Linking older Ugandans to hypertension and diabetes care

Joseph Mugisha is a Ugandan epidemiologist and is the Head of the General Population Cohort with Medical Research Council (MRC)/Uganda Virus Research Institute (UVRI) and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit. He is also a Postdoctoral Fellow of the Training Health Researchers into Vocational Excellence (THRiVE) Fellowship, one of the eleven Developing Excellence, Leadership and Training in Science in Africa (DELTAS Africa) programmes. DELTAS Africa funds Africa-based scientists to amplify the development of world-class research and scientific leadership on the continent while strengthening African institutions. It is implemented through the Alliance for Accelerating Excellence in Science in Africa (AESA) platform, a funding, agenda-setting, programme management initiative of the African Academy of Sciences (AAS), the African Union Development Agency (AUDA-NEPAD), founding and funding global partners, and through a resolution of the summit of African Union Heads of Governments. DELTAS Africa is supported by Wellcome and the United Kingdom Foreign, Commonwealth and Development Office (FCDO, formerly DFID).

Summary

Chronic non-communicable diseases (NCDs) disproportionally affect older people. Village health teams can be effectively trained to control and prevent NCDs by identifying and linking older people with hypertension and diabetes to care.

Background

Uganda, like most countries, is experiencing an increasing population of older people (those aged 60 and above). Compared to other adults, these people face extreme levels of poverty and are at higher risk of poor physical and mental health. Evidence suggests that chronic non-communicable diseases (NCDs) disproportionally affect older people, and that most old people with NCDs have multiple comorbidities. Most with chronic conditions are not aware that they have them and are not being treated. Health education talks alone are ineffective: evidence suggests that a big proportion of old people with chronic NCDs are still not linked to care. Intervention for NCDs in Africa has focused on strengthening health systems to cope more effectively with the increasing burden of NCDs. There is a need for interventions to link the elderly directly to health care facilities for early management.

Village Health Teams (VHTs) are community health workers introduced by the Uganda Ministry of Health to promote health services including referral of people to health care facilities. VHTs are selected by their communities and work as volunteers albeit receiving a minimal facilitation payment provided by government. Responsibilities of VHTs include mobilising communities to take health action, promoting health and preventive measures, treating simple illnesses at home, checking for danger signs at home, referring sick people to health workers and keeping up-to-date village records.

Advantages of involving VHTs to control and prevent chronic conditions in Uganda include their existing integration in the primary health care system with prior experience in implementing select interventions especially in maternal and child health; VHTs enable task shifting in an already understaffed Ugandan health care system and serve as valuable screeners of older adults with chronic conditions and VHTs are a cost effective way to provide health care.  

The use of smartphones to link patients to care and management is increasing. In Uganda, community health workers can use smartphones to register pregnant women at home and relay gestational age-specific SMS messages to them to reduce morbidity and mortality of women who give birth at home.  Smartphones can also be used to help rehabilitate people who have suffered from stroke.

Study description

A preliminary study of VHTs from Kalungu district in rural southwest Uganda established their experience in dealing with older people with hypertension and diabetes mellitus; their experience with smartphones and whether they are willing to be trained to use a smartphone-guided intervention to link older Ugandans with hypertension and diabetes to care.

Between October 2017 and December 2018, we selected a random sample of 20 VHTs from Bukulula Sub County in rural southwestern Uganda.

Interviews were audio-recorded and field notes made. Transcription and translation (for interviews in Luganda) were undertaken by two social science research assistants within two days after the interviews. Researchers reviewed scripts to check for completeness. After the first two interviews, the interview guide was slightly revised to introduce a question on the challenges faced by VHTs while doing their work. Researchers established a coding framework that was applied to all the data, using a matrix with the main themes that arose including demographic characteristics, definitions for purposes of the research, VHT recruitment and period of service, training and activities of the VHTs, experiences in dealing with older people and with linking people to necessary care, knowledge of common chronic diseases, experiences, ownership and perception of smartphones and willingness to use a smartphone-guided intervention. Data were analysed by thematic content analysis.  

VHTs underwent three-day non-residential basic training and some of the topics covered included aging in Uganda, common diseases associated with aging, identification of simple symptoms and signs of hypertension and diabetes, complications of hypertension and diabetes, the referral process from villages to formal health care facilities and how to complete referral forms.

VHTs were also taught how to draw blood and test for blood sugar using a portable glucometer (ONETOUCH SelectSimple blood glucose meter), and how to measure blood pressure using a digital blood pressure machine (OMRON, Automatic Upper Arm Blood Pressure Monitor M7 Intelli IT (HEM-7322T-E).) Practical exercises for measuring blood sugar and blood pressure were conducted. A qualified nurse, working with MRC/UVRI and LSHTM Uganda Research Unit and the district VHT coordinator (a qualified clinical officer) conducted the hands-on sessions, which were supervised by the PI (JOM), a qualified medical doctor with a long time experience managing older people with chronic conditions in Uganda. Each VHT drew blood from a colleague and tested the blood sugar level. Likewise, each took at least three blood pressure measurements from a colleague and recorded them.

Scores were assigned to each step of the practical exercises: one point for each step executed correctly. Tests for blood pressure measurement and blood sugar measurement were scored separately. For blood sugar measurement, steps included:

1. Preparing the person for the blood draw
2. Wearing gloves correctly
3. Inserting the strip in the glucometer correctly
4. Identifying and cleaning the finger for the blood draw
5. Drawing blood
6. Reading the glucometer correctly
7. Removing the gloves correctly
8. Proper disposal of sharps and other materials
9. Recording glucometer reading accurately
10. Final advice given to the client in accordance with the level of the blood sugar

For blood pressure measurement, points were awarded for:

1. Preparing the person for blood pressure measurement
2. Using the right blood pressure cuff
3. Measuring the blood pressure
4. Recording blood pressure accurately
5. Advice given to client after blood pressure measurement

A score of at least 80% was considered passing.

Study outcomes

Regarding experiences of VHTs working on older people, the study found out that none of them had experience in treating old people with health problems. This is because when the concept of VHTs was introduced in Kalungu district, they were selected and trained to only deal with children between two and five years who had fever and diarrhoea. However, some VHTs assist in supervising people with chronic conditions like tuberculosis (TB) who are referred to them from formal health care facilities for supervision in taking their medications properly.

For the study objective on assessing VHTs knowledge of chronic conditions, it was discovered that all of them were able to define and mention some of the chronic conditions that were common in their communities. Some of the diseases mentioned included hypertension, diabetes, asthma, HIV/AIDS, diseases of the heart, cancer, persistent cough, stomach ulcers, swelling of the whole body, and high cholesterol.

Regarding their experiences with smart phones, some had smart phones and most were familiar with additional smart phones functions such as taking and exchanging photos, chatting on WhatsApp, twitter, and making communication quicker. All of them were interested in the use of the phones and said they would accept using a smartphone-guided intervention to link older people with NCDs to care.

After study completion, a manuscript was published in AAS Open Research (https://doi.org/10.12688/aasopenres.13049.1). Using study data, a grant application to develop and test the smart phone-guided intervention to link older adults with chronic conditions to care is in preparation. All data has been deposited with the LSHTM data compass (https://doi.org/10.17037/DATA.00001699)

Lessons

VHTs and community health workers in general have been left behind in the prevention and control of NCDs. This study indicates that VHTs are willing and can be effectively trained to control and prevent NCDs by identifying and linking older people with hypertension and diabetes to care.