This study demonstrates the feasibility of VHTs conducting HTN screening and referrals. The VHT screening exceeded the target by 48%, showing their potential to extensively conduct HTN screening with a wider community reach. The VHTs also effectively screened participants, with a high level of agreement between their BP values and those of qualified health workers. This aligns with a study from Ethiopia, where trained CHWs detected high BPs as effectively as trained health workers.[12] This success could be attributed to increased knowledge following the training (59.2 ± 3.4% Vs. 80.6 ± 2.4%, t = 5.59, p < 0.001), translating into field practice, consistent with other studies that have also trained CHWs.[12, 17] In addition, studies conducted in rural areas of Uganda have shown that VHTs can effectively screen and manage hypertensive patients.[17–19] Therefore, with proper training, VHTs can significantly help screen for HTN in Uganda and similar low-resource settings.[19, 22]
This study revealed that 22.4% of those screened had HTN, similar to the HTN rates (22%) reported in a rural area of Kisoro in Western Uganda.[18] Another study in rural Islands in Uganda found a higher proportion of HTN (28%). The studies indicate a high prevalence of HTN in Ugandan communities that needs urgent attention. The differences in HTN prevalence could be explained by the differences in urbanization and lifestyle adaptations that drive the risks of HTN, as reflected in the 2014 national survey.[23] In addition, this study revealed that more than half (54.2%) of the participants had never had blood pressure measurements in their lifetime, and 41.9% of those found with HTN had also never screened and were unaware. Similar studies in Western Uganda (84%) and rural Islands of Uganda (89%) reported higher prevalences of unawareness.[12, 18] These studies were conducted in more rural areas than our study, which could explain the differences in unawareness rates. People in rural areas often live far from health facilities and have poor health-seeking behaviors.[17] However, health facilities in rural areas are also not well equipped to screen and manage HTN.[7] Efforts to reduce HTN need reinforcement across individual factors and the entire health system in Uganda. Empowering and motivating CHWs to screen and provide education on HTN could improve awareness, as they have extensive reach to the last mile in their communities.[24]
Furthermore, efforts to address HTN should be informed by understanding the demographic and behavioral risk factors associated with the condition. In our study, we found that increasing age, male gender, alcohol use, and a family history of HTN are significant factors linked to HTN. A similar study utilizing VHTs for HTN screening reported older age as a factor associated with having high blood pressure. [17] Therefore, tailored community education programs could effectively target older adults and men at higher risk, providing them with better information on the risks and management of HTN.
Despite successful screening, there were challenges in referring individuals with HTN for further assessment and treatment. Only 23.8% of patients found with HTN accepted referral. This is similar to a large community study conducted in Uganda and Kenya, where of the 92% of participants who screened hypertensive, only 42% were subsequently linked to care.[25] Upon following up with the participants in this study, reasons noted for referral decline and failure to reach the health facility included lack of transport and financial constraints, feeling well (asymptomatic), concerns about poor service delivery at the health center (particularly long waiting times and drug unavailability), and doubts about the competence of VHTs in screening blood pressure. Other Uganda studies further confirm community members' low confidence in VHTs regarding their competence in screening and managing NCDs such as HTN.[22, 26] Similar concerns have been reported in other countries in sub-Saharan Africa, such as South Africa and Swaziland, affecting the performance and acceptability of CHW services despite their credibility and effectiveness.[27–29] Further empowering VHTs to build greater community trust in fighting NCDs is important to improving VHT-led HTN screening and referral activities in Uganda and other LMICs.
Strengths and Limitations
This study's strength lies in the comprehensive training of VHTs and well-calibrated automatic blood pressure machines used in the screening. The VHTs also screened many individuals, providing reliable findings and relatively generalizable data for similar settings in Uganda. However, the study has some limitations. The absence of a control group limits the ability to attribute observed changes directly to the intervention, as external factors could have influenced the outcomes. The study was conducted over a relatively short period (four months), which may not capture long-term adherence to VHT-led referral advice. These factors should be considered when interpreting the findings and planning future research. In addition, we only followed up with patients referred to Bugembe Health Center IV. The lack of strategies to include participants who visited private facilities limited the comprehensive evaluation of post-referral assessments. The reliability of blood pressure measurements between VHTs and health workers could have been better assessed if both parties screened all patients, not just those referred with high blood pressure. Although logistical issues prevented this, the current analysis offers valuable insights into the reliability of VHT measurements. Future studies in Uganda could build on these findings.