1 Flor LS, et al. BMJ Global Health 2020;5: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 Flor, 1 Shelley Wilson, 1 Paurvi Bhatt, 2 Miranda Bryant, 1 Aaron Burnett, 3,4 Joseph N Camarda, 1 Vasudha Chakravarthy, 5 Chandrashekhar Chandrashekhar, 6 Nayanjeet Chaudhury, 2 Christiane Cimini, 7 Danny V Colombara, 8 Haricharan Conjeevaram Narayanan, 9 Matheus Lopes Cortes, 10 Krycia Cowling, 1 Jessica Daly, 2 Herbert Duber, 1,11 Vinayakan Ellath Kavinkare, 6 Patrick Endlich, 7 Nancy Fullman, 1 Rose Gabert, 12 Thomas Glucksman, 1 Katie Panhorst Harris, 1 Maria Angela Loguercio Bouskela, 13 Junia Maia, 14 Charlie Mandile, 15 Milena S Marcolino, 14 Susan Marshall, 4 Claire R McNellan, 16 Danielle Souto de Medeiros, 10 Sóstenes Mistro, 10 Vasudha Mulakaluri, 1 Jennifer Murphree, 4 Marie Ng, 17 J A Q Oliveira, 14 Márcio Galvão Oliveira, 10 Bryan Phillips, 18 Vânia Pinto, 7 Tara Polzer Ngwato, 19 Tia Radant, 4 Marissa B Reitsma, 1 Antonio Luiz Ribeiro, 14 Gregory Roth, 1 Davi Rumel, 13,20 Gaurav Sethi, 6 Daniela Arruda Soares, 10 Tsega Tamene, 21 Blake Thomson, 22 Harsha Tomar, 6 Mark Thomaz Ugliara Barone, 2,23 Sameer Valsangkar, 24 Alexandra Wollum, 25 Emmanuela Gakidou 1 Original research To cite: Flor LS, Wilson S, Bhatt P, et al. 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. BMJ Global Health 2020;5:e001959. doi:10.1136/ bmjgh-2019-001959 Handling editor Valery Ridde ► Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ bmjgh-2019-001959). Received 3 September 2019 Revised 25 March 2020 Accepted 15 April 2020 For numbered affliations see end of article. Correspondence to Dr Emmanuela Gakidou; gakidou@uw.edu © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. 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 fndings 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 signifcant 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 signifcantly higher relative to comparison group patients. Qualitative analysis identifed 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. INTRODUCTION Hypertension and diabetes account for increasingly more early death and illness worldwide, 1–3 particularly in places where rapid sociodemographic changes have on November 28, 2021 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2019-001959 on 4 June 2020. Downloaded from