2016. [DOI: 10.1080/20786190.2016.1198089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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108
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Wanji S, Kengne-Ouafo JA, Datchoua-Poutcheu FR, Njouendou AJ, Tayong DB, Sofeu-Feugaing DD, Amvongo-Adjia N, Fovennso BA, Longang-Tchounkeu YF, Tekola-Ayele F, Enyong PA, Newport MJ, Davey G. Detecting and staging podoconiosis cases in North West Cameroon: positive predictive value of clinical screening of patients by community health workers and researchers. BMC Public Health 2016; 16:997. [PMID: 27650390 PMCID: PMC5029032 DOI: 10.1186/s12889-016-3669-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 09/13/2016] [Indexed: 11/12/2022] Open
Abstract
Background The suitability of using clinical assessment to identify patients with podoconiosis in endemic communities has previously been demonstrated. In this study, we explored the feasibility and accuracy of using Community Health Implementers (CHIs) for the large scale clinical screening of the population for podoconiosis in North-west Cameroon. Methods Before a regional podoconiosis mapping, 193 CHIs and 50 health personnel selected from 6 health districts were trained in the clinical diagnosis of the disease. After training, CHIs undertook community screening for podoconiosis patients under health personnel supervision. Identified cases were later re-examined by a research team with experience in the clinical identification of podoconiosis. Results Cases were identified by CHIs with an overall positive predictive value (PPV) of 48.5% [34.1–70%]. They were more accurate in detecting advanced stages of the disease compared to early stages; OR 2.07, 95% CI = 1.15–3.73, p = 0.015 for all advanced stages). Accuracy of detecting cases showed statistically significant differences among health districts (χ2 = 25.30, p = 0.0001). Conclusion Podoconiosis being a stigmatized disease, the use of CHIs who are familiar to the community appears appropriate for identifying cases through clinical diagnosis. However, to improve their effectiveness and accuracy, more training, supervision and support are required. More emphasis must be given in identifying early clinical stages and in health districts with relatively lower PPVs.
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Affiliation(s)
- Samuel Wanji
- Parasites and Vector Biology research unit (PAVBRU), Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon. .,Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon.
| | - Jonas A Kengne-Ouafo
- Parasites and Vector Biology research unit (PAVBRU), Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon
| | | | - Abdel Jelil Njouendou
- Parasites and Vector Biology research unit (PAVBRU), Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon
| | - Dizzel Bita Tayong
- Parasites and Vector Biology research unit (PAVBRU), Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon
| | - David D Sofeu-Feugaing
- Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon.,Department of Biochemistry and Molecular Biology, University of Buea, Buea, Cameroon
| | - Nathalie Amvongo-Adjia
- Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon.,Laboratory of Parasitology and Ecology, Department of Animal Biology and Physiology, University of Yaoundé I, Yaounde, Cameroon
| | - Bridget A Fovennso
- Parasites and Vector Biology research unit (PAVBRU), Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon
| | | | - Fasil Tekola-Ayele
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter A Enyong
- Parasites and Vector Biology research unit (PAVBRU), Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Research Foundation for Tropical Diseases and the Environment (REFOTDE), Buea, Cameroon
| | - Melanie J Newport
- Wellcome Trust Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, Brighton, BN1 9PX, UK
| | - Gail Davey
- Wellcome Trust Centre for Global Health Research, Brighton and Sussex Medical School, Falmer Campus, Brighton, BN1 9PX, UK
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109
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Flood D, Mux S, Martinez B, García P, Douglas K, Goldberg V, Lopez W, Rohloff P. Implementation and Outcomes of a Comprehensive Type 2 Diabetes Program in Rural Guatemala. PLoS One 2016; 11:e0161152. [PMID: 27583362 PMCID: PMC5008811 DOI: 10.1371/journal.pone.0161152] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/01/2016] [Indexed: 12/29/2022] Open
Abstract
Background The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings. Program Description We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting. Methods We conduct a retrospective chart review from our electronic medical record to evaluate our program’s performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes. Results A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%. Conclusion We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.
