An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study

Development and evaluation of a training program on non-communicable diseases to empower community health workers in rural India

Objective

We developed and evaluated a training program for Accredited Social Health Activists (ASHAs), female community health workers (CHWs) in India, on non-communicable diseases (NCDs).

Methods

A 5-day training program, developed using government-approved manuals, was tested in a randomised controlled trial in the Tehri-Garhwal district. Quantitative comparisons were undertaken using Student's t-test and two-way ANOVA. ASHAs in the intervention group were asked questions about new skills learnt.

Results

Thirty-six ASHAs (20 intervention, 16 controls) participated (response rate 75.0%). Mean pre-test knowledge score was 43.3/100 points (95% CI 36.7-49.9) for the intervention group and 44.4 (38.9-49.9) for controls. The mean post-test knowledge score increased more in the intervention group (48.5-point increase; P < 0.0001), than in controls (9.8-point increase, P = 0.016; ANOVA interaction term (time*allocation) P < 0.0001). ASHAs in the intervention group reported learning new skills for detecting NCDs.

Conclusion

The training program increased knowledge of ASHAs on NCDs and improved their skills to detect NCDs. Our development and testing process for this training program, coupled with open-source resources, fosters innovation and collaboration in managing NCDs in LMICs.

Innovation

Our novel and adaptable training program incorporates interactive elements, case studies, and real-world scenarios to augment routine communication between ASHAs and community members for preventing NCDs.

Group-based Education and monitoring program delivered by community health workers to improve control of high blood pressure in island districts of lake victoria, Uganda

BACKGROUND

Individuals living in communities with poor access to healthcare may be unaware of their high blood pressure (BP). While the use of community health workers (CHWs) can address gaps in human resources for health, CHWs in Uganda have not been used previously for BP screening and management. We report the results of an initiative to train CHWs to evaluate BP and to administer group-based education in Kalangala and Buvuma Island Districts of Lake Victoria, Uganda.

METHODS

We randomly selected 42 of 212 villages. We trained CHWs based in island districts on measuring BP. CHWs visited all households in the selected villages and invited all adults ≥ 18 years to be screened for high BP. We used the World Health Organization's STEPwise tool to collect data on demographic and behavioral characteristics and BP measurements. High blood pressure was defined as systolic BP (SBP) ≥ 140 mm Hg and/or diastolic BP (DBP) ≥ 90 mm Hg over three readings. CHWs created and led fortnight support groups for individuals identified with high blood pressure at baseline. At each group meeting, CHWs re-measured BP and administered an intervention package, which included self-management and lifestyle education to participants. The paired t-test was used to compare mean values of systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after the intervention. Generalized estimating equations (GEE) were used to model longitudinal changes in BP.

RESULTS

We trained 84 CHWs to measure BP and deliver the intervention package. Among 2,016 community members, 570 (28.3%) had high blood pressure; of these, 63 (11.1%) had a previous diagnosis of hypertension. The comparison of SBP and DBP before and after the intervention revealed significant reductions in mean SBP from 158mmHg (SD = 29.8) to 149 mmHg (SD = 29.8) (p < 0.001) and mean DBP from 97mmHg (SD = 14.3) to 92mmHg (p < 0.001). GEE showed decreases of -1.133 (SBP) and - 0.543 mmHg (DBP)/fortnight.

CONCLUSION

High BP was common but previously undiagnosed. The CHW-led group-based self-management and education for controlling high BP was effective in the island districts in Uganda. Scaling up the intervention in other hard-to-reach districts could improve control of high BP on a large scale.

The role of community health workers in non-communicable diseases in Cape Town, South Africa: descriptive exploratory qualitative study

BACKGROUND

Community health workers (CHW) are an integral part of primary health care re-engineering in South Africa. Cape Town is developing community-orientated primary care, with a central role for CHWs. Their role in human immunodeficiency virus, tuberculosis, maternal and child health has been articulated, but is less clear for non-communicable diseases (NCDs). Non-communicable diseases are now a major contributor to the burden of disease. The aim was to explore the current role of CHWs regarding NCDs in the Eastern sub-district of Cape Town, South Africa.

METHODS

An exploratory descriptive qualitative study made use of non-participant observation and qualitative interviews with CHWs, their managers, and nurse coordinators. Data from nine semi-structured interviews and ten observations were analysed with the framework method and Atlas-ti.

RESULTS

The CHWs were embedded in their communities and provided services via support groups, household visits and delivery of medication. They linked people to care with assistance of nurse coordinators. They could also provide physical care in the home. They lacked the ability to counsel people on the risk factors for NCDs and their role in rehabilitation and palliative care was unclear. More nurse coordinators were needed to provide supportive supervision. Inter-sectoral collaboration was weak and hindered CHWs from addressing social issues. More standardised and comprehensive training should equip CHWs for health promotion and disease prevention during household visits. Data collected in the community needed to be analysed, reported on and integrated with data from the primary care facility. This should also contribute to a community diagnosis. Their relationship with facility-based members of the primary health care team needed to be improved. Attention needed to be given to the requirements for and conditions of employment, as well as working hours and remuneration. Some equipment was absent and hindered their services for NCDs.

CONCLUSIONS

CHWs have the potential to provide a comprehensive approach to NCDs, but community-orientated primary care needs to be strengthened in many of the key areas to support their activities. In relation to NCDs, they need training in basic and brief behaviour change counselling and risk factors as well as in the areas of rehabilitation and palliative care.

Comparison of the performance of cardiovascular risk prediction tools in rural India: the Rishi Valley Prospective Cohort Study

AIMS

We compared the performance of cardiovascular risk prediction tools in rural India.

METHODS AND RESULTS

We applied the World Health Organization Risk Score (WHO-RS) tools, Australian Risk Score (ARS), and Global risk (Globorisk) prediction tools to participants aged 40-74 years, without prior cardiovascular disease, in the Rishi Valley Prospective Cohort Study, Andhra Pradesh, India. Cardiovascular events during the 5-year follow-up period were identified by verbal autopsy (fatal events) or self-report (non-fatal events). The predictive performance of each tool was assessed by discrimination and calibration. Sensitivity and specificity of each tool for identifying high-risk individuals were assessed using a risk score cut-off of 10% alone or this 10% cut-off plus clinical risk criteria of diabetes in those aged >60 years, high blood pressure, or high cholesterol. Among 2333 participants (10 731 person-years of follow-up), 102 participants developed a cardiovascular event. The 5-year observed risk was 4.4% (95% confidence interval: 3.6-5.3). The WHO-RS tools underestimated cardiovascular risk but the ARS overestimated risk, particularly in men. Both the laboratory-based (C-statistic: 0.68 and χ2: 26.5, P = 0.003) and non-laboratory-based (C-statistic: 0.69 and χ2: 20.29, P = 0.003) Globorisk tools showed relatively good discrimination and agreement. Addition of clinical criteria to a 10% risk score cut-off improved the diagnostic accuracy of all tools.

CONCLUSION

Cardiovascular risk prediction tools performed disparately in a setting of disadvantage in rural India, with the Globorisk performing best. Addition of clinical criteria to a 10% risk score cut-off aids assessment of risk of a cardiovascular event in rural India.

LAY SUMMARY

In a cohort of people without prior cardiovascular disease, tools used to predict the risk of cardiovascular events varied widely in their ability to accurately predict who would develop a cardiovascular event.The Globorisk, and to a lesser extent the ARS, tools could be appropriate for this setting in rural India.Adding clinical criteria, such as sustained high blood pressure, to a cut-off of 10% risk of a cardiovascular event within 5 years could improve identification of individuals who should be monitored closely and provided with appropriate preventive medications.

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

Drivers of cardiovascular disease risk factors in slums in Kampala, Uganda: a qualitative study

BACKGROUND

Cardiovascular disease (CVD) risk factors are increasing in many sub-Saharan African countries and disproportionately affecting communities in urban slums. Despite this, the contextual factors that influence CVD risk among slum communities have not been fully documented to guide interventions to prevent and control the disease.

OBJECTIVE

This study explored the drivers of CVD risk factors in slums in Kampala, Uganda.

METHODS

This qualitative study employed focus group discussions (FGDs) to collect data among slum residents. A total of 10 FGDs separate for gender and age group were held in community public places. Discussions were audio-recorded, transcribed, and transcripts analysed thematically with the aid of Atlas ti 7.0. Study themes and sub-themes are presented supported by participant quotations.

