Driving NCD screening at scale: outcomes of a digital, CHW-led hypertension surveillance program in rural Rwanda

Hypertension is the leading risk factor for cardiovascular diseases, with the greatest burden in low- and middle-income countries where access to care and infrastructure for prevention and management is limited. In Rwanda, community health workers (CHWs) have long played a critical role in improving access to health services. In 2023, the Turambe ('Live Longer') program integrated digitally enabled hypertension screening into Rwanda's community health program across three districts, equipping CHWs with blood pressure monitors and mobile devices loaded with the mUzima mobile application. This study aimed to assess the CHW-led screening process, evaluate the screening cascade from CHW identification to diagnosis confirmation, and determine the factors associated with hypertension diagnosis.

Data was extracted and socio-demographic and clinical characteristics were analyzed using frequencies and percentages. Chi-square tests assessed associations between diagnosis and patient characteristics, and logistic regression identified factors associated with hypertension diagnosis following referral.

The program supported the screening of 499,475 community members representing 55.9% of the population aged 15 years and above. The majority of those screened were female (54.5%) and most were aged 35-44 years (29.6%). Of those screened, 63,291 (12.7%) individuals were found to have elevated blood pressure and were referred to health facilities. Among these referrals, 4,537 (7.2%) completed the referral by visiting a health facility and 2,873 (63.3%) of them were confirmed to have hypertension; 2,218 (48.9%) were newly diagnosed and 655 (14.4%) with a prior diagnosis. Among those who completed referral to health facilities, the proportion of those confirmed to have hypertension increased with age, reaching 71.0% among individuals aged above 65 years. Multivariable analysis showed that increasing age was strongly associated with a hypertension diagnosis, with those aged ≥ 65 years having 3.91 times higher odds (aOR: 3.91; 95% CI: 2.06-7.43) compared to those aged 25-34 years. Male sex was associated with 15% reduced odds (aOR: 0.85; 95% CI: 0.75-0.98) compared to females.

This digital community-based hypertension screening program achieved substantial population coverage and a relatively high diagnostic yield among those who completed referral, demonstrating the potential of leveraging CHW networks and mobile technology for large-scale NCD detection and monitoring. However, low referral-to-care linkage limits inference on CHW diagnostic accuracy at the population level. Strengthened referral systems and further research into barriers to linkage are needed to translate community screening into timely diagnosis and management.