Training community health workers to screen for cardiovascular disease risk in the community: experiences from Cape Town, South Africa

This article describes a training process to equip community health workers (CHWs) with knowledge and skills to identify individuals at high risk for cardiovascular disease (CVD) in a township in Cape Town.Methods: CHWs were employed by a non-governmental organisation (NGO) primarily focusing on non-communicable diseases (NCDs). They were trained in the theory of CVD, including physiological changes and related risk factors and in obtaining anthropometric and blood pressure measurements. Pre- and post-training tests assessed learning needs and the effectiveness of imparting knowledge about CVD, respectively.Results: Training increased knowledge about CVD risk factors. CHWs were able to screen and identify those at risk for CVD and refer them to health professionals for validation of scores. The initial one-week training was too short, given the amount of information covered. Some CHWs had difficulty with English as the primary instruction medium and as the only language in which tests were offered.Conclusion: Although CHWs could be trained to screen for CVD risk, increased training time was required to impart the knowledge. The language used during training and testing presented challenges for those trainees whose dominant, spoken language was not English

Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, South Africa.

BACKGROUND: Low socioeconomic status is associated with the risk of hypertension. There are few reports of the effect of socioeconomic and potentially modifiable factors on the control of hypertension in South Africa (SA). OBJECTIVES: To investigate associations between patients' socio-economic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients. METHODS: We enrolled hypertensive patients attending 38 public sector primary care clinics in the Western Cape, SA, in 2011, and followed them up 14 months later as part of a randomised controlled trial. Blood pressure was measured and prescriptions for antihypertension medications were recorded at baseline and follow-up. Logistic regression models assessed associations between patients' socioeconomic status, characteristics of primary healthcare facilities, and control and treatment of blood pressure. RESULTS: Blood pressure was uncontrolled in 60% (1 917/3 220) of patients at baseline, which was less likely in patients with a higher level of education (p=0.001) and in English compared with Afrikaans respondents (p=0.033). Treatment was intensified in 48% (892/1 872) of patients with uncontrolled blood pressure at baseline, which was more likely in patients with higher blood pressure at baseline (p<0.001), concurrent diabetes (p=0.013), more education (p=0.020), and those who attended clinics offering off-site drug supply (p=0.009), with a doctor every day (p=0.004), or with more nurses (p<0.001). CONCLUSION: Patient and clinic factors influence blood pressure control and treatment in primary care clinics in SA. Potential modifiable factors include ensuring effective communication of health messages, providing convenient access to medications, and addressing staff shortages in primary care clinics.

Economic burden and the cost-effectiveness of treatment of cardiovascular diseases in Africa.

Cardiovascular disease is the leading cause of death in those over the age of 45 in Africa. The economic toll from cardiovascular diseases is equally devastating, leading to billions of dollars lost due to healthcare costs and reduced productivity from the disabling and fatal outcomes related to diabetes, hypertension, stroke, valvular heart disease, and heart failure. Much of it is preventable. With reasonable screening programmes and judicious use of scarce resources much of the suffering can be alleviated. This article reviews the economic burden attributable to cardiovascular disease in Africa and many of the potential cost-effective solutions to the large burden. It further outlines many of the areas where we know less and must focus our future research in trying to outline cost-effective solutions.

Hypertension in South African adults: results from the Demographic and Health Survey, 1998.

OBJECTIVES: To determine the prevalence and treatment status of hypertension in South Africa. DESIGN: National cross-sectional survey. SETTING: 13 802 randomly selected South Africans, 15 years and older, were visited in their homes in 1998. METHODS: Trained fieldworkers completed questionnaires on lifestyle and chronic diseases, measured blood pressure with an Omron manometer and recorded chronic drug utilization. Drugs were classified using the Anatomical Therapeutic Chemical index. RESULTS: The mean systolic blood pressure for men and women was 123 mmHg (SE 0.37) and 119 mmHg (SE 0.36), while the mean diastolic level was 76 mmHg (SE 0.25) and 75 mmHg (SE 0.20), respectively. When using a cut-off point of 140/90 mmHg the hypertension prevalence rate (age-adjusted to the South African Population, Census 1996) was 21% for both genders. Using the current cut-off point (160/95 mmHg) for South Africa, the prevalence rate was 11% for men and 14% for women. For men with hypertension, the level of awareness, taking antihypertensive medication and having controlled blood pressure (< 160/95 mmHg) were 41, 39 and 26% respectively, while for women these rates were 67, 55 and 38% respectively. CONCLUSIONS: This survey revealed high levels of hypertension in the South African community with inadequate treatment status.

Light-to-moderate alcohol consumption and mortality in the Physicians' Health Study enrollment cohort.

OBJECTIVES: This study examined the relationship between light-to-moderate alcohol consumption and cause-specific mortality. BACKGROUND: Previous studies suggest a J-shaped relation between alcohol and total mortality in men. A decrease in cardiovascular disease (CVD) mortality without a significant increase in other causes of mortality may explain the overall risk reduction at light-to-moderate levels. METHODS: We conducted a prospective cohort study of 89,299 U.S. men from the Physicians' Health Study enrollment cohort who were 40 to 84 years old in 1982 and free of known myocardial infarction, stroke, cancer or liver disease at baseline. Usual alcohol consumption was estimated by a limited food frequency questionnaire. RESULTS: There were 3,216 deaths over 5.5 years of follow-up. We observed a U-shaped relationship between alcohol consumption and total mortality. Compared with rarely/never drinkers, consumers of 1, 2 to 4 and 5 to 6 drinks per week and 1 drink per day had significant reductions in risk of death (multivariate relative risks [RRs] of 0.74, 0.77, 0.78 and 0.82, respectively) with no overall benefit or harm detected at the > or =2 drinks per day level (RR = 0.95; 95% confidence interval (CI), 0.79 to 1.14). The relationship with CVD mortality was inverse or L-shaped with apparent risk reductions even in the highest category of > or =2 drinks per day (RR = 0.76; 95% CI, 0.57 to 1.01). We found no clear harm or benefit for total or common site-specific cancers. For remaining other cancers, there was a nonsignificant 28% increased risk for those consuming > or =2 drinks per day. CONCLUSIONS: These data support a U-shaped relation between alcohol and total mortality among light-to-moderate drinking men. The U-shaped curve may reflect an inverse association for CVD mortality, no association for common site-specific cancers and a possible positive association for less common cancers.