RESULTS

Five themes highlighted the drivers of CVD risk factors in slum communities. (1) Poverty: a critical underlying factor which impacted access and choice of food, work, and housing. (2) Poverty-induced stress: a key intermediate factor that led to precarious living with smoking and alcohol use as coping measures. (3) The social environment which included socialisation through drinking and smoking, and family and peers modelling behaviours. (4) The physical environment such as the high availability of affordable alcohol and access to amenities for physical activity and healthy foods. (5) Knowledge and information about CVD risk factors which included understanding of a healthy diet and the dangers of smoking and alcohol consumption.

CONCLUSION

To address CVD risk in slums, broad-ranging multisectoral interventions are required, including economic empowerment of the slum population, stress reduction and coping interventions, and alcohol legislation. Also, there is a need for community CVD sensitisation and screening as well as increasing access to physical activity amenities and healthy foods within slums.

Lay health worker research personnel for home-based data collection in clinical and translational research: Qualitative and quantitative findings from two trials in hard-to-reach populations

Aims

The role of lay health workers in data collection for clinical and translational research studies is not well described. We explored lay health workers as data collectors in clinical and translational research studies. We also present several methods for examining their work, i.e., qualitative interviews, fidelity checklists, and rates of unusable/missing data.

Methods

We conducted 2 randomized, controlled trials that employed lay health research personnel (LHR) who were employed by community-based organizations. In one study, n = 3 Latina LHRs worked with n = 107 Latino diabetic participants. In another study, n = 6 LHR worked with n = 188 Cambodian American refugees with depression. We investigated proficiency in biological, behavioral, and psychosocial home-based data collection conducted by LHR. We also conducted in-depth interviews with lay LHR to explore their experience in this research role. Finally, we described the training, supervision, and collaboration for LHR to be successful in their research role.

Results

Independent observers reported a very high degree of fidelity to technical data collection protocols (>95%) and low rates of missing/unusable data (1.5%-11%). Qualitative results show that trust, training, communication, and supervision are key and that LHR report feeling empowered by their role. LHR training included various content areas over several weeks with special attention to LHR and participant safety. Training and supervision from both the academic researchers and the staff at the community-based organizations were necessary and had to be well-coordinated.

Conclusions

Carefully selected, trained, and supervised LHRs can collect sophisticated data for community-based clinical and translational research.

The Pre-Implementation Phase of a Project Seeking to Deliver a Community-Based CVD Prevention Intervention (SPICES-Sussex): A Qualitative Study Exploring Views and Experience Relating to Intervention Development

BACKGROUND.

Community-led health care interventions may be an effective way to tackle cardiovascular disease (CVD) risk factors, especially in materially deprived communities where health care resources are stretched and engagement with institutions is often low. To do so effectively and equitably, interventions might be developed alongside community members through community engagement.

OBJECTIVES.

The aim of this project was to carry out stakeholder mapping and partnership identification and to understand the views, needs, experiences of community members who would be involved in later stages of a community-based CVD prevention intervention's development and implementation.

METHODS.

Stakeholder mapping was carried out to identify research participants in three communities in Sussex, United Kingdom. A qualitative descriptive approach was taken during the analysis of focus groups and interviews with 47 participants.

FINDINGS.

Three themes were highlighted related to intervention design (a) Management: the suitability of the intervention for the community, management of volunteers, and communication; (b) Logistics: the structure and design of the intervention; and (c) Sociocultural issues, the social and cultural expectations/experiences of participants and implementers.

CONCLUSIONS.

Study participants were open and willing to engage in the planned community-based intervention, particularly in elements of co-design and community-led delivery. They also highlighted the importance of sociocultural factors. Based on the findings, we developed recommendations for intervention design which included (but were not limited to): (a) a focus on a bottom-up approach to intervention design, (b) the recruitment of skilled local volunteers, and (c) the importance of fun and simplicity.

Risk assessment of dietary factors in global pattern of ischemic heart disease mortality and disability-adjusted life years over 30 years

Objectives

The aim of this study was to investigate differences in the burden of ischemic heart disease (IHD)-related mortality and disability-adjusted life years (DALYs) caused by dietary factors, as well as the influencing factors with age, period, and cohort effects, in regions with different social-demographic status from 1990 to 2019.

Methods

We extracted data on IHD mortality, DALYs, and age-standardized rates (ASRs) related to dietary risks from 1990 to 2019 as IHD burden measures. Hierarchical age-period-cohort analysis was used to analyze age- and time-related trends and the interaction between different dietary factors on the risk of IHD mortality and DALYs.

Results

Globally, there were 9.2 million IHD deaths and 182 million DALYs in 2019. Both the ASRs of death and DALYs declined from 1990 to 2019 (percentage change: -30.8% and -28.6%, respectively), particularly in high and high-middle socio-demographic index (SDI) areas. Low-whole-grain, low-legume, and high-sodium diets were the three main dietary factors that increased the risk of IHD burden. Advanced age [RR (95%CI): 1.33 (1.27, 1.39)] and being male [1.11 (1.06, 1.16)] were independent risk factors for IHD mortality worldwide and in all SDI regions. After controlling for age effects, IHD risk showed a negative period effect overall. Poor diets were positively associated with increased risk of death but were not yet statistically significant. Interactions between dietary factors and advanced age were observed in all regions after adjusting for related variables. In people aged 55 and above, low intake of whole grains was associated with an increased risk of IHD death [1.28 (1.20, 1.36)]. DALY risks showed a similar but more obvious trend.

Conclusion

IHD burden remains high, with significant regional variations. The high IHD burden could be attributed to advanced age, sex (male), and dietary risk factors. Dietary habits in different SDI regions may have varying effects on the global burden of IHD. In areas with lower SDI, it is recommended to pay more attention to dietary problems, particularly in the elderly, and to consider how to improve dietary patterns in order to reduce modifiable risk factors.

Community Health Worker-Led Cardiovascular Disease Risk Screening and Referral for Care and Further Management in Rural and Urban Communities in Rwanda

Cardiovascular disease (CVD) is a global health issue. Low- and middle-income countries (LMICs) are facing early CVD-related morbidity. Early diagnosis and treatment are an effective strategy to tackle CVD. The aim of this study was to assess the ability of community health workers (CHWs) to screen and identify persons with high risks of CVD in the communities, using a body mass index (BMI)-based CVD risk assessment tool, and to refer them to the health facility for care and follow-up. This was an action research study conducted in rural and urban communities, conveniently sampled in Rwanda. Five villages were randomly selected from each community, and one CHW per each selected village was identified and trained to conduct CVD risk screening using a BMI-based CVD risk screening tool. Each CHW was assigned to screen 100 fellow community members (CMs) for CVD risk and to refer those with CVD risk scores ≥10 (either moderate or high CVD risk) to a health facility for care and further management. Descriptive statistics with Pearson's chi-square test were used to assess any differences between rural and urban study participants vis-à-vis the key studied variables. Spearman's rank coefficient and Cohen's Kappa coefficient were mainly used to compare the CVD risk scoring from the CHWs with the CVD risk scoring from the nurses. Community members aged 35 to 74 years were included in the study. The participation rates were 99.6% and 99.4% in rural and urban communities, respectively, with female predominance (57.8% vs. 55.3% for rural and urban, p-value: 0.426). Of the participants screened, 7.4% had a high CVD risk (≥20%), with predominance in the rural community compared to the urban community (8.0% vs. 6.8%, p-value: 0.111). Furthermore, the prevalence of moderate or high CVD risk (≥10%) was higher in the rural community than in the urban community (26.7% vs. 21.1%, p-value: 0.111). There was a strong positive correlation between CHW-based CVD risk scoring and nurse-based CVD risk scoring in both rural and urban communities, 0.6215 (p-value < 0.001) vs. 0.7308 (p-value = 0.005). In regard to CVD risk characterization, the observed agreement to both the CHW-generated 10-year CVD risk assessment and the nurse-generated 10-year CVD risk assessment was characterized as "fair" in both rural and urban areas at 41.6% with the kappa statistic of 0.3275 (p-value < 001) and 43.2% with kappa statistic of 0.3229 (p-value =0.057), respectively. In Rwanda, CHWs can screen their fellow CMs for CVD risk and link those with high CVD risk to the healthcare facility for care and follow-up. CHWs could contribute to the prevention of CVDs through early diagnosis and early treatment at the bottom of the health system.

