Impact of Bridging Income Generation with Group Integrated Care (BIGPIC) on Hypertension and Diabetes in Rural Western Kenya

Abstract

Background: Rural settings in Sub-Saharan Africa (SSA) consistently report low participation in non-communicable disease (NCD) treatment programs and poor outcomes.

Objective: The objective of this study is to assess the impact of the implementation of a patient-centered rural NCD care delivery model called Bridging Income Generation through grouP Integrated Care (BIGPIC).

Design: The study prospectively tracked participation and health outcomes for participants in a screening event and compared linkage frequencies to a historical comparison group.

Participants: Rural Kenyan participants attending a voluntary NCD screening event were included within the BIGPIC model of care.

Interventions: The BIGPIC model utilizes a contextualized care delivery model designed to address the unique barriers faced in rural settings. This model emphasizes the following steps: (1) find patients in the community, (2) link to peer/microfinance groups, (3) integrate education, (4) treat in the community, (5) enhance economic sustainability and (6) generate demand for care through incentives.

Main measures: The primary outcome is the linkage frequency, which measures the percentage of patients who return for care after screening positive for either hypertension and/or diabetes. Secondary measures include retention frequencies defined as the percentage of patients remaining engaged in care throughout the 9-month follow-up period and changes in systolic (SBP) and diastolic blood pressure (DBP) and blood sugar over 12 months.

Key results: Of the 879 individuals who were screened, 14.2 % were confirmed to have hypertension, while only 1.4 % were confirmed to have diabetes. The implementation of a comprehensive microfinance-linked, community-based, group care model resulted in 72.4 % of screen-positive participants returning for subsequent care, of which 70.3 % remained in care through the 12 months of the evaluation period. Patients remaining in care demonstrated a statistically significant mean decline of 21 mmHg in SBP [95 % CI (13.9 to 28.4), P < 0.01] and 5 mmHg drop in DBP [95 % CI (1.4 to 7.6), P < 0.01].

Conclusions: The implementation of a contextualized care delivery model built around the unique needs of rural SSA participants led to statistically significant improvements in linkage to care and blood pressure reduction.

Keywords: agriculture; diabetes; hypertension; incentives; microfinance; portable care; rural; sub-Saharan Africa.

Fig. 1

BIGPIC model of care

Fig. 2

Flow chart of participant progression through the linkage and retention cascade. M = male participants, F = female participants, RBS = random blood sugar, HTN = hypertension, DM = diabetes mellitus, HTN Screen+ defined as SBP ≥150 mmHg or DBP ≥90 mmHg, DM Screen+ defined RBS ≥7 mmol/l (126 mg/dl). ^*Fifteen individuals refused blood sugar screening; ^†8 patients were HTN screen+ and DM screen– on confirmation; ^‡32 patients were screened for DM via point-of-care HbA1c testing when available with 9 becoming positive; ^§8 patients did not have an elevated blood pressure upon returning to the groups and were excluded from further care assessments; ^‖7 new female patients with known disease joined the groups over the course of the intervention but were not included within this figure as they were not identified via screening

Fig. 3

a Men. b Women. DM = diabetes mellitus, HTN = hypertension. a and b Linkage frequencies and prevalence of hypertension and diabetes for men and women for hypertension and diabetes in the BIGPIC model and traditional facility-based model. *P < 0.05 via two-sided paired t test compared to baseline screening result

Fig. 4

Blood pressure trends throughout the care cascade. SBP = systolic blood pressure in mmHg, DBP = diastolic blood pressure in mmHg. *P < 0.05 via two-sided paired t test compared to baseline screening result