Global implementation research capacity building to address cardiovascular disease: An assessment of efforts in eight countries.

Cardiovascular diseases are the leading causes of morbidity and mortality worldwide, but implementation of evidence-based interventions for risk factors such as hypertension is lacking, particularly in low and middle income countries (LMICs). Building implementation research capacity in LMICs is required to overcome this gap. Members of the Global Research on Implementation and Translation Science (GRIT) Consortium have been collaborating in recent years to establish a research and training infrastructure in dissemination and implementation to improve hypertension care. GRIT includes projects in Ghana, Guatemala, India, Kenya, Malawi, Nepal, Rwanda, and Vietnam. We collected data from each site on capacity building activities using the Potter and Brough (2004) model, mapping formal and informal activities to develop (a) structures, systems and roles, (b) staff and infrastructure, (c) skills, and (d) tools. We captured information about sites' needs assessments and metrics plus program adaptations due to the COVID-19 pandemic. All sites reported capacity building activities in each layer of the Capacity Pyramid, with the largest number of activities in the Skills and Tools categories, the more technical and easier to implement categories. All sites included formal and informal training to build Skills. All sites included a baseline needs assessment to guide capacity building activities or assess context and inform intervention design. Sites implementing evidence-based hypertension interventions used common implementation science frameworks to evaluate implementation outcomes. Although the COVID-19 pandemic affected timelines and in-person events, all projects were able to pivot and carry out planned activities. Although variability in the activities and methods used existed, GRIT programs used needs assessments to guide locally appropriate design and implementation of capacity building activities. COVID-19 related changes were necessary, but strong collaborations and relationships with health ministries were maintained. The GRIT Consortium is a model for planning capacity building in LMICs.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward.

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Moderate-to-vigorous physical activity changes in a diabetes prevention intervention randomized trial among South Asians with prediabetes - The D-CLIP trial.

AIMS: The Diabetes Community Lifestyle Improvement Program (D-CLIP) was a lifestyle education program to prevent diabetes in South Asians with prediabetes. This paper examines the impact of the D-CLIP intervention on moderate-to-vigorous intensity physical activity (MVPA). METHODS: This randomized controlled trial to prevent diabetes included 573 individuals with prediabetes from Chennai, India. The intervention was designed to increase MVPA to ≥150 minutes per week. MVPA was measured by questionnaire at baseline, six, 12, 18, 24, 30 and 36 months of follow-up. Random effects models were used to examine the relationship between treatment group and odds of reporting ≥150 weekly minutes of MVPA and to examine the impact of the intervention on weekly MVPA. RESULTS: With the exception of the proportion of respondents at baseline with a high waist circumference, selected sample characteristics did not differ at baseline between the intervention and control groups. The intervention significantly (p < 0.05) increased the proportion of respondents who reported ≥150 weekly minutes of MVPA by 28.5%, 13.6% and 14.0% at six, 12 and 18 months respectively. Mean minutes of weekly MVPA significantly (p < 0.05) increased by an additional 56.7, 34.3, 23.6 and 24.3 minutes/week at six, 12, 18, and 24 months, respectively. CONCLUSION: The D-CLIP intervention significantly increased MVPA at six, 12 and 18 months of follow-up. Interventions to prevent diabetes in South Asians with prediabetes can significantly increase MVPA in this population.

The Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) program: scalable strategies for the management of hypertension and diabetes within the government healthcare system of India.

BACKGROUND: Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed. METHODS: The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program's electronic database. DISCUSSION: I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India. TRIAL REGISTRATION: The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723 ). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.

Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India.

Importance: A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective. Objective: To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program. Design, Setting, and Participants: This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India. Interventions: The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice. Main Outcomes and Measures: Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $). Results: The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained. Conclusions and Relevance: The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.

Perceived Barriers to Type 2 Diabetes Prevention for Low-Income Women With a History of Gestational Diabetes: A Qualitative Secondary Data Analysis.