Implementing and Evaluating Community Health Worker-Led Cardiovascular Disease Risk Screening Intervention in Sub-Saharan Africa Communities: A Participatory Implementation Research Protocol

The increasing burden of non-communicable diseases (NCDs), particularly cardiovascular diseases (CVD) in low- and middle-income countries (LMICs) poses a considerable threat to public health. Community-driven CVD risk screening, referral and follow-up of those at high CVDs risk is essential to supporting early identification, treatment and secondary prevention of cardiovascular events such as stroke and myocardial infarction. This protocol describes a multi-country study that aims to implement and evaluate a community health worker (CHW)-led CVD risk screening programme to enhance referral linkages within the local primary care systems in sub-Saharan Africa (SSA), using a participatory implementation science approach. The study builds upon a prior community-driven multicentre study conducted by the Collaboration for Evidence-based Health Care and Public Health in Africa (CEBHA+). This is a participatory implementation research. The study will leverage on the CVD risk citizen science pilot studies conducted in the four selected CEBHA+ project countries (viz. Ethiopia, Rwanda, Malawi, and South Africa). Through planned engagements with communities and health system stakeholders, CHWs and lay health worker volunteers will be recruited and trained to screen and identify persons that are at high risk of CVD, provide referral services, and follow-up at designated community health clinics. In each country, we will use a multi-stage random sampling to select and then screen 1000 study participants aged 35-70 years from two communities (one rural and one urban). Screening will be done using a simple validated non-laboratory-based CVD risk assessment mobile application. The RE-AIM model will be used in evaluating the project implementation outcomes, including reach, fidelity, adoption and perceived effectiveness. Developing the capacities of CHWs and lay health worker volunteers in SSA to support population-based, non-invasive population-based CVD risk prevention has the potential to impact on early identification, treatment and secondary prevention of CVDs in often under-resourced communities. Using a participatory research approach to implementing mobile phone-based CHW-led CVD risk screening, referral and follow-up in SSA will provide the evidence needed to determine the effectiveness of CVD risk screening and the potential for scaling up in the wider region.

Lung cancer awareness training experiences of community health workers in KwaZulu-Natal, South Africa

BACKGROUND

Lung cancer is the leading cause of cancer mortality worldwide. Awareness interventions in the developing world remain scarce. Community health workers (CHWs) are a critical component towards ensuring efficient delivery of healthcare services in low- and middle-income countries.

AIM

This study explored the experiences of CHWs of their training as lung cancer awareness intervention implementers.

SETTING

The study was conducted in a resource-poor setting, with CHWs from previously disadvantaged communities.

METHODS

On the last day of training, 10 CHWs were requested to voluntarily participate in a focus group discussion regarding their experiences of the training, utilising a discussion guide.

RESULTS

The participants expressed positive experiences with the training. They cited the amenable and conducive learning environment established by the facilitator. The participants felt empowered through the newly acquired knowledge and wanted to help their communities. However, some participants expressed a desire to have other forms of learning incorporated in future training. The participants were also cognisant of existing gaps in their own knowledge that could be elaborated upon in preparation for potential questions by the community. Some participants confirmed their role as agents of change.

CONCLUSION

The authors propose large-scale intervention studies of lung cancer awareness utilising the CHW programme to gather conclusive evidence regarding their effectiveness at a community level.Contribution: This article provides insight into the training of community health workers on lung cancer awareness and future research on the integration of the intervention into already existing programmes.

Optimizing Hypertension Control Globally: WHF Roadmap

PURPOSE OF REVIEW

Hypertension represents the most important cardiovascular risk factor, affecting over 4.06 billion adults worldwide. In this review, we will discuss potential barriers and their solutions to improve prevention, detection, and management of hypertension.

RECENT FINDINGS

The prevalence of hypertension has been increasing in low- and middle-income countries, requiring new strategies to improve its recognition and proper management. The World Heart Federation (WHF) developed a roadmap for hypertension, advising health system policies and clinical practices as part of its commitment to improving global cardiovascular health. The World Health Organization (WHO) has published in 2021 practical guidelines for the pharmacological treatment of hypertension in adults. Identifying potential roadblocks and solutions deserves high priority to improve the detection, management, and control of hypertension.

[Integrating hypertension and diabetes management in primary health care settings: HEARTS as a toolIntegrando o manejo da hipertensão e do diabetes na atenção primária à saúde: uso do HEARTS como instrumento]

Hypertension and diabetes are modifiable cardiovascular disease (CVD) risk factors that contribute to nearly one-third of all deaths in the Americas Region each year (2.3 million deaths). Despite advances in the detection and clinical management of hypertension and diabetes, there are substantial gaps in their implementation globally and in the Region. The considerable overlap in risk factors, prognosis, and treatment of hypertension and diabetes creates a unique opportunity for a unified implementation model for management at the population level. This report highlights one such high-profile effort, the Pan American Health Organization's "HEARTS in the Americas" program, based on the World Health Organization's HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care. The HEARTS program aims to improve the implementation of preventive CVD care in primary health systems using six evidence-based, pragmatic components: Healthy-lifestyle counseling, Evidence-based protocols, Access to essential medicines and technology, Risk-based CVD management, Team-based care, and Systems for monitoring. To date, HEARTS implementation projects have focused primarily on hypertension given that it is the leading modifiable CVD risk factor and can be treated cost-effectively. The objective of this report is to describe opportunities for integration of diabetes clinical care and policy within the HEARTS hypertension framework. A substantial global burden of disease could be averted with integrated primary care management of these conditions. Thus, there is an urgency in applying lessons from HEARTS to close these implementation gaps and improve the integrated detection, treatment, and control of diabetes and hypertension.

Comparison of community and clinic-based blood pressure measurements: A cross-sectional study from Haiti

Hypertension (HTN) is the leading modifiable cardiovascular disease (CVD) risk factor in low and middle-income countries, and accurate and accessible blood pressure (BP) measurement is essential for identifying persons at risk. Given the convenience and increased use of community BP screening programs in low-income settings, we compared community and clinic BP measurements for participants in the Haiti CVD Cohort Study to determine the concordance of these two measurements. Participants were recruited using multistage random sampling from March 2019 to August 2021. HTN was defined as systolic BP (SBP) ≥ 140mmHg, diastolic BP (DBP) ≥ 90mmHg or taking antihypertensives according to WHO guidelines. Factors associated with concordance versus discordance of community and clinic BP measurements were assessed with multivariable Poisson regressions. Among 2,123 participants, median age was 41 years and 62% were female. Pearson correlation coefficients for clinic versus community SBP and DBP were 0.78 and 0.77, respectively. Using community BP measurements, 36% of participants screened positive for HTN compared with 30% using clinic BPs. The majority of participants had concordant measurements of normotension (59%) or HTN (26%) across both settings, with 4% having isolated elevated clinic BP (≥140/90 in clinic with normal community BP) and 10% with isolated elevated community BP (≥140/90 in community with normal clinic BP). These results underscore community BP measurements as a feasible and accurate way to increase HTN screening and estimate HTN prevalence for vulnerable populations with barriers to clinic access.

Non-communicable diseases prevention in remote areas of Vietnam: Limited roles of health education and community workers

Objective

This study aimed to measure the exposure of residents to health education messages about non-communicable diseases (NCD)-related risk factors, and activities of village health workers (VHWs) in NCDs prevention and control in the mountainous setting of Vietnam.

Method

A cross-sectional study was performed in Dap Thanh commune (Ba Che, Quang Ninh province, Vietnam), a mountainous area. There were 151 residents aged 18 years or above recruited for this study. Information regarding exposure to messages about risk factors of NCDs, and activities of VHWs was collected via face-to-face interviews using a structured questionnaire. Multivariate logistic regression was employed to identify associated factors with exposing messages about NCD-related risk factors.

Results

The majority of participants heard about messages related to risk factors of NCDs in the last 30 days, from 56.3% (physical inactivity message), 59.6% (diet message), 75.5% (alcohol use message) to 79.5% (smoking message). Radio/television was the most common source of the messages (from 91.8% to 95.8%) and the majority of participants heard these messages from one source (from 77.1% to 80.9%). Most of sample reported the unavailability of VHWs in their locals (53.6%). Among locals having VHWs, health communication and education was the most common service provided (54.3%); however, only 30% received NCD management services. Participants who had other jobs were less likely to hear about diet-related messages (OR = 0.32; 95%CI = 0.11–0.92), and those ever smoking were more likely to hear these messages in the last 30 days (OR = 6.86; 95%CI = 1.06–44.51). People who had diabetes mellitus were more likely to hear physical activity-related messages in the last 30 days (OR = 2.55; 95%CI = 1.20–5.41).

Conclusion

Our findings indicated that health communication regarding risk factors of NCDs in mountainous areas in Vietnam was insufficient, and the role of health workers as formal information source was not recognized. Efforts should be made to increase the capacity and involvement of VHWs in health education and NCD prevention in mountainous regions.

