Village Health Volunteers Research Articles

Validity and reliability of a thoracic kyphotic assessment tool measuring distance of the seventh cervical vertebra from the wall.

Background:In primary healthcare (PHC) service, community residents, village health volunteers (VHVs), and healthcare professionals need to work in partnership to facilitate universal and equitable healthcare services. However, these partnerships may need an appropriate tool helping them to execute an effective health-related activity.Objectives:To investigate the reliability and validity of a simple kyphosis measure using a perpendicular distance from the seventh cervical vertebra (C7) to the wall (C7WD).Methods:Elderly people with different degrees of kyphosis (n = 179) were cross-sectionally investigated for the intra- and interrater reliability of the measurement by a physical therapist (PT), VHV, and caregiver. The validity was assessed in terms of concurrent validity as compared with the Flexicurve, and discriminative validity for functional deterioration in participants with mild, moderate, and severe kyphosis.Results:The method showed excellent reliability among PT, VHV, and caregivers (ICC > 0.90, p < 0.001), and excellent correlation to the data from the Flexicurve. Results of the assessment were greater than a level of minimal detectable change and could clearly discriminate functional deterioration in participants with different severity of kyphosis (p < 0.001).Conclusion:C7WD is valid and reliable, thus it can be used to promote the standardisation of kyphosis measures among PHC members.

Development of a Culturally‐based Care Model for Muslim Mothers in a Rural Community in Southern Thailand

This study applies community-based participatory research to develop a culturally-based care model for Muslim mothers. It was conducted in a rural community in one of the three southernmost provinces in Thailand from May 2013–June 2014. The study involved three groups of participants: 26 Muslim mothers and 17 of their husbands, 14 community and religious leaders, and 14 healthcare providers, including village health volunteers and traditional birth attendants. Qualitative data were collected through focus group discussions, in-depth interviews and participatory observations. Data were analyzed using content analysis. The results indicate that the critical elements of a culturally-based care model include community partnerships and networks, cultural competence in care among healthcare providers, culturally-sensitive maternal care guidelines, trained village maternity care volunteers, and the adoption of a standard continuum of culturally-sensitive care. The culturally-based care model was implemented in harmony with religious practices, meeting cultural needs in order to improve maternal and child health in the rural community.

Knowledge, Attitudes and Practices Regarding Breastfeeding Support among Village Health Volunteers in Nakhon Nayok, Thailand

Background: In Thailand, village health volunteer play an important role for breastfeeding support in the community. Objective: to assess the knowledge, attitudes and breastfeeding support practices provided by village health volunteers. Materials and Methods : The subjects were 72 village health volunteers from three sub-districts; Klong Yai, Buangsan and Chomphol of the Ongkharak district in the Nakhon Nayok province. The study was done during the period from the beginning of March to the end of June, 2014. The questionnaire has been designed to assess the knowledge, attitudes and breastfeeding support practice provided by the village health volunteers. The questionnaires were distributed to the village health volunteers and the data analyzed. The 6-month exclusive breastfeeding rates of each area were determined by home visitation. The data was collected and analyzed by the Chi square and Kruskal-Wallis test. Results: The knowledge score totaled 8 points. The median of the knowledge scores of Klong Yai, Buangsan and Chomphol were 7, 8 and 7 points, respectively. The attitude score totaled 30 points. The median of attitude scores of Klong Yai, Buangsan and Chomphol were 26, 30 and 28 points; percentages of the village health volunteer’s home visits and breastfeeding support were 75.0, 90.5 and 87.5; and the exclusive breastfeeding rates for six months were 33.3%, 39.3% and 37.0%, respectively. Conclusion: The knowledge, attitudes and breastfeeding support practices among village health volunteers in the three sub-districts were high and were consistent with the 6-month, exclusive breastfeeding rates for each area.

Implementation of Health Behavior Education Concerning Liver Flukes among Village Health Volunteers in an Epidemic Area of Thailand.

