Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA

Abstract

Introduction: As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation.

Methods: The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time.

Results: Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges.

Conclusions: Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

Keywords: diabetes; hypertension; public health.

Figure 1

Differences among US HealthRise and comparison patients from baseline to endline for systolic blood pressure (A), percentage of hypertension patients meeting disease treatment targets (B), haemoglobin A1c (C) and percentage of diabetes patients meeting disease treatment targets (D). Included us patients are limited to prevalent cases of hypertension or diabetes at baseline with at least two biometric measures. Treatment targets were <140 mm Hg SBP and <90 mm Hg DBP for hypertension, and <8% A1c for diabetes. The effect of HealthRise was quantified with a difference-in-difference analysis; the effect of HealthRise by endline is reported for each site, with statistical significance denoted by *P<0.05, **P<0.01. DBP, diastolic blood pressure; SBP, systolic blood pressure.

Figure 2

Cascade of care for diabetes (A) and hypertension (B) based on patient interviews at facilities located in HealthRise implementation and comparison areas in Shimla, India and in South Africa sites. Included patients are limited to prevalent cases of hypertension or diabetes with biometric measures corresponding with prevalent conditions. Treatment targets were <140 mm Hg SBP and <90 mm Hg DBP for hypertension, and <8% A1c for diabetes. Statistical significance was determined by Welch's t-test, and is denoted by *P<0.05 and **P<0.01. DBP, diastolic blood pressure; SBP, systolic blood pressure.