Strengthening primary care systems for prevention & control of cardiovascular diseases in Kenya: feasibility study of health kiosks in markets

Non-communicable diseases (NCDs), including cardiovascular diseases (CVD) and type 2 diabetes, are a major challenge to healthcare. NCD-risk factors include raised blood pressure, diabetes, high cholesterol, smoking, and obesity. In Kenya, CVDs are the leading cause of NCD-mortality. Rising CVD-related mortality is related to ageing populations, urbanization, lifestyle changes such as unhealthy diets, lack of exercise, alcohol consumption, smoking and other environmental and social factors. The effect of these factors on health are worse in poor communities and health systems face growing challenges meeting the needs of those affected. Lack of access to health systems (e.g. primary care centres) is problematic in low-middle income countries such as Kenya. Sustainable, community-based initiatives that interface with health systems may offer a unique route to address lack of access. There is a scarcity of these initiatives, particularly in resource poor areas. Community markets are social establishments with untapped potential to promote public health messages and interventions for CVD. The Kenya Medical Research Institute (KEMRI), in collaboration with University of Nairobi, Moi University, Strathmore University and King's College London, will investigate whether Health Kiosks, manned by community health workers (CHWs) and nurses, in community markets can support prevention and management of CVD.
The study will take place in Vihiga County, which faces a shortage of physicians and nurses and the challenge of providing high quality care. We will work with the county's local market traders to identify local champions to promote use of the kiosks. CHWs will be trained to conduct simple tests to assess CVD risk such as measuring blood pressure, weight, encourage people to take medication as prescribed, follow prescribed treatments and attend clinic appointments, and support behaviour change for more active lifestyle such as providing exercise plans. CHWs will be supervised by nurses who will provide feedback, probable 'diagnosis' and make referrals. Market champions will promote kiosk engagement in the community.
We will also gather information on health outcomes, which together with the other findings from this study will help us plan future large-scale studies of the effectiveness of nurse and CHW-led Health Kiosks in local markets. We will conduct real-time evaluation to look at how the intervention works and for whom. If successful, the research will support guidance on how the Kenyan health system and communities can work together to combat NCDs. Transformation of the current health systems in this way will reach more vulnerable people than through the current model by providing accessible and regular health advice and support in the local community. If successful it will result in significant social and economic benefits by reducing health care costs and preventing morbidity and premature death from CVD.

This is a feasibility study to explore whether the creation of public health kiosks in community markets, managed by nurses and community health workers (CHWs), can improve the prevention and control of cardiovascular diseases (CVD) in Vihiga county, a deprived rural setting in Kenya with rising CVD rates and poor health care access. The integration of health promotion and relevant practice into culturally-rich social spaces of markets is predicted to increase engagement, promote sustained behaviour change and function as a bridge to the health care system.
Task-shifting strategies and collaborative community-based interventions are often advocated to reduce health inequalities and the NCD burden, but little evidence is available in LMICs. In collaboration with Vihiga County Health Department and WHO, the CHWs will be trained to provide health promotion and conduct screening using tablets programmed to identify those required for follow-up, while the nurse will provide feedback, probable 'diagnosis' and make referrals. Market champions will promote kiosk engagement in the community. Detailed developmental work will take place in 4 health centre-market clusters (2 intervention, 2 comparator). Evaluation will focus on understanding how sociocultural and organisational contexts of markets and health systems influence implementation. Based on the principles of realist evaluation and MRC guidelines for the evaluation of complex interventions, we will use a mixed methods approach including: 1) concept mapping with stakeholders to develop a model of factors that could affect implementation; 2) interviews with traders, market users, nurses and CHWs to understand barriers and facilitators; 3) simple mobile technologies to obtain live evaluation data on likely reach, effectiveness, adoption, implementation and maintenance. If the results are favourable we will hold policy workshops to discuss likely translational impact, and conduct wider testing of the intervention.

We plan to evaluate the integration of community markets and their environments (market traders) into the care pathway to prevent and control non-communicable diseases (NCDs). Universal health coverage is crucial to reach vulnerable populations. Situating kiosks in local markets will embed the intervention in the community, providing accessible and visible connections between communities and the health system. Given the wide reach of community markets, this innovative model of service delivery will increase health literacy and accelerate access to care among vulnerable communities, thus reducing social inequalities in NCD.

If the findings are favourable, then they could have societal benefit by improving the health and well being of the entire population. It will reduce care costs and prevent morbidity, mortality and reduced productivity. This approach will have significant impact on the organisational culture and effectiveness of primary health care. It helps to bring health care and information closer to people, and is embedded in the cultural and social context. The intervention will strengthen collaboration between health services and communities, increase awareness of community needs among health workers, and strengthen the health workforce through the use of task shifting and skills mix strategies among health practitioners, nurses, community health workers (CHWs).

The study will also benefit nurses and CHWs through strengthening their capacity to tackle CVDs in their communities and the acquisition of IT skills by recording and transferring data efficiently and securely, and thereafter will support their own personal and professional development. Early intervention and prevention in primary care should reduce the need for treatment of CVDs and complications in secondary and tertiary services. Training of primary care workers and CHWs will continue after the close of the project, supported by the County Government. A network of practitioners and CHWs will act as mentors and trainers for other community-based interventions and findings will be relevant to other health domains e.g. reproductive health) across the life course.