Liver fluke infection is associated with cholangiocarcinoma; the bile duct cancer found frequently in the northeast and north of Thailand. Prevention and control particularly requires health education and behavior change. This study aimed to improve health behavior among village health volunteers (VHV) regarding liver fluke exposure in an epidemic area. A quasi-experimental study was performed during July 2015 to January 2016 in Sang Kha district of Surin province, Thailand. A total of 67 VHVs underwent a health education program (HEP) and data were collected on knowledge, attitude, and practice (KAP) before and after participation for HEP 3 months with a pre-designed questionnaire. The Students paired T-test was used for comparisons of mean KAP levels before/after the intervention. The results revealed that knowledge (P-value=0.004), attitude (P-value=0.004), and practice level (P-value=0.000) were significantly improved after participation in the HBP. Attitude was significantly associated with knowledge (r=0.266, <0.05), and practice (r=0.348, <0.01) . The implementation of health education among VHVs is feasible and increases their KAP. This improvement should have potential in liver fluke prevention and control in local communities in rural Thailand.

Health Behavior Regarding Liver Flukes among Rural People in Nakhon Ratchasima, Thailand

Opisthorchiasis is a health problem in Thailand particularly in northeast and north regions where have been reported the highest of cholangiocarcinoma. Active surveillance is required, therefore a cross-sectional surveyed was conducted in Nong Bunnak sub-district of Nakhon Ratchasima province, Thailand. A total of 367 participants were selected by multistage sampling from 5 villages located near natural water resources. Participants completed a predesigned questionnaire containing behavior questions regarding liver fluke disease, covering reliability and validity knowledge (Kuder-Richardon-20) = 0.80, attitude and practice (Cronbach's alpha coefficient) = 0.82 and 0.79, respectively. Descriptive statistics included frequencies, percentages, means, and standard deviations. The majority of the participants were female (58.3%), age group between 21-30 years old (42.5%), with primary school education (59.9%), occupation in agriculture (38.1%), and married (80.9%). They had past histories of raw fish consumption (88.3%), stool examination (1.4%), anti-parasite medication used (4.6%). Heads of villages, village health volunteers, television, and village newstations were the main sources for disease information. Participants had a moderate level of behavior regarding liver fluke disease. The mean scored of knowledge regarding liver fluke life cycle, transmission, severities, treatment, prevention and control was 10.9 (SD=0.5), most of them had a moderate level, 95.1%. The mean score for attitude regarding liver fluke prevention and control was 45.7 (SD=9.7), and for practice was 30.6 (SD=10.5). Participants had a moderate level of attitude and practice, 94.5% and 47.7, respectively. This study indicates that health education is required in this community including stool examination for liver fluke as further active surveillance screening.

Evaluation of intensified behaviour change communication strategies in an artemisinin resistance setting.

BackgroundIn Cambodia, behaviour change communication (BCC) represents an integral component of malaria efforts aimed at fighting artemisinin resistant parasites and achieving elimination. The multi-pronged BCC interventions include interpersonal communication through village health volunteers (VHVs) and village malaria workers (VMWs), broadcasting malaria prevention, diagnosis and treatment messages via TV, radio and mobile broadcasting units (MBUs), distributing information education and communication (IEC) materials and introducing mobile malaria workers (MMWs) in endemic villages.MethodsThis was a cross sectional household survey using a stratified multi-stage cluster sampling approach, conducted in December 2012. A stratified multi-stage cluster sampling approach was used; 30 villages were selected (15 in each stratum) and a total of 774 households were interviewed. This survey aimed to assess the potential added effect of ‘intense’ BCC interventions in three Western provinces. Conducted 2 years after start of these efforts, ‘non-intense’ BCC (niBBC) interventions (e.g., radio or TV) were compared to “intense” BCC (iBBC) implemented through a set of interpersonal communication strategies such as VMWs, VHVs, mobile broadcasting units and listener viewer clubs.ResultsIn both groups, the knowledge of the mode of malaria transmission was high (96.9 vs 97.2 %; p = 0.83), as well as of fever as a symptom (91.5 vs 93.5 %; p = 0.38). Knowledge of local risk factors, such as staying in the forest (39.7 vs 30.7 %; p = 0.17) or the farm (7.1 vs 5.1 %; p = 0.40) was low in both groups. Few respondents in either group knew that they must get tested if they suspected malaria (0.3 vs 0.1; p = 0.69). However, iBBC increased the discussions about malaria in the family (51.7 vs 35.8 %; p = 0.002) and reported prompt access to treatment in case of fever (77.1 vs 59.4 %; p < 0.01).ConclusionThe use of iBCC supported positive improvements in both attitudes and behaviours among the population with regard to malaria compared to mass media (niBCC) only. The significantly increase in people seeking treatment for fever in iBCC villages supports Objective Five of the Strategic Plan in the Cambodia Malaria Elimination Action Framework (2016–2020). Therefore, this study provides evidence for the planning and implementation of future BCC interventions to achieve the elimination of artemisinin resistant Plasmodium falciparum malaria.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1276-8) contains supplementary material, which is available to authorized users.

