The role of health extension workers in combating hypertension in Ethiopia

Abstract

Ethiopia faces a triple disease burden of communicable diseases, non-communicable diseases (NCDs), and injuries (1), with hypertension affecting nearly one in four adults (2). Hypertension is the major modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality, accounting for more than half CVD-related  deaths (3). Several community-based studies in Ethiopian cities revealed a high prevalence of hypertension, ranging from 25.1% to 31.9% in the Amhara region (4, 5), 25% to 32.3% in Addis Ababa (6, 7), and 19.7% to 35.2% in southern Ethiopia (8, 9). In rural  areas, nearly one in five adults also suffers from hypertension (2), highlighting its growing public health  significance.

Early detection and management of hypertension are critical for improving the care cascade (10), preventing complications (11), and saving lives (12). However, hypertension remains largely underdiagnosed and poorly managed, making hypertension an iceberg disease. The 2018 Ethiopian NCDI Commission summary report showed that less than 40% of hypertensive patients were diagnosed, 28% of those diagnosed patients received treatment, and only 26% of those treated had their blood pressure adequately controlled (13). A study in Ethiopia also showed that 77% of the population had never undergone blood pressure measurement (14), and 60% were unaware of their hypertension status (5). Another study in the rural districts of northwest Ethiopia also identified 84% of adults with hypertension were unaware of their condition (15), underscoring the urgent need for community-based interventions to improve early detection, treatment, and care.

Even though the Ministry of Health Ethiopia sets a goal in its second health sector transformation plan to increase the proportion of individuals with controlled blood pressure from 26% to 60% by 2025 (16), challenges such as a shortage of health care providers and limited access to healthcare  remain the most significant barriers to providing care at the primary health care level (17). One strategy to bridge the gap between the community and the health system in other contexts is task-sharing, in which specific tasks are shared from more qualified healthcare providers to a less trained cadre, such as community health workers (18). This approach reduces time and transportation costs for patients and brings healthcare services closer to the community. A study in northwest Ethiopia indicated that community-based hypertension screening led by HEWs can improve awareness, treatment, and control of hypertension in the community (19). Health extension workers-led home-based multicomponent interventions, which provided home health education, behavioural counseling, and referral to a nearby health facility, have been shown to enhance linkage to hypertension care and lead to a significant reduction of high blood pressure, with a higher proportion of patients achieving optimal blood pressure control (20).

To implement this strategy, integrating it into primary healthcare services at the village and health post level in rural areas is essential. However, successful implementation of the strategy requires scaling up of hypertension training programs for health extension workers and their supervisors, provision of standardized protocols, provision of adequate blood pressure measuring equipment, and regular supportive supervision.