Linkage to primary care public health facilities for cardiovascular disease prevention : A community based cohort study from urban slums in India

Objectives Hypertension and diabetes mellitus are key risk factors for Cardiovascular diseases. Pharmacotherapy and life-style modifications are necessary. Once screened, individuals need to be linked to primary health-care system for initiation and maintenance of therapies, to achieve optimal blood pressure and glycemic control. In the current study we evaluate predictors and barriers for non-linkage to primary-care public health facilities for CVD risk reduction. Methods We conducted a community-based longitudinal study in 16 urban slum clusters in central India. Community health workers (CHWs) in each urban slum cluster screened all adults aged 30 years or more for hypertension and diabetes, and those positively screened were sought to be linked to Urban Primary Health Centres (UPHCs). We performed univariate and multivariate analysis to identify independent predictors for non-linkage to primary-care providers. We conducted in-depth assessment in 10% of all positively screened, to identify key barriers that potentially prevented linkages to primary-care facilities. Results Of 6174 individuals screened 1451(23.5%; 95%-CI 22.5-24.6) were identified as high-risk, and required linkage to primary-care facilities for pharmacotherapy. Out of these, 544(37.5%) were linked to public primary-care facilities, 259(17.9%) to private providers, 142(9.8%) were treatment interrupters, and 506(34.9%) didn’t get linked to any provider. On multivariate analysis, as compared to those linked to public primary care facilities, those who were not linked had age less than 45 years (OR 2.2 (95%CI 1.3-3.5)); were in lowest wealth quintile (OR 1.8 (95%CI 1.1-2.9); resided beyond a kilometre from UPHC (OR 1.7 (95%CI 1.2-2.4); and were engaged late by CHWs (OR 2.6 95%CI (1.8-3.7)). Despite having comparable knowledge level, denial about their risk-status and lack of family support were key barriers in this group. Conclusions This study highlights importance of early engagement through CHWs after positive screening, strategies to engage with younger individuals who may be in denial about their risk-status. Article summary - Strengths and limitations of this study This is community based longitudinal study implemented through community health workers (CHWs). It is “real-world” implementation as per national non-communicable disease control program in India (known as NPCDCS), which envisages population based screening through community health workers (CHWs), and linkages to public health facilities. This study highlights that within urban slum, being young, in a low socioeconomic position, distance from health facility are important determinants of linkage to public health facility. Early engagement by CHWs enhances likelihood of linkage. This study was limited to urban slum clusters from a single city, however we believe that health-infrastructure is broadly similar in such settings elsewhere.