Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Stephens JH

PROVIDER: S-EPMC7906377 | biostudies-literature | 2021

REPOSITORIES: biostudies-literature

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Publications

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

Stephens Joseph H JH Addepalli Aravind A Chaudhuri Shombit S Niyonzima Abel A Musominali Sam S Uwamungu Jean Claude JC Paccione Gerald A GA

PloS one 20210225 2

<h4>Background</h4>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 ...[more]

PMID: 33630935

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Project description:BackgroundVillage health workers (VHWs) can serve as a valuable resource to address public health needs in resource-limited settings such as Uganda. However, the successful implementation of VHW programs can be limited by poor acceptability among community members. Kisoro District Hospital (KDH) in Kisoro District, Uganda operates a VHW program and, at the time of the study, was expanding its services to 11 additional villages.ObjectiveThe objective of this study was to evaluate community perceptions of VHWs in villages of Kisoro District with no prior exposure to the KDH VHW program in order to improve community acceptance when expanding the program to additional villages.MethodsWe administered surveys to 658 community members from 11 villages to evaluate their perceptions of VHWs prior to receiving VHW services. Additionally, we conducted focus group discussions among 97 participants to explore perceptions of VHWs in further depth.FindingsCommunity members were generally accepting of VHWs. They preferred that VHWs provide both curative and preventive services across a broad range of health domains as opposed to a single disease. Expectations of the responsibilities of a VHW were influenced by agricultural occupational and household responsibilities, particularly for women. Participants expressed a preference to be actively involved in the selection and oversight of VHWs and that VHWs receive compensation.Conclusions1) Community members' expectations of VHWs are shaped by environmental, cultural, and social factors. 2) Active community engagement in the VHW program is key. 3) Aligning a VHW program with community perceptions may improve acceptance, in turn influencing effectiveness and sustainability. These findings were used to expand the KDH VHW Program into the participating villages in a manner consistent with community preferences. Our findings may provide guidance on enhancing the uptake of community-based VHW programs for VHW stakeholders and policymakers in other settings.

Project description:BackgroundUganda is a low-income country with high fertility, adolescent birth, and maternal mortality rates. How Ugandan Ministry of Health antenatal education guidelines have been implemented into standardized health education and how pregnant women utilize health facilities remains unclear.ObjectiveWe aimed to determine how women obtain education during pregnancy, what guidelines health educators follow, and what barriers exist to receiving antenatal care in Lweza Village, Uganda.MethodsHousehold surveys were conducted with women in Lweza who were or had previously been pregnant. Focus group discussions were conducted with community members and Lweza Primary School teachers. Interviews were conducted with key informants, including midwives, a traditional birth attendant, a community leader, and a Village Health Team member. Data collection was done in English along with a Luganda translator.ResultsOf the 100 household surveys conducted, 86% of women did not meet the WHO recommendation of 8 antenatal appointments during their pregnancies. Reasons cited for inadequate visits included facing long wait times (>7 h) at health facilities, getting education from family or traditional healers, or being told to delay antenatal care until 6 months pregnant. Informant interviews revealed that no standardized antenatal education program exists. Respondents felt least educated on family planning and postpartum depression, despite 37% of them reporting symptoms consistent with postpartum depression. Education was also lacking on the use of traditional herbs, although most women (60%) reported using them during pregnancy.ConclusionsMost women in Lweza do not receive 8 antenatal appointments during their pregnancies or any standardized antenatal education. Educational opportunities on family planning, postpartum depression, and the safety of traditional herbs during pregnancy exist. Future studies should focus on ways to overcome barriers to antenatal care, which could include implementing community-based education programs to improve health outcomes for women in Lweza Village.

