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Table 3 Kisoro VHW program’s response to the system requirements for community management of chronic disease

From: Family health sheets: a vital instrument for village health workers providing comprehensive healthcare

Requirement for community based, CHW management of chronic disease

Kisoro VHW program responses

Early (preclinical) diagnosis through comprehensive community Screening

Biannual health Census by dedicated trained staff partnering with VHWs

Diagnostic verification by a health professional

Supervisor verification during home visit of screen-positive people

Follow-up of “borderline” cases below treatment thresholds

VHWs in the field, targeting specified clinical indices periodically and keeping track of patients via Family Health Sheets

Community-based treatment: easy-access for high-risk patients who would not seek care otherwise, with referral/consultation when needed;

Chronic Disease in the Community (CDCom) program, ongoing 10 years; 39 monthly outdoor community clinic sites; referral pathways to district hospital established

Geriatric treatment for common disabilities of aging: diagnosis and management

Elders program: VHW-mediated screening of sight, hearing, mobility, depression, and appropriate community-based therapies

Malnutrition treatment: food supplementation when needed

Community nutrition program: VHW identification, supervisor verification, village-level food supplementation

Use of health census and ongoing documentation of family observations to improve community health

Family Health Sheets and FHS binder

Maintenance of VHW interest and investment over time: incentivize health actions financially, educationally, socially; prevent burnout

Stipends for health activities undertaken, regular meetings around educational topics, bi-monthly field supervision, community respect for achievements in providing health care