title: Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa.
abstract: BACKGROUND
  We have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management.
  
  
  METHODS
  Patient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained.
  
  
  RESULTS
  Thirty-seven percent (96/263) of those referred attended follow-up: 36 of 52 (69%) were urgent and 60 of 211 (28.4%) were non-urgent referrals. A diagnosis of hypertension (HTN) was made in 69% of urgent referrals and 37% of non-urgent referrals with treatment instituted in all cases. Reasons for non-attendance included limited self-perception of risk, associated costs, health system obstacles, and lack of trust in CHWs to conduct CVD risk assessments and to refer community members into the health system.
  
  
  CONCLUSIONS
  The existing barriers to referral in the health care systems negatively impact the gains to be had through screening by training CHWs in the use of a simple risk assessment tool. The new diagnoses of HTN and commencement on treatment in those that attended referrals underscores the value of having persons at the highest risk identified in the community setting and referred to a clinic for further evaluation and treatment.
authors: Chronic Disease Initiative for Africa, Cape Town, South Africa.|Division of Endocrinology and Diabetes, Department of Medicine, University of Cape Town, Cape Town, South Africa.
authors: Naomi S
authors: NS
authors: Levitt
authors: Chronic Disease Initiative for Africa, Cape Town, South Africa.|School of Public Health, University of the Western Cape, Cape Town, South Africa.
authors: Thandi
authors: T
authors: Puoane
authors: Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Mexico.
authors: Catalina A
authors: CA
authors: Denman
authors: Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA.
authors: Shafika
authors: S
authors: Abrahams-Gessel
authors: Chronic Disease Initiative for Africa, Cape Town, South Africa; samsurka@gmail.com.
authors: Sam
authors: S
authors: Surka
authors: Institute of Nutrition of Central America and Panama (INCAP), Ciudad de Guatemala, Guatemala.
authors: Carlos
authors: C
authors: Mendoza
authors: School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.|Chronic Non-Communicable Disease Unit, International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors: Masuma
authors: M
authors: Khanam
authors: Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA.
authors: Sartaj
authors: S
authors: Alam
authors: Brigham & Women's Hospital, Harvard School of Public Health, Harvard University, Cambridge, MA, USA.
authors: Thomas A
authors: TA
authors: Gaziano
mesh_terms: D001459:Bangladesh; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000628:therapy*; D003150:Community Health Workers / Q000458:organization & administration*; D005260:Female; D006166:Guatemala; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000628:therapy; D008297:Male; D008800:Mexico; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011203:Poverty / Q000706:statistics & numerical data; D015397:Program Evaluation; D012017:Referral and Consultation / Q000458:organization & administration* / Q000706:statistics & numerical data*; D018570:Risk Assessment / Q000379:methods; D013019:South Africa
keywords: Bangladesh; Guatemala; Mexico; South Africa; cardiovascular risk assessment; community health workers; low-middle income countries; referral outcomes