Role of female community health volunteers in the prevention and early detection of chronic kidney disease in Nepal

Chronic kidney disease (CKD) is a complex, gradually advancing, and irreversible disease characterized by loss of renal function and progression to end-stage kidney disease (ESKD), cardiovascular complications, and premature death1,2. CKD is defined as “kidney damage or glomerular filtration rate <60 mL/min/1.73 m2 for 3 months or more, irrespective of the cause.” The Kidney Disease: Improving Global Outcomes classified CKD into 5 stages on the basis of severity, with stage 5 being the most severe2. A meta-analysis showed that the global CKD prevalence in stages 1–5 is 13.4% and 10.6% in stages 3–53. The overall prevalence of CKD in the general population in South Asia is 14%4. A nationwide population-based cross-sectional study conducted in Nepal showed that the overall prevalence of CKD in the country is 6%5. Despite the high prevalence of the disease, only 6% of the general population and 10% of the high-risk population are aware of their CKD status6. Clinical symptoms are not prominent in the early stage of CKD, this may be the one reason for low awareness of CKD in the country1. A nationally representative study has shown that older age [adjusted odds ratio (aOR): 2.6, 95% CI: 1.9–3.6), hypertension (aOR: 2.4, 95% CI: 2.0–3.0) and diabetes mellitus (aOR: 3.2, 95% CI: 2.5–4.1) are the common prevalent risk factors of CKD in Nepal5. Early identification of patients with CKD is desirable because interventions can then be implemented to reduce the progression to ESKD and cardiovascular events2. To combat CKD in Nepal, more focus should be given to prevention along with early detection and treatment. Diabetes and high blood pressure are important modifiable risk factors that initiate and allow CKD to progress to late stages2. Appropriate control of deranged blood glucose levels and high blood pressure will help in both the prevention and progression of CKD to ESKD. The government of Nepal started the Female Community Health Volunteer (FCHV) program in Nepal in 1988, and about 50,000 FCHVs are actively working in Nepal currently7. At its inception, FCHVs played a major role in the improvement of accessibility and uptake of family planning services. Gradually, their roles were expanded to include other programs8. Currently, FCHVs have a major role in promoting safe motherhood, child health, and family planning7. FCHVs are behind the improvement in child and maternal health through programs, like routine immunization, oral rehydration solution distribution, integrated management of childhood illnesses, distribution of family planning devices like pills and condoms, support and care to postpartum women and newborns in case of home deliveries, encouraging for postpartum visits to institutions, counseling on breastfeeding and danger signs of mother and child, postnatal care, and promoting nutritional services. The FCHV program has a crucial role in improving maternal and infant health and achieving millennium development goals in Nepal9,10. Besides safe motherhood, child health, and family planning, FCHVs are willing to contribute to the prevention and control of rising noncommunicable diseases (NCDs) too11. A systematic analysis of the global burden of disease study showed that globally, deaths due to communicable, maternal, neonatal, and nutritional (CMNN), causes continue to decline, whereas deaths from NCDs are increasing. Unlike 3 decades ago, NCDs are now the leading causes of death globally, and their burden is rising. More than ever, deaths from diabetes-related CKD have risen12. About 30 years ago, CMNN diseases were the leading cause of death, accounting for ~2 in every 3 deaths in Nepal. In the same period, NCDs were responsible for nearly one-third of the total deaths (29.91%, 95% UI: 26.0%–34.12%). By 2015, the situation had reversed, NCDs had become the major cause of deaths (63.21%, 95% UI: 59.25%–66.75%), with CMNN diseases causing less than a third of the total deaths (26.8%, 95% UI: 23.30%–31.18%). By 2040, the burden of NCDs is estimated to rise further, causing close to 4 in 5 deaths in the country13. As deaths due to NCDs are increasing, developing countries like Nepal should also focus on all levels of prevention of NCDs. We believe that FCHVs could be employed for this purpose in Nepal, as they play an excellent role in improving maternal health, child health, and family planning. Early identification of patients with CKD is desirable because simple urine tests can identify patients at an early stage, and the availability of treatments can prevent complications and progression to kidney failure2,14. Urinary analysis tests done in general population-based settings to identify CKD in the early stages are not cost-effective. Detection of proteinuria in our patients with CKD in the early stages is cost-effective when selectively directed towards high-risk groups, such as older people, and patients with existing risk factors, such as diabetes and hypertension15,16. FCHVs could be trained for early detection of urine protein among high-risk groups like old age, persons with hypertension, diabetes, and referral to hospitals for further evaluation and management. The FCHV program has been successful because it works at the household level17. Our firsthand observation reveals that health-seeking behavior is low among many Nepalese people until they are symptomatic, especially until they experience pain. Hence, FCHVs can play a vital role in screening high-risk groups for urine protein at the household level, which can facilitate early identification and intervention of CKD. Besides, these FCHVs can disseminate information about the “Bipanna Nagarik Ausadhi Program”, which offers free hemodialysis, free peritoneal dialysis, and financial support for a kidney transplantation to impoverished Nepalese citizens7. Recently, the finance minister announced that he would make provisions for a monthly medical stipend for individuals undergoing kidney transplantation and dialysis18. As our FCHVs