Utilization of community health volunteers in identification of hypertension cases in Kajiado county, Kenya

INTRODUCTION

Non-communicable diseases (NCDs) are chronic and persist over a long duration. According to Shukri et al, hypertension contributes greatly to cardiovascular diseases and is the number one cause of morbidity and mortality in the world.¹ It is a continually increasing burden globally responsible for more than 10 million deaths each year.² Kenya too is going through an epidemiological transition characterised by a reduction in morbidity and mortality as a result of communicable conditions, and an increase in the burden of NCDs.³ According to a survey, conducted in Kenya, hypertension prevalence is high among adults with little awareness and unacceptably low levels of treatment and control.⁴ The STEPwise approach to surveillance (STEPs) survey 2015 revealed that close to a quarter of Kenyans have hypertension. In those individuals previously diagnosed only 12% were on treatment, and only 4% had achieved control.⁵

Poor blood pressure control can be attributed to both health system and patient-related factors.⁶ Recent studies have indicated that CHVs can promote hypertension care and blood pressure (BP) regulation as they bridge the gap between the health system and the patients. CHVs are volunteers who have undertaken basic training and are capable of providing preventive, promotional and rehabilitation care. Evidence depicts a positive impact when CHVs are incorporated into hypertension programs. It has been recommended that the health system should devise mechanisms to encourage preventive measures through controlling risk factors, because preventive care is more cost effective than curative care.⁷

Reliance on CHVs for health care has been increasing, especially in resource-limited areas across Africa. Their roles are better understood in the areas of communicable diseases such as HIV infection, Tuberculosis and Malaria; however, little is known about their role in non-communicable diseases. It is evident that CHVs can contribute significantly to most health services; prevention and identification of hypertension included. ^8,9

A study in South Africa indicates that CHVs have various roles in the management of NCDs such as health advisors and educators, rehabilitators and support group facilitators. At community level they also screen and refer patients while helping them navigate the formal system.¹⁰ These multiple roles are modelled by the health system expectations and in response to community needs.¹¹

Hypertension, even though it bears a genetic predisposition, is largely associated with lifestyle factors that can be modifiable. The greatest gains in the successful control of the hypertension epidemic begin with its prevention, followed by early detection and proper management.¹² Lack of awareness on the disease and poor control in those identified remains a major challenge in Kenya.² Home visits by CHVs reduce the number of trips made by the patients to the hospital reducing the cost while educating and screening the people at the community.

In Kajiado County, Ongosi et al found the crude prevalence of hypertension to be 72.7% (80.6% in men and 63.8% in women). The age-standardized prevalence of hypertension was also slightly higher (26.2%) than the national hypertension prevalence average of 24.5%.¹³

Despite Kajiado having such high prevalence of elevated blood pressure (72.7%), a disturbingly high proportion (46.7%) has never had their blood pressure checked.¹³ Even worse, only 34.7% of those found to be hypertensive knew of their condition, an indication that most of the patients did not seek screening and treatment. Similar findings are depicted in the national Stepwise survey as aforementioned.⁵

The study aimed to determine the CHVs socio-demographic characteristics and to assess their level of knowledge in hypertension identification.

METHODS

This was a cross-sectional study with a mixed method approach. The study was conducted by interviewing the CHVs on their activities in regards to hypertension identification. Data was collected using researcher administered questionnaires which minimized the non-response rate and increased uniformity in how questions were answered. The questionnaire covered sections on demography, knowledge, and activities carried out by CHVs. Questions on knowledge entailed training on hypertension, source of knowledge on the disease, signs and symptoms of hypertension, causes/risk factors and ways of identifying hypertension cases. A correct answer was given 1 score and 0 score for wrong answer. The score varied from 0-16 points and was classified into 3 levels as follows using Bloom’s cut off point: high level/good knowledge (80-100), moderate level (60-80%), and low levels/poor knowledge (less than 59%).

A key informant guide was used to collect data from relevant health care personnel (Ministry of Health-Subcounty officer, the community health strategy coordinator, community health officers, community health assistants, facility in charges and representatives from non-governmental organizations (NGOs) working with CHVs in the area).

The study was conducted in Kajiado county, Loitokitok Sub County in Kenya. Loitoktok has five wards namely; Rombo, Kuku, Kimana, Entonet and Imbirikani/Eselenkei. It is served largely by Loitoktok sub-county Hospital as the referral centre. This facility is supported by government health centres and dispensaries, privately owned facilities and various NGOs across the sub-county. The data was collected in March and April 2022. The target population was all the active CHVs (involved in designated community work and reporting to the respective link facility in the past 6 months) in a community unit that was attached to a link facility from the five wards and had agreed to sign an informed consent form.