Effectiveness of a Health Educational Program Based on Self-Efficacy and Social Support for Preventing Liver Fluke Infection in Rural People of Surin Province, Thailand.

Opisthorchiasis is a major problem in Thailand particularly in northeast region which also has a high incidence of cholangiocarcinomas. Since health modification is needed, this quasi-experimental study aimed to assess the effectiveness of a health education program based on self-efficacy and social support in Tha Tum district, Surin province, Thailand. A total of 70 participants were purposive selected with a history of opisthorchiasis. Participants were divided into experimental and control groups, each with 35 subjects. The experimental group received a health education program composed of: (1) knowledge improvement, lectured with multimedia, demonstration, brochure, and handbook; (2) group discussion about their health beliefs, sharing their ideas and experience; and (3) social support from village health volunteers (VHV), heads of villages (HV), friends, and members of families, and public health officer (PHO). Follow-up was by PHO/VHV/HV, with provision of certificates and flasg for household that did not eat raw fish. Data were collected by predesigned questionnaires after implementation of the program for 3 months. Comparative data was analyzed by paired simple t-test and independent t-test. The results revealed that the experimental group had mean score of knowledge higher more than before the experiment (mean difference=3.1, t=3.915, 95%CI-3.3, -1.8 p-value=0.001), and the control group (mean difference=2.5, t=4.196, 95%CI=1.4, 3.6, p-value=0.001) with statistical significance. The mean scores of practice were higher than before the experiment (mean difference=4.6, t=4.331, 95%CI-5.3, -3.1, p-value=0.001), and control group (mean difference=4.4, t=6.142, 95%CI=4.2, 7.9, p-value=0.001) . The mean scores of perceived susceptibility and perceived severity of opisthorchiasis, al well as perceived benefits and perceived barriers to prevention of opisthorchiasis, were also higher than before the experiment and in the control group (p-value <0.001). In conclusion, this was a successful health education program for liver fluke avoidance. Therefore, it may useful for further behavior modification in the other epidemic areas.

Factors influencing the intention to leave elderly care among village health volunteers in Mueang district in Nakhon Ratchasima province, Thailand

Factors influencing the intention to leave elderly care among village health volunteers in Mueang district in Nakhon Ratchasima province, Thailand

Population-Based Intervention for Liver Fluke Prevention and Control in Meuang Yang District, Nakhon Ratchasima Province, Thailand.

Opisthorchiasis is still a major health problem in rural communities of Thailand. Infection is associated with cholangiocarcinoma (CCA), which is found frequently in Thailand, particularly in the northeastern. Therefore, this study aimed to evaluate the effectiveness of health intervention in the population at risk for opisthorchiasis and CCA. A quasi-experimental study was conducted in Meuang Yang district, Nakhon Ratchasima province, northeastern Thailand, between June and October 2015. Participants were completed health intervention comprising 4 stations; 1, VDO clip of moving adult worm of liver fluke; 2, poster of life cycle of liver fluke; 3, microscopy with adult and egg liver fluke; and 4, brochure with the knowledge of liver fluke containing infection, signs, symptoms, related disease, diagnosis, treatment, prevention, and control. Pre-and-post-test questionnaires were utilized to collect data from all participants. Students paired t-tests were used to analyze differences between before and after participation in the health intervention. Knowledge (mean difference=-7.48, t=-51.241, 95% CI, -7.77, -7.19, p-value =0.001), attitude (mean difference=-9.07, t=-9.818, 95% CI=-10.9, -7.24, p-value=0.001), and practice (mean difference=-2.04, t=-2.688, 95% CI=-3.55, -0.53, p-value=0.008), changed between before and after time points with statistical significance. Community rules were concluded regarding: (1) cooked cyprinoid fish consumption; (2) stop under cooked cyprinoid fish by household cooker; (3) cooked food consumption; (4) hygienic defecation; (5) corrected knowledge campaign close to each household; (6) organizing a village food safety club; (7) and annual health check including stool examination featuring monitoring by village health volunteers and local public health officers. The results indicates that the present health intervention program was effective and easy to understand, with low cost and taking only a short time. Therefore, this program may useful for further work at community and provincial levels for liver fluke prevention and control.

