Maseru

This research aims to evaluate community-based, lay-led chronic disease screening and care interventions in rural Lesotho, focusing on diseases like hypertension, diabetes, cardiovascular risk factors, and HIV. The study establishes a prospective platform managed by Chronic Care Village Health Workers CC-VHWs, supported by eHealth tools, to monitor and refer patients within rural communities. It addresses the growing burden of non-communicable diseases in low-resource settings where access barriers exist, building on lessons from HIV care programs. The CC-VHWs receive training and essential tools such as blood pressure machines, scales, glucometers, and urine dipsticks to conduct screening, diagnosis, and referral services. They visit participants regularly to assess signs and symptoms, provide counseling, and record data using a tablet-based application. The village health workers are supervised by nurses through meetings, visits, and remote communication. This cohort study also serves as a platform for future trials evaluating specific chronic disease interventions. Participants are regularly screened and monitored by CC-VHWs who collect data on disease indicators and risk factors at baseline and follow-up visits approximately every six months. Outcomes measured include screening coverage, disease awareness, linkage to care, engagement in care, disease control, and clinically relevant events up to three years after enrollment. Continuous monitoring, data collection, and referral services occur under the guidance of local health centers, ensuring ongoing participant support throughout the study period.