Perceived barriers and enablers influencing health extension workers toward home-based hypertension screening in rural northwest Ethiopia: interpretive descriptive study

Background

Hypertension, a major but modifiable risk factor for cardiovascular diseases, is a global health problem including Ethiopia. In a limited infrastructure task sharing of hypertension screening for community health workers is a feasible strategy to improve hypertension management. Recent finding have shown that trained health extension workers (HEWs) can identify high blood pressure, which was effective and feasible. Identifying barriers and enablers for home-based hypertension screening by HEWs is crucial for its implementation. This study aimed to explore barriers and enablers that influence health extension workers’ home-based hypertension screening in the community.

Methods

The interpretive descriptive design was implemented. In-depth interviews were conducted during October, 2020. A total of 26 participants including HEWs, supervisors, and heads of district health office were purposively selected. They were asked to describe their perception toward home-based hypertension screening by the HEWs. The interviews were audio-recorded, transcribed verbatim into Amharic, and translated into English. The transcripts were coded and themes were identified. Thematic approach was used for data analysis.

Results

The participants identified key perceived barriers and enablers of HEWs home-based hypertension screening. The most common barriers were a lack of hypertension training, blood pressure measuring devices, blood pressure guidelines and manuals, skilled HEWs, financial incentives, and poor community awareness of the disease. The most common enablers were support from community leaders, presence of functional development army and community trust for HEWs, presence of routine campaign on vaccination and community based health insurance, and an integrated health system.

Conclusions

Our findings have implications for the HEWs' ongoing implementation of home-based hypertension screening. Successful implementation of this strategy requires scaling up of hypertension training programs for health extension workers and their supervisors, provision of standardized protocols, provision of adequate blood pressure measuring equipment, and regular supportive supervision.

Bibliometric analysis of core competencies associated nursing management publications

AIMS

This study aimed to identify high-impact papers on global nursing to determine and analyze the publication of articles on core competencies in nursing-related journals and the research trends in the era of globalization.

BACKGROUND

Bibliometrics has been shown to be an effective method for analyzing publications. Through bibliometrics, nursing managers and researchers can understand the trends of high-impact international nursing core competencies research, identify mainstream research directions, and obtain relevant knowledge and information, thereby facilitating the translation of research outcomes into nursing management practice.

EVALUATION

The study adopted bibliometric analysis and the VOSviewer software to explore dynamic publication trends and analyze the current situation of nursing research from a comprehensive development perspective, which was realized by searching for nursing core competencies papers in the Web of Science (WoS) database, calculating citations, and determining the trends of the most influential papers.

RESULTS

Nursing core competencies research grew rapidly between 1997 and 2022. Countries with the most core competencies publications were the United States, England, Australia, and Canada. The Journal of Nursing Management has attracted substantial attention from researchers worldwide. Education, Management, and Nurses were the most frequently used keywords in the study. A total of 534 papers were retrieved from the WoS database with the main research fields, including nursing, business economics, public environmental occupational health, and health care science services.

CONCLUSION

Equipping nursing graduates with core competencies has always been an important goal of global medical and nursing education. This study analyzed papers across 35 years, most of which were published in the Journal of Nursing Management. In addition, the study identified some of the main research topics of nursing management, such as the integration of education with nursing management and the cultivation of nurses' core competencies. The study also provides a fresh review of highly cited articles. The results of the study show that high-quality articles play the role of improving both the quality and the quantity of related research. By analyzing the trends of the research on core competencies, this study lays a bibliometric foundation for researchers regarding international journals, hot topics, and relevant fields. In addition, the highly cited articles reveal new perspectives for the nursing field, providing inspiration for nursing management and education researchers.

IMPLICATIONS FOR NURSING MANAGEMENT

This study provides scholars and managers with an overview of the current situation of nursing management research and the development of benchmark journals. The study provides researchers not only with a better understanding of various international journals, allowing them to transition out of traditional thinking in the era of science and technology, but also with innovative thinking by combining research with nursing management. The results of this study invite nursing managers to study relevant topics of core competencies and integrate information technology to education, management, and nurses, thereby contributing to nursing management and educational research.

Integrating hypertension and diabetes management in primary health care settings: HEARTS as a tool

Hypertension and diabetes are modifiable cardiovascular disease (CVD) risk factors that contribute to nearly one-third of all deaths in the Americas Region each year (2.3 million deaths). Despite advances in the detection and clinical management of hypertension and diabetes, there are substantial gaps in their implementation globally and in the Region. The considerable overlap in risk factors, prognosis, and treatment of hypertension and diabetes creates a unique opportunity for a unified implementation model for management at the population level. This report highlights one such high-profile effort, the Pan American Health Organization's "HEARTS in the Americas" program, based on the World Health Organization's HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care. The HEARTS program aims to improve the implementation of preventive CVD care in primary health systems using six evidence-based, pragmatic components: Healthy-lifestyle counseling, Evidence-based protocols, Access to essential medicines and technology, Risk-based CVD management, Team-based care, and Systems for monitoring. To date, HEARTS implementation projects have focused primarily on hypertension given that it is the leading modifiable CVD risk factor and can be treated cost-effectively. The objective of this report is to describe opportunities for integration of diabetes clinical care and policy within the HEARTS hypertension framework. A substantial global burden of disease could be averted with integrated primary care management of these conditions. Thus, there is an urgency in applying lessons from HEARTS to close these implementation gaps and improve the integrated detection, treatment, and control of diabetes and hypertension.

Knowledge and attitude of peripheral health workers regarding Non-Communicable diseases in a Rural area of Rajasthan

Background: Mortality due to Non communicable disease (NCD) has increased from 50% to 60% in India from 2004 to 2014. Increasing mortality due to NCD has compelled Government of India to launch a national program (NPCDCS). This program has involved peripheral health workers hence this study was conducted to assess level of knowledge and attitude of peripheral health workers working in rural area of CHC Naila regarding NCDs. Methods: Present study was conducted at CHC Naila, Rajasthan, during June to Dec 2019. All (38) peripheral health staff working under CHC Naila were assessed and categorised regarding NCD and NPCDCS program. Results: Majority (77%) peripheral health workers had more than ten years of field experience. All have heard about NPCDCS program and type of NCDs covered under it. they were aware of sign & symptoms of common NCDs, however 18.42% of these were not aware of their role of community awareness about risk factors of NCDs and conducting regular screening. Conclusion: Though the level of awareness of health workers regarding type of NCDs, its consequences and risk factors was good however skill development training is needed so that they can screen people effectively and motivate them for healthy life style for optimum result.

Influence of interaction between community health workers and adults with chronic diseases on risk mitigation through care coordination

Introduction

Addressing health disparities and barriers to care requires a comprehensive approach that involves participation of health care providers, multiple organizations, and service providers in the communities affected. Given the importance of using community health workers to help address the complex and overlapping medical, social, and behavioral needs of high-risk individuals, it is of utmost importance to understand their impact on health outcomes. This study examines how in-person interaction between community health workers and their clients influence the client's level of risk mitigation achieved through care coordination using the Pathways Community HUB model.

Methods

The study utilized two years of data extracted from the Care Coordination Systems database for 391 adults who participated in the Northwest Ohio Pathways Community HUB program. Using multinomial logistic regression analysis, we assessed how the interaction between community health workers and adults with chronic diseases who participated in the Northwest Ohio Pathways Community HUB program influenced the successful mitigation of their social, behavioral, and other medical risks over a 2-year period.

Results

Our findings show that as the number of in-person contacts between the community health worker and the client increased, the likelihood of completing all Pathways increased by 27% when compared to completing less than 50% of the assigned Pathways, after adjusting for potential confounders (odds ratio: 1.27, 95% confidence interval: 1.07−1.52).

Discussion

Using community health workers as part of care coordination teams may be effective in connecting communities to systems of care, helping individuals manage their health conditions and connecting individuals to needed social services. Their direct in-person interaction with at-risk individuals may increase the extent to which these individuals successfully address risks to their health and well-being.

Trained health extension workers correctly identify high blood pressure in rural districts of northwest Ethiopia: a diagnostic accuracy study

Background

Hypertension is a public health issue in Ethiopia. The vast majority of cases remain undiagnosed and untreated. Early and accurate identification of hypertension can help with timely management and reduce the risk of complications. In resource-constrained rural settings where poor access to care and a shortage of healthcare providers are major barriers, task-sharing of some primary healthcare duties from well-trained healthcare workers to community health workers has been found to be a cost-effective strategy. This study aimed to assess the ability of trained health extension workers to correctly identify high blood pressure among adults in rural areas of northwest Ethiopia.

Methods

A cross-sectional study was conducted in rural areas of northwest Ethiopia from June to October 2020. Trained health extension workers and health professionals measured the blood pressure of 1177 study participants using a calibrated aneroid sphygmomanometer. A Kappa test statistic was used to compare the two sets of measurements for agreement. The sensitivity, specificity, positive, and negative predictive values were used to assess the validity of health extension workers’ ability to identify high blood pressure in comparison to health professionals.

