Shafika Abrahams-Gessel

Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries

Coronary heart disease (CHD) is the single largest cause of death in the developed countries and is one of the leading causes of disease burden in developing countries. In 2001, there were 7.3 million deaths due to CHD worldwide. Three-fourths of global deaths due to CHD occurred in the low- and middle-income countries. The rapid rise in CHD burden in most of the low- and middle-income countries is due to socio-economic changes, increase in lifespan, and acquisition of lifestyle-related risk factors. The CHD death rate, however, varies dramatically across the developing countries. The varying incidence, prevalence, and mortality rates reflect the different levels of risk factors, other competing causes of death, availability of resources to combat cardiovascular disease, and the stage of epidemiologic transition that each country or region finds itself. The economic burden of CHD is equally large but solutions exist to manage this growing burden.

An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study

Summary Background Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study we investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. Methods This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community’s predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35–74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The primary endpoint of this study was the level of direct agreement between risk scores assigned by the community health workers and the health professionals. Findings Of 68 community health worker trainees recruited between June 4, 2012, and Feb 8, 2013, 42 were deemed qualified to do fieldwork (15 in Bangladesh, eight in Guatemala, nine in Mexico, and ten in South Africa). Across all sites, 4383 community members were approached for participation and 4049 completed screening. The mean level of agreement between the two sets of risk scores was 96 8% (weighted κ =0 948, 95% CI 0 936–0 961) and community health workers showed that 263 (6%) of 4049 people had a 5-year cardiovascular disease risk of greater than 20%. Interpretation Health workers without formal professional training can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease. Using community health workers for this screening would free up trained health professionals in low-resource settings to do tasks that need high levels of formal, professional training. Funding US National Heart, Lung, and Blood Institute and National Institutes of Health, UnitedHealth Chronic Disease Initiative.

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

In low-resource settings, a physician is not always available. We recently demonstrated that community health workers-instead of physicians or nurses-can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone-based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.

The Training and Fieldwork Experiences of Community Health Workers Conducting Population-Based, Noninvasive Screening for CVD in LMIC

BACKGROUND Cardiovascular disease (CVD) is on the rise in low- and middle-income countries and is proving difficult to combat due to the emphasis on improving outcomes in maternal and child health and infectious diseases against a backdrop of severe human resource and infrastructure constraints. Effective task-sharing from physicians or nurses to community health workers (CHW) to conduct population-based screening for persons at risk has the potential to mitigate the impact of CVD on vulnerable populations. CHW in Bangladesh, Guatemala, Mexico, and South Africa were trained to conduct noninvasive population-based screening for persons at high risk for CVD. OBJECTIVES This study sought to quantitatively assess the performance of CHW during training and to qualitatively capture their training and fieldwork experiences while conducting noninvasive screening for CVD risk in their communities. METHODS Written tests were used to assess CHWs acquisition of content knowledge during training, and focus group discussions were conducted to capture their training and fieldwork experiences. RESULTS Training was effective at increasing the CHWs content knowledge of CVD, and this knowledge was largely retained up to 6 months after the completion of fieldwork. Common themes that need to be addressed when designing task-sharing with CHW in chronic diseases are identified, including language, respect, and compensation. The importance of having intimate knowledge of the community receiving services from design to implementation is underscored. CONCLUSIONS Effective training for screening for CVD in community settings should have a strong didactic core that is supplemented with culture-specific adaptations in the delivery of instruction. The incorporation of expert and intimate knowledge of the communities themselves is critical, from the design to implementation phases of training. Challenges such as role definition, defining career paths, and providing adequate remuneration must be addressed.

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

Background We 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. Design Patient 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. Results Thirty-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. Conclusions The 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.Background We 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. Design Patient 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. Results Thirty-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. Conclusions The 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.

Hypertension management in a population of older adults in rural South Africa.

