The Effectiveness of Community Health Workers for CVD Prevention in LMIC

Readiness of primary healthcare and community markets for joint delivery of cardiovascular disease prevention services in Kenya: an observational feasibility study of Health Kiosks in Markets (HEKIMA)

OBJECTIVES

The increasing burden of cardiovascular diseases (CVDs) in Kenya threatens its healthcare system. There is a need for innovative models that improve equitable access to CVD prevention services. Community markets are social establishments with untapped potential to promote public health. This is a multiphased feasibility study that explores the potential of Health Kiosks in Markets (HEKIMA) to improve access to CVD prevention services. In this formative phase, the aim was to assess the readiness of primary healthcare centres (HCs) and community markets to jointly deliver CVD prevention services.

DESIGN

Mixed methods using concept mapping and readiness surveys. Concept mapping with 35 stakeholders from different sectors (health and non-health) to identify feasible priorities for HEKIMA. The readiness questionnaire contained 193 items which were based on the guidance of the WHO Handbook for Monitoring the Building Blocks of Health Systems and adapted to suit the context of a single HC.

SETTING

Vihiga County is located in western Kenya and has a population of 590 013. A total of 18 HCs and 19 markets were assessed, with 10 HCs and 15 markets included in the evaluation.

RESULTS

91 statements were generated from concept mapping and distilled into 8 clusters, namely equipment and supplies, access and referral, communication, manpower, networks and linkages, practice, service delivery and health promotion. Agreed actions for HEKIMA were provision of efficient quality services, health promotion and partnerships sensitive to the local context. HCs and markets had established governance systems and basic infrastructure. The majority of the HCs lacked essential CVD medications. No HC-market interface existed but there was willingness for a partnership.

CONCLUSION

There was strong consensus that an HC-market interface via community health worker manned kiosks could have a positive impact on health systems, markets and CVD prevention in vulnerable communities. However, significant infrastructural, technical and resource gaps were observed that need to be addressed.

Assessing the knowledge and skill of ASHA community health workers in blood pressure measurement and primary care of hypertension

Introduction

India has a high burden of hypertension, and community health workers (CHWs) can contribute to its primary care. Studies of small-scale interventions have shown that trained CHWs can be useful contributors to hypertension care. No assessments are available in India on effectiveness of CHW training when conducted on a large scale.

Methods

A study was conducted in Chhattisgarh, where 38,000 Accredited Social Health Activist (ASHA) CHWs had been trained in blood pressure (BP) measurement and counselling skills related to hypertension. The study involved a skill test and a knowledge test with ten points each, administered to two representative samples of trained CHWs - 433 in rural areas and 422 in urban slums.

Results

The mean skill score out of 10 was 7.79 (7.59-7.99) and 8.11 (7.93-8.29) for the rural and urban CHWs, respectively. Around 75.3% (71.0-79.1%) of the rural and 80.3% (76.2-83.9%) of urban CHWs were able to score 70% (7 out of 10) or higher in the skill test. The mean knowledge score out of 10 was 8.18 (8.04-8.33) and 8.82 (8.78-8.93) for the rural and urban CHWs, respectively. Around 83.2% (79.3-86.4%) and 95.0% (94.4-96.7%) of the rural and urban CHWs, respectively, were able to score 70% or higher in the knowledge test.

Conclusion

The ASHAs in Chhattisgarh demonstrated the necessary competence to contribute to BP measurement and primary care of hypertension. It shows feasibility of training a large number of CHWs in such skills. Efforts to equip and support the 1 million strong cadre of ASHAs across India need to be speeded up.

The role of community health workers in the management of hypertension in Nigeria

BACKGROUND

Hypertension is the number one risk factor for cardiovascular death worldwide and its prevalence has been on the increase in LMICs including Nigeria. There is an increasing awareness and recognition of the contributions of the community health workers (CHWs) in the healthcare system. This study assessed their current role in the management of hypertension and patient satisfaction with the care received.

METHODS

A mixed method study (cross-sectional study of 381 CHWs and key informant interview of 14 patients with hypertension selected using multi-stage and purposive sampling respectively) was conducted across five states in different geopolitical zones of Nigeria to assess the role of CHWs in hypertension management and the patients' level of satisfaction with services of CHWs. Chi-square test was used to assess relationship between categorical variables. A p-value ≤ 0.05 was considered statistically significant. Thematic analysis of the text data from the KII was done using Nvivo® version 12 pro.

RESULTS

A total of 381 CHWs completed the study. They were predominantly males (63%) with mean age of 40.96 ± 12.51 years. Only about one-third of the CHWs (31%) could correctly diagnose hypertension while only 15% knew the base-line investigations to be requested. Being female (FE = 9.205, p = 0.008) and resident in northwest geopolitical region (χ2 = 20.920, p < 0.001) had statistically significant associations with appropriate diagnostic skills for hypertension. Being supervised by doctors was associated with appropriate knowledge of baseline investigations for hypertension (χ2 = 5.534, p = 0.019). Mostly, hypertensive patients reported positive experiences and satisfaction with the services provided by the CHWs.

CONCLUSIONS

Community health workers currently have critical contributions in the management of hypertension in Nigeria. Hypertensive patients generally reported satisfactory experience with CHWs managing them. The services rendered by CHWs can be improved upon by adequate supervision and training.

Community-based management of arterial hypertension and cardiovascular risk factors by lay village health workers for people with controlled and uncontrolled blood pressure in rural Lesotho: joint protocol for two cluster-randomized trials within the ComBaCaL cohort study (ComBaCaL aHT Twic 1 and ComBaCaL aHT TwiC 2)

BACKGROUND

Arterial hypertension (aHT) is a major cause for premature morbidity and mortality. Control rates remain poor, especially in low- and middle-income countries. Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems may help to overcome the current aHT care cascade gaps. However, evidence on the effectiveness of comprehensive VHW-led aHT care models, in which VHWs provide antihypertensive drug treatment and manage cardiovascular risk factors is scarce.

METHODS

Using the trials within the cohort (TwiCs) design, we are assessing the effectiveness of VHW-led aHT and cardiovascular risk management in two 1:1 cluster-randomized trials nested within the Community-Based chronic disease Care Lesotho (ComBaCaL) cohort study (NCT05596773). The ComBaCaL cohort study is maintained by trained VHWs and includes the consenting inhabitants of 103 randomly selected villages in rural Lesotho. After community-based aHT screening, adult, non-pregnant ComBaCaL cohort participants with uncontrolled aHT (blood pressure (BP) ≥ 140/90 mmHg) are enrolled in the aHT TwiC 1 and those with controlled aHT (BP < 140/90 mmHg) in the aHT TwiC 2. In intervention villages, VHWs offer lifestyle counseling, basic guideline-directed antihypertensive, lipid-lowering, and antiplatelet treatment supported by a tablet-based decision support application to eligible participants. In control villages, participants are referred to a health facility for therapeutic management. The primary endpoint for both TwiCs is the proportion of participants with controlled BP levels (< 140/90 mmHg) 12 months after enrolment. We hypothesize that the intervention is superior regarding BP control rates in participants with uncontrolled BP (aHT TwiC 1) and non-inferior in participants with controlled BP at baseline (aHT TwiC 2).

DISCUSSION

The TwiCs were launched on September 08, 2023. On May 20, 2024, 697 and 750 participants were enrolled in TwiC 1 and TwiC 2. To our knowledge, these TwiCs are the first trials to assess task-shifting of aHT care to VHWs at the community level, including the prescription of basic antihypertensive, lipid-lowering, and antiplatelet medication in Africa. The ComBaCaL cohort and nested TwiCs are operating within the routine VHW program and countries with similar community health worker programs may benefit from the findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05684055. Registered on January 04, 2023.

A community health worker led approach to cardiovascular disease prevention in the UK-SPICES-Sussex (scaling-up packages of interventions for cardiovascular disease prevention in selected sites in Europe and Sub-saharan Africa): an implementation research project

Background

This paper describes a UK-based study, SPICES-Sussex, which aimed to co-produce and implement a community-based cardiovascular disease (CVD) risk assessment and reduction intervention to support under-served populations at moderate risk of CVD. The objectives were to enhance stakeholder engagement; to implement the intervention in four research sites and to evaluate the use of Voluntary and Community and Social Enterprises (VCSE) and Community Health Worker (CHW) partnerships in health interventions.

Methods

A type three hybrid implementation study design was used with mixed methods data. This paper represents the process evaluation of the implementation of the SPICES-Sussex Project. The evaluation was conducted using the RE-AIM framework.

Results

Reach: 381 individuals took part in the risk profiling questionnaire and forty-one women, and five men participated in the coaching intervention. Effectiveness: quantitative results from intervention participants showed significant improvements in CVD behavioural risk factors across several measures. Qualitative data indicated high acceptability, with the holistic, personalised, and person-centred approach being valued by participants. Adoption: 50% of VCSEs approached took part in the SPICES programme, The CHWs felt empowered to deliver high-quality and mutually beneficial coaching within a strong project infrastructure that made use of VCSE partnerships. Implementation: Co-design meetings resulted in local adaptations being made to the intervention. 29 (63%) of participants completed the intervention. Practical issues concerned how to embed CHWs in a health service context, how to keep engaging participants, and tensions between research integrity and the needs and expectations of those in the voluntary sector. Maintenance: Several VCSEs expressed an interest in continuing the intervention after the end of the SPICES programme.

