. 2020 Jun;5(6):e001959.

doi: 10.1136/bmjgh-2019-001959.

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

Luisa S Flor¹, Shelley Wilson¹, Paurvi Bhatt², Miranda Bryant¹, Aaron Burnett^{3

4}, Joseph N Camarda¹, Vasudha Chakravarthy⁵, Chandrashekhar Chandrashekhar⁶, Nayanjeet Chaudhury², Christiane Cimini⁷, Danny V Colombara⁸, Haricharan Conjeevaram Narayanan⁹, Matheus Lopes Cortes¹⁰, Krycia Cowling¹, Jessica Daly², Herbert Duber^{1

11}, Vinayakan Ellath Kavinkare⁶, Patrick Endlich⁷, Nancy Fullman¹, Rose Gabert¹², Thomas Glucksman¹, Katie Panhorst Harris¹, Maria Angela Loguercio Bouskela¹³, Junia Maia¹⁴, Charlie Mandile¹⁵, Milena S Marcolino¹⁴, Susan Marshall⁴, Claire R McNellan¹⁶, Danielle Souto de Medeiros¹⁰, Sóstenes Mistro¹⁰, Vasudha Mulakaluri¹, Jennifer Murphree⁴, Marie Ng¹⁷, J A Q Oliveira¹⁴, Márcio Galvão Oliveira¹⁰, Bryan Phillips¹⁸, Vânia Pinto⁷, Tara Polzer Ngwato¹⁹, Tia Radant⁴, Marissa B Reitsma¹, Antonio Luiz Ribeiro¹⁴, Gregory Roth¹, Davi Rumel^{13

20}, Gaurav Sethi⁶, Daniela Arruda Soares¹⁰, Tsega Tamene²¹, Blake Thomson²², Harsha Tomar⁶, Mark Thomaz Ugliara Barone^{2

23}, Sameer Valsangkar²⁴, Alexandra Wollum²⁵, Emmanuela Gakidou²⁶

Affiliations

¹ Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA.
² Medtronic Foundation, Minneapolis, Minnesota, USA.
³ Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
⁴ Regions Hospital, Saint Paul, Minnesota, USA.
⁵ Development Solutions, New Delhi, Delhi, India.
⁶ MAMTA Health Institute for Mother and Child, New Delhi, Delhi, India.
⁷ School of Medicine, Federal University of Jequitinhonha and Mucuri Valleys, Teofilo Otoni, MG, Brazil.
⁸ Public Health Seattle and King County, Seattle, Washington, USA.
⁹ ABT Associates Inc, Cambridge, Massachusetts, USA.
¹⁰ Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil.
¹¹ Department of Emergency Medicine, University of Washington, Seattle, Washington, USA.
¹² School of Medicine, University of Washington, Seattle, Washington, USA.
¹³ Research and Teaching Institute, Hospital Sirio-Libanes, Sao Paulo, São Paulo, Brazil.
¹⁴ Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
¹⁵ HealthFinders Collaborative, Northfield, Minnesota, USA.
¹⁶ National CASA/GAL Association for Children, Seattle, Washington, USA.
¹⁷ IBM Watson Health, San Jose, California, USA.
¹⁸ Health Policy and Management, University of California Los Angeles, Los Angeles, California, USA.
¹⁹ Social Surveys Africa, Johannesburg, Gauteng, South Africa.
²⁰ School of Medicine, Municipal University Sao Caetano do Sul, Sao Caetano do Sul, Sao Paulo, Brazil.
²¹ Pillsbury United Communities, Minneapolis, Minnesota, USA.
²² Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK.
²³ Global Health Leaders, Public Health Institute, Sao Paulo, Sao Paulo, Brazil.
²⁴ Research and Monitoring Systems, The Catholic Health Association of India, Hyderabad, Telangana, India.
²⁵ Ibis Reproductive Health, Cambridge, Massachusetts, USA.
²⁶ Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA gakidou@uw.edu.

PMID: 32503887
PMCID: PMC7279660
DOI: 10.1136/bmjgh-2019-001959

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

Luisa S Flor et al. BMJ Glob Health. 2020 Jun.

. 2020 Jun;5(6):e001959.

doi: 10.1136/bmjgh-2019-001959.

Authors

Affiliations

¹ Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA.
² Medtronic Foundation, Minneapolis, Minnesota, USA.
³ Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
⁴ Regions Hospital, Saint Paul, Minnesota, USA.
⁵ Development Solutions, New Delhi, Delhi, India.
⁶ MAMTA Health Institute for Mother and Child, New Delhi, Delhi, India.
⁷ School of Medicine, Federal University of Jequitinhonha and Mucuri Valleys, Teofilo Otoni, MG, Brazil.
⁸ Public Health Seattle and King County, Seattle, Washington, USA.
⁹ ABT Associates Inc, Cambridge, Massachusetts, USA.
¹⁰ Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil.
¹¹ Department of Emergency Medicine, University of Washington, Seattle, Washington, USA.
¹² School of Medicine, University of Washington, Seattle, Washington, USA.
¹³ Research and Teaching Institute, Hospital Sirio-Libanes, Sao Paulo, São Paulo, Brazil.
¹⁴ Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
¹⁵ HealthFinders Collaborative, Northfield, Minnesota, USA.
¹⁶ National CASA/GAL Association for Children, Seattle, Washington, USA.
¹⁷ IBM Watson Health, San Jose, California, USA.
¹⁸ Health Policy and Management, University of California Los Angeles, Los Angeles, California, USA.
¹⁹ Social Surveys Africa, Johannesburg, Gauteng, South Africa.
²⁰ School of Medicine, Municipal University Sao Caetano do Sul, Sao Caetano do Sul, Sao Paulo, Brazil.
²¹ Pillsbury United Communities, Minneapolis, Minnesota, USA.
²² Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK.
²³ Global Health Leaders, Public Health Institute, Sao Paulo, Sao Paulo, Brazil.
²⁴ Research and Monitoring Systems, The Catholic Health Association of India, Hyderabad, Telangana, India.
²⁵ Ibis Reproductive Health, Cambridge, Massachusetts, USA.
²⁶ Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA gakidou@uw.edu.

PMID: 32503887
PMCID: PMC7279660
DOI: 10.1136/bmjgh-2019-001959

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.

PubMed Disclaimer

Conflict of interest statement

Competing interests: PB, NC, JD and MTUB are employees of the Medtronic Foundation. AB, CCh, CCi, MLC, VEK, PE, MALB, JMa, CM, MSM, SMa, DSdM, SMi, JMu, HCN, JAQO, MGO, VP, TR, ALR, DR, GS, DAS, TT, HT and SV are recipients of HealthRise grants from the Medtronic Foundation to implement HealthRise interventions. LSF, SW, MB, JNC, DVC, KC, HCD, NF, RG, TG, KPH, CRM, VM, MN, BP, MBR, GR, BT, AW, VC, TPN, and EG are recipients of funding from grants from the Medtronic Foundation to evaluate HealthRise interventions.

Figures

**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.

See this image and copyright information in PMC

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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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

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References

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MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Research Materials