Results

The trained health extension workers and health professionals identified 219 (18.6%) and 229 (19.5%) of the participants with high blood pressure, respectively. The inter-rater agreement between health extension workers and health professionals for high blood pressure detection was 91.2% (k = 0.912, 95% CI: 0.88, 0.94, p-value = 0.000). The sensitivity and specificity of high blood pressure detection by health extension workers were 90.8% (95% CI: 89.6, 92.0) and 98.8% (95% CI: 98.1, 99.5), respectively. While the positive and negative predictive values were 95.0% (95% CI: 92.1, 97.9) and 97.8% (95% CI: 97.3, 98.3), respectively.

Conclusions

The inter-rater agreement between the trained health extension workers and health professionals on high blood pressure detection was excellent. The findings indicate that training health extension workers is a reliable and valid strategy for early detection of hypertension. Thus, the strategy can be integrated with the essential services provided by primary health care units at the village and health post level in rural settings.

Effectiveness of community health workers on identification and mobilization of persons living with epilepsy in rural Rwanda using a validated screening tool

INTRODUCTION

Engagement and training of community health workers (CHWs) have demonstrated their value in different conditions. Despite repeat epilepsy trainings of CHWs in Northern Rwanda, the treatment gap remained high. We hypothesized that effectiveness of CHWs on mobilization of patients living with epilepsy (PwE) could be improved using a validated tool for epilepsy screening.

METHODS

CHWs associated with health centers (HCs) of Gataraga, Kimonyi and Karwasa attended a 1-day training on epilepsy and Limoges epilepsy screening questionnaire (Kinyarwanda version). Thereafter, CHWs screened households in their villages for persons with one or more positive answer. CHWs then accompanied positively screened persons to a consultation for clinical evaluation and diagnosis by neurologists, and demographic data were collected. CHW variables were collected retrospectively.

RESULTS

A total of 1308 persons were screened positive by 281 CHWs. Clinical diagnosis of epilepsy was confirmed in 589 and in 93 additional unscreened PwE, presenting voluntarily at the consultation. Pre-intervention number of 48 PwE increased to 682 after, a 14.2-fold increase. The overall treatment gap amounted to 93.0%. The age distribution of male PwE preponderance at younger age inverted to females at older age. CHW characteristics showed non-significant differences within and across HCs. Logistic regression did not relate CHW age, gender, and experience to screening results.

DISCUSSION

Equipping CHWs with a validated screening tool was effective in identifying and mobilizing PwE in a short time frame and offers opportunity for future scaling. Nonetheless, barriers to sustainability of care will need to be addressed before.

Engaging Female Community Health Volunteers (FCHVs) for cardiovascular diseases risk screening in Nepal

Introduction

Non-Communicable Diseases (NCDs) have become the leading public health problems worldwide and the cardiovascular diseases (CVDs) is one of the major NCDs. Female Community Health Volunteers (FCHVs) in Nepal are the key drivers to implementing frontline health services. We explored the potential for engaging FCHVs for CVD risk screening at the community level in Nepal.

Methods

We used multiple approaches (quantitative and qualitative) for data collection. The trained FCHVs administered CVD risk screening questionnaire among 491 adults in rural and urban areas and calculated the CVD risk scores. To maintain consistency and quality, a registered medical doctor also, using the same risk scoring chart, independently calculated the CVD risk scores. Kappa statistics and concordance coefficient were used to compare these two sets of risk screening results. Sensitivity and specificity analyses were conducted. Two focus group discussions among the FCHVs were conducted to determine their experiences with CVD risk screening and willingness to engage with CVD prevention and control efforts.

Results

The mean level of agreement between two sets of risk screening results was 94.5% (Kappa = 0.77, P<0.05). Sensitivity of FCHV screening was 90.3% (95% CI: 0.801–0.964); and the specificity was 97% (95% CI: 0.948, 0.984). FCHVs who participated in the FGDs expressed a strong enthusiasm and readiness to using the CVD risk screening tools. Despite their busy workload, all FCHVs showed high level of motivation and willingness in using CVD risk screening tools and contribute to the prevention and control efforts of NCDs. The FCHVs recommended needs for providing additional training and capacity building opportunities.

Conclusion

We conclude that there is a potential for engaging FCHVs to use simple CVD risk screening tools at the community level. The findings are promising, however, further studies engaging larger number of FCHVs and larger population would warrant feasibility of such tools within the existing healthcare systems in Nepal.

Characteristics and Outcomes of Community Health Worker Training to Improve the Prevention and Control of Cardiometabolic Diseases in Low and Middle-Income Countries: A Systematic Review

Community health workers (CHWs) play an important role in controlling non-communicable diseases in low- and middle-income countries. The aim of this review was to describe the characteristics and outcomes of CHW training programs that focused on the prevention and control of cardiometabolic diseases in low- and middle-income countries (LMICs). Medline, CINAHL Complete, Academic Search Complete, Directory of Open Access Journal, ScienceDirect, ERIC, Gale Academic, and OneFile). Studies that described the training programs used to train CHWs for prevention and control of cardiovascular diseases and type2 diabetes mellitus in LMICs. Only studies that evaluated the outcomes of training programs in at least one of the 4 levels of Kirkpatrick’s training evaluation model were included in the review. CHWs who underwent training focused on the prevention and control of cardiovascular disease and type 2 diabetes mellitus. We summarized the resulting evidence using qualitative synthesis through a narrative review. Training outcomes were assessed in relation to (1) CHW reactions to training, their degree of learning, and their behaviors following training, and (2) changes in biochemical and anthropometric indicators in target populations following the CHW program implementation. PROSPERO (CRD42020162116). Thirty-two studies were included. Methods used to train CHWs included: face-to-face lectures, interactive group activities, and blended teaching with online support. Training focused on identifying people with elevated risk of cardiometabolic diseases and their risk factors as well as supporting people to adopt healthy lifestyles. Many studies that utilized trained CHWs did not publish CHW training methods and evaluations, and therefore could not be included in this study. Training programs resulted in an increase in knowledge and skills among CHWs demonstrating that there are certain activities that can be shifted to CHWs following training.

Constructing a Nurse-led Cardiovascular Disease Intervention in Rural Ghana: A Qualitative Analysis

Background

Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region.

Objective

This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure.

Methods

Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants.

Findings

Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies.

Conclusions

Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

Roles for community health workers in diabetes prevention and management in low- and middle-income countries

Diabetes prevalence is increasing worldwide, especially in low- and middle-income countries (LMIC), posing the need for improved detection and management strategies. Chronic disease models and lifestyle medicine provide structures for action. Community health workers (CHWs) can significantly contribute to chronic disease care if they are trained and integrated into low-resource health systems. Although most current CHWs worldwide are performing maternal/child health and infectious disease-related tasks, other programs involving CHWs for noncommunicable disease prevention and management are increasing. In this article, we discuss the advantages, challenges, and questions regarding possible roles assigned to CHWs in the prevention and management of diabetes. These roles include performing simple screening tests, implementing lifestyle/behavioral interventions, and connecting patients with alternatives to biomedicine. Specifically, CHWs can aid diabetes epidemiological surveillance by conducting risk score-based screening or capillary glucose testing, and they can facilitate diabetes self-management by delivering interventions described in the transcultural diabetes nutrition algorithm. Furthermore, while this role has not formally been assigned, CHWs can leverage their intimate knowledge of local practices to provide decision-making support to patients in environments with pluralistic health systems. Ethnocultural differences in CHW functions and transcultural adaptations of their roles in diabetes care should also be considered. In summary, CHWs can improve diabetes care by screening high-risk individuals and implementing lifestyle interventions, especially in LMIC.

Family health sheets: a vital instrument for village health workers providing comprehensive healthcare

INTRODUCTION

Community Health Worker (CHW) programs have long been used to provide acute care for children and women in healthcare shortage areas, but their provision of comprehensive longitudinal care for chronic problems is rare. The Village Health Worker (VHW) program, initiated in 2007, is an example of a long standing "horizontal" CHW program in rural Southwestern Uganda that has delivered village-level care for chronic disease based on a biannual village health census that identifies individual and family health risks. To facilitate continuity of care for problems identified, health census data were electronically transformed into family-specific Family Health Sheets (FHS) in 2016 which summarize the pertinent demographic and health data for each family, as well as health topics the family would like to learn more about. The FHS, evaluated and discussed here, serves as an epidemiologically-informed "bedside" tool to help VHWs provide longitudinal care in their villages.