Conclusion

Community-engagement approaches have the potential to have positively impact the health and wellbeing of certain groups. Furthermore, VCSEs and CHWs represent a significant untapped resource in the UK. However, more work needs to be done to understand how links between the sectors can be bridged to deliver evidence-based effective alternative preventative healthcare. Reaching vulnerable populations remains a challenge despite partnerships with VCSEs which are embedded in the community. By showing what went well and what did not, this project can guide future work in community engagement for health.

Impact of community health workers on improving identification and primary care of hypertension among the urban poor - findings from Chhattisgarh state of India

BACKGROUND

Hypertension is a major health problem globally and in India. Around 60% of people with hypertension in India are not aware that they have the condition. Less than 30% of individuals with hypertension are on treatment. Existing studies have indicated that community health workers (CHWs) can play a useful role in expanding the care for hypertension. Evaluations are needed to study the impact when an intervention is implemented by the government in its existing large-scale CHW programme to improve the identification, regular follow-up and medication adherence for hypertension.

METHODS

Chhattisgarh state implemented a pilot intervention to improve screening and follow-up for hypertension by equipping Mitanin-CHWs to measure blood pressure (BP). The study design involved an intervention-group and a comparison-group of urban slum population. The survey covered 5974 individuals (30-79 years age) in intervention-group and 5131 in comparison-group. Multivariate analysis was conducted to find out the effect of intervention on the desired outcomes.

RESULTS

In intervention-group, 80.2% of the individuals (30-79 years age) had been screened for hypertension whereas the proportion was 37.9% in comparison-group. For 47.0% of individuals in intervention-group, Mitanin CHW was the provider who measured BP for the first time. Around 16.3% of individuals in intervention-group and 9.5% in comparison-group had been diagnosed with hypertension. Around 85.9% of hypertension cases in intervention-group and 77.0% in comparison-group were on treatment. BP had been measured in preceding 30 days for 81.8% of hypertension-cases in intervention-group and 64.3% in comparison-group. Around 70.3% of hypertension-cases in intervention-group and 55.1% in comparison-group had taken their complete medication for last seven days. Multivariate analysis showed that CHW intervention was associated significantly with improvements in all the desired outcomes.

CONCLUSION

Equipping the CHWs to measure BP was effective in increasing the screening and identification of hypertension, regular measurement of BP of individuals with hypertension and the adherence to medication. This shows the potential if the one-million strong work-force of Accredited-Social-Health-Activists (ASHA) CHWs in India gets equipped for this role. Governments need to provide a stronger policy push to get this materialised.

Diabetic Kidney Disease Prevention Care Model Development

More than one-third of people with diabetes develop diabetic kidney disease (DKD), which substantially increases risks of kidney failure, cardiovascular disease (CVD), hypoglycemia, death, and other adverse health outcomes. A multifaceted approach incorporating self-management education, lifestyle optimization, pharmacological intervention, CVD prevention, and psychosocial support is crucial to mitigate the onset and progression of DKD. The American Diabetes Association convened an expert panel to develop the DKD Prevention Model presented herein. This model addresses prevention and treatment, including screening guidelines, diagnostic tools, and management approaches; comprehensive, holistic interventions; well-defined roles for interdisciplinary health care professionals; community engagement; and future directions for research and policy.

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

BACKGROUND

Type 2 diabetes (T2D) poses a growing public health burden, especially in low- and middle-income countries (LMICs). Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems (CDSS) are promising approaches to tackle the current T2D care gap in LMICs. However, evidence on the effectiveness of lay worker-led T2D care models, in which VHWs initiate and monitor drug treatment in addition to community-based screening and referral services, is lacking.

METHODS

We are conducting a cluster-randomized trial nested within the Community-Based Chronic Disease Care Lesotho (ComBaCaL) cohort study (NCT05596773) using the trial within cohort (TwiC) design to assess the effectiveness of a VHW-led, CDSS-assisted T2D care model in rural Lesotho. Participants are non-pregnant members of the ComBaCaL cohort study with T2D. The ComBaCaL cohort study is conducted in approximately 100 villages in two rural districts in Lesotho and is managed by trained and supervised VHWs. In intervention villages, VHWs offer a community-based T2D care package including lifestyle counselling, first-line oral antidiabetic, lipid-lowering, and antiplatelet treatment guided by a tablet-based CDSS to participants who are clinically eligible, as well as treatment support to participants who prefer or clinically require facility-based T2D care. In control clusters, all participants will be referred to a health facility for T2D management. The primary endpoint is the mean glycosylated haemoglobin (HbA1c) 12 months after enrolment. Secondary endpoints include the 10-year risk for cardiovascular events estimated using the World Health Organization risk prediction tool.

DISCUSSION

The trial was launched on May 13, 2023, and has enrolled 226 participants at the date of submission (October 6, 2023). To our knowledge, the trial is the first to assess task-shifting of T2D care to VHWs at the community level, including the prescription of first-line antidiabetic, lipid-lowering, and antiplatelet medication in sub-Saharan Africa, and will thus provide the missing evidence on the effectiveness of such a T2D care model in this setting. The study is operating within the established Lesotho VHW programme. Similar community health worker programmes which exist across sub-Saharan Africa may benefit from the findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05743387. Registered on February 24 2023.

"We just have to help": Community health workers' informal task-shifting and task-sharing practices for hypertension and diabetes care in Nigeria

Introduction

Nigeria's skilled health professional health workforce density is insufficient to achieve its national targets for non-communicable diseases (NCD) which include 25% reduction in the prevalence of diabetes and hypertension, particularly at the primary health care (PHC) level. This places a great demand on community health workers (CHWs) who constitute the majority of PHC workers. Traditionally, CHWs are mainly involved in infectious diseases programmes, and maternal and child health services. Their involvement with prevention and control of NCDs has been minimal. With government prioritization of PHC for combating the rising NCD burden, strengthening CHWs' skills and competencies for NCD care delivery is crucial.

Methods

We conducted a mixed methods study to explore the roles and practices of CHWs in the delivery of hypertension and diabetes care at PHC facilities in four states (two each in northern and southern regions) in Nigeria. We reviewed the National Standing Orders that guide CHWs' practices at the PHC facilities and administered a survey to 76 CHWs and conducted 13 focus groups (90 participants), and in-depth individual interviews with 13 CHWs and 7 other local and state government stakeholders.

Results

Overall, we found that despite capacity constraints, CHWs frequently delivered services beyond the scope of practice stipulated in the National Standing Orders. Such informal task-shifting practices were primarily motivated by a need to serve the community.

Discussion

While these practices may partially support health system functions and address unmet need, they may also lead to variable care quality and safety. Several factors could mitigate these adverse impacts and strengthen CHW roles in the health system. These include a stronger enabling policy environment to support NCD task-sharing, investment in continuous capacity building for CHWs, improved guidelines that can be implemented at the point of care, and improved coordination processes between PHC and higher-level facilities.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.

METHODS

We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.

RESULTS

CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.

CONCLUSIONS

CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Effect of a Nurse-Led Intervention on Knowledge of the Modifiable Risk Behaviors of Cardiovascular Disease: A Randomized Controlled Trial

INTRODUCTION

Cardiovascular disease (CVD) has disproportionately burdened the low- and middle-income countries where awareness and detection rates remain very low. Interventions directed to promote the community's awareness of CVD may help reduce the public's exposure to behavioral risk factors. However, the effectiveness of interventions implemented through a nurse on knowledge of the modifiable behavioral risk factors and preventive measures of CVD has not been determined in Kenya.

OBJECTIVE

To establish the effect of a nurse-led intervention on knowledge of the modifiable risk behaviors of CVD in adults with metabolic syndrome (MetS) attending a mission-based hospital in Kenya.

METHODS

A two-armed parallel-group randomized controlled trial design was conducted among 352 adults aged 18-64 years with MetS. The participants were recruited from a faith-based hospital in Nairobi, Kenya and randomly allocated to either a nurse-led lifestyle intervention or a control group. The intervention group received a comprehensive health education intervention using the World Health Organization (WHO) guideline recommendations for CVD control and prevention. Individuals in the control group were exposed to the usual CVD care according to hospital protocol. The duration of the intervention was 12 months. The primary outcome measure was a change in levels of knowledge on the modifiable risk factors and preventive measures of CVD. Outcome measures were assessed at baseline and at 15 months postintervention. Pre- and postintervention difference in the level of knowledge between the two groups was determined using the chi-square test of independence.

RESULTS

The knowledge level of CVD risk factors and preventive measures was very low in both groups at baseline without significant difference. A significant improvement in the level of knowledge on CVD risk factors (78.2% vs. 30.4%, p < .001) and preventive measures (74.4% vs. 29.0%, p < .001) was observed in the intervention group relative to the control at the end-line.

CONCLUSIONS

The nurse-led lifestyle intervention significantly improved participants' level of knowledge on CVD risk factors and preventive measures. It is highly recommended that nurses incorporate routine health education interventions for patients with cardio-metabolic abnormalities.