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Affiliation(s)
- David Flood
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
- Medicine-Pediatrics Residency Program, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Sandy Mux
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
| | - Boris Martinez
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
| | - Pablo García
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
- Internal Medicine Residency Program, Saint Peter’s University Hospital, New Brunswick, New Jersey, United States of America
| | - Kate Douglas
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
| | - Vera Goldberg
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Waleska Lopez
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
| | - Peter Rohloff
- Wuqu’ Kawoq | Maya Health Alliance, Santiago Sacatepéquez, Sacatepéquez, Guatemala
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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110
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Rubinstein A. mHealth plus community health worker interventions: the future research agenda - Author's reply. Lancet Diabetes Endocrinol 2016; 4:388. [PMID: 27106687 DOI: 10.1016/s2213-8587(16)30002-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 03/15/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Adolfo Rubinstein
- South American Center of Excellence for Cardiovascular Health (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires C1414CPV, Argentina.
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111
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Oti SO, van de Vijver S, Gomez GB, Agyemang C, Egondi T, Kyobutungi C, Stronks K. Outcomes and costs of implementing a community-based intervention for hypertension in an urban slum in Kenya. Bull World Health Organ 2016; 94:501-9. [PMID: 27429489 PMCID: PMC4933135 DOI: 10.2471/blt.15.156513] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 12/21/2015] [Accepted: 02/04/2016] [Indexed: 01/16/2023] Open
Abstract
Objective To describe the processes, outcomes and costs of implementing a multi-component, community-based intervention for hypertension among adults aged > 35 years in a large slum in Nairobi, Kenya. Methods The intervention in 2012–2013 was based on four components: awareness-raising; improved access to screening; standardized clinical management of hypertension; and long-term retention in care. Using multiple sources of data, including administrative records and surveys, we described the inputs and outputs of each intervention activity and estimated the outcomes of each component and the impact of the intervention. We also estimated the costs associated with implementation, using a top-down costing approach. Findings The intervention reached 60% of the target population (4049/6780 people), at a cost of 17 United States dollars (US$) per person screened and provided access to treatment for 68% (660/976) of people referred, at a cost of US$ 123 per person with hypertension who attended the clinic. Of the 660 people who attended the clinic, 27% (178) were retained in care, at a cost of US$ 194 per person retained; and of those patients, 33% (58/178) achieved blood pressure control. The total intervention cost per patient with blood pressure controlled was US$ 3205. Conclusion With moderate implementation costs, it was possible to achieve hypertension awareness and treatment levels comparable to those in high-income settings. However, retention in care and blood pressure control were challenges in this slum setting. For patients, the costs and lack of time or forgetfulness were barriers to retention in care.
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Affiliation(s)
- Samuel Oji Oti
- African Population and Health Research Center, PO Box 10787-00100, Nairobi, Kenya
| | | | - Gabriela B Gomez
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Charles Agyemang
- Department of Public Health, University of Amsterdam, Amsterdam, Netherlands
| | - Thaddaeus Egondi
- African Population and Health Research Center, PO Box 10787-00100, Nairobi, Kenya
| | - Catherine Kyobutungi
- African Population and Health Research Center, PO Box 10787-00100, Nairobi, Kenya
| | - Karien Stronks
- Department of Public Health, University of Amsterdam, Amsterdam, Netherlands
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112
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Jeemon P, Narayanan G, Kondal D, Kahol K, Bharadwaj A, Purty A, Negi P, Ladhani S, Sanghvi J, Singh K, Kapoor D, Sobti N, Lall D, Manimunda S, Dwivedi S, Toteja G, Prabhakaran D. Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India. BMC Public Health 2016; 16:264. [PMID: 26975187 PMCID: PMC4791774 DOI: 10.1186/s12889-016-2891-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/18/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Effective task-shifting interventions targeted at reducing the global cardiovascular disease (CVD) epidemic in low and middle-income countries (LMICs) are urgently needed. METHODS DISHA is a cluster randomised controlled trial conducted across 10 sites (5 in phase 1 and 5 in phase 2) in India in 120 clusters. At each site, 12 clusters were randomly selected from a district. A cluster is defined as a small village with 250-300 households and well defined geographical boundaries. They were then randomly allocated to intervention and control clusters in a 1:1 allocation sequence. If any of the intervention and control clusters were <10 km apart, one was dropped and replaced with another randomly selected cluster from the same district. The study included a representative baseline cross-sectional survey, development of a structured intervention model, delivery of intervention for a minimum period of 18 months by trained frontline health workers (mainly Anganwadi workers and ASHA workers) and a post intervention survey in a representative sample. The study staff had no information on intervention allocation until the completion of the baseline survey. In order to ensure comparability of data across sites, the DISHA study follows a common protocol and manual of operation with standardized measurement techniques. DISCUSSION Our study is the largest community based cluster randomised trial in low and middle-income country settings designed to test the effectiveness of 'task shifting' interventions involving frontline health workers for cardiovascular risk reduction. TRIAL REGISTRATION CTRI/2013/10/004049 . Registered 7 October 2013.