Project description:BackgroundThe prevalence of hypertension is increasing among people living with HIV/AIDS (PLWHA) in low- and middle-income countries (LMICs). However, knowledge of the complications and management of hypertension among PLWHA in Uganda remains low. We explored the acceptability of implementing hypertension (HTN) specific health education by community health workers (CHWs) among PLWHA in rural Uganda.MethodsWe conducted a qualitative study consisting of 22 in-depth interviews (14 PLWHA/HTN and 8 CHWs), 3 focus group discussions (FGDs), 2 with PLWHA/HTN and 1 with CHWs from Nakaseke district, Uganda. Participants were interviewed after a single session interaction with the CHW. Data were transcribed from luganda (local language) into English and analyzed using thematic analysis. We used Sekhon's model of acceptability of health Interventions to explore participants' perceptions.ResultsParticipants believed CHWs utilized easy-to-understand, colloquial, non-technical language during education delivery, had a pre-existing rapport with the CHWs that aided faster communication, and had more time to explain illness than medical doctors had. Participants found the educational material (PocketDoktor™) to be simple and easy to understand, and perceived that the education would lead to improved health outcomes. Participants stated their health was a priority and sought further disease-specific information. We also found that CHWs were highly motivated to carry out the patient-centered education. While delivering the education, CHWs experienced difficulties in keeping up with the technical details regarding hypertension in the PocketDoktor™, financial stress and patient questions beyond their self-perceived skill level and experience. PLWHA/HTN had challenges accessing the health facility where the intervention was delivered and preferred a household setting.ConclusionsHypertension patient-centered education delivered by CHWs using the PocketDoktor™ was acceptable to PLWHA and hypertension in Nakaseke area in rural, Uganda. There is need for further studies to determine the cost implications of delivering this intervention among PLWHA across LMIC settings.

Project description:BackgroundCommunity health workers (CHWs) are an important cadre of the global health workforce as they are involved in providing health services at the community level. However, evidence on the role of CHWs in delivering interventions for non-communicable diseases (NCDs) in Uganda is limited. This study, therefore, assessed the involvement of CHWs in the prevention and control of NCDs in Wakiso District, Uganda with a focus on their knowledge, attitudes and practices, as well as community perceptions.MethodsA cross-sectional study using mixed methods was conducted which involved a structured questionnaire among 485 CHWs, and 6 focus group discussions (FGDs) among community members. The study assessed knowledge, perceptions including the importance of the various risk factors, and the current involvement of CHWs in NCDs, including the challenges they faced. Quantitative data were analysed in STATA version 13.0 while thematic analysis was used for the qualitative data.ResultsThe majority of CHWs (75.3%) correctly defined what NCDs are. Among CHWs who knew examples of NCDs (87.4%), the majority mentioned high blood pressure (77.1%), diabetes (73.4%) and cancer (63.0%). Many CHWs said that healthy diet (86.2%), physical activity (77.7%), avoiding smoking/tobacco use (70.9%), and limiting alcohol consumption (63.7%) were very important to prevent NCDs. Although more than half of the CHWs (63.1%) reported being involved in NCDs activities, only 20.9 and 20.6% had participated in community mobilisation and referral of patients respectively. The majority of CHWs (80.1%) who were involved in NCDs prevention and control reported challenges including inadequate knowledge (58.4%), lack of training (37.6%), and negative community perception towards NCDs (35.1%). From the FGDs, community members were concerned that CHWs did not have enough training on NCDs hence lacked enough information. Therefore, the community did not have much confidence in them regarding NCDs, hence rarely consulted them concerning these diseases.ConclusionsDespite CHWs having some knowledge on NCDs and their risk factors, their involvement in the prevention and control of the diseases was low. Through enhanced training and community engagement, CHWs can contribute to the prevention and control of NCDs, including health education and community mobilisation.

Project description:BACKGROUND:Non-communicable diseases (NCDs) are rapidly becoming leading causes of morbidity and mortality in low- and middle-income countries, including those in sub-Saharan Africa. In contrast to high-income countries, the sociodemographic distribution, including socioeconomic inequalities, of NCDs and their risk factors is unclear in sub-Saharan Africa, particularly among rural populations. METHODS:We undertook a cross-sectional population-based survey of 7809 residents aged 13 years or older in the General Population Cohort in south-western rural Uganda. Information on behavioural, physiological and biochemical risk factors was obtained using standardized methods as recommended by the WHO STEPwise Approach to Surveillance. Socioeconomic status (SES) was determined by principal component analysis including household features, ownership, and occupation and education of the head of household. RESULTS:SES was found to be associated with NCD risk factors in this rural population. Smoking, alcohol consumption (men only) and low high-density lipoprotein (HDL) cholesterol were more common among those of lower SES. For example, the prevalence of smoking decreased 4-fold from the lowest to the highest SES groups, from 22.0% to 5.7% for men and 2.2% to 0.4% for women, respectively. In contrast, overweight, raised blood pressure, raised HbA1c (women only) and raised cholesterol were more common among those of higher SES. For example, the prevalence of overweight increased 5-fold from 2.1% to 10.1% for men, and 2-fold from 12.0% to 23.4% for women, from the lowest to highest SES groups respectively. However, neither low physical activity nor fruit, vegetable or staples consumption was associated with SES. Furthermore, associations between NCD risk factors and SES were modified by age and sex. CONCLUSIONS:Within this rural population, NCD risk factors are common and vary both inversely and positively across the SES gradient. A better understanding of the determinants of the sociodemographic distribution of NCDs and their risk factors in rural sub-Saharan African populations will help identify populations at most risk of developing NCDs and help plan interventions to reduce their burden.