Exploring Challenges to Primary Occupational Health Care Service for Informal Sector Workers

Informal sector workers are a significant part of the Thai workforce but occupational health service provision for them is under-developed. This multi-method study investigated occupational health policies and service provision in 10 primary health units in four north eastern Thailand provinces. Questionnaires, in-depth interviews and focus group discussions were used to collect data. Descriptive statistics and content analysis were used to analyse quantitative and qualitative data respectively. Results showed limited policy and budget support for such services. Even though service providers’ occupational health knowledge overall was good, only two of the units provided such services. They were notable for very good functional relationships with their local administration organizations, community and worker leadership and village health volunteers, plus strong staff commitment to support workers health in their own communities. We suggest that enhancing primary care services for worker health and safety requires development of stronger policy directives, budget provision and management support.

The Choice of Healthcare Providers for Febrile Children after Introducing Non-professional Health Workers in a Malaria Endemic Area in Papua New Guinea.

Disease burden of malaria in Papua New Guinea (PNG) is the highest in Asia and the Pacific, and prompt access to effective drugs is the key strategy for controlling malaria. Despite the rapid economic growth, primary healthcare services have deteriorated in rural areas; the introduction of non-professional health workers [village health volunteers (VHVs)] is expected to improve antimalarial drug deliveries. Previous studies on PNG suggested that distance from households negatively affected the utilization of health services; however, price effect on healthcare demand decisions has not been explored. Empirical studies on household's affordability as well as accessibility of healthcare services contribute to policy implications, such as efficient introduction of out-of-pocket costs and effective allocation of health facilities. Therefore, we investigate price responsiveness and other determinants of healthcare provider choice for febrile children in a malaria endemic rural area wherein VHVs were introduced. Cross-sectional surveys were conducted using a structured questionnaire distributed in a health center's catchment area of East Sepik Province in the 2011/2012 rainy seasons. Caretakers were interviewed and data on fever episodes of their children in the preceding 2 weeks were collected. Mixed logit model was employed to estimate the determinants of healthcare provider choice. Among 257 fever episodes reported, the main choices of healthcare providers were limited to self-care, VHV, and a health center. Direct cost and walking distance negatively affected the choice of a VHV and the health center. An increase of VHV's direct cost or walking distance did not much affect predicted probability of the health center, but rather that of self-care, while drug availability and illness severity increased the choice probability of a VHV and the health center. The results suggest that the net healthcare demand increases with the introduction of a VHV. Allocations from the government's budget are required to sustain VHV activities because the introduction of a small user fee could impede the utilization of a VHV. A large travel cost related to the choice of the health center suggests that resource allocation is required for the expansion of formal healthcare providers to adequately operate a referral system.

Development of the competency scale for primary care managers in Thailand: Scale development.

BackgroundThe complexity of the primary care system requires a competent manager to achieve high-quality healthcare. The existing literature in the field yields little evidence of the tools to assess the competency of primary care administrators. This study aimed to develop and examine the psychometric properties of the competency scale for primary care managers in Thailand.MethodsThe scale was developed using in-depth interviews and focus group discussions among policy makers, managers, practitioners, village health volunteers, and clients. The specific dimensions were extracted from 35 participants. 123 items were generated from the evidence and qualitative data. Content validity was established through the evaluation of seven experts and the original 123 items were reduced to 84 items. The pilot testing was conducted on a simple random sample of 487 primary care managers. Item analysis, reliability testing, and exploratory factor analysis were applied to establish the scale’s reliability and construct validity.ResultsExploratory factor analysis identified nine dimensions with 48 items using a five-point Likert scale. Each dimension accounted for greater than 58.61 % of the total variance. The scale had strong content validity (Indices = 0.85). Each dimension of Cronbach’s alpha ranged from 0.70 to 0.88.ConclusionsBased on these analyses, this instrument demonstrated sound psychometric properties and therefore is considered an effective tool for assessment of the primary care manager competencies. The results can be used to improve competency requirements of primary care managers, with implications for health service management workforce development.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0388-5) contains supplementary material, which is available to authorized users.