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Affiliation(s)
- Panniyammakal Jeemon
- />Centre for Control of Chronic Conditions, Public Health Foundation of India, New Delhi, India
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Gitanjali Narayanan
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Dimple Kondal
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Kashvi Kahol
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Ashok Bharadwaj
- />Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh India
| | - Anil Purty
- />Pondicherry Institute of Medical Sciences, Puducherry, India
| | | | | | - Jyoti Sanghvi
- />Sri Aurbindo Institute of Medical Sciences, Indore, India
| | - Kuldeep Singh
- />Sri Aurbindo Institute of Medical Sciences, Indore, India
| | - Deksha Kapoor
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Nidhi Sobti
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Dorothy Lall
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - Sathyaprakash Manimunda
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
- />National Centre for Disease Informatics and Research, ICMR, Bangalore, India
| | | | | | - Dorairaj Prabhakaran
- />Centre for Control of Chronic Conditions, Public Health Foundation of India, New Delhi, India
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
| | - On behalf of DISHA study investigators
- />Centre for Control of Chronic Conditions, Public Health Foundation of India, New Delhi, India
- />Centre for Chronic Disease Control, Sector 44, Plot 47, Gurgaon, Haryana India
- />Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh India
- />Pondicherry Institute of Medical Sciences, Puducherry, India
- />Indira Gandhi Medical College, Shimla, India
- />Aga Khan Health Services, Mumbai, India
- />Sri Aurbindo Institute of Medical Sciences, Indore, India
- />National Centre for Disease Informatics and Research, ICMR, Bangalore, India
- />Indian Council of Medical Research, New Delhi, India
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113
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Engelgau MM, Sampson UK, Rabadan-Diehl C, Smith R, Miranda J, Bloomfield GS, Belis D, Narayan KMV. Tackling NCD in LMIC: Achievements and Lessons Learned From the NHLBI-UnitedHealth Global Health Centers of Excellence Program. Glob Heart 2016; 11:5-15. [PMID: 27102018 PMCID: PMC4843818 DOI: 10.1016/j.gheart.2015.12.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 01/14/2023] Open
Abstract
Effectively tackling the growing noncommunicable disease (NCD) burden in low- and middle-income countries (LMIC) is a major challenge. To address research needs in this setting for NCDs, in 2009, National Heart, Lung, and Blood Institute (NHLBI) and UnitedHealth Group (UHG) engaged in a public-private partnership that supported a network of 11 LMIC-based research centers and created the NHLBI-UnitedHealth Global Health Centers of Excellence (COE) Program. The Program's overall goal was to contribute to reducing the cardiovascular and lung disease burdens by catalyzing in-country research institutions to develop a global network of biomedical research centers. Key elements of the Program included team science and collaborative approaches, developing research and training platforms for future investigators, and creating a data commons. This Program embraced a strategic approach for tackling NCDs in LMICs and will provide capacity for locally driven research efforts that can identify and address priority health issues in specific countries' settings.
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Affiliation(s)
- Michael M Engelgau
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Uchechukwu K Sampson
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cristina Rabadan-Diehl
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Richard Smith
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jaime Miranda
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Gerald S Bloomfield
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Deshiree Belis
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - K M Venkat Narayan
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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114
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Balcazar HG. Community health workers for recovery from acute coronary syndrome. Lancet Diabetes Endocrinol 2016; 4:194-195. [PMID: 26857997 DOI: 10.1016/s2213-8587(15)00490-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Hector G Balcazar
- University of Texas Health Science Center, School of Public Health, El Paso, TX 79902, USA.