Multi-stage sampling was used to select the sample size of 226 CHVs. All the 5 wards in Loitoktok sub-county were included. The second stage was the Link facilities through purposive sampling of facilities with active community units (CU) (1 sub-county hospital, 7 health centres and 5 dispensaries); a total of 15 CUs were included. Systematic random sampling was used to select active CHVs whereby every 2^nd person was included in the study. Participants in the KIIs were selected using purposive sampling of health care workers who worked with CHVs. There is not much data documented on the utilization of CHVs in hypertension identification in Loitoktok and not every facility had an active community unit. Owing to this, the results are less generalized and may not represent CHV utilization in the whole county but obtained a baseline for further research.

The quantitative data collected was entered, coded, cleaned and captured using statistical package for the social sciences (SPSS) version 23. Descriptive statistics were computed to generate frequencies; Pearson Chi square and multivariate logistic regression was used to get the association between categorical variables. The qualitative data gathered was transcribed, coded and analyzed using content thematic analysis then presented in a narrative.

Ethical approval was obtained from the Kenyatta University Ethics Review Committee. Permission to conduct the study was sought from the National Commission for Science, Technology and Innovation (NACOSTI), Kajiado county Office of Public Health and MOH- Loitoktok Sub-county.

RESULTS

Socio-demographic characteristics of the study respondents

The total respondents were 226, 154 (68.1%) were female while 72 (31.9%) were male. The majority 75 (33.2%) were middle age (41-50 years); 79.2% of the respondents were married. Most of the respondents 191 (84.5%) had been to school with 49.6% having attended primary school; 30.5% secondary school and 4.4% had tertiary education. Only 15.5% had no formal training but had the ability to read and write. Of the total respondents; 57.1% were self-employed, 38.0% were unemployed and 4.9% were employed in various informal sectors. The majority (56.2%) had been working as CHVs for more than 9 years with 32.7% having served for between 5-9 years. The majority (80.5%) reported that their work was purely voluntary with only 19.5% reporting to have received a monthly stipend from an NGO up until May 2022 when the NGOs stopped supporting them since this was based on the project being conducted and donor funding. None of the CHVs reported to have gotten any stipend from the government (Table 1). There is a strong association between age and hypertension screening with the likelihood of screening being higher among the middle age group (41-50 years) (p<0.031, 95% CI).

The level of knowledge of CHVs on identification of hypertension

The overall CHV knowledge level on hypertension was poor as assessed by the Bloom’s cut off point. (Table 2).

A strong statistical difference between ever-received training on hypertension and knowledge levels was found with the likelihood of having good knowledge being recorded among those who received training. None of those who had never attended training had good knowledge (p=0.000, 95% CI) (Table 3).

*Statistically significant

All CHVs had completed the basic module training as required. However, only 34.1% had attended a CHV training specifically for hypertension with 65.9% reporting that they had never attended a training on hypertension. Of those trained 40.2% had been trained in facility sessions by MOH staff and the majority (59.8%) had been trained by NGOs (Table 4).

There was a strong association between ever attended hypertension training and hypertension screening with the likelihood of screening being higher among those who were trained (p<0.005, 95% CI) and even higher among those trained by NGOs (p<0.008, 95% CI).

The likelihood of screening was significantly higher among those with knowledge on hypertension: who knew/perceived hypertension to be a serious killer disease (p<0.033, 95% CI); who knew hypertension is not curable but is managed with treatment and lifestyle adjustments (p<0.005, 95% CI) and knew the signs and symptoms (p<0.001, 95% CI). The number of CHVs who used the signs and symptoms as a method to identify hypertensive cases was significantly higher than use of BP machines (p<0.000, 95% CI) (Table 5).

All respondents had some knowledge on the risk factors with 89.7% associating hypertension with stress, 52.7% with old age, 39.3% with obesity, 37.5% with unhealthy diet. Other risk factors mention were alcohol and tobacco, genetics, lack of physical activity, pregnancy and underlying conditions at 26.3%, 16.5%, 12.5%, 7.6% and 4.0% respectively (Figure 1).

Among the respondents, 88.6% knew at least one sign/symptom of hypertension with 19.5% lacking knowledge on signs and symptoms. The majority (97.3%) confirmed that hypertension was a non-communicable disease and was thus not infectious with 85.4% stating that hypertension cannot be cured but only managed by treatment and lifestyle changes. On hypertension case identification methods; 22.1% of the respondents had a blood pressure machine at their disposal and the know-how to use it for screening purposes but 56.6% used only signs and symptoms in their screening and 21.2% referred any sick person since they were not very versed with the signs and symptoms (Figure 2).

Majority of the respondents (99.6%) reported that they had a role in identification of hypertension cases in the community and carried activities such as educating, sensitizing, screening, referral, follow up and defaulter tracing as shown in Figure 3.

Hypertension screening among the public was highly recommended by 64.5% of the respondents with 61.5% confirming that they had checked their blood pressure in the recent 6 months. 92.9% had given health education on hypertension in the recent 6 months; 49.6% in individual one on one sessions and 43.4% in group sessions. 98.7% of the CHVs had referred patients for check up to the nearest facility, 41.2% did follow up on referred patients, newly diagnosed patients and those living with hypertension.