METHODS

48 VHWs in the program completed a survey on the utility of the FHS and 24 VHWs participated in small discussion groups. Responses were analyzed using both quantitative and standard conceptual content analysis models RESULTS: 46 out of 48 VHWs reported that the FHS made them a "much better VHW." In addition to helping target interventions in child health, women's health, and sanitation, the FHS assisted follow-up of non-communicable diseases in the community. In discussion groups, VHWs reported that the FHS helped them understand risks for future disease, facilitated earning stipends, and increased credibility and trust in the community. Limitations cited were the infrequent updates of the FHS, only biannually with the census, and the lack of cross-reference capability by health problem.

DISCUSSION

The FHS supports VHWs in providing longitudinal and comprehensive healthcare of chronic diseases in their villages. Limitations, potential solutions, and future directions are discussed.

Community health worker-led, technology-enabled private sector intervention for diabetes and hypertension management among urban poor: a retrospective cohort study from large Indian metropolitan city

OBJECTIVES

We assessed the effectiveness of community health workers (CHWs)-led, technology-enabled programme as a large-scale, real-world solution for screening and long-term management of diabetes and hypertension in low-income and middle-income countries.

DESIGN

Retrospective cohort design.

SETTING

Forty-seven low-income neighbourhoods of Hyderabad, a large Indian metropolis.

PARTICIPANTS

Participants (aged ≥20 years) who subscribed to an ongoing community-based chronic disease management programme employing CHWs and technology to manage diabetes and hypertension.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used deidentified programme data between 1 March 2015 and 8 October 2018 to measure participants' pre-enrolment and post-enrolment retention rate and within time-interval mean difference in participants' fasting blood glucose and blood pressure using Kaplan-Meier and mixed-effect regression models, respectively.

RESULTS

51 126 participants were screened (median age 41 years; 65.2% women). Participant acquisition rate (screening to enrolment) was 4%. Median (IQR) retention period was 163.3 days (87.9-288.8), with 12 months postenrolment retention rate as 16.5% (95% CI 14.7 to 18.3). Reduction in blood glucose and blood pressure levels varied by participants' retention in the programme. Adjusted mean difference from baseline ranged from -14.0 mg/dL (95% CI -18.1 to -10.0) to -27.9 mg/dL (95% CI -47.6 to -8.1) for fasting blood glucose; -2.7 mm Hg (95% CI -7.2 to 2.7) to -7.1 mm Hg (95% CI -9.1 to -4.9) for systolic blood pressure and -1.7 mm Hg (95% CI -4.6 to 1.1) to -4.2 mm Hg (95% CI -4.9 to -3.6) for diastolic blood pressure.

CONCLUSIONS

CHW-led, technology-enabled private sector interventions can feasibly screen individuals for non-communicable diseases and effectively manage those who continue on the programme in the long run. However, changes in the model (eg, integration with the public health system to reduce out-of-pocket expenditure) may be needed to increase its adoption by individuals and thereby improve its cost-effectiveness.

Evaluating the cascade of care for hypertension in Sierra Leone

OBJECTIVE

To assess the care for hypertension in Sierra Leone, by the use of a cascade-of-care approach, to identify where the need for healthcare system interventions is greatest.

METHODS

Using data from a nationwide household survey on surgical conditions undertaken in 1956 participants ≥18 years from October 2019 to March 2020, a cascade of care for hypertension consisting of four categories - hypertensive population, those diagnosed, those treated and those controlled - was constructed. Hypertension was defined as having a blood pressure ≥140/90 mmHg, or self-reported use of antihypertensive medication. Logistic regression analysis was used to investigate factors associated with undiagnosed hypertension.

RESULTS

The prevalence of hypertension was 22%. Among those with hypertension, 23% were diagnosed, 11% were treated and 5% had controlled blood pressure. The largest loss to care (77%) was between being hypertensive and receiving a diagnosis. Male sex, age and living in a rural location, were significantly associated with the odds of undiagnosed hypertension. There was no significant difference between men and women in the number of patients with controlled blood pressure. Adults aged 40 or older were observed to be better retained in care compared with those younger than 40 years of age.

CONCLUSION

There is a significant loss to care in the care cascade for hypertension in Sierra Leone. Our results suggest that increasing awareness of cardiovascular risk and risk factor screening for early diagnosis might have a large impact on hypertension care.

Geographic and Sociodemographic Disparities in Cardiovascular Risk in Burkina Faso: Findings from a Nationwide Cross-Sectional Survey

Background

Cardiovascular disease (CVD) risk assessment is a critical step in the current approach to the primary prevention of CVD, particularly in low-income countries such as Burkina Faso. In this study, we aimed to assess the geographic and sociodemographic disparities of the ten-year cardiovascular risk in Burkina Faso.

Methods

We conducted a secondary analysis of the data from the first nationwide survey using the World Health Organization (WHO) STEPwise approach. Ten-year cardiovascular risk was determined using the WHO 2019 updated risk chart (WHO risk) as main outcome, and the Framingham risk score (FRS) and the Globorisk chart for secondary outcomes. We performed a modified Poisson regression model using a generalized estimating equation to examine the association between CVD risk and sociodemographic characteristics.

Results

A total of 3081 participants aged 30 to 64 years were included in this analysis. The overall age and sex-standardized mean of absolute ten-year cardiovascular risk assessed using the WHO risk chart was 2.5% (95% CI: 2.4–2.6), ranging from 2.3% (95% CI: 2.2–2.4) in Centre Est to 3.0% (95% CI: 2.8–3.2) in the Centre region. It was 4.6% (95% CI: 4.4–4.8) for FRS and 4.0% (95% CI: 3.8–4.1) for Globorisk. Regarding categorized CVD risk (absolute risk ≥10%), we found out that the age and sex-standardized prevalence of elevated risk was 1.7% (95% CI: 1.3–2.1) for WHO risk, 10.4% (95% CI: 9.6–11.2) for FRS, and 5.9% (95% CI: 5.1–6.6) for Globorisk. For all of the three risk scores, elevated CVD risk was associated with increasing age, men, higher education, urban residence, and health region (Centre).

Conclusion

We found sociodemographic and geographic inequalities in the ten-year CVD risk in Burkina Faso regardless of risk score used. Therefore, population-wide interventions are needed to improve detection and management of adult in the higher CVD risk groups in Burkina Faso.

The Influence of Anthropometric Indices and Intermediary Determinants of Hypertension in Bangladesh

Hypertension is a major public health burden in Bangladesh. However, studies considering the underlying multifaceted risk factors of this health condition are sparse. The present study concurrently examines anthropometric parameters and intermediary factors influencing hypertension risk in Bangladesh. Using the 2018 World Health Organisation (WHO) STEPwise approach to non-communicable disease risk factor surveillance (STEPS) study conducted in Bangladesh and involving 8019 nationally representative adult respondents, bivariate and multivariate logistic regression analyses were performed to determine the association between anthropometrics, other intermediary factors and hypertension. The regression results were presented using the odds ratio (OR) and adjusted odds ratio (AOR) at 95% confidence intervals (CIs). The risk of hypertension was higher among females and males who were 40 years and older. However, among females, those who were age 60 years and older were more than twice and thrice more likely to be hypertensive compared to those in the younger age groups (18–39, 40–59). Females who were obese (body mass index [BMI], waist to hip ratio [WHR], waist to height ratio [WHtR]) or had high waist circumference [WC] were twice as likely to be hypertensive. Males and females who were physically active, consuming more fruits and vegetables daily and educated had lower odds of developing hypertension. Key findings suggest that the association between anthropometric indices (body mass index [BMI], waist to hip ratio [WHR], waist to height ratio [WHtR]), waist circumference [WC]), other intermediary determinants (e.g., education, physical activity) and hypertension exist across gender and with increasing age among adults in Bangladesh. Developing appropriate public health interventions (e.g., regular assessment of anthropometric parameters) for early identification of the risk and pattern of hypertension through appropriate screening and diagnosis is required to meet the specific health needs of the adult Bangladesh population.

A Mobile Health Tool for Peer Support of Individuals Reentering Communities After Incarceration

Individuals just released from prison, or returning citizens (RCs), face high mortality rates during the reentry period, with cardiovascular disease (CVD) being a leading cause. Peer mentors can support RCs' health, but they traditionally work in person, which may not always be feasible, particularly during pandemic outbreaks such as COVID-19. We used human-centered design to build a prototype of RCPeer, a web/mobile application (app) to support peer-led reentry efforts through CVD risk screening, action planning, linkage to resources addressing reintegration needs (e.g., housing, transportation), and goal-setting. We assessed feasibility, acceptability, and usability of RCPeer using mixed-methods. System Usability Scale (SUS) scores were 68 for peers and 66 for RCs, indicating good usability. Qualitative data suggests that RCPeer can support reentry tasks through RCs and peers sharing data, strengthen RC-peer relationships, and facilitate RCs meeting their goals. Future work is needed to enhance usability for RCs with limited technology experience.