Building the capacity of community health volunteers for non-communicable disease prevention in low-income urban communities in Malaysia

Background

To address the rising non-communicable diseases (NCDs) in Malaysia, the Better Health Programme Malaysia (BHP MYS) engaged and trained community health volunteers (CHVs) to undertake health promotion activities with poor urban communities in Kuala Lumpur to reduce their NCD risk. This study evaluates the extent that the capacity-building programme achieved the objectives of increasing knowledge and confidence in NCD prevention and adopting personal lifestyle changes.

Methods

A capacity-building programme was designed to emphasise active learning approaches and blended learning (in-person and digital) and was delivered between January to December 2021 (during the Malaysian Government “Movement Control Orders” in response to the COVID-19 pandemic). Thirty CHVs participated in the capacity-building programme. A mixed methods evaluation approach was used, including quantitative surveys and routine data, focus group discussions, and semi-structured interviews.

Findings

Community Health Volunteers increased their NCD knowledge (85.2% provided correct answers in post-programme assessment compared to 43.3% at pre-programme assessment), made changes to their dietary and physical activity practices (100%), and adopted new engagement techniques, particularly a digital social influencer role for NCD behaviour change. The most important factors for sustaining participation were individual motivation and a supportive environment. CHVs were satisfied with the blended in-person-digital approach and perceived that the usefulness and applicability of the health information received was the primary benefit across all delivery modes. Cohort-based, active learning approaches and actionable messages can encourage learning retention and facilitate application. Dedicated technical support and ‘job aid’ tools are required for CHVs to perform and sustain NCD prevention roles effectively.

Conclusions

The capacity-building programme effectively increased CHV capacities to address NCDs in their own lives and communities and was acceptable to CHVs. The findings suggest the value of cohort-based, active learning approaches in building capacity. Expanding on capacity-building and sustaining involvement are important considerations for this cohort and, in general, for health volunteer capacity-building in Malaysia and elsewhere.

Psychosocial interventions and mental health in patients with cardiovascular diseases living in low and middle-income countries: A systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of psychosocial interventions on mental health outcomes in adult patients with Cardiovascular Diseases (CVDs) living in low- and middle-income countries (LMICs).

INTRODUCTION

Mental health issues are highly prevalent among patients with CVDs leading to poor disease prognosis, self-care/ management, and Quality of Life (QOL). In the context of LMICs, where the disease burden and treatment gap are high and resources are inadequate for accessing essential care, effective psychosocial interventions can make significant contributions for improving mental health and reducing mental health problems among patients who live with cardiovascular diseases.

INCLUSION CRITERIA

This review will include studies published between 2010 and 2021 that evaluated the effect of psychosocial interventions on mental health outcomes (resilience, self-efficacy, QOL, depression and anxiety) on adult patients (aged ≥18 years) with any cardiovascular diseases using experimental and quasi experimental designs.

METHODS

The search will be conducted from the following databases: MEDLINE via OVID (1946-Present), EMBASE via OVID (1974 -Present), Cumulative Index for Nursing and Allied Health Literature (CINAHL) via EBSCOhost (1936-Present), PsycINFO via OVID (1806-Present), Scopus via Elsevier (1976-Present), and Cochrane Library via Wiley (1992-Present). Data will be critically appraised using standard tools and extracted by two reviewers and disagreement will be solved by the third reviewer. Meta-analysis will be performed, if possible, otherwise, data will be synthesized in narrative and tabular forms.

DISCUSSION

The findings of this review will provide a key insight into contextually relevant psychosocial interventions for promoting mental health of patients with CVDs living in LMICs. The review findings will be potentially useful for health care providers and researchers to implement such interventions not only for reducing the burden of mental health issues but also for improving the overall well-being among patients with chronic illnesses.

SYSTEMATIC REVIEW REGISTRATION NUMBER

Prospero-CRD42020200773.

A community health worker delivered intervention to address hypertension among adults engaged in HIV care in northern Tanzania: Outcomes from a pilot feasibility study

Current care models are inadequate to address the dual epidemic of hypertension and HIV in sub‐Saharan Africa. We developed a community health worker (CHW)‐delivered educational intervention, integrated into existing HIV care to address hypertension in persons living with HIV. A detailed educational curriculum was created with five sessions: three in‐person clinic sessions and two telephone sessions. The intervention was piloted among hypertensive adults at one HIV clinic in northern Tanzania over a 4‐week period. Primary outcomes were feasibility, fidelity, and acceptability of the intervention. Secondary outcomes included hypertension care engagement and systolic and diastolic blood pressure (SBP and DBP). Among 16 eligible participants, 14 (64% women, median age of 54.5 years) were recruited into the study, and 13 (92.9%) completed all five intervention sessions. The intervention was delivered with 98.8% fidelity to the curriculum content. Hypertension care engagement improved following the intervention. At baseline, two (15.4%) participants had seen a doctor previously for hypertension, compared to 11 (84.6%) participants post‐intervention (P = .0027). No participant was using antihypertensives at baseline, compared to 10 (76.9%) post‐intervention (P = .0016). Pre‐intervention median SBP was 164 (IQR 152–170) mmHg, compared to post‐intervention SBP of 146 (IQR 134–154) mmHg (P = .0029). Pre‐intervention median DBP was 102 (IQR 86–109) mmHg, compared to post‐intervention DBP of 89 (IQR 86–98) mmHg (P = .0023). A CHW‐delivered educational intervention, integrated into existing HIV care, is feasible and holds promise in improving hypertension care engagement and reducing blood pressure. Further research is needed to evaluate the efficacy and scale‐up of our intervention.

Strategies to increase access to basic sickle cell disease care in low- and middle-income countries

INTRODUCTION

Sickle cell disease (SCD) is the most common hemoglobinopathy in the world. Over 90% of those born with SCD live in low- and middle-income countries (LMICs), yet individuals in these settings have much poorer outcomes compared to those in high-income countries.

AREAS COVERED

This manuscript provides an in-depth review of the cornerstones of basic SCD care, the barriers to implementing these in LMICs, and strategies to increase access in these regions. Publications in English language, peer-reviewed, and edited from 2000 to 2021 were identified on PubMed. Google search was used for gray literature.

EXPERT OPINION

Outcomes for patients with SCD in high-income countries have improved over the last few decades due to the implementation of universal newborn screening programs and use of routine antimicrobial prophylaxis, increase in therapeutic and curative options, and the adoption of specific measures to decrease risk of stroke. This success has not translated to LMICs due to several reasons including resource constraints. A combination of several strategies is needed to increase access to basic SCD care for patients in these settings.

Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study)

Background Population-wide reduction in mean blood pressure is proposed as a key strategy for primary prevention of cardiovascular disease. We evaluated the effectiveness of a task-sharing strategy involving frontline health workers in the primary prevention of elevated blood pressure. Methods and Results We conducted DISHA (Diet and lifestyle Interventions for Hypertension Risk reduction through Anganwadi Workers and Accredited Social Health Activists) study, a cluster randomized controlled trial involving 12 villages each from 4 states in India. Frontline health workers delivered a custom-made and structured lifestyle modification intervention in the selected villages. A baseline survey was conducted in 23 and 24 clusters in the control (n=6663) and intervention (n=7150) groups, respectively. The baseline characteristics were similar between control and intervention clusters. In total 5616 participants from 23 clusters in the control area and 5699 participants from 24 clusters in the intervention area participated in a repeat cross-sectional survey conducted immediately after the intervention phase of 18-months. The mean (SD) systolic blood pressure increased from 125.7 (18.1) mm Hg to 126.1 (16.8) mm Hg in the control clusters, and it increased from 124.4 (17.8) mm Hg to 126.7 (17.5) mm Hg in the intervention clusters. The population average adjusted mean difference in difference in systolic blood pressure was 1.75 mm Hg (95% CI, -0.21 to 3.70). Conclusions Task-sharing interventions involving minimally trained nonphysician health workers are not effective in reducing population average blood pressure in India. Expanding the scope of task sharing and intensive training of health workers such as nurses, nutritionists, or health counselors in management of cardiovascular risk at the population level may be more effective in primary prevention of cardiovascular disease. Registration URL: https://www.ctri.nic.in; Unique identifier: CTRI/2013/10/004049.

Conceptualizing multi-level determinants of infant and young child nutrition in the Republic of Marshall Islands-a socio-ecological perspective

The East and Pacific region includes 14 Pacific Island Countries where, between 2000 and 2016, indicators of stunting, wasting, and micronutrient deficiencies have plateaued or worsened, while rates of overweight, obesity, and associated disease have risen. The Republic of Marshall Islands (RMI) is no exception: maternal and child nutrition indicators have not improved in decades. A study of the contemporary factors shaping the RMI nutrition situation was needed for informing policy and tailoring interventions. This formative study had an iterative design utilizing qualitative methods. An exploratory Phase 1 included 59 semi-structured interviews with community members, 86 free lists with caregivers, 8 participatory workshops, and 20 meal observations (round 1). Findings were synthesized to inform a confirmatory Phase 2 where 13 focus groups, 81 pile sorts, 15 meal observations (round 2), and 2 seasonal food availability workshops were conducted. Textual data were analyzed thematically using NVivo while cultural domain analysis was conducted in Anthropac. RMI faces interrelated challenges that contribute to a lack of nutritious and local food availability, which is compounded by high food costs relative to household incomes. A decades-long cultural transition from local to processed diets has resulted in infant and young child diets now characterized by morning meals of doughnuts, bread, and ramen with tea, coffee, or Kool-Aid and afternoon meals that include rice with canned meats (e.g., store-bought chicken, hot dogs). Individual preferences for processed food imports have increased their supply. Low maternal risk perception toward nutrition-related illnesses may further explain sub-optimal diets. Improving the RMI food environment will require approaches that align with the multi-level determinants of sub-optimal diets found in this study. As the ten-year 2013 RMI Food Security Policy soon ends, study findings may be used to inform new policy development and investments for improving the nutrition situation.

