Objective To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs) in typical primary health-care settings. Methods Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate logit regression. Findings Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant. Conclusion Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care. IntroductionChronic noncommunicable diseases, especially cardiovascular diseases, are a major and increasing cause of death and disability worldwide, and may have retarding effects on the economies of affected individuals, households and countries. 1,2 The epidemiological and economic effects of cardiovascular diseases (specifically stroke and heart diseases) and diabetes, are especially pervasive in low-and middle-income countries 1-3 where health systems are less likely to adequately respond to the challenges of the increasing burden. Socioeconomic barriers and inequalities in access to treatment, suboptimal staffing of health-care facilities and limited capacity for ancillary investigations that complement cardiovascular risk profiling are some of the common problems limiting these countries' control of chronic diseases, especially at the primary healthcare level. 4 This situation is worsened by the brain-drain syndrome 5-9 resulting in shortages of skilled workers.Can non-physician health-care workers assess and manage cardiovascular risk in primary care? 29 However, such risk profiling protocols lack universal applicability 11,13,14,[29][30][31][32][33][34][35][36][37][38][39][40][41][42] and may be of limited applicability in developing countries, whose populations were not sampled for the Framingham 31,32 and other studies. Uncritical adoption of such protocols may result in negative clinical and economic consequences. 43 To address the absence of a CVD risk profiling tool for developing countries, WHO in 2000 developed a package for the assessment and management of cardiovascular risk in low-resource settings. 44 The package, developed through consultations with experts from all WHO regions, was designed as an adaptable, cost-effective tool for systematic case management at all health-care levels, and consequently for scaling up countries' health systems. The expert panel based the design of the package on the graded evidence available.The package includes three scenarios that reflect commonl...

This paper, which summarizes the conclusions of a WHO Expert meeting, is aimed at proposing indications to develop technical specifications for an accurate and affordable blood pressure measuring device for office/clinic use in low resource settings. Blood pressure measuring devices to be used in low resource settings should be accurate, affordable, and easily available worldwide. Given the serious inherent inaccuracy of the auscultatory technique, validated and affordable electronic devices, that have the option to select manual readings, seem to be a suitable solution for low resource settings. The agreement on the technical specifications for automated blood pressure measuring devices for office/clinic use in low resource settings included the following features: high accuracy, adoption of electronic transducers and solar batteries for power supply, standard rates of cuff inflation and deflation, adequate cuff size, digital display powered by solar batteries, facilities for adequate calibration, environmental requirements, no need of memory function, resistance to shock and temperature changes, and low cost. Availability of a device with these features should be accompanied by adequate training of health care personnel, who should guarantee implementation of the procedures recommended in recent European and American Guidelines for accurate blood pressure measurement.