Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project.

BACKGROUND: The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs). METHODS: This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach. RESULTS: 46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs. CONCLUSION: In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India.

OBJECTIVE: To inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed. METHODS: A household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care. RESULTS: 5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care. CONCLUSIONS: Overall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review.

INTRODUCTION: Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries. METHODS: We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper. RESULTS: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated). CONCLUSION: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.