Treating hypertension in rural South Africa: strengthening community-based outreach services for integrated chronic care

Background

Extensive research in the Agincourt HDSS research site in the rural North-East of South Africa has demonstrated high rates of hypertension, a high prevalence of survivors of stroke and very low rates of successful detection and management of hypertension. At the time the project started, the South African Department of Health was revitalising primary health care through the introduction of community health worker outreach teams, which in the Agincourt area had responsibility for supporting the management of chronic disease. However, the workload for these teams was enormous and there were no plans for extra resources to support the work of the clinical team of nurses based in the local primary care clinics.

Aims

The aim of the trial was to reduce population levels of uncontrolled hypertension, especially in those individuals at greatest risk, by supporting and strengthening the management of hypertension in primary care clinics.

Project plan

• Compare the effectiveness of clinic based lay health workers to ‘usual care’, in improving the management of hypertension (including access to care, adherence to treatment, and management), in rural South Africa.

• Conduct a realist evaluation to understand the patient, intervention, implementation, health system and community barriers and facilitators that explain patient outcomes in the intervention and ‘usual care’ clinics.

• Contribute specific recommendations to strengthen policy and practice in similar rural settings of South and Southern Africa.

The trial involved randomising clinics to receive support from lay health workers (LHW). Four clinics were randomised to receive the LHWs, and four were control clinics. The outcome of the trial was assessed by two population-based cross sectional surveys; one at baseline and one at the end of the intervention. The surveys collected data on cardiovascular risk factors, use of clinics, and current medication, as well as measuring blood pressure. The hypothesis was that the LHWs would improve clinic functioning, thus encouraging more use of the clinics and more consistent use of medication for high blood pressure. Alongside the trial there was a system linking the clinic records and the existing Health and Demographic Survey System database, enabling the team to collect patient specific data on clinic use. There was an extensive process evaluation involving interviews with nurses, clinic managers and supervisors, LHWs, and our implementation manager. The team also carried out observations in the clinics, conducting patient exit interviews and interviewing three purposely selected samples of clinic users.

Impact

The project showed that clinic based lay health workers can be an important resource for managing increasing patient demand in primary healthcare, however the project team noted that local managers needed to be better trained in order to manage these additional staff.

Publications and output

GACD have published an end-of-programme report, providing a comprehensive summary of the programme and outcomes.

Principal investigators

Team members

Funding organisations

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