Objective: Assess awareness, treatment, and control of hypertension, as an indication of its management, in rural South Africa, especially regarding modifiers of these variables. Methods: A population-representative sample of adults aged at least 40 years residing in the rural Agincourt subdistrict (Mpumalanga Province) covered by a long-term health and sociodemographic surveillance system was recruited. In-person interviews, physical exams, and dried blood spots were collected. Hypertension awareness, treatment, and control rates were assessed. A regression model was built to identify predictors of those outcomes. Results: The mean age of the 2884 hypertensive participants was 64.1 ± 12.7 years. Hypertension awareness rate was 64.4%, treatment among those aware was 89.3 and 45.8% of those treated were controlled. Considering aware and unaware hypertensives, treatment rate was 49.7% and control 22.8%. In the multivariable regression model, awareness was predicted by female sex, age at least 60 years, higher social economic status, prior cardiovascular disease (CVD), nonimmigrant status, literacy, and physical limitation. Improved control among those treated was predicted by age at least 60 years. Blood pressure control among all hypertensive study participants was predicted by female sex, being HIV-negative, age at least 60 years, nonimmigrant status, and prior CVD. Conclusion: High rates of awareness and treatment of hypertension as well as good levels of control were found in this population, probably explained by the long-term surveillance program conducted in the area. Considering the predictors of hypertension management, particular attention should be given to men, residents younger than 60 years, immigrants, and study participants without CVD as these characteristics were predictors of poor outcome.

Healthcare Professional Shortage and Task-Shifting to Prevent Cardiovascular Disease: Implications for Low- and Middle-Income Countries

Cardiovascular diseases (CVD) account for 18 million of annual global deaths with more than three quarters of these deaths occurring in low- and middle-income countries (LMIC). In LMIC, the distribution of risk factors is heterogeneous, with urban areas being the worst affected. Despite the availability of effective CVD interventions in developed countries, many poor countries still struggle to provide care due to lack of resources. In addition, many LMIC suffer from staff shortages which pose additional burden to the healthcare system. Regardless of these challenges, there are potentially effective strategies such as task-shifting which have been used for chronic conditions such as HIV to address the human resource crisis. We propose that through task-shifting, certain tasks related to prevention be shifted to non-physician health workers as well as non-nurse health workers such as community health workers. Such steps will allow better coverage of segments of the underserved population. We recognise that for task-shifting to be effective, issues such as clearly defined roles, evaluation, on-going training, and supervision must be addressed.

Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the US Supplemental Nutrition Assistance Program (SNAP): A microsimulation study

Background The Supplemental Nutrition Assistance Program (SNAP) provides approximately US

Awareness, treatment, and control of dyslipidemia in rural South Africa: The HAALSI (Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study

70 billion annually to support food purchases by low-income households, supporting approximately 1 in 7 Americans. In the 2018 Farm Bill, potential SNAP revisions to improve diets and health could include financial incentives, disincentives, or restrictions for certain foods. However, the overall and comparative impacts on health outcomes and costs are not established. We aimed to estimate the health impact, program and healthcare costs, and cost-effectiveness of food incentives, disincentives, or restrictions in SNAP. Methods and findings We used a validated microsimulation model (CVD-PREDICT), populated with national data on adult SNAP participants from the National Health and Nutrition Examination Survey (NHANES) 2009–2014, policy effects from SNAP pilots and food pricing meta-analyses, diet–disease effects from meta-analyses, and policy, food, and healthcare costs from published literature to estimate the overall and comparative impacts of 3 dietary policy interventions: (1) a 30% incentive for fruits and vegetables (F&V), (2) a 30% F&V incentive with a restriction of sugar-sweetened beverages (SSBs), and (3) a broader incentive/disincentive program for multiple foods that also preserves choice (SNAP-plus), combining 30% incentives for F&V, nuts, whole grains, fish, and plant-based oils and 30% disincentives for SSBs, junk food, and processed meats. Among approximately 14.5 million adults on SNAP at baseline with mean age 52 years, our simulation estimates that the F&V incentive over 5 years would prevent 38,782 cardiovascular disease (CVD) events, gain 18,928 quality-adjusted life years (QALYs), and save

Disparities in Management of Cardiovascular Disease in Rural South Africa: Data From the HAALSI Study (Health and Aging in Africa: Longitudinal Studies of International Network for the Demographic Evaluation of Populations and Their Health Communities)

1.21 billion in healthcare costs. Adding SSB restriction increased gains to 93,933 CVD events prevented, 45,864 QALYs gained, and