Community Action for Health programme
Community involvement to detect people with hypertension in Kyrgyzstan
Von Tolkun Jamangulova, Aigul Ilyazova, Rahat Aideraliev, Baktygul Toktorbaeva and Gulmira Aitmurzaeva & Tobias Schüth
The Community Action for Health programme in Kyrgyzstan contributes to improvement of care of hypertensive patients through its countrywide network of Village Health Committees. They screened over 400,000 people during hypertension action weeks in December 2012 and identified over 22,000 people with high blood pressure who were not aware of a hypertensive disease. This programme is part of an overall health sector strategy on hypertension that involves other components as well.
Kyrgyzstan is one of the top ten countries in regard to coronary heart disease and it has the highest stroke-related mortality of all countries. The main reason is a high prevalence of hypertension (31%) and the fact that only 2.4% of those with hypertension have a controlled blood pressure through treatment. (Jakab et al) The Community Action for Health Project, triggered by the people’s priority studies in all regions, initiated an action research with Village Health Committees (VHCs) in 2006 using automatic blood pressure cuffs. In three regions VHCs measured blood pressure of over 140,000 adults. It raised awareness among the population on the one hand and on the other helped to start the development of the health sector strategy on hypertension; for this action research found an average prevalence of over 40% of hypertension among adults. While the selection of people in this action research obviously was not representative this high figure raised alarm and triggered the planning of a representative countrywide study in 2007 which yielded an average of 30.98% among people 18 years and older. (Jakab et al)
At the same time we began to experiment together with VHCs which role they could play in improving control of hypertension. We started with a very broad approach where VHCs had the task of screening, raising awareness about generic drugs, increasing compliance, controlling and documenting blood pressure, etc. We reported about an early stage of that attempt in an earlier issue of this journal (Bulletin MMS, Nr. 106, 2007, 34-8). However, these all-in-one-approaches failed. They were too complex. On the one hand people did not like to come together in groups and VHCs spent more time collecting them for a meeting then holding a meeting. And on the other, going regularly from house to house was a far too demaninding task for a high prevalence disease like hypertension.
The representative study had looked at all aspects of hypertension control and found that awareness of hypertension was very low. Only 27% of people who had hypertension were aware of it. As screening was the strength of the VHCs it was agreed with other partners in the emerging national hypertension strategy that VHCs should focus on raising awareness about hypertension through screening. Other partners would focus on quality improvement of primary and secondary care of hypertension and of its complications.
Countrywide screening for hypertension
In order to focus efforts of VHCs and attention of the population we decided to concentrate the screening in a hypertension action week. The project produced a one-minute TV spot on the danger of hypertension which ends with the announcement of the “Week of hypertension” with numerous occasions to get free measurements of one’s blood pressure. In addition, national and local newspapers run stories about the action week.
Each VHC was equipped with one semi-automatic, upper-arm blood pressure cuff (UA-705) (semi-automatic means the pumping is done by hand, saving battery power, so that one battery lasts for about a thousand measurements). They were trained how to properly measure blood pressure, document the results if there is an elevated blood pressure and send these people with elevated blood pressure to the nearest primary care provider.
These people receive a leaflet where their measurement is noted and the most important short information about hypertension is given. In addition, it says (and volunteers are trained to tell people) that with a systolic measurement of over 180 mmHg they should seek care within the next 2-3 days and with any heart ache they should go immediately to the next hospital.
They also hand a brochure with extensive information about hypertension and other CVD risk factors to those with elevated blood pressure. Finally, they hand the sheet with the names and addresses of these people to the primary care providers of the area.
As VHCs exist only in villages (where about 60% of the Kyrgyz population lives) actions in towns, district centres and the two major cities of the country are added in the following way. Primary care providers, on order of the Ministry of Health, provide measurement points at especially populous points during the week as well as offer corners only for blood pressure measurement in their premises for anybody who comes in.
Table 1 gives the results of the hypertension weeks in 2011 and 2012. The figure of 403, 717 screened people in 2012 represents about 12% of the official adult population of Kyrgyzstan. Given, that a large part of the adult population actually lives abroad as migrant workers, estimated to be up to a million people, the proportion of the adult population living in Kyrgyzstan captured by the screening probably was around 17% in the 2012 action week.
