Can lay health workers support the management of hypertension? Findings of a cluster randomised trial in South Africa

Abstract

IntroductionIn low/middle-income countries with substantial HIV and tuberculosis epidemics, health services often neglect other highly prevalent chronic conditions, such as hypertension, which as a result are poorly managed. This paper reports on a study to assess the effect on hypertension management of lay health workers (LHW) working in South African rural primary healthcare clinics to support the provision of integrated chronic care.MethodsA pragmatic cluster randomised trial with a process evaluation in eight rural clinics assessed the effect of adding two LHWs supporting nurses in providing chronic disease care in each intervention clinic over 18 months. Control clinics continued with usual care. The main outcome measure was the change in the difference of percentage of clinic users who had elevated cardiovascular risk associated with high blood pressure (BP) before and after the intervention, as measured by two cross-sectional population surveys.ResultsThere was no improvement in BP control among users of intervention clinics as compared with control clinics. However, the LHWs improved clinic functioning, including overall attendance, and attendance on the correct day. All clinics faced numerous challenges, including rapidly increasing number of users of chronic care, unreliable BP machines and cuffs, intermittent drug shortages and insufficient space.ConclusionLHWs improved the process of providing care but improved BP control required improved clinical care by nurses which was compromised by large and increasing numbers of patients, the dominance of the vertically funded HIV programme and the poor standards of equipment in clinics.Trial registration numberISRCTN12128227.

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi

“…Crucially, effective models for managing NCDs among adults with HIV must be contextualised within health systems. For example, an intervention that used lay health workers to assist nurses at health centres in South Africa for the provision of hypertension care was effective at improving patients’ clinic attendance but not their health status (controlled blood pressure); this was hypothesised to be due to health system challenges, such as insufficient nursing workforce and space, drug stockouts and equipment failures 47. Integrated services require the co-ordination of multiple health system inputs, and this must be carefully considered before implementing and scaling up new models of care 9 39.…”

Task shifting to improve the provision of integrated chronic care: realist evaluation of a lay health worker intervention in rural South Africa

“…If the intervention were to be rolled out, we envisaged that the implementation manager’s role could be performed by the clinic supervisors, who are responsible for four to five clinics. At the end of the intervention there was no difference in the primary outcome of the trial, which was prevalence of clinic users at moderate or higher risk of cardiovascular disease as assessed by two population surveys 10…”

“…They go for consultation in a designated chronic care room for diagnosis, prescription and dispensation of medication. Although this is the intended process for every clinic, functioning of designated queues and consultation rooms depends on sufficient staff, equipment and space in the clinic 10…”

Optimización del desempeño del observador al medir la presión arterial en el consultorio: declaración de posición de la Comisión Lancet de Hipertensión

“…Se recomienda enfáticamente la transferencia de competencias y redistribución de tareas mediante la capacitación de profesionales sanitarios no médicos, como enfermeras y agentes comunitarios de salud, para llevar a cabo las mediciones, pues libera a los médicos, escasos en relación con otros profesionales de la salud, para realizar otras tareas, y reduce también el efecto de la bata blanca [ 27 , 63 , 64 ]. La división de tareas por sí sola puede no mejorar el control de la PA si los consultorios están sobrecargados, el equipamiento no es confiable o no se dispone de tratamiento antihipertensivo [ 65 ]. Los planes de estudios de las escuelas de profesionales de la salud y programas formativos de posgrado deben incluir la capacitación estandarizada y el examen del desempeño en medición de la presión arterial.…”