Hypertension in Low- and Middle-Income Countries

In recent decades low- and middle-income countries (LMICs) have been witnessing a significant shift toward raised blood pressure; yet in LMICs, only 1 in 3 are aware of their hypertension status, and ≈8% have their blood pressure controlled. This rising burden widens the inequality gap, contributes to massive economic hardships of patients and carers, and increases costs to the health system, facing challenges such as low physician-to-patient ratios and lack of access to medicines. Established risk factors include unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity. Emerging risk factors include pollution (air, water, noise, and light), urbanization, and a loss of green space. Risk factors that require further in-depth research are low birth weight and social and commercial determinants of health. Global actions include the HEARTS technical package and the push for universal health care. Promising research efforts highlight that successful interventions are feasible in LMICs. These include creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. As the blood pressure trajectory continues creeping upward in LMICs, contextual research on effective, safe, and cost-effective interventions is urgent. New emergent risk factors require novel solutions. Lowering blood pressure in LMICs requires urgent global political and scientific priority and action.

The contribution of family physicians and primary care doctors to community-orientated primary care

South Africa envisages a community-orientated approach to primary health care (PHC). Family physicians and primary care doctors have important roles to play in leading, implementing, supporting and maintaining community-orientated primary care (COPC). In this article, we define COPC, its key principles and approaches to implementing it in health services. Following this we describe the key competencies expected of family physicians and primary care doctors in leading and supporting its implementation; providing clinical support to the PHC teams and linking these teams to other parts of the health system, other sectors and the community. The required knowledge and skills underlying these competencies are also discussed and some specific tools included.

Cancer related knowledge, attitude, and practice among community health care providers and health assistants in rural Bangladesh

BACKGROUND

Cancer remains one of the primary causes of death in Bangladesh. The success of cancer control in rural areas depends on the ability of the health care system and workforce to identify and manage cases properly at early stages. Community Health Workers (CHW) can play a vital role in this process. The present study aims to assess cancer related Knowledge, Attitude, and Practice (KAP) among 2 categories of CHWs - Community Health Care Providers (CHCP) and Health Assistants (HA) in rural Bangladesh.

METHODS

A descriptive cross-sectional study was conducted using a self-administered questionnaire from July 2019 to June 2020. Multi-stage sampling technique was used to determine the sample. One Upazilla Health Complex (UHC) from each of the eight administrative divisions of Bangladesh were randomly chosen as study sites, from which 325 CHCPs and HAs were in the final sample. Multivariate logistic regression models were developed to determine the association between KAP scores and demographic variables.

RESULTS

Our study shows that a modest number of respondents scored above average in the knowledge (54.15%), attitude (58.15%), and practice (65.54%) sections. Majority CHCPs (90.91%) and HAs (96.06%) did not receive govt. training on cancer. Only 20.71% HAs and 25.2% CHCPs knew about the availability of cancer treatment options in Bangladesh. Uncertainty about the availability of relevant treatments or vaccinations at public facilities was also high. Having cancer in the family, income, duration of employment and workplace locations were important predictors of cancer related KAP scores.

CONCLUSION

Healthcare workforce's knowledge gap and unfavorable attitude towards cancer may result in poor delivery of care at the rural level. For many people in rural areas, CHCPs and HAs are the first point of contact with the healthcare system and thus effective cancer control strategies must consider them as key stakeholders. Targeted training programs must be adopted to address the cancer related KAP gaps among CHCPs and HAs.

Chronic Disease in the Community (CDCom) Program: Hypertension and non-communicable disease care by village health workers in rural Uganda

Background

Although hypertension, the largest modifiable risk factor in the global burden of disease, is prevalent in sub-Saharan Africa, rates of awareness and control are low. Since 2011 village health workers (VHWs) in Kisoro district, Uganda have been providing non-communicable disease (NCD) care as part of the Chronic Disease in the Community (CDCom) Program. The VHWs screen for hypertension and other NCDs as part of a door-to-door biannual health census, and, under the supervision of health professionals from the local district hospital, also serve as the primary providers at monthly village-based NCD clinics.

Objective/Methods

We describe the operation of CDCom, a 10-year comprehensive program employing VHWs to screen and manage hypertension and other NCDs at a community level. Using program records we also report hypertension prevalence in the community, program costs, and results of a cost-saving strategy to address frequent medication stockouts.

Results/Conclusions

Of 4283 people ages 30–69 screened for hypertension, 22% had a blood pressure (BP) ≥140/90 and 5% had a BP ≥ 160/100. All 163 people with SBP ≥170 during door-to-door screening were referred for evaluation in CDCom, of which 91 (59%) had repeated BP ≥170 and were enrolled in treatment. Of 761 patients enrolled in CDCom, 413 patients are being treated for hypertension and 68% of these had their most recent blood pressure below the treatment target. We find: 1) The difference in hypertension prevalence between this rural, agricultural population and national rates mirrors a rural-urban divide in many countries in sub-Saharan Africa. 2) VHWs are able to not only screen patients for hypertension, but also to manage their disease in monthly village-based clinics. 3) Mid-level providers at a local district hospital NCD clinic and faculty from an academic center provide institutional support to VHWs, stream-line referrals for complicated patients and facilitate provider education at all levels of care. 4) Selective stepdown of medication doses for patients with controlled hypertension is a safe, cost-saving strategy that partially addresses frequent stockouts of government-supplied medications and patient inability to pay. 5) CDCom, free for village members, operates at a modest cost of 0.20 USD per villager per year. We expect that our data-informed analysis of the program will benefit other groups attempting to decentralize chronic disease care in rural communities of low-income regions worldwide.

Community-driven citizen science approach to explore cardiovascular disease risk perception, and develop prevention advocacy strategies in sub-Saharan Africa: a programme protocol

BACKGROUND

In sub-Saharan Africa (SSA), which experiences a disproportionately high cardiovascular disease (CVD) burden, population-based screening and prevention measures are hampered by low levels of knowledge about CVD and associated risk factors, and inaccurate perceptions of severity of risk.

METHODS

This protocol describes the planned processes for implementing community-driven participatory research, using a citizen science method to explore CVD risk perceptions and to develop community-specific advocacy and prevention strategies in the rural and urban SSA settings. Multi-disciplinary research teams in four selected African countries will engage with and train community members living in rural and urban communities as citizen scientists to facilitate conceptualization, co-designing of research, data gathering, and co-creation of knowledge that can lead to a shared agenda to support collaborative participation in community-engaged science. The emphasis is on robust community engagement, using mobile technology to support data gathering, participatory learning, and co-creation of knowledge and disease prevention advocacy.

DISCUSSION

Contextual processes applied and lessons learned in specific settings will support redefining or disassembling boundaries in participatory science to foster effective implementation of sustainable prevention intervention programmes in Low- and Middle-income countries.

Evaluation of household assessment data collected by community health workers in Cape Town, South Africa

Background

South Africa has implemented ward-based outreach teams as part of re-engineering primary health care with teams of community health workers (CHWs). In Cape Town, such a community-orientated primary care (COPC) approach was developed at four learning sites. Community health workers registered and assessed the households they were responsible for, but a year later the data were not analysed or converted into useful information. The aim was to analyse the household data and evaluate its contribution to a community diagnosis, its quality and any implications for the performance of CHWs.

Methods

This article used descriptive secondary analysis of household data collected by CHWs at three COPC learning sites in Cape Town (Nomzamo, Eastridge and Mamre).

Results

Data were analysed for 16 852 people from Eastridge, 1338 people from Mamre and 1008 people from Nomzamo. Data were compared in terms of household composition and demographics, type of dwelling, identification of people on treatment for chronic conditions, identification of health risks (e.g. tuberculosis symptoms, tobacco smoking, missed immunisations, missed vitamin A prophylaxis, need for human immunodeficiency virus (HIV) testing or family planning, pregnant or postnatal, and wound care) and for referrals.

Conclusion

Household assessment visits have great potential. Data collected is currently of poor quality, inconsistent or not captured, infrequently analysed and not comprehensive. There is a need to introduce an electronic m-health solution to assist the health information system, to revise the contents of the household assessment form and to ensure that CHWs are competent to identify risks and respond appropriately.