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115
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Surka S, Steyn K, Everett-Murphy K, Gaziano TA, Levitt N. Knowledge and perceptions of risk for cardiovascular disease: Findings of a qualitative investigation from a low-income peri-urban community in the Western Cape, South Africa. Afr J Prim Health Care Fam Med 2015; 7:891. [PMID: 26842511 PMCID: PMC4656922 DOI: 10.4102/phcfm.v7i1.891] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/10/2015] [Accepted: 08/10/2015] [Indexed: 12/03/2022] Open
Abstract
Background South Africa currently faces an increasing burden of cardiovascular disease. Although referred to clinics after community screening initiatives, few individuals who are identified to be at high risk for developing cardiovascular disease attend. Low health literacy and risk perception have been identified as possible causes. We investigated the knowledge and perceptions about risk for cardiovascular disease in a community. Method We conducted a series of focus group discussions with individuals from a low-income peri-urban community in the Western Cape, South Africa. Different methods of presenting risk were explored. The data were organised into themes and analysed to find associations between themes to provide explanations for our findings. Results Respondents’ knowledge of cardiovascular disease and its risk factors varied, but most were familiar with the terms used to describe cardiovascular disease. In contrast, understanding of the concept of risk was poor. Risk was perceived as a binary concept and evaluation of different narrative and visual methods of presenting risk was not possible. Conclusion Understanding cardiovascular disease and its risk factors requires a different set of skills from that needed to understand uncertainty and risk. The former requires knowledge of facts, whereas understanding of risk requires numerical and computational skills. Without a better understanding of risk, risk assessments for cardiovascular disease may fail in this community.
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Affiliation(s)
- Sam Surka
- Chronic Disease Initiative for Africa, Cape Town.
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116
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Balcázar HG, de Heer HD. Community health workers as partners in the management of non-communicable diseases. LANCET GLOBAL HEALTH 2015; 3:e508-9. [PMID: 26187362 DOI: 10.1016/s2214-109x(15)00142-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 03/26/2015] [Indexed: 01/25/2023]
Affiliation(s)
- Héctor G Balcázar
- University of Texas Health Science Center UTHealth, School of Public Health, El Paso Regional Campus, El Paso, TX 79902, USA.
| | - Hendrik D de Heer
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ, USA
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117
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Levitt NS, Puoane T, Denman CA, Abrahams-Gessel S, Surka S, Mendoza C, Khanam M, Alam S, Gaziano TA. Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa. Glob Health Action 2015; 8:26318. [PMID: 25854780 PMCID: PMC4390559 DOI: 10.3402/gha.v8.26318] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 11/14/2022] Open
Abstract
Background We have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management. Design Patient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained. Results Thirty-seven percent (96/263) of those referred attended follow-up: 36 of 52 (69%) were urgent and 60 of 211 (28.4%) were non-urgent referrals. A diagnosis of hypertension (HTN) was made in 69% of urgent referrals and 37% of non-urgent referrals with treatment instituted in all cases. Reasons for non-attendance included limited self-perception of risk, associated costs, health system obstacles, and lack of trust in CHWs to conduct CVD risk assessments and to refer community members into the health system. Conclusions The existing barriers to referral in the health care systems negatively impact the gains to be had through screening by training CHWs in the use of a simple risk assessment tool. The new diagnoses of HTN and commencement on treatment in those that attended referrals underscores the value of having persons at the highest risk identified in the community setting and referred to a clinic for further evaluation and treatment.
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Affiliation(s)
- Naomi S Levitt
- Chronic Disease Initiative for Africa, Cape Town, South Africa.,Division of Endocrinology and Diabetes, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Thandi Puoane
- Chronic Disease Initiative for Africa, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Catalina A Denman
- Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Mexico
| | - Shafika Abrahams-Gessel
- Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA
| | - Sam Surka
- Chronic Disease Initiative for Africa, Cape Town, South Africa;
| | - Carlos Mendoza
- Institute of Nutrition of Central America and Panama (INCAP), Ciudad de Guatemala, Guatemala
| | - Masuma Khanam
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Chronic Non-Communicable Disease Unit, International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sartaj Alam
- Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA
| | - Thomas A Gaziano
- Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA
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