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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
  1. Luisa S Flor1,
  2. Shelley Wilson1,
  3. Paurvi Bhatt2,
  4. Miranda Bryant1,
  5. Aaron Burnett3,4,
  6. Joseph N Camarda1,
  7. Vasudha Chakravarthy5,
  8. Chandrashekhar Chandrashekhar6,
  9. Nayanjeet Chaudhury2,
  10. Christiane Cimini7,
  11. Danny V Colombara8,
  12. Haricharan Conjeevaram Narayanan9,
  13. Matheus Lopes Cortes10,
  14. Krycia Cowling1,
  15. Jessica Daly2,
  16. Herbert Duber1,11,
  17. Vinayakan Ellath Kavinkare6,
  18. Patrick Endlich7,
  19. Nancy Fullman1,
  20. Rose Gabert12,
  21. Thomas Glucksman1,
  22. Katie Panhorst Harris1,
  23. Maria Angela Loguercio Bouskela13,
  24. Junia Maia14,
  25. Charlie Mandile15,
  26. Milena S Marcolino14,
  27. Susan Marshall4,
  28. Claire R McNellan16,
  29. Danielle Souto de Medeiros10,
  30. Sóstenes Mistro10,
  31. Vasudha Mulakaluri1,
  32. Jennifer Murphree4,
  33. Marie Ng17,
  34. J A Q Oliveira14,
  35. Márcio Galvão Oliveira10,
  36. Bryan Phillips18,
  37. Vânia Pinto7,
  38. Tara Polzer Ngwato19,
  39. Tia Radant4,
  40. Marissa B Reitsma1,
  41. Antonio Luiz Ribeiro14,
  42. Gregory Roth1,
  43. Davi Rumel13,20,
  44. Gaurav Sethi6,
  45. Daniela Arruda Soares10,
  46. Tsega Tamene21,
  47. Blake Thomson22,
  48. Harsha Tomar6,
  49. Mark Thomaz Ugliara Barone2,23,
  50. Sameer Valsangkar24,
  51. Alexandra Wollum25,
  52. Emmanuela Gakidou1
  1. 1Department of Health Metrics Sciences, University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
  2. 2Medtronic Foundation, Minneapolis, Minnesota, USA
  3. 3Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
  4. 4Regions Hospital, Saint Paul, Minnesota, USA
  5. 5Development Solutions, New Delhi, Delhi, India
  6. 6MAMTA Health Institute for Mother and Child, New Delhi, Delhi, India
  7. 7School of Medicine, Federal University of Jequitinhonha and Mucuri Valleys, Teofilo Otoni, MG, Brazil
  8. 8Public Health Seattle and King County, Seattle, Washington, USA
  9. 9ABT Associates Inc, Cambridge, Massachusetts, USA
  10. 10Anisio Teixeira Campus, Federal University of Bahia Multidisciplinary Institute in Health, Vitoria da Conquista, Bahia, Brazil
  11. 11Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
  12. 12School of Medicine, University of Washington, Seattle, Washington, USA
  13. 13Research and Teaching Institute, Hospital Sirio-Libanes, Sao Paulo, São Paulo, Brazil
  14. 14Telehealth Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
  15. 15HealthFinders Collaborative, Northfield, Minnesota, USA
  16. 16National CASA/GAL Association for Children, Seattle, Washington, USA
  17. 17IBM Watson Health, San Jose, California, USA
  18. 18Health Policy and Management, University of California Los Angeles, Los Angeles, California, USA
  19. 19Social Surveys Africa, Johannesburg, Gauteng, South Africa
  20. 20School of Medicine, Municipal University Sao Caetano do Sul, Sao Caetano do Sul, Sao Paulo, Brazil
  21. 21Pillsbury United Communities, Minneapolis, Minnesota, USA
  22. 22Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
  23. 23Global Health Leaders, Public Health Institute, Sao Paulo, Sao Paulo, Brazil
  24. 24Research and Monitoring Systems, The Catholic Health Association of India, Hyderabad, Telangana, India
  25. 25Ibis Reproductive Health, Cambridge, Massachusetts, USA
  1. Correspondence to Dr Emmanuela Gakidou; gakidou{at}


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.

  • diabetes
  • hypertension
  • public health

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  • Handling editor Valery Ridde

  • Contributors LSF, KC, NF and EG contributed to the analysis of the data, produced tables and figures, and wrote the initial draft of the manuscript. LSF, NF and EG finalised the manuscript based on reviewer feedback. LSF, SW, MB, JNC, DVC, KC, HCD, NF, RG, TG, KPH, CRM, VM, MN, BP, MBR, GR, BT, AW and EG developed survey instruments, collected data, verified and managed data, contributed to analyses or some combination of the aforementioned contributions. EG conceptualised and managed the evaluation. PB, NC, JD and MTUB provided guidance on the HealthRise project as a whole. AB, CCh, CCi, HCN, MLC, VEK, PE, MALB, JMa, CM, MSM, SMa, DSdM, SMi, JMu, JAQO, MGO, VP, TR, ALR, DR, GS, DAS, TT, HT and SV developed, managed or implemented HealthRise intervention activities or data monitoring systems, or some combination of the aforementioned activities. VC and TPN managed data collection activities. All authors read and approved the final manuscript.

  • Funding Funding for the HealthRise project came from the Medtronic Foundation. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001. JAQO received doctoral scholarship from CNPq/CAPES/IATS, Brazil. ALR was supported in part by CNPq (grant 310679/2016–8), and Instituto de Avaliação de Tecnologia em Saúde - IATS, grant 465518/2014–1) and by FAPEMIG (Programa Pesquisador Mineiro, PPM-00 428–17).

  • 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.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for this study was obtained from the institutional review board of the University of Washington, as well as the local data collection agencies and government entities for each site. This research conforms to the principles embodied in the Declaration of Helsinki. All personal identifiers were removed prior to the data being sent to IHME for analysis; only de-identified data were analysed.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. The datasets generated and/or analysed during the current study are available, when possible, in the GHDx data repository,