In Vitro Efficacy of Aqueous and Methanol Extract of Cassia siamea Against the Motility of Caenorhabditis elegans

Gastrointestinal nematode infections can cause great losses in revenue due to decrease livestock production and animal death. The use of anthelmintic to control gastrointestinal nematode put a selection pressure on nematode populations which led to emergence of anthelmintic resistance. Because of that, this study was carried out to investigate the efficacy of aqueous and methanol extract of Cassia siamea against the motility of C. elegans Bristol N2 and C. elegans DA1316. Caenorhabditis elegans Bristol N2 is a susceptible strain and C. elegans DA1316 is an ivermectin resistant strain. In vitro bioassay of various concentrations of (0.2, 0.6, 0.8, 1.0 and 2.0 mg mL⁻¹) aqueous and methanol extracts of C. siamea was conducted against the motility of L4 larvae of C. elegans Bristol N2 and C. elegans DA1316. The L4 larvae were treated with 0.02 μg mL⁻¹ of ivermectin served as positive control while those in M9 solution served as negative control. The activity of the extracts was observed after 24 h and 48 h. A significant difference was recorded in the extract performance compared to control at (P < 0.001) after 48 h against the motility of the larvae of both strains. The methanol extracts inhibited the motility of C. elegans Bristol N2 by 86.7% as well as DA1316 up to 84.9% at 2.0 mg mL⁻¹ after 48 h. The methanol extract was more efficient than aqueous extract (P < 0.05) against the motility of both strains of C. elegans. Cassia siamea may be used as a natural source of lead compounds for the development of alternative anthelmintic against parasitic nematodes as well ivermectin resistant strains of nematodes.

Critical appraisal of a mHealth-assisted community-based cardiovascular disease risk screening program in rural Kenya: an operational research study

Community health workers (CHWs) can participate in the cascade of hypertension and diabetes management in low and middle-income countries (LMICs). Their services may be enhanced with mobile health (mHealth) tools. In this operational research study, we describe the AFYACHAT mHealth-assisted cardiovascular health screening program in rural Kenya. In this study, A CHW screened a convenience sample of adults ≥ 40 years old in rural Kenya for cardiovascular disease (CVD) risk using the two-way AFYACHAT mHealth instrument. AFYACHAT analyzes a patient's age, sex, smoking, diabetes and systolic blood pressure and provides a four-tiered 10-year CVD risk score. User acceptability was assessed by an end-of-study interview with the CWH. Automated error logs were analyzed. Patient satisfaction was measured with a six-question satisfaction questionnaire. Screened participants with high CVD risk were followed-up via telephone to explore any actions taken following screening. In 24 months, one CHW screened 1650 participants using AFYACHAT. The 10-year risk of CVD was <10% for 1611 (98%) patients, 10 to <20% for 26 (1.6%), 20 to <30% in 12 (0.7%), and ≥30% for 1 (0.1%). The point prevalence of hypertension and diabetes was 27% and 1.9%, respectively. Seventy-five percent of participants with elevated CVD risk sought further medical care. There was high acceptability, a 15% miscode error rate, and high participant satisfaction with the screening program. Our operational research outlines how AFYACHAT mHealth tool can assist CHW perform rapid CVD screening; this provides a model framework for non-communicable disease screening in LMICs.

Public knowledge of cardiovascular disease and response to acute cardiac events in three municipalities in Brazil

Objective

To conduct a landscape assessment of public knowledge of cardiovascular disease risk factors and acute myocardial infarction symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) awareness and training in three underserved communities in Brazil.

Methods

A cross-sectional, population-based survey of non-institutionalised adults age 30 or greater was conducted in three municipalities in Eastern Brazil. Data were analysed as survey-weighted percentages of the sampled populations.

Results

3035 surveys were completed. Overall, one-third of respondents was unable to identify at least one cardiovascular disease risk factor and 25% unable to identify at least one myocardial infarction symptom. A minority of respondents had received training in CPR or were able to identify an AED. Low levels of education and low socioeconomic status were consistent predictors of lower knowledge levels of cardiovascular disease risk factors, acute coronary syndrome symptoms and CPR and AED use.

Conclusions

In three municipalities in Eastern Brazil, overall public knowledge of cardiovascular disease risk factors and symptoms, as well as knowledge of appropriate CPR and AED use was low. Our findings indicate the need for interventions to improve public knowledge and response to acute cardiovascular events in Brazil as a first step towards improving health outcomes in this population. Significant heterogeneity in knowledge seen across sites and socioeconomic strata indicates a need to appropriately target such interventions.

Evaluating a multicomponent program to improve hypertension control in Guatemala: study protocol for an effectiveness-implementation cluster randomized trial

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease (CVD). Despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (LMICs). We will evaluate an adapted version of a multilevel and multicomponent hypertension control program in Guatemala, previously proven effective and feasible in Argentina. The program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback.

METHODS

Using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in Guatemala over an 18-month period. Through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 to enhanced usual care across five departments, enrolling 44 participants per health district and 1584 participants in total. The clinical outcomes are (1) the difference in the proportion of patients with controlled hypertension (< 130/80 mmHg) between the intervention and control groups at 18 months and (2) the net change in systolic and diastolic blood pressure from baseline to 18 months. The context-enhanced Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM)/Practical Robust Implementation and Sustainability Model (PRISM) framework will guide the evaluation of the implementation at the level of the patient, provider, and health system. Using a mixed-methods approach, we will evaluate the following implementation outcomes: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost-effectiveness.

DISCUSSION

We will disseminate the study findings, and promote scale up and scale out of the program, if proven effective. This study will generate urgently needed data on effective, adoptable, and sustainable interventions and implementation strategies to improve hypertension control in Guatemala and other LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03504124. Registered on 20 April 2018.

Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA

INTRODUCTION

As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation.

METHODS

The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time.

RESULTS

Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges.

CONCLUSIONS

Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

Comparative performance of pooled cohort equations and Framingham risk scores in cardiovascular disease risk classification in a slum setting in Nairobi Kenya

BACKGROUND

Cardiovascular diseases (CVD) cause 18 million deaths annually. Low- and middle-income countries (LMICs) account for 80% of the CVD burden, and the burden is expected to grow in the region in the coming years. Screening for and identification of individuals at high risk for CVD in primary care settings can be accomplished using available CVD risk scores. However, few of these scores have been validated/recalibrated for use in sub-Saharan Africa (SSA).

METHODS

Pooled cohort equations (PCE) and Framingham risk scores for 10-year CVD risk were applied on 1960 men and women aged 40 years and older from the AWI-Gen (Africa, Wits-INDEPTH Partnership for GENomic studies) study 2015. Low, moderate/intermediate or high CVD risk classifications correspond to <10%, 10-20% and >20% chance of developing CVD in 10 years respectively. Agreement between the risk scores was assessed using kappa and correlation coefficients.

RESULTS

High CVD risk was 10.3% in PCE 2013, 0.4% in PCE 2018, 2.9% in Framingham and 3.6% in Framingham non-laboratory scores. Conversely, low CVD risk was 62.2% in PCE 2013 and 95.6% in PCE 2018, 84.0% and 80.1% in Framingham and Framingham non-laboratory scores, respectively. A moderate agreement existed between the Framingham functions (kappa = 0.64, 95% CI 0.59-0.68, correlation, rs = 0.711). There was no agreement between the PCE 2013 and 2018 functions (kappa = 0.05, 95% CI 0.04-0.06).

CONCLUSIONS

Newer cohort-based data is necessary to validate and recalibrate existing CVD risk scores in order to develop appropriate functions for use in SSA.

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: a qualitative study

Background

Cardiovascular Disease (CVD) is a growing cause of morbidity and mortality in Ghana, where rural primary health care is provided mainly by the Community-based Health Planning and Services (CHPS) initiative. CHPS locates nurses in community-level clinics for basic curative and preventive health services and provides home and outreach services. But CHPS currently lacks capacity to screen for or treat CVD and its risk factors.

Methods

In two rural districts, we conducted in-depth interviews with 21 nurses and 10 nurse supervisors to identify factors constraining or facilitating CVD screening and treatment. Audio recordings were transcribed, coded for content, and analyzed for key themes.

Results

Respondents emphasized three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. Nurses and supervisors noted that community members were often unaware of CVD, despite high reported prevalence of risk factors. Community members were unable to travel for care or afford treatment once diagnosed. Nurses lacked relevant training and medications for treating conditions such as hypertension. Respondents recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve ancillary support for primary care operations.

Conclusions

CHPS staff expressed multiple constraints to CVD care, but also cited actions to address them: CVD-focused training, provision of essential equipment and pharmaceuticals, community education campaigns, and referral and outreach transportation equipment. Results attest to the need for trial of these interventions to assess their impact on CVD risk factors such as hypertension, depression, and alcohol abuse.