Social and demographic correlates of cardiovascular mortality in the Kassena-Nankana districts of Ghana: a verbal post-mortem analysis

BACKGROUND

The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data.

METHODS

We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area.

RESULTS

From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy.

CONCLUSIONS

The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed.

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.

ASHA-Led Community-Based Groups to Support Control of Hypertension in Rural India Are Feasible and Potentially Scalable

Background: To improve the control of hypertension in low- and middle-income countries, we trialed a community-based group program co-designed with local policy makers to fit within the framework of India's health system. Trained accredited social health activists (ASHAs), delivered the program, in three economically and developmentally diverse settings in rural India. We evaluated the program's implementation and scalability. Methods: Our mixed methods process evaluation was guided by the United Kingdom Medical Research Council guidelines for complex interventions. Meeting attendance reports, as well as blood pressure and weight measures of attendees and adherence to meeting content and use of meeting tools were used to evaluate the implementation process. Thematic analysis of separate focus group discussions with participants and ASHAs as well as meeting reports and participant evaluation were used to investigate the mechanisms of impact. Results: Fifteen ASHAs led 32 community-based groups in three rural settings in the states of Kerala and Andhra Pradesh, Southern India. Overall, the fidelity of intervention delivery was high. Six meetings were delivered over a 3-month period to each of the intervention groups. The mean number of meetings attended by participants at each site varied significantly, with participants in Rishi Valley attending fewer meetings [mean (SD) = 2.83 (1.68)] than participants in West Godavari (Tukeys test, p = 0.009) and Trivandrum (Tukeys test, p < 0.001) and participants in West Godavari [mean (SD) = 3.48 (1.72)] attending significantly fewer meetings than participants in Trivandrum [mean (SD) = 4.29 (1.76), Tukeys test, p < 0.001]. Culturally appropriate intervention resources and the training of ASHAs, and supportive supervision of them during the program were critical enablers to program implementation. Although highly motivated during the implementation of the program ASHA reported historical issues with timely remuneration and lack of supportive supervision. Conclusions: Culturally appropriate community-based group programs run by trained and supported ASHAs are a successful and potentially scalable model for improving the control of hypertension in rural India. However, consideration of issues related to unreliable/insufficient remuneration for ASHAs, supportive supervision and their formal role in the wider health workforce in India will be important to address in future program scale up. Trial Registration: Clinical Trial Registry of India [CTRI/2016/02/006678, Registered prospectively].

Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review

Background: Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. However, no systematic investigation of factors influencing hypertension treatment and control in Nepal is available. This study aimed to systematically review the published literature and synthesise the findings on barriers, enablers, and strategies for hypertension treatment and control in Nepal.

Methods: Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, and Nepali journals and government websites were searched for qualitative, quantitative, and mixed-methods studies on factors or strategies related to hypertension treatment and control in Nepal. Information from qualitative studies was analysed using template analysis, while results from quantitative studies were narratively synthesised. Summary findings were framed under “health system”, “provider”, and “patient” domains. The protocol was registered in PROSPERO (registration number: CRD42020145823).

Results: We identified 15 studies; ten related to barriers and enablers and five to strategies. The identified barriers associated with the health system were: lack of affordable services and lack of resources. The barriers at the provider's level were: communication gaps, inadequate counselling, long waiting hours for appointments, lack of national guidelines for hypertension treatment, and provider's unsupportive behaviours. Non-adherence to medication, irregular follow-up visits, lack of awareness on blood pressure target, poor help-seeking behaviours, reluctance to change behaviours, perceived side-effects of anti-hypertensive medication, self-medication, lack of family support, financial hardship, lack of awareness on blood pressure complications, and comorbidity were barriers identified at patient level. The following enablers were identified: free essential health care services, family support, positive illness perception, and drug reminders. Strategies implemented at the health system, provider and patient levels were: establishing digital health records at health centres, health worker's capacity development, and health education.

Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, health providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

Community-based cardiovascular disease prevention programmes and cardiovascular risk factors: a systematic review and meta-analysis

OBJECTIVES

This study aimed to summarise the effect of community-based intervention programmes on the prevention of cardiovascular disease (CVD) by reducing cardiometabolic risk factors.

STUDY DESIGN

This was a systematic review and meta-analysis.

METHODS

A systematic search in the PubMed database and screening of reference lists aimed to identify community-based CVD prevention programmes from inception up to April 2020. The mean differences and standard deviations for CVD risk factors, including blood pressure, lipid profile, blood glucose and body weight indices, were extracted and pooled using a random effects model.

RESULTS

Screening of 11,889 titles/abstracts and full texts resulted in 48 studies being included in this review. The meta-analysis showed that community-based programmes have led to considerable decreases in systolic blood pressure (weighted mean difference [WMD] = -2.90 mm Hg, 95% confidence interval [95% CI]: -3.63, -2.16), diastolic blood pressure (WMD = -2.21 mm Hg, 95% CI: -3.12, -1.29), serum levels of low-density lipoprotein cholesterol (LDL-C; WMD = -8.88 mg/dl, 95% CI: -12.84, -4.92), triglycerides (WMD = -8.40 mg/dl, 95% CI: -12.10, -4.70), total cholesterol (WMD = -2.96 mg/dl, 95% CI: -3.10, -2.81) and fasting blood glucose (WMD = -2.06 mg/dl, 95% CI: -3.02, -1.10). A moderate decrease in body weight was also found with community-based CVD prevention programmes. However, community-based CVD prevention programmes were not associated with any significant changes in serum levels of high-density lipoprotein.

CONCLUSIONS

The present study indicates that community-based strategies have successfully led to an improvement in CVD risk factors, particularly by reducing blood pressure, serum levels of LDL-C and triglycerides, obesity indices and blood glucose. The impact of these programmes on CVD is modified by the type of intervention and by different cultural and physical environments.

Community-Based Interventions for Cardiovascular Disease Prevention in Low-and Middle-Income Countries: A Systematic Review

Objectives: To synthesize evidence on the effectiveness of community-based interventions for cardiovascular disease (CVD) prevention in low- and middle-income countries (LMICs) to inform design of effective strategies for CVD prevention. Methods: We searched MEDLINE, EMBASE, CINAHL, Cochrane register of controlled studies and PSYCINFO databases for studies published between January 2000 and June 2019. Other studies were identified from gray literature sources and review of reference lists of included studies. The primary outcomes for the review were those aimed at primary prevention of CVD targeting physical activity, diet, smoking and alcohol consumption. Results: Database searches yielded 15,885 articles and 94 articles were identified through snowball searching. After screening, the articles from LMICs were 32 emanating from 27 studies: 9 cluster randomized trials, eight randomized controlled trials and 10 controlled before and after studies. Community-based interventions successfully improved population knowledge on CVD and risk factors and influenced physical activity and dietary practices. Evidence of interventions on smoking cessation and reduced alcohol consumption was inconsistent. Conclusion: This evidence should inform policy makers in decision-making and prioritizing evidence-based interventions.

A household-based community health worker programme for non-communicable disease, malnutrition, tuberculosis, HIV and maternal health: a stepped-wedge cluster randomised controlled trial in Neno District, Malawi

BACKGROUND

Community health worker (CHW) programmes are a valuable component of primary care in resource-poor settings. The evidence supporting their effectiveness generally shows improvements in disease-specific outcomes relative to the absence of a CHW programme. In this study, we evaluated expanding an existing HIV and tuberculosis (TB) disease-specific CHW programme into a polyvalent, household-based model that subsequently included non-communicable diseases (NCDs), malnutrition and TB screening, as well as family planning and antenatal care (ANC).

METHODS

We conducted a stepped-wedge cluster randomised controlled trial in Neno District, Malawi. Six clusters of approximately 20 000 residents were formed from the catchment areas of 11 healthcare facilities. The intervention roll-out was staggered every 3 months over 18 months, with CHWs receiving a 5-day foundational training for their new tasks and assigned 20-40 households for monthly (or more frequent) visits.

FINDINGS

The intervention resulted in a decrease of approximately 20% in the rate of patients defaulting from chronic NCD care each month (-0.8 percentage points (pp) (95% credible interval: -2.5 to 0.5)) while maintaining the already low default rates for HIV patients (0.0 pp, 95% CI: -0.6 to 0.5). First trimester ANC attendance increased by approximately 30% (6.5pp (-0.3, 15.8)) and paediatric malnutrition case finding declined by 10% (-0.6 per 1000 (95% CI -2.5 to 0.8)). There were no changes in TB programme outcomes, potentially due to data challenges.

INTERPRETATION

CHW programmes can be successfully expanded to more comprehensively address health needs in a population, although programmes should be carefully tailored to CHW and health system capacity.