Project description:The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.

Project description:ObjectivesThis study aimed to investigate the effect of a peer-training program for village health volunteers (VHVs) to improve chronic disease management among older adults in rural Thailand.MethodsThe study was guided by community-based participatory research (CBPR). The peer-training program was developed by engaging diverse stakeholders, including community organizations, healthcare services, VHVs, older adults with chronic illnesses, and folk scholars in remote communities with high healthcare needs. The peer-training program comprised a three-day training workshop that convened once a week for three weeks with the following six sessions: knowledge sharing, peer support and empowerment, health literacy and health behavior, the general caring procedure for older adults with chronic illnesses, information sharing and communication, and home visit. From January to April 2021, a total of 28 VHVs completed the peer training program in a rural area in Chiang Rai province, Thailand. The Health Literacy and Health Behavior-3E2S (HLHB-3E2S), the Management of Non-Communicable Diseases Questionnaire (MNCDQ), and a self-confidence questionnaire were used to survey pre (week 1) and post-intervention (week 12), respectively. Then VHVs were interviewed to collect attitudes, and opinions about the intervention.ResultsAfter the intervention, the HLHB-3E2S scores (49.39 ± 5.54 vs. 52.35 ± 4.26, P = 0.001), the MNCDQ scores (44.10 ± 6.27 vs. 50.60 ± 4.84, P < 0.001), and the self-confidence questionnaire scores (22.28 ± 2.46 vs. 23.21 ± 1.81, P = 0.01) of VHVs significantly increased. VHVS also reported that the peer-training program enhanced their healthcare services, including health education, chronic disease management, leadership skills, and improving their relationship with healthcare providers.ConclusionPeer training programs are a practical strategy to improve VHVs' capacities.Healthcare professionals should provide a continuous training program for VHVs with their peers to increase capacities, confidence, and satisfaction in caring for the older adults with chronic diseases in the community.

Project description:Background/objectiveThe increasing burden of non-communicable diseases (NCDs) in Nepal underscores the importance of strengthening primary healthcare systems to deliver efficient care. In this study, we examined the barriers and facilitators to engaging community health workers (CHWs) for NCDs prevention and control in Nepal.DesignWe used multiple approaches including (a) review of relevant literature, (b) key personnel and stakeholders' consultation meetings and (c) qualitative data collection using semistructured interviews. A grounded theory approach was used for qualitative data collection and the data were analysed thematically.SettingData were collected from health facilities across four districts in Nepal and two stakeholder consultative meetings were conducted at central level.ParticipantsWe conducted in-depth interviews with CHWs (Health Assistants, Auxiliary Health Workers, Auxiliary Nurse Midwife) (n=5); key informant interviews with health policymakers/managers (n=3) and focus group discussions (FGDs) with CHWs (four FGDs; total n=27). Participants in two stakeholder consultative meetings included members from the government (n=8), non-government organisations (n=7), private sector (n=3) and universities (n=6).ResultsThe CHWs were engaged in a wide range of public health programmes and they also deliver NCDs specific programmes such as common NCDs screening, provisional diagnosis, primary care, health education and counselling, basic medication and referral and so on. These NCD prevention and control services are concentrated in those districts, where the WHO, Package for prevention and control of NCDs) program is being implemented. Some challenges and barriers were identified, including inadequate NCD training, high workload, poor system-level support, inadequate remuneration, inadequate supply of logistics and drugs. The facilitating factors included government priority, formation of NCD-related policies, community support systems, social prestige and staff motivation.ConclusionEngaging CHWs has been considered as key driver to delivering NCDs related services in Nepal. Effective integration of CHWs within the primary care system is essential for CHW's capacity buildings, necessary supervisory arrangements, supply of logistics and medications and setting up effective recording and reporting systems for prevention and control of NCDs in Nepal.

Dataset Information

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

Background

Objective/methods

Results/conclusions

Publications

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

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