Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa

Abstract

BackgroundWe have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management.DesignPatient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained.ResultsThirty-seven percent (96/263) of those referred attended follow-up: 36 of 52 (69%) were urgent and 60 of 211 (28.4%) were non-urgent referrals. A diagnosis of hypertension (HTN) was made in 69% of urgent referrals and 37% of non-urgent referrals with treatment instituted in all cases. Reasons for non-attendance included limited self-perception of risk, associated costs, health system obstacles, and lack of trust in CHWs to conduct CVD risk assessments and to refer community members into the health system.ConclusionsThe existing barriers to referral in the health care systems negatively impact the gains to be had through screening by training CHWs in the use of a simple risk assessment tool. The new diagnoses of HTN and commencement on treatment in those that attended referrals underscores the value of having persons at the highest risk identified in the community setting and referred to a clinic for further evaluation and treatment.

Community-based screening for cardiovascular risk using a novel mHealth tool in rural Kenya

“…The Kenyan STEPS survey reported that only 12% of Kenyans have ever had their blood glucose tested by a healthcare professional 2. A cross-sectional study conducted by public health officials in Kenya showed that only 27% of participants had a good understanding of diabetes 25. Given the current knowledge about the lack of diabetic testing in Kenya, it is probable that our 3.2% prevalence rate for diabetes is an under representation of the actual number of those living with diabetes in the region.…”

“…A study conducted by Levitt et al 25 used trained CHWs to implement a non-laboratory-based CVD risk model to identify high-risk patients in Bangladesh, Guatamala, Mexico and South Africa. They found that 77.4% of patients were at low risk, 17.4% were at low to moderate risk, 3.7% were at moderate risk, 1.1% were at moderate to high risk and 0.2% were at high risk.…”

Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries

“…The rates at which referred people (those whose cardiovascular disease risk score was over 20 percent) completed a visit to a primary health center were as low as 33 percent in the three countries in our study. 17 Formal studies are needed to evaluate how mobile health tools can also be used for improving referral rates and initiation of appropriate treatment at primary health centers.…”

“…Our previous work established that of those referred to treatment, approximately 37 percent overall and 69 percent of those at highest risk actually visited a local clinic within the recommended two weeks of screening. 17 However, each country has different rates of initiation for treatment with essential blood pressure medications or statins. We therefore used current treatment rate information for hypertension from published surveys for each country studied 25–27 (Appendix Exhibit A7).…”

“…16 Approximately30–70percent of individuals identified as high risk sought care at primary health centers, where a high percentage were started on appropriate treatment for their cardiovascular disease risk factors. 17 …”