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia

Non-communicable diseases are increasing in developing countries and control of diabetes and hypertension is needed to reduce rates of the leading causes of morbidity and mortality, stroke and ischaemic heart disease. We evaluated a programme in Cambodia, financed by a revolving drug fund, which utilizes Peer Educators to manage diabetes and hypertension in the community. We assessed clinical outcomes and retention in the programme. For all people enrolled in the programme between 2007 and 2016, the average change in blood pressure (BP) and percentage with controlled hypertension (BP < 140/<90 mmHg) or diabetes (fasting blood glucose (BG) < 7mg/dl, post-prandial BG < 130 mg/dl, or HBA1C < 7%) was calculated every 6 months from enrolment.  Attrition rate in the nth year of enrolment was calculated; associations with loss to follow-up were explored using cox regression. A total of 9139 patients enrolled between January 2007 and March 2016. For all people with hypertension, mean change in systolic and diastolic BP within the first year was −15.1 mmHg (SD 23.6, P < 0.0001) and −8.6 mmHg (SD 14.0, P < 0.0001), respectively. BP control was 50.5% at year 1, peaking at 70.6% at 5.5 years. 41.3% of people with diabetes achieved blood sugar control at 6 months and 44.4% at 6.5 years.  An average of 2.3 years [SD 1.9] was spent in programme. Attrition rate within year 1 of enrolment ranged from 29.8% to 61.5% with average of 44.1% [SD 10.3] across 2008–15. Patients with hypertension were more likely to leave the program compared to those with diabetes and males more likely than females. The programme shows a substantial and sustained rate of diabetes and hypertension control for those who remain in the program and could be a model for implementation in other low middle-income settings, however, further work is needed to improve patient retention.

Efficacy of a Community Health Worker-Based Intervention in Improving Dietary Habits Among Community-Dwelling Older People: A Controlled, Crossover Trial in Japan

Background. Community health workers (CHWs), often called "health promotion volunteers" in Japan, are individuals who act as a natural helping resource in the community. Aim. This study tested the efficacy of a CHW-based intervention to improve dietary habits among community-dwelling older people in Japan, using a controlled, crossover design. Method. Seventy-eight people aged 65 to 74 years with poor dietary variety living in four administrative districts in Hikone City (Shiga Prefecture, Japan) were nonrandomly allocated to an immediate-intervened group (IIG; n = 41) or a delayed-intervened group (DIG; n = 37). Participants joined a biweekly, four-session program (120 minutes/session), comprising "CHW drama-style lectures," "group discussion among participants and CHWs," "tasting of dishes," and "take-home practical activities." For the initial 2-month period, the IIG received the intervention and the DIG did not. The groups were crossed over for the subsequent 2-month period. The primary outcome measure was participants' dietary variety score (score range: 0-10). Results. The dietary variety score in the IIG significantly increased in the initial 2-month period compared with the DIG (effect size 1.60 points; 95% confidence interval: 0.75, 2.45). The intervention had a similar effect in the DIG in the subsequent 2-month period. Moreover, an analysis within the IIG showed that the intervention effects persisted for at least 2 months after the intervention. Conclusions. The CHW-based intervention improved dietary habits among older people. Our findings provide evidence that a CHW-based natural helping approach is a possible solution to promote healthy aging in the community.

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.

Mild cognitive impairment is associated with fall-related injury among adults aged ≥65 years in low- and middle-income countries

OBJECTIVES

There is a scarcity of data on the association between mild cognitive impairment (MCI) and falls, especially from low- and middle-income countries (LMICs) where 70% of all older adults reside. Thus, we investigated the association between MCI and fall-related injury among older adults residing in six LMICs (China, Ghana, India, Mexico, Russia, South Africa).

DESIGN

Cross-sectional, community-based data from the WHO Study on global AGEing and adult health (SAGE) were analyzed.

METHODS

The definition of MCI was based on the National Institute on Ageing-Alzheimer's Association criteria, and information on past 12-month fall-related injury was also collected. Multivariable logistic regression analysis was conducted to assess associations.

RESULTS

The analytical sample consisted of 13,623 individuals aged ≥65 years [mean (SD) age 72.3 (10.9) years; 45.6% males]. The prevalence of fall-related injury was higher among those with MCI (6.3%) vs. no MCI (4.1%). After adjustment for potential confounders, MCI was associated with a 1.53 (95%CI = 1.12-2.07) times higher odds for fall-related injury.

CONCLUSIONS

MCI was associated with higher odds for fall-related injury among older adults in LMICs. Future studies are warranted to investigate the mechanisms underlying this association and to elucidate whether targeting those with MCI can lead to reduced risk for falls among older adults.

Using Community Health Workers and a Smartphone Application to Improve Diabetes Control in Rural Guatemala

BACKGROUND

The global prevalence of diabetes has nearly doubled since 1980. Seventy-five percent of patients with diabetes live in low- and middle-income countries, such as Guatemala, where health care systems are often poorly equipped for chronic disease management. Community health workers (CHWs) and mobile health technology have increasingly been applied to the diabetes epidemic in these settings, although mostly in supportive rather than primary roles in diabetes management. We sought to improve diabetes care in rural Guatemala through the development of a CHW-led diabetes program and a smartphone application to provide CHWs with clinical decision support.

METHODS

We worked with our local partners to develop a program model and the smartphone application (using the CommCare platform) and to train CHWs. We recruited patients with type 2 diabetes living in rural communities. Program evaluation used a single-group, pre-post design. Primary outcomes were hemoglobin A1c and the percentage of patients meeting A1c goals compared with baseline. We also followed a variety of process metrics, including application reliability.

RESULTS

Eighty-nine patients enrolled during the study period. The hemoglobin A1c percentage decreased significantly at 3 months (-1.0; 95% CI=-1.7, -0.6), 6 months (-1.5; 95% CI=-2.2, -0.8), 9 months (-1.3; 95% CI=-2.0, -0.6), and 12 months (-1.0; 95% CI=-1.7, -0.4). The percentage of patients with A1c ≤ 8% increased significantly at 3 months (23.6% to 44.4%, P=.007), 6 months (22.0% to 44.0%, P=.015), and 9 months (23.9% to 45.7%, P=.03). CHWs and supervising physicians agreed with application medication recommendations >90% of the time.

CONCLUSION

Our results suggest that CHWs can safely and effectively manage diabetes with the assistance of a smartphone application and remote physician supervision. This model should be evaluated versus other standards of care and could be adapted to other low-resource settings and chronic diseases.

Mortality and risk factors of disease in Nepal: Trend and projections from 1990 to 2040

BACKGROUND

Between 1990 and 2017, Nepal experienced a shift in the burden of disease from communicable, maternal, neonatal and nutritional (CMNN) diseases to non-communicable diseases (NCDs). With an increasing ageing population and life-style changes including tobacco use, harmful alcohol consumption, unhealthy diets, and insufficient physical activity, the proportion of total deaths from NCDs will continue to increase. An analysis of current diseases pattern and projections of the trends informs planning of health interventions. This analysis aims to project the mortality and risk factor of disease until 2040, based on past trends.

METHODS

This study uses secondary data from the Global Burden of Disease (GBD) Study which analyses historic data from 1990 to 2016 to predict key variables such as, the mortality rates, life expectancy and Years of Life Lost for different causes of death from 2017 to 2040. 'GBD Foresight Visualization', a visualisation tool publicly available in the webpage of Institute for Health Metrics and Evaluation was the source of data for this analysis. GBD forecasting uses three-component modelling process: the first component captures variations due to risk factors and interventions, the second takes into consideration the variation due to measures of development quantified as social development index and the third uses an autoregressive integrated moving average model to capture the unexplained component correlated over time. We extracted Nepal specific data from it and reported number of deaths, mortality rates (per 100,000 population) as well as causes of death for the period 1990 to 2040.

RESULTS

In 1990, CMNN diseases were responsible for approximately two-thirds (63.6%) of total deaths in Nepal. The proportion of the deaths from the CMNN diseases has reduced to 26.8% in 2015 and is estimated to be about a fifth of the 1990 figure (12.47%) in 2040. Conversely, deaths from NCDs reflect an upward trend. NCDs claimed a third of total deaths (29.91%) in the country in 1990, while in 2015, were responsible for about two-thirds of the total deaths (63.31%). In 2040, it is predicted that NCDs will contribute to over two-thirds (78.64%) of total deaths in the country. Less than a tenth (6.49%) of the total deaths in Nepal in 1990 were associated with injuries which increased to 13.04% in 2015 but is projected to decrease to 8.89% in 2040. In 1990, metabolic risk factors including high systolic blood pressure, high total cholesterol, high fasting plasma glucose, high body mass index and impaired kidney functions collectively contributed to a tenth of the total deaths (10.38%) in Nepal, whereas, in 2040 more than a third (37.31%) of the total deaths in the country could be attributed to it.

CONCLUSION

A reverse of the situation in 1990, NCDs are predicted to be the leading cause of deaths and metabolic risk factors are predicted to contribute to the highest proportion of deaths in 2040. NCDs could demand a major share of resources within the health sector requiring extensive multi-sectoral prevention measures, re-allocation of resources and re-organisation of the health system to cater for long-term care.

Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan

IMPORTANCE

The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management.

OBJECTIVE

To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019.

EXPOSURES

Primary care delivered through a humanitarian organization since 2012.

MAIN OUTCOMES AND MEASURES

The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes.