Severe Complicated Malaria in High Risk Areas of Mon State, Myanmar, 2006-2012

Cases of severe complicated malaria in Myanmar had declined during 2006-2012, yet some townships in the southeastern part continued to report poor outcome of malaria patients in spite of applying similar interventions as other high-risk areas. The purpose of this paper was to understand the reasons behind the poor malaria outcome of some townships in Mon State. We described trends and distribution of severe complicated malaria cases in 2006-2012. During 2006-2012, Yae Township contributed one-third to half of all severe complicated malaria cases in Mon State every year. In 2012, more than 25% of confirmed malaria cases were reported from high risk areas, including Beelin, Kyaikhto, Thaton and Yae Townships. Among these townships, Yae and Kyaikhto reported higher proportion of severe complicated malaria cases among under five children and pregnant women in 2012. In addition, fewer number of malaria cases was detected by village health volunteers than basic health staff in these townships, which might be due to inaccessibility to health services. Strengthening surveillance system and community-based malaria control program in Yae and Kyaikhto might reduce severe complicated malaria in these areas.

Knowledge, attitudes and practices regarding cervical cancer screening among village health volunteers.

In the years 2014, coverage rates of cervical cancer screening in Nakornnayok province accounted to 76.5%. This was lower than the government's specified goal of 80%. Community health volunteers are members of a Thai healthcare alliance established to help promoting healthcare service communication and collaboration at the primary level. Such village health volunteers (VHVs) are established in most villages. To assess the knowledge and attitudes of cervical cancer screening among VHVs. The subjects were 128 VHVs from four Nakornnayok sub-districts; namely KlongYai, Chomphol, Buangsan and Suksara, Thailand. The study was conducted from December 2014 to January 2015. The questionnaire was designed to assess the knowledge and attitude of cervical cancer screening provided by the VHVs. In addition, cervical cancer screening coverage rates of each area were collected. The demographic data, scores of knowledge, attitudes, practices and the cervical cancer screening coverage rates were analyzed by one-way ANOVA. The questionnaire reliability was assessed as 0.81. The total knowledge and attitude scores were 10 and 15 points. The mean knowledge scores of KlongYai, Chomphol, Buangsan and Suksara were 6.8, 7.0, 6.5 and 9.0 points, respectively. The VHVs had a high level of overall knowledge about cervical cancer screening. The mean attitude scores were 12.4, 13.2, 13.4 and 13.1 points. VHVs had a positive attitude to the promotion of cervical cancer screening at the overall level. The percentages of VHVs promoting cervical cancer information in respective districts were 72.2, 94.3, 94.9 and 50.0. However, the cervical cancer screening coverage rates were 62.4%, 34.7%, 80.3% and 47.3% respectively. The knowledge, attitudes and percentages of promoting information of cervical cancer screening among VHVs in the four sub-districts were high but did not correlate with the cervical screening coverage rates for each area. VHVs needed to understand socio-cultural beliefs of the women in the target population and design suitable strategies to encourage higher cervical screening coverage.

Developing primary care occupational health services for informal sector workers in Thailand

This study demonstrates action research’s emancipatory traditions in enabling community stakeholders in rural Thai settings to increase self-reliance and collaboration in improving primary care occupational health services. Most of the Thai workforce are informal sector workers outside Thai labor law protections, health and safety regulatory frameworks, and without specific occupational health services to provide for work-related health needs. This project brought together community leader teams, village health volunteers and informal workers themselves to collaboratively develop community services for this underserved group. Significant changes were effected at community team level, with improvements in networking and community nurses’ health care for the workers and in their oversight and supervision of village health volunteers (VHVs) in the community. Most notably, VHVs’ self-confidence improved at providing illness prevention and health promotion support in workers’ homes and work settings congruent with their daily lifestyle and work schedules. Informal workers’ health self-care behaviors improved.

Community Health Workers as Agents of Health Promotion: Analyzing Thailand's Village Health Volunteer Program.