are willing to contribute to the prevention and control of noncommunicable diseases, they can be trained to prevent and control the modifiable risk factors of CKD11. Prevention and control of diabetes, hypertension, and obesity not only prevent the initiation and progression of CKD but also many other systemic comorbidities. With interactive training sessions for a few days, FCHVs can be taught to evaluate the common risk factors of CKD, such as screening for hypertension through blood pressure measurement, monitoring of diabetes control through home-based screening of blood glucose level, and measuring body mass index19,20. FCHVs can refer newly diagnosed hypertension and high blood glucose level to nearby health centers. Moreover, frequent visits by FCHVs will improve medication adherence through their frequent reminder. Existing FCHV programs in Nepal have proved to be highly successful in reducing blood pressure in individuals with hypertension, preventing age-related increases in blood pressure in adults without hypertension in the general population, and achieving a significant reduction in fasting blood glucose levels among adults with diabetes19,20. An open-label, cluster-randomized trial by Neupane and colleagues showed that a straightforward lifestyle intervention led by FCHVs combined with monitoring of blood pressure is effective for reducing blood pressure in individuals with hypertension. In addition, it helps mitigate age-related increases in blood pressure in adults without hypertension in the general population of Nepal19. Another study performed Neupane’s cluster-randomized trial’s retrospective cost-effectiveness and budget impact analysis, which showed that the program was highly cost-effective compared with the WHO thresholds for cost-effectiveness for Nepal21. In another cluster-randomized clinical trial that included 244 adults diagnosed with type 2 diabetes, the intervention administered by FCHVs resulted in a notable decrease in fasting blood glucose level (−27.90 mg/dL) compared with the control group over 12 months. This finding suggests that interventions delivered by FCHVs could improve diabetes control among adults with type 2 diabetes in a low-resource setting like Nepal20. Although the community-based management of hypertension in Nepal is shown to be cost-effective, the cost-effectiveness of FCHV intervention in reducing blood sugar and urine protein tests is doubtful. As a volunteer, there is no provision for salary for FCHVs. The only incentives in monetary terms they will get before their farewell are dress allowance and travel allowance7. FCHVs are not satisfied with the number of incentives and that becomes a major challenge for already overburdened volunteers9,17. Allocating FCHVs extra work without suitable incentives can lead to the early failure of the “Prevention and Early Detection of CKD” program. Moreover, the majority of FCHVs have limited medical knowledge, which hampers data collection, interpretation, and reporting, leading to challenges in monitoring and evaluation9,22. Furthermore, FCHVs have reported a shortage of medicines and contraceptives in health care facilities occasionally, and sometimes they have to pay for these supplies by themselves. Similar challenges with the shortage of screening tolls may also be present. In addition, certain communities may not be receptive to the advice given by FCHVs, especially those who believe in traditional healers17. The lack of professional respect for FCHVs by some highly trained health care workers is another challenge that undermines their professional legitimacy and may lead to demotivation22. Finally, the task of performing urine protein detection tests can be challenging for FCHVs with colorblindness as it involves comparing colors. Firstly, it is recommended that a study be conducted to evaluate the cost-effectiveness of urine protein detection tests among high-risk populations in our setting. Similarly, the cost-effectiveness of Gyawali et al20 study, which focuses on the intervention of FCHVs in reducing blood glucose among adults with diabetes, should be evaluated. We recommend that FCHVs be designated as leaders in health education efforts, as a healthy lifestyle can aid in the prevention of CKD. Furthermore, Nepalese citizens over 40 years will be eligible for annual free screening for NCDs at local health institutes18. We highly suggest that this free screening should be done at the household level with increased frequencies. With a few days of training, FCHVs can screen for urinary, blood glucose levels, and blood pressure. Such activities will aid in the prevention and early detection of CKD at the community level. During the screening, FCHVs can also check the medication adherence of the patients on treatment. The government of Nepal can hike up the number of FCHVs with the provision of proper allowances and supplies to ensure the success of the program. In conclusion, the high prevalence of CKD in Nepal underscores the necessity of implementing prevention and early detection strategies. One promising approach involves utilizing FCHVs to promote healthy lifestyles, conduct CKD screening through urine protein tests, and encourage the management of modifiable risk factors, such as diabetes and hypertension. However, engaging and empowering a large number of FCHVs to take on these additional responsibilities presents a significant challenge. Furthermore, providing extra incentives for their involvement may be financially burdensome for developing countries like Nepal. Despite these obstacles, a cost-effectiveness analysis should be conducted to assess the potential of this program, and health policymakers in Nepal should devise a comprehensive plan for effectively mobilizing FCHVs to address the mounting burden of CKD. Ethical approval None. Sources of funding None. Author contributions K.M.P.: conceptualization of the idea, data curation, and manuscript writing and preparation. P.L. and U.M.: manuscript writing and reviewing. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Kailash Mani Pokhrel.