RESULTS

In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3%]), and 915 adults aged 30 years or older (608 women [66.5%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2% (95% CI, 15.9%-18.6%) for hypertension, 9.8% (95% CI, 8.6%-11.1%) for diabetes, and 7.3% (95% CI, 6.3%-8.5%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5% (95% CI, 36.4%-42.6%) for hypertension, 19.3% (95% CI, 16.7%-22.1%) for diabetes, and 13.5% (95% CI, 11.4%-15.9%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3%; 95% CI, 1.0%-1.7%), although the difference was not significant. Complications (57.4%; 95% CI, 51.5%-63.1%) and obese or overweight status (82.8%; 95% CI, 79.7%-85.5%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1% (95% CI, 90.9%-96.2%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8% (95% CI, 21.3%-33.1%) missed a medication dose in the past week, and 49.1% (95% CI, 43.3%-54.9%) sought care in the last month.

CONCLUSIONS AND RELEVANCE

During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.

Identifying barriers, facilitators, and implementation strategies for a faith-based physical activity program

Background

Community engagement is critical to the acceleration of evidence-based interventions into community settings. Harnessing the knowledge and opinions of community leaders increases the likelihood of successful implementation, scale-up, and sustainment of evidence-based interventions. Faith in Action (Fe en Acción) is an evidence-based promotora-led physical activity program designed to increase moderate-to-vigorous physical activity among churchgoing Latina women.

Methods

We conducted in-depth interviews using a semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR) at various Catholic and Protestant churches with large Latino membership in San Diego County, California to explore barriers and facilitators to implementation of Faith in Action and identify promising implementation strategies for program scale-up and dissemination. We interviewed 22 pastors and church staff and analyzed transcripts using an iterative-deductive team approach.

Results

Pastors and church staff described barriers and facilitators to implementation within three domains of CFIR: characteristics of individuals (lack of self-efficacy for and knowledge of physical activity; influence on churchgoers' behaviors), inner setting (church culture and norms, alignment with mission and values, competing priorities, lack of resources), and outer setting (need for buy-in from senior leadership). From the interviews, we identified four promising implementation strategies for the scale-up of faith-based health promotion programs: (1) health behavior change training for pastors and staff, (2) tailored messaging, (3) developing community collaborations, and (4) gaining denominational support.

Conclusions

While churches can serve as valuable partners in health promotion, specific barriers and facilitators to implementation must be recognized and understood. Addressing these barriers through targeted implementation strategies at the adopter and organizational level can facilitate improved program implementation and lead the way for scale-up and dissemination.

Cardiovascular disease prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda

Background

With the growing epidemic of Cardiovascular Disease (CVD) in sub-Saharan Africa, behavioural change interventions are critical in supporting populations to achieve better cardiovascular health. Population knowledge regarding CVD is an important first step for any such interventions. This study examined CVD prevention knowledge and associated factors among adults in Mukono and Buikwe districts in Uganda.

Methods

The study was cross-sectional in design conducted among adults aged 25 to 70 years as part of the baseline assessment by the Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa (SPICES) – project. Data were collected using pretested semi-structured questionnaires, and respondents categorized as knowledgeable if they scored at least five out of six in the knowledge questions. Data were exported into STATA version 15.0 statistical software for analysis conducted using mixed-effects Poisson regression with fixed and random effects and robust standard errors.

Results

Among the 4372 study respondents, only 776 (17.7%) were knowledgeable on CVD prevention. Most respondents were knowledgeable about foods high in calories 2981 (68.2%), 2892 (66.1%) low fruit and vegetable intake and high salt consumption 2752 (62.9%) as CVD risk factors. However, majority 3325 (76.1%) thought the recommended weekly moderate physical activity was 30 min and half 2262 (51.7%) disagreed or did not know that it was possible to have hypertension without any symptoms. Factors associated with high CVD knowledge were: post-primary education [APR = 1.55 (95% CI: 1.18–2.02), p = 0.002], formal employment [APR = 1.69 (95% CI: 1.40–2.06), p < 0.001] and high socio-economic index [APR = 1.35 (95% CI: 1.09–1.67), p = 0.004]. Other factors were: household ownership of a mobile phone [APR = 1.35 (95% CI: 1.07–1.70), p = 0.012] and ever receiving advice on healthy lifestyles [APR = 1.38 (95% CI: 1.15–1.67), p = 0.001].

Conclusions

This study found very low CVD knowledge with major gaps around recommended physical activity duration, diet and whether hypertension is asymptomatic. Observed knowledge gaps should inform suitable interventions and strategies to equip and empower communities with sufficient information for CVD prevention.

Trial registration

ISRCTN Registry ISRCTN15848572, January 2019, retrospectively registered.

Layperson-Led vs Professional-Led Behavioral Interventions for Weight Loss in Pediatric Obesity: A Systematic Review and Meta-analysis

IMPORTANCE

The appropriate approach for weight loss among children and adolescents with overweight and obesity remains unclear.

OBJECTIVE

To evaluate the difference in the treatment outcomes associated with behavioral weight loss interventions led by laypersons and professionals in comparison with unsupervised control arms among children and adolescents with overweight and obesity.

DATA SOURCES

For this systematic review and meta-analysis, the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, the Cochrane Library, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases were searched from January 1, 1996, to June 1, 2019.

STUDY SELECTION

Included in this study were randomized clinical trials (RCTs) of behavioral interventions lasting at least 12 weeks for children and adolescents (aged 5-18 years) with overweight and obesity. Exclusion criteria included non-RCT studies, interventions lasting less than 12 weeks, adult enrollment, participants with other medical diagnoses, pharmacological treatment use, and articles not written in English. Two of 6 reviewers independently screened all citations. Of 25 586 citations, after duplicate removal, 78 RCTs (5780 participants) met eligibility criteria.

DATA EXTRACTION AND SYNTHESIS

A bayesian framework and Markov chain Monte Carlo simulation methods were used to combine direct and indirect associations. Random-effects and fixed-effect network meta-analysis models were used with the preferred model chosen by comparing the deviance information criteria. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

The immediate and sustained changes in weight and body mass index (BMI) standardized mean difference (SMD) were primary outcomes planned before data collection began, whereas waist circumference and percent body fat were secondary outcomes. The hypothesis being tested was formulated before the data collection.

RESULTS

Of 25 586 citations retrieved, we included 78 RCTs (5780 participants), with a follow-up of 12 to 104 weeks. Compared with the control condition, random-effects models revealed that professional-led weight loss interventions were associated with reductions in weight (mean difference [MD], -1.60 kg [95% CI, -2.30 to -0.99 kg]; 68 trials; P < .001) and BMI (SMD, -0.30 [95% CI, -0.39 to -0.20]; 59 trials; P < .001) that were not sustained long term (weight MD, -1.02 kg [95% CI, -2.20 to 0.34 kg]; 21 trials; P = .06; BMI SMD, -0.12 [95% CI, -0.46 to 0.21]; 20 trials; P < .001). There was no association between layperson-led interventions and weight loss in the short-term (MD, -1.40 kg [95% CI, -3.00 to 0.26 kg]; 5 trials; P = .05) or long-term (MD, -0.98 kg [95% CI, -3.60 to 1.80 kg]; 1 trial; P = .23) compared with standard care. No difference was found in head-to-head trials (professional vs layperson MD, -0.25 kg [95% CI -1.90 to 1.30 kg]; 5 trials; P = .38).

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found that professional-led weight loss interventions were associated with short-term but not sustained weight reduction among children and adolescents with overweight or obesity, and the evidence for layperson-led approaches was insufficient to draw firm conclusions.

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.

Preventive Community-Based Strategies of Cardiovascular Diseases in Iran: A Multi-Method Study

BACKGROUND

Community-based strategies for preventing non-communicable diseases, particularly cardiovascular diseases, are of great importance.

AIMS

This study aimed to formulate a policy brief to identify and prioritize community-based strategies to prevent cardiovascular disease in Iran.

METHODS

This multi-method study was conducted over three phases. In the first phase, rapid review, community-based strategies which mentioned to people's participation had been identified. PubMed and Scopus had been searched. In the second phase, a focus group discussion (FGD) was held by the participation of 15 experts from different disciplines to have been summarized and finalized the community-based strategies to prevent cardiovascular disease as policy options. Content analysis method was used. In the third phase, policy options were prioritized. In addition, the points of interest and the appropriate budget were suggested for each policy option by using the Delphi method with the participation of 15 experts.

RESULTS

Community-based approach includes six strategies: engagement of non-governmental and charitable organizations, use of health marketing strategies, activating the role of community health workers, implementing of mobile health programs, social prescribing, and peripheral medicine.‌‌‌ Utilizing Community health workers, using mobile health and engaging NGOs and charities were ported in higher levels. In all policy options, public-private partnership as the best investment as well as the Ministry of Health as the best focal point were proposed.

CONCLUSION

Implementing multiple prevention strategies in the form of public engagement, incorporating prevention programs delivered by community health workers and increasing public-private partnership financial support may be effective in reducing cardiovascular disease.

Observational stepped-wedge analysis of a community health worker-led intervention for diabetes and hypertension in rural Mexico

OBJECTIVES

There is emerging interest and data supporting the effectiveness of community health workers (CHWs) in non-communicable diseases (NCDs) in low/middle-income countries (LMICs). This study aimed to determine whether a CHW-led intervention targeting diabetes and hypertension could improve markers of clinical disease control in rural Mexico.