Table 1: results of hypertension action weeks in December 2011 and 2012
|2011 ||2012 |
|No. people screened||311,342||403,717|
No. people newly discovered with high blood pressure
We believe with this action week we have found the appropriate form for involving VHCs and other community groups in the improvement of hypertension control in Kyrgyzstan. In addition, emerging urban community groups are being engaged in similar, and successful ways. The response from both, VHCs and population is very positive. VHCs like the “action” part of it, it’s not talking, it’s doing something. They feel very appreciated by the community. A limiting factor is the fact that project funds only permitted to purchase one blood pressure cuff per VHC so that this cuff has to move from volunteer to volunteer, limiting severly the amount of people who can be covered for screening during the action week but also during the whole year. Other donors have now mentioned interest to purchase additional cuffs. Multiple cuffs per VHC could increase informal screening throughout the year when people approach VHC members for having their blood pressure measured. It could possibly also have implications for compliance, as people taking drugs might come more often to know that their blood pressure is not under control.
We still do not have numbers of registered hypertensive patients from primary care providers before and after the first and second action week. We can therefore not yet prove the effect of these weeks on the registered number of hypertensive patients in primary care. These numbers unfortunately have been notoriously unreliable for various reasons and efforts to untangle the issues have so far been unsuccessful.
We need to think how to increase screening numbers in urban areas, but this hopefully will succeed with the emerging community involvement in these areas.
In order to bring the action week in tune with the WHO Heart Day we shifted the action week for 2013 to September.
Community based organisations can successfully be engaged in screening efforts for detecting hypertensive patients using semi-automatic cuffs. If a broad network of community based organisations exists then a countrywide action week (or weeks) on hypertension, accompanied by broad media coverage, can be an effective tool at raising awareness and for screening on hypertension in a low awareness environment.
Village Health Committees (VHCs) are community based organisations whose members volunteer time for efforts to improve health and well-being in their villages. There are now 1700 VHCs in Kyrgyzstan, in almost 90% of all villages; they form their own NGOs and a national association. The Ministry of Health and donors in the health sector closely cooperate with them on a number of health promotion issues. The partnership between VHCs and Ministry of Health and health promotion donors is called the Community Action for Health (CAH) programme. For further information please consult: www.cah.kg/en
The Community Action for Health programme is mainly supported by the Community Action for Health (CAH) Project, financed by Swiss Agency for Development and Cooperation (SDC), currently co-financed by Liechtenstein Development Service (LED), implemented by the Swiss Red Cross. Formerly named Kyrgyz-Swiss-Swedish Health Project, when co-financed by Sida.
*Tolkun Jamangulova is deputy coordinator of the Commununity Action for Health Project. She is a public health physician by education and finishes currently her master in public health from the London School of Public Health and Hygiene.
Aigul Ilyazova is a physician. She has been in charge of the Community Action for Health Programme in the Republican Centre for Health Promotion during 5 years and is currently engaged in a program for urban health promotion. Rahat Aideraliev is a physician by background. He is responsible for the Commununity Action forHealth Programme within the Commununity Action for Health Project.
Baktygul Toktorbaeva is a paedagogue with long expereience in health promotion and currently in charge of the Community Action for Health Programme in the Republican Centre for Health Promotion.
Gulmira Aitmurzaeva is the director of the Republican Centre for Health Promotion. A cardiologist by background she has been interested in health promotion from the beginning of her career.
Dr. med. Tobias Schueth is a public health physician and holds a PhD in social and behavioural sciences. He is the coordinator of the Community Action for Health Project. He has been engaged in community development and health promotion in South and Central Asia for the last 19 years.
Contact with authors: firstname.lastname@example.org
- Jakab, M., Lundeen, E., Akkazieva, B., (2007) Health System Effectiveness in Hypertension Control in Kyrgyzstan, Policy Research Paper 44, Center for Health System Development, WHO-Europe, Swiss Red Cross, http://www.hpac.kg/images/pdf/PRP44.E.pdf (accessed 13 May 2013)