Only 39.8% reported to carrying our defaulter tracing for clients who were no longer adhering to their scheduled appointments. Only 7.1% had not conducted any health education. 64.2% had conducted screening in the past 6 months and 98.7% reported they had referred at least one person to the link facility for further screening or blood pressure check-up (Table 6).

It was also clear from the qualitative data that CHVs are engaged in a number of activities majorly communicable diseases including HIV/AIDs, water and sanitation (WASH), livelihoods and family planning. Non communicable diseases were yet to pick up the pace. In addition, NGOs remain the major drivers of activities in the area.

“They do get trainings but hypertension they have not been trained; mostly they have been trained and are most involved in family planning, antenatal, immunization, TB, HIV, trachoma, nutrition and malezi bora, COVID” (health facility in-charge).

“As the community health volunteers were working within the community, we realized that it is something that has always been coming up. Every time they do a household visitation we would hear someone say when I went to the hospital I was told that my blood pressure is very high, so that is why we said no why don’t we do this rather than waiting for them to go to the facilities why don’t we do the training on the same and empower the CHVs so that at least people would be knowing at the grass route level before they reach the dispensary” (NGO representative).

Multiple logistic regression in our final model found that the odds of identifying hypertensive persons in the community was 3.74 times higher among those who knew the signs and symptoms of hypertension compared to those who did not know as shown in Table 7.

*Statistically significant

DISCUSSION

CHVs’ socio-demographic characteristics

All CHVs in the study were able to read and write and most had some basic formal education. This is in accordance with the Kenya Community Health Policy 2020–2025, which indicates that CHVs should be chosen based on the fact that they reside within the communities they serve, they can speak the local languages, can read and write and understands that their role is unremunerated.¹⁴

Majority were middle age, female, had been CHVs for >4 years and their role was voluntary in nature with exception of a few who on specific instances received a monthly stipend from a donor/NGO. This is also as depicted by Agarwal and Abuya, with CHVs been mostly female with high attrition rates due to the voluntary nature of their role.¹⁵ This was the finding as well with CHVs starting out in large numbers but gradually reducing with time. They were mostly self-employed mainly involved in small scale business and agriculture or doing odd jobs to sustain themselves. Striking a balance between volunteer work and other economic and social demands of life such as child care, household chores, community functions and work makes their work really challenging.^16,17 The vast majority (96%) of CHVs in a study in South Africa were female, with a mean age of 35 years had some secondary schooling and working for 4 years or more. Similar to a study in Nepal who have only female CHVs with a median age 41.3 years, can read and write and 45% of them have completed primary education.¹⁸

In a different study in India the average age of CHVs is between 25 and 34 years with males slightly more than females. The majority are married and able to read and write. Most of them had no working experience concerning health before and had been volunteers for more than 2 years.¹⁷

Level of knowledge of CHVs on identification of hypertension

Overall the CHVs had poor knowledge on hypertension similar to the findings by Neupane et al that CHVs in general have little knowledge on hypertension; the risk factors, causes, signs and symptoms, management and prognosis.¹⁹ CHVs who had ever-received training on hypertension had good knowledge on hypertension as compare to those who had only the basic training. It is important for CHVs to be trained specifically on hypertension to allow them to identify high risk populations through targeted screening. They would then be able to identify patients with elevated blood pressure, link them to care and offer dietary and lifestyle education. In a similar review which demonstrated that CHVs with low levels of formal education can be trained effectively for CVD and risk factor prevention and management.²⁰

A systematic review by Mbuthia et al showed that CHW play diverse roles ranging from preventive, therapeutic and health systems utilization in management of hypertension. Their intervention entailed screening, promotion and monitoring of BP and its control strategies at both at home and community levels.²¹ Trained non-physician health workers can accurately perform cardiovascular risk screening to identify high-risk patients and counsel them on behaviour change.²² Training is vital for those involved in changing other people’s health-related behaviours to convince them to adopt healthy behaviours; share accurate, updated information while completing their tasks effectively and maintaining confidentiality.^23,24

Research conducted on the training and CHV skills indicate that they are inadequately trained suggesting that training to include differentiating grades of hypertension, aiding patients to create self-care plans and patient referral to appropriate health services is crucial.²⁵

CONCLUSION

There was overall poor knowledge level of hypertension among the CHVs. The CHVs are an untapped resource and once empowered can curb the upward trend of hypertension through primary prevention and identification; improve the prognosis of patients through education, linkage and follow up. Based on the conclusions above the study recommends initial and continuous training on hypertension for all CHVs by the Ministry of health and revision of the CHV manual to include hypertension training. Further studies should be conducted to assess the impact of CHVs involvement in hypertension on health outcomes.

ACKNOWLEDGEMENTS

Authors would like to acknowledge the Department of Family Medicine, Community Health and Epidemiology, School of Health Sciences for the opportunity, support and guidance to ensure successful completion of this study. They would also like to thank Kajiado County health officials (Subcounty MOH, Community Health strategy Coordinator, Public Health Office, Facility In-charges, and Community Health Officers) who were very supportive and co-operative; not forgetting all the study participants for their contribution in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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