DESIGN AND SETTING

A prospective observational stepped-wedge study was conducted across seven communities in rural Chiapas, Mexico from March 2014 to April 2018.

PARTICIPANTS

149 adults with hypertension and/or diabetes.

INTERVENTION

This study was conducted in the context of the programmatic roll-out of an accompaniment-based CHW-led intervention designed to complement comprehensive primary care for adults with diabetes and/or hypertension. Implementation occurred sequentially at 3-month intervals with point-of-care data collected at baseline and every 3 months thereafter for 12 months following roll-out in all communities.

OUTCOME MEASURES

Primary outcomes were glycated haemoglobin (HbA1c) and systolic blood pressure (SBP), overall and stratified by baseline disease control. We conducted an individual-level analysis using mixed effects regression, adjusting for time, cohort and clustering at the individual and community levels.

RESULTS

Among patients with diabetes, the CHW-led intervention was associated with a decrease in HbA1c of 0.35%; however, CIs were wide (95% CI -0.90% to 0.20%). In patients with hypertension, there was a 4.7 mm Hg decrease in SBP (95% CI -8.9 to -0.6). In diabetic patients with HbA1c ≥9%, HbA1c decreased by 0.96% (95% CI -1.69% to -0.23%), and in patients with uncontrolled hypertension, SBP decreased by 10.2 mm Hg (95% CI -17.7 to -2.8).

CONCLUSIONS

We found that a CHW-led intervention resulted in clinically meaningful improvement in disease markers for patients with diabetes and hypertension, most apparent among patients with hypertension and patients with uncontrolled disease at baseline. These findings suggest that CHWs can play a valuable role in supporting NCD management in LMICs.

TRIAL REGISTRATION NUMBER

NCT02549495.

Acceptability of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: a qualitative study

BACKGROUND

Cardiovascular diseases (CVDs) are on the rise in many low-and middle-income countries where 80% of related deaths are registered. Community CVD prevention programmes utilizing self-care approaches have shown promise in contributing to population level reduction of risk factors. However, the acceptability of these programmes, which affects their uptake and effectiveness, is unknown including in the sub-Saharan Africa context. This study used the Theoretical Framework of Acceptability to explore the prospective acceptability of a community CVD prevention programme in Mukono and Buikwe districts in Uganda.

METHODS

This qualitative descriptive study was conducted in March 2019 among community health workers (CHWs), who would implement the intervention and community members, the intervention recipients, using eight focus group discussions. All discussions were audio-recorded, transcribed verbatim and analysed thematically guided by the theoretical framework.

RESULTS

CHWs and community members reported high eagerness to participate in the programme. Whereas CHWs had implemented similar community programmes and cited health promotion as their role, community members looked forward to health services being brought nearer to them. Although the intervention was preventive in nature, CHWs and community members expressed high interest in treatments for risk factors and were skeptical about the health system capacity to deliver them. CHWs anticipated barriers in mobilising communities who they said sometimes may not be cooperative while community members were concerned about failing to access treatment and support services after screening for risk factors. The major cost to CHWs and community members for engaging in the intervention was time that they would have dedicated to income generating activities and social events though CHWs also had the extra burden of being exemplary. CHWs were confident in their ability to deliver the intervention as prescribed if well trained, supported and supervised, and community members felt that if provided sufficient information and supported by CHWs, they could change their behaviours.

CONCLUSIONS

The community CVD prevention programme was highly acceptable among CHWs and community members in Mukono and Buikwe districts of Uganda amidst a few burdens and opportunity costs. Suggestions made by study participants to improve programme effectiveness informed programme design and implementation for impact.

Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation

Background

Hypertension (HTN) is the single leading risk factor for human mortality worldwide, and more prevalent in sub-Saharan Africa than any other region [1]–although resources for HTN screening, treatment, and control are few. Most regional pilot studies to leverage HIV programs for HTN control have achieved blood pressure control in half of participants or fewer [2,3,4]. But this control gap may be due to inconsistent delivery of services, rather than ineffective underlying interventions.

Methods

We sought to evaluate the consistency of HTN program delivery within the SEARCH study (NCT01864603) among 95,000 adults in 32 rural communities in Uganda and Kenya from 2013–2016. To achieve this objective, we designed and performed a fidelity evaluation of the step-by-step process (cascade) of HTN care within SEARCH, calculating rates of HTN screening, linkage to care, and follow-up care. We evaluated SEARCH’s assessment of each participant’s HTN status against measured blood pressure and HTN history.

Findings

SEARCH completed blood pressure screens on 91% of participants. SEARCH HTN screening was 91% sensitive and over 99% specific for HTN relative to measured blood pressure and patient history. 92% of participants screened HTN+ received clinic appointments, and 42% of persons with HTN linked to subsequent care. At follow-up, 82% of SEARCH clinic participants received blood pressure checks; 75% received medication appropriate for their blood pressure; 66% remained in care; and 46% had normal blood pressure at their most recent visit.

Conclusion

The SEARCH study’s consistency in delivering screening and treatment services for HTN was generally high, but SEARCH could improve effectiveness in linking patients to care and achieving HTN control. Its model for implementing population-scale HTN testing and care through an existing HIV test-and-treat program–and protocol for evaluating the intervention’s stepwise fidelity and care outcomes–may be adapted, strengthened, and scaled up for use across multiple resource-limited settings.

Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis

IMPORTANCE

Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood.

OBJECTIVE

To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries.

DATA SOURCES

All systematic reviews in PubMed published by May 1, 2018.

STUDY SELECTION

The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed.

DATA EXTRACTION AND SYNTHESIS

Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive.

MAIN OUTCOMES AND MEASURES

All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems.

RESULTS

This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles.

CONCLUSIONS AND RELEVANCE

Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature

The use of community health workers (CHWs) has been explored as a viable option to provide home health education, counselling and basic health care, notwithstanding their challenges in training and retention. In this manuscript, we review the evidence and discuss how the digitalization affects the CHWs programmes for tackling non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). We conducted a review of literature covering two databases: PubMED and Embase. A total of 97 articles were abstracted for full text review of which 26 are included in the analysis. Existing theories were used to construct a conceptual framework for understanding how digitalization affects the prospects of CHW programmes for NCDs. The results are divided into two themes: (1) the benefits of digitalization and (2) the challenges to the prospects of digitalization. We also conducted supplemental search in non-peer reviewed literature to identify and map the digital platforms currently in use in CHW programmes. We identified three benefits and three challenges of digitalization. Firstly, it will help improve the access and quality of services, notwithstanding its higher establishment and maintenance costs. Secondly, it will add efficiency in training and personnel management. Thirdly, it will leverage the use of data generated across grass-roots platforms to further research and evaluation. The challenges posed are related to funding, health literacy of CHWs and systemic challenges related to motivating CHWs. Several dozens of digital platforms were mapped, including mobile-based networking devices (used for behavioural change communication), Web-applications (used for contact tracking, reminder system, adherence tracing, data collection and decision support), videoconference (used for decision support) and mobile applications (used for reminder system, supervision, patients' management, hearing screening and tele-consultation). The digitalization efforts of CHW programmes are afflicted by many challenges, yet the rapid technological penetration and acceptability coupled with the gradual fall in costs constitute encouraging signals for the LMICs. Both CHWs interventions and digital technologies are not inexpensive, but they may provide better value for the money when applied at the right place and time.

What do Accredited Social Health Activists need to provide comprehensive care that incorporates non-communicable diseases? Findings from a qualitative study in Andhra Pradesh, India

BACKGROUND

The Indian National Program for Cardiovascular Disease, Diabetes, Cancer and Stroke (NPCDCS) was introduced to provide non-communicable disease (NCD) care through primary healthcare teams including Accredited Social Health Activists (ASHAs). Since ASHAs are being deployed to provide NCD care on top of their regular work for the first time, there is a need to understand the current capacity and challenges faced by them.

METHODS

A desktop review of NPCDCS and ASHA policy documents was conducted. This was followed by group discussions with ASHAs, in-depth interviews with their supervisors and medical officers and group discussions with community members in Guntur, Andhra Pradesh, India. The multi-stakeholder data were analysed for themes related to needs, capacity, and challenges of ASHAs in providing NCD services.

RESULTS

This study identified three key themes-first, ASHAs are unrecognised as part of the formal NPCDCS service delivery team. Second, they are overburdened, since they deliver several NPCDCS activities without receiving training or remuneration. Third, they aspire to be formally recognised as employees of the health system. However, ASHAs are enthusiastic about the services they provide and remain an essential link between the health system and the community.

CONCLUSION

ASHAs play a key role in providing comprehensive and culturally appropriate care to communities; however, they are unrecognised and overburdened and aspire to be part of the health system. ASHAs have the potential to deliver a broad range of services, if supported by the health system appropriately.

TRIAL REGISTRATION

The study was registered with "Clinical Trials Registry - India" (identifier CTRI/2018/03/012425 ).

Effect of a Community Health Worker-Based Approach to Integrated Cardiovascular Risk Factor Control in India: A Cluster Randomized Controlled Trial

BACKGROUND

Eighty percent of premature mortality from cardiovascular disease occurs in low- and middle-income countries. Hypertension, diabetes, and smoking are the top risk factors causing this disease burden.

OBJECTIVES

The study aimed to test the hypothesis that utilizing community health workers (CHWs) to manage hypertension, diabetes and smoking in an integrated manner would lead to improved control of these conditions.