The village health volunteers (VHVs) have been a regular part of Thailand's health system since the 1960s. Despite widespread recognition, little research has been conducted to describe VHV activities, the settings in which VHVs provide help, how the program is administered, and how changing politics and health problems in Thailand have influenced the program. In order to understand the roles and practices of the VHVs, we conducted in-depth semi-structured interviews and focus groups with VHVs, community leaders and members, and public health officials in three semi-urban communities in central Thailand. Using the Social Ecological Framework, we mapped factors that influenced how the VHVs provided support, including governmental oversight, collaboration with public health officials, and community trust. These influences are discussed as "points of consideration," which help to identify the strengths and tensions within the VHV program and best practices in supporting and assessing community health worker efforts.

Effects of edutainment on knowledge and perceptions of Lisu mothers about the immunisation of their children

Objective: This study assessed the immediate effects of edutainment modules on changes in knowledge and perceptions towards the Expanded Programme for Immunisation (EPI) among an under served minority (Lisu) population. Method: An edutainment module was developed on mobile tablets for use by village health volunteers. As the study was conducted among a vulnerable population in a low-resource setting, it was designed as a simple pre–post assessment without a comparison group. Results: Participating Lisu mothers accepted and understood the edutainment module, and the intervention appears to have successfully improved their knowledge and perceptions of EPI. Tests showed a significant immediate improvement in knowledge, and an increasing proportion of participants reported having positive perceptions of the EPI process. The edutainment module may be an effective tool for highlighting the importance of appropriate practices and addressing misconceptions. Conclusion: The edutainment modules were considered user-friendly and attractive health-promotion tools by both health-care providers and villagers. This initiative’s effect on knowledge and perceptions towards child immunisation programmes among this group showed the positive potential of using modern technology when approaching hard-to-reach, under-vaccinated populations.

Maternal instinct semantic factors model innovation: alcohol drinking behaviour modification learning in health volunteer housewives

The purpose is to identify the semantic factors with attention to arouse the maternal instinct of housewives being as health volunteers. The samples of this research are 18 housewives being village health volunteers with high maternal instinct and alcohol drinking behaviour learning in the rural communities, Thailand. By using adaptive control of thought rational (ACT-R) process, based on maternal instinct implemented from the semantic model, maternal instinct semantic factors model innovation is found. It engages with six cognitions; finance, health, family, children, society’s recognition and environment. Importantly, this model illustrates the 13 significant methods of activity designing.

Learning Innovative Maternal Instinct: Activity Designing Semantic Factors of Alcohol Modification in Rural Communities of Thailand

At present, Thailand is confronting a serious problem of alcohol drinking behavior which needs to be solved urgently. This research aimed to identify the semantic factors on alcohol drinking behavior and to use maternal instinct driving for housewives as village health volunteers in rural communities, Thailand. Two methods were implemented as the problematic classification and the semantic factors model among thirty housewives being as village health volunteers. The findings revealed two aspects: health and children’s cognitions had the maximum percentage. Most of them were related to the method of social skills, being a role model in families and communities and the designing activities implemented which led to the prominent caretaking characteristics relating to the life skills. Furthermore, this study can expand the idea and new alternative to the rural communities which might face with the same trouble arising from the alcohol drinking behavior.

Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT study): rationale and design of the study [NCT01978951

BackgroundIn developing countries, accessibility to specialists, and physician to patient contact time is limited. In Thailand, A unique community health service is provided by subdistrict health care officers and Village Health Volunteers (VHVs). If the personnel were trained on proper chronic kidney disease (CKD) care, CKD progression would be delayed.Methods/DesignWe conducted a community-based, cluster randomized controlled trial at Kamphaeng Phet Province, located about 400 kilometers north of Bangkok. Two out of eleven districts of the province were randomly selected. Approximatly 500 stage 3–4 CKD patients from 2 districts were enrolled. Patients in both groups will be treated with standard guidelines. The patients in intervention group were provided the additional treatments by multidisciplinary team in conjunction with community CKD care network (subdistrict health care officers and VHVs) which will provide group counseling during each hospital visit and quarterly home visits to monitor dietary protein and sodium intake, blood pressure measurement and drug compliance. Duration of the study is 2 years. The primary outcome is the difference of rate of eGFR decline. The secondary outcomes are laboratory parameters and incidence of clinical endpoints such as mortality rate and cardiovascular events, end-stage renal disease (ESRD), etc.DiscussionInsights of this study may set forth a new standard of community-based CKD care.Trial registrationNCT01978951.