ENSURING CONTINUUM OF CARE TO ADDRESS THE HIDDEN EPIDEMIC OF HIGH BLOOD PRESSURE IN RURAL EASTERN NEPAL

Objective: Kidney, Hypertension, Diabetes and Cardiovascular diseases (KHDC) program offers community-based services for early detection and management of diabetes, hypertension, cardiovascular and chronic kidney diseases to prevent complications since 2003. It has been involved in building capacity of primary care providers and offers on site and remote mentoring. This abstract intends to explore factors influencing blood pressure control across different follow up visits during the early stages of program implementation in three wards of a remote municipality of Eastern Nepal (Province Koshi). Design and method: Female Community health Volunteers (FCHVs) performed high-risk screening in communities by measuring capillary blood sugar (BS), blood pressure (BP), waist circumference and assessing behavioral and medical/family history, with subsequent management at healthcare centers (HCCs). Individuals with confirmed diagnosis at HCCs were then followed up by FCHVs for treatment adherence and referred to HCCs for assessment of BP and BS control. Optimal BP target was defined as systolic/diastolic BP below 140/90 mmHg measured during follow up visits. Results: During April-July 2024, 51 FCHV screened 3251 individuals for NCDs risk. 71.5% (n=2325) of screened individuals identified as high risk were consulted at five primary HCCs by 14 trained healthcare workers. 510 of 2325 individuals consulted at HCCs were diagnosed with hypertension. On subsequent three follow ups, 291, 54, and 11 diagnosed cases presented at the HCC. Among the diagnosed cases presenting at three follow ups, BP control was achieved among 95 (32.6%), 18 (33%) and 3 cases (27%), respectively. 42.9% (n=219) individuals were lost to follow up. Predictors for uncontrolled BP during follow up visits included age [OR: 0.98 (0.96-0.99)], baseline SBP/DBP above 180/110 mmHg [OR: 7.4 (4.0-13.7)], concurrent diagnosis of other NCDs [OR: 0.4 (0.3-0.7)]. Conclusions: While undetected cases of hypertension can be identified through high-risk screening by efficient mobilization of available human resource; employing an integrated strategy is essential to ensure treatment adherence. Exploring factors which influence favorable treatment outcomes at primary care setting should remain a priority. KHDC offers an innovative approach to ensure continuum of care from the community to the HCC.