METHODS

This was a 2-year cluster (n = 12) randomized controlled trial of 3,556 adults (35 to 70 years of age) in a single town in India, who were screened at home for hypertension, diabetes, and smoking. Of these adults, 1,242 (35%) had at least 1 risk factor (hypertension = 650, diabetes = 317, smoking = 500) and were enrolled in the study. The intervention group had behavioral change communication through regular home visits from community health workers. The control group received usual care in the community. The primary outcomes were changes in systolic blood pressure, fasting blood glucose, and average number of cigarettes/bidis smoked daily among individuals with respective risk factors.

RESULTS

The mean ± SD change in systolic blood pressure at 2 years was -12.2 ± 19.5 mm Hg in the intervention group as compared with -6.4 ± 26.1 mm Hg in the control group, resulting in an adjusted difference of -8.9 mm Hg (95% confidence interval [CI]: -3.5 to -14.4 mm Hg; p = 0.001). The change in fasting blood glucose was -43.0 ± 83.5 mg/dl in the intervention group and -16.3 ± 77.2 mg/dl in the control group, leading to an adjusted difference of -21.3 mg/dl (95% CI: 18.4 to -61 mg/dl; p = 0.29). The change in mean number of cigarettes/bidis smoked was nonsignificant at +0.2 cigarettes/bidis (95% CI: 5.6 to -5.2 cigarettes/bidis; p = 0.93).

CONCLUSIONS

A population-based strategy of integrated risk factor management through community health workers led to improved systolic blood pressure in hypertension, an inconclusive effect on fasting blood glucose in diabetes, and no demonstrable effect on smoking. (Study of a Community-Based Approach to Control Cardiovascular Risk Factors in India [SEHAT]; NCT02115711).

Standardizing hypertension management in a primary care setting in India through a protocol based model

Hypertension is a leading cause of death in India. Control rates of hypertension are abysmal, even for people on treatment. There are a number of barriers to adequate control of hypertension in India, including therapeutic inertia and the lack of a systematic, simplified approach. Standardizing hypertension management through an evidence based model that sets thresholds for diagnosis, treatment goals, follow up intervals and choice of drugs can lead to improved management of hypertension in an individual hospital or health system. In this paper, we summarize the evidence for such a model, and adapt it to the Indian context, focusing on maximizing effectiveness, safety and ease of use by a non-expert. This model can be utilized by individual practitioners, hospitals, primary health centers (PHCs) and the Health and Wellness Centers (HWCs) under the Ayushman Bharat initiative.

The effect of youths as change agents on cardiovascular disease risk factors among adult neighbours: a cluster randomised controlled trial in Sri Lanka

BACKGROUND

Mobilising non-professional health workers has been successful in improving community health, but the effectiveness of an education program targeting youths in a community-based approach remains unclear. The objective of this study was to investigate the effect of an intervention with youth on cardiovascular disease risk factors of community adults.

METHODS

A 12-month cluster randomised trial was conducted in a semi-urban area of Colombo in Sri Lanka. Facilitators trained youth club members aged 15-29 years to assess cardiovascular disease risk factors and take actions in the community to address relevant issues. The control group received no intervention. Body weight and blood pressure as primary outcomes and lifestyle of adults as secondary outcomes were measured pre- and post-intervention. Multilevel linear and logistic regressions were used to assess the effects of the intervention on changes in continuous and binary outcomes, respectively, from baseline to endpoint.

RESULTS

Of 512 participants at baseline, 483 completed the final assessment after the intervention. Regarding primary outcomes, the intervention group showed a significantly greater decrease in body weight after intervention than the control group. The mean (95% confidence interval) difference of body weight change for intervention versus control group was - 2.83 kg (- 3.31, - 2.35). There was no statistically significant difference in blood pressure between the two groups. Turning to the secondary outcomes, in diet, the intervention group had a higher probability of consuming at least one serving/day of fruits (p = 0.02) and a lower probability of consuming snacks twice/day or more (p < 0.001) than the control group.

CONCLUSIONS

An intervention employing youths as change agents was effective in lowering body weight among community adults in Sri Lanka.

TRIAL REGISTRATION

Trial registration number: SLCTR/2017/002 , Name of registry: Sri Lanka Clinical Trials Registry, Date of registration: 19th January 2017, Date of enrolment of the first participant to the trial: 1st February 2017.

Rationale and design of a study to test the effectiveness of a combined community health worker and text messaging-based intervention for smoking cessation in India (Project MUKTI)

BACKGROUND

Nearly 275 million individuals in India consume tobacco every day, with more than 1 million dying annually as a result. Few people in India have access to smoking cessation services, an essential component of combating tobacco use globally. We hypothesize that a strategy of systematic community health worker (CHW) based counseling that covers eligible people who smoke in a geographical area, combined with text messaging support, will result in improved quit rates.

METHODS

The study is a cluster randomized controlled trial that will be conducted at 2 sites in India. Sixteen clusters will be randomized into either an intervention or control arm. A total of 560 smokers between the age of 18 and 70 will be recruited from their home through CHWs. Smokers at all stages of change will be offered the intervention, which is based on the transtheoretical model of change.

RESULTS

Pre-contemplative participants will be offered health education and motivational interviewing through CHWs. They will also be offered a low frequency form of text messaging, focused on health education and the benefits of quitting. Participants who are actively contemplating quitting smoking will be offered a more intensive intervention, with more frequent visits by CHWs and more intensive text messaging support. Contemplative participants will be encouraged to set a quit date, and all participants will be assessed periodically for stage of change to provide the appropriate intervention. Participants who set a quit date will be encouraged to use NRT to help with quitting. Control group participants are provided with brief smoking cessation advice only, at the start of the trial. The primary outcome will be self-reported abstinence for the past 14 days, biochemically verified by exhaled CO levels (cut-off 10 ppm) assessed at the end of 1 year of the intervention.

CONCLUSIONS

We will test whether a CHW-based intervention that incorporates motivational interviewing, text messaging and supportive counseling can prove effective in systematically helping smokers quit.

Task Sharing in the Diagnosis, Prevention, and Management of Rheumatic Heart Disease: A Systematic Review

BACKGROUND

Globally, rheumatic heart disease (RHD) is a major contributor to the burden of cardiovascular disease. Major gaps in RHD prevention and treatment have been documented at all levels of health systems in low- and middle-income countries. Task sharing is an approach that could prove effective in remediating bottlenecks in RHD-related care.

OBJECTIVES

This study conducted a systematic review to assess the state of the evidence for the use of task sharing in the diagnosis, prevention, and management of RHD.

METHODS

Guided by a previously published protocol, we searched various databases using a systematic search strategy including MeSH and free-text terms for (1) group A streptococcus, acute rheumatic fever, and RHD and (2) strategies of task sharing in limited-resource settings. Two investigators independently screened the search outputs, selected the studies, extracted the data, and assessed the risk of bias, resolving discrepancies by discussion and consensus.

RESULTS

The publications search yielded 212 records, of which 18 articles were deemed as potentially eligible for inclusion. None of the studies, however, met with the inclusion criteria.

CONCLUSIONS

There is a lack of evidence for the use of task-sharing approaches in scaling up RHD prevention and treatment services in limited-resource settings. Considering the persistent burden of group A streptococcus, acute rheumatic fever, and RHD in low- and middle-income countries, this work highlights the urgent need to develop and test models of RHD-related care utilizing an evidence-based approach to task sharing. [Task Sharing in the Diagnosis, Prevention, and Management of Rheumatic Heart Disease: A Systematic Review; CRD42017072989].

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. They aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used individual screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is therefore important to assess whether general health checks do more good than harm. This is the first update of the review published in 2012.

OBJECTIVES

To quantify the benefits and harms of general health checks.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases and two trials registers on 31 January 2018. Two review authors independently screened titles and abstracts, assessed papers for eligibility and read reference lists. One review author used citation tracking (Web of Knowledge) and asked trial authors about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the trials. We contacted trial authors for additional outcomes or trial details when necessary. When possible, we analysed the results with a random-effects model meta-analysis; otherwise, we did a narrative synthesis.

MAIN RESULTS

We included 17 trials, 15 of which reported outcome data (251,891 participants). Risk of bias was generally low for our primary outcomes. Health checks have little or no effect on total mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.97 to 1.03; 11 trials; 233,298 participants and 21,535 deaths; high-certainty evidence, I² = 0%), or cancer mortality (RR 1.01, 95% CI 0.92 to 1.12; 8 trials; 139,290 participants and 3663 deaths; high-certainty evidence, I² = 33%), and probably have little or no effect on cardiovascular mortality (RR 1.05, 95% CI 0.94 to 1.16; 9 trials; 170,227 participants and 6237 deaths; moderate-certainty evidence; I² = 65%). Health checks have little or no effect on fatal and non-fatal ischaemic heart disease (RR 0.98, 95% CI 0.94 to 1.03; 4 trials; 164,881 persons, 10,325 events; high-certainty evidence; I² = 11%), and probably have little or no effect on fatal and non-fatal stroke (RR 1.05 95% CI 0.95 to 1.17; 3 trials; 107,421 persons, 4543 events; moderate-certainty evidence, I² = 53%).

AUTHORS' CONCLUSIONS

General health checks are unlikely to be beneficial.