Core health-components, contextual factors and program elements of community-based interventions in Southeast Asia - a realist synthesis regarding hypertension and diabetes.

BACKGROUND: In Southeast Asia, diabetes and hypertension are on the rise and have become major causes of death. Community-based interventions can achieve the required behavioural change for better prevention. The aims of this review are 1) to assess the core health-components of community-based interventions and 2) to assess which contextual factors and program elements affect their impact in Southeast Asia. METHODS: A realist review was conducted, combining empirical evidence with theoretical understanding. Documents published between 2009 and 2019 were systematically searched in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar and PsycINFO and local databases. Documents were included if they reported on community-based interventions aimed at hypertension and/or diabetes in Southeast Asian context; and had a health-related outcome; and/or described contextual factors and/or program elements. RESULTS: We retrieved 67 scientific documents and 12 grey literature documents. We identified twelve core health-components: community health workers, family support, educational activities, comprehensive programs, physical exercise, telehealth, peer support, empowerment, activities to achieve self-efficacy, lifestyle advice, activities aimed at establishing trust, and storytelling. In addition, we found ten contextual factors and program elements that may affect the impact: implementation problems, organized in groups, cultural sensitivity, synergy, access, family health/worker support, gender, involvement of stakeholders, and referral and education services when giving lifestyle advice. CONCLUSIONS: We identified a considerable number of core health-components, contextual influences and program elements of community-based interventions to improve diabetes and hypertension prevention. The main innovative outcomes were, that telehealth can substitute primary healthcare in rural areas, storytelling is a useful context-adaptable component, and comprehensive interventions can improve health-related outcomes. This extends the understanding of promising core health-components, including which elements and in what Southeast Asian context.

Implementation outcomes and strategies for delivering evidence-based hypertension interventions in lower-middle-income countries: Evidence from a multi-country consortium for hypertension control.

Guidance on contextually tailored implementation strategies for the prevention, treatment, and control of hypertension is limited in lower-middle income countries (Lower-MIC). To address this limitation, we compiled implementation strategies and accompanying outcomes of evidence-based hypertension interventions currently being implemented in five Lower-MIC. The Global Research on Implementation and Translation Science (GRIT) Coordinating Center (CC) (GRIT-CC) engaged its global network sites at Ghana, Guatemala, India, Kenya, and Vietnam. Purposively sampled implementation science experts completed an electronic survey assessing implementation outcomes, in addition to implementation strategies used in their ongoing hypertension interventions from among 73 strategies within the Expert Recommendations for Implementing Change (ERIC). Experts rated the strategies based on highest priority to their interventions. We analyzed the data by sorting implementation strategies utilized by sites into one of the nine domains in ERIC and summarized the data using frequencies, proportions, and means. Seventeen implementation experts (52.9% men) participated in the exercise. Of Proctor's implementation outcomes identified across sites, all outcomes except for appropriateness were broadly assessed by three or more countries. Overall, 59 out of 73 (81%) strategies were being utilized in the five countries. The highest priority implementation strategies utilized across all five countries focused on evaluative and iterative strategies (e.g., identification of context specific barriers and facilitators) to delivery of patient- and community-level interventions, while the lowest priority was use of financial and infrastructure change strategies. More capacity building strategies (developing stakeholder interrelationships, training and educating stakeholders, and supporting clinicians) were incorporated into interventions implemented in India and Vietnam than Ghana, Kenya, and Guatemala. Although robust implementation strategies are being used in Lower -MICs, there is minimum use of financial and infrastructure change strategies. Our study contributes to the growing literature that demonstrates the use of Expert Recommendations for Implementing Change (ERIC) implementation strategies to deliver evidence-based hypertension interventions in Lower-MICs and will inform future cross-country data harmonization activities in resource-constrained settings.