Experiences of addressing cardiovascular disease at the community level

Community members in Bangladesh do not perceive risk of developing cardiovascular disease, but health workers are now ready to diagnosis it

Community health workers (CHWs) in low- and middle-income countries can be trained to effectively assess risk for cardiovascular disease, but barriers to referring patients in the healthcare system may negate any gains that might be made.

These are the results of a multi-country study, led in Bangladesh by icddr,b’s Dr Masuma Khanam, an assistant scientist in the chronic non-communicable disease unit in the Centre for Equity and Health Systems, on the experiences, challenges and successes of training CHWs in cardiovascular disease management, and the benefits this training had for increased diagnosis and treatment by a skilled health worker.

Photo by DFID, CC BY 2.0

Sixty-four CHWs were enrolled in four countries—Bangladesh, Guatemala, Mexico and South Africa—and 42 completed all aspects of evaluation. They each received four months of training, including learning how to take blood pressure measurements, how to calculate body mass index, how to generate a cardiovascular disease risk score using data collected through a pre-printed risk chart and a period of supervised fieldwork wherein they practiced these skills on patients.

The scientists tested the content knowledge of the CHWs immediately post-training and again three to six months after the completion of the fieldwork. They then evaluated the eventual outcomes of the community-level cardiovascular disease screening by comparing the referrals made by the CHWs to patient records at the respective health centres within six months of the initial referral.

Ultimately, the evaluation of the training showed that it was a success and that the CHWs both welcomed the in-depth training and retained the knowledge for at least three months after they completed their fieldwork. But the impact of this training on referral outcomes was mediocre.

For example, while 69% of patients who received an urgent referral by their CHW scheduled and attended an appointment at a health centre, and 100% of all patients who received a hypertension diagnosis by a trained health worker were prescribed the correct medicine, only 37% of all referrals, including non-urgent referrals, actually attended a health clinic. The scientists say this could be due to a lack of risk perception by patients about cardiovascular disease and a lack of trust in referral diagnoses made by CHWs. Other barriers include the costs associated with seeking treatment, and skilled healthcare workers viewing the CHWs as a threat.

However, given the global shortages of skilled health workers and the increasing burden of non-communicable diseases in low- and middle-income countries, there is a great need for community-level diagnoses of cardiovascular diseases like hypertension in countries like Bangladesh.

The scientists say that the success of this training design could prove valuable for the development of future CHW cardiovascular disease screening programs, but they also recommend the testing of new models of referral, such as linking CHWs to nurses of larger care teams or the creation of dedicated appointment slots at health centres for individuals at high risk of cardiovascular disease.