PURPOSE: The purpose of this qualitative study was to examine perceived barriers to adoption of lifestyle changes for type 2 diabetes prevention among a diverse group of low-income women with a history of gestational diabetes mellitus (GDM). METHODS: A secondary data analysis of 10 semistructured focus group discussions was conducted. Participants were low-income African American, Hispanic, and Appalachian women ages 18 to 45 years who were diagnosed with GDM in the past 10 years. A qualitative content analysis was conducted to identify key themes that emerged within and between groups. RESULTS: Four key themes emerged on the role of knowledge, affordability, accessibility, and social support in type 2 diabetes prevention. Women discussed a lack of awareness of the benefits of breastfeeding and type 2 diabetes prevention, inaccessibility of resources in their local communities to help them engage in lifestyle change, and the desire for more culturally relevant education on healthful food options and proper portion sizes. DISCUSSION: Study findings suggests that to improve effectiveness of type 2 diabetes prevention efforts among low-income women with GDM history, health care providers and public health practitioners should avoid using "one-size-fits-all" approaches to lifestyle change and instead use tailored interventions that address the cultural and environmental factors that impact women's ability to engage in recommended behavior change.

Reprint of: Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series.

The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series.

The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

Healthcare Experiences of Low-Income Women with Prior Gestational Diabetes.

Introduction An important yet understudied component of postpartum type 2 diabetes risk reduction among high risk women is experiences with the healthcare system. Our objective was to describe the healthcare experiences of a diverse, low-income sample of women with prior GDM, including their suggestions for improving care. Methods Focus groups were conducted among African American, Hispanic, and Appalachian women who were diagnosed with GDM within the past 10 years. Participants were recruited from community and medical resources. Twelve focus groups were conducted, four within each race-ethnic group. Results Three broad themes were identified around barriers to GDM care, management, and follow-up: (1) communication issues; (2) personal and environmental barriers; and (3) type and quality of healthcare. Many women felt communication with their provider could be improved, including more education on the severity of GDM, streamlining information to be less overwhelming, and providing additional support through referrals to community resources. Although women expressed interest in receiving more actionable advice for managing GDM during pregnancy and for preventing type 2 diabetes postpartum, few women reported changing behaviors. Barriers to behavior change were related to cost, transportation, and competing demands. Several opportunities for improved care were elucidated. Discussion Our findings suggest that across all racial and ethnic representations in our sample, low-income women with GDM experience similar communication, personal, and environmental barriers related to the healthcare they receive for their GDM. Considering the increased exposure to the health care system during a GDM-affected pregnancy, there are opportunities to address barriers among women with GDM across different race-ethnic groups.

International Models of Care that Address the Growing Diabetes Prevalence in Developing Countries.

Diabetes care involves a complex interaction between patients, physicians, the health care system, and society. In low- and middle-income countries (LMICs), where the majority of individuals with diabetes live, there is a shortage of resources and infrastructure for diabetes care. Translation of proven interventions for diabetes prevention and care from experimental settings to the real world is a major challenge, and there is limited evidence from LMICs. To curtail the diabetes burden in LMICs, it is crucial to develop and execute innovative diabetes care models that improve access to care, knowledge, and outcomes. Additionally, adequate training of local health professionals and community engagement can help LMICs become self-sufficient in delivery of diabetes care. In this paper, we reviewed the existing models of diabetes care and prevention in LMICs and provided recommendations to guide the development of a comprehensive and effective future model for diabetes care in LMICs.

Quality issues of court reporters and transcriptionists for qualitative research.

Transcription is central to qualitative research, yet few researchers identify the quality of different transcription methods. We explored the quality of verbatim transcripts from traditional transcriptionists and court reporters by reviewing 16 transcripts from 8 focus group discussions using four criteria: transcription errors, cost, time of transcription, and effect on study participants. Transcriptionists made fewer errors, captured colloquial dialogue, and errors were largely influenced by the quality of the recording. Court reporters made more errors, particularly in the omission of topical content and contextual detail, and were less able to produce a verbatim transcript; however, the potential immediacy of the transcript was advantageous. In terms of cost, shorter group discussions favored a transcriptionist and longer groups a court reporter. Study participants reported no effect by either method of recording. Understanding the benefits and limitations of each method of transcription can help researchers select an appropriate method for each study.

A model of translational research for diabetes prevention in low and middle-income countries: The Diabetes Community Lifestyle Improvement Program (D-CLIP) trial.

AIMS: The Diabetes Community Lifestyle Improvement Program (D-CLIP) aims to implement and evaluate in a controlled, randomized trial the effectiveness, cost-effectiveness, and sustainability of a culturally appropriate, low-cost, and sustainable lifestyle intervention for the prevention of type 2 diabetes mellitus in India. METHODS: D-CLIP, a translational research project adapted from the methods and curriculum developed and tested for efficacy in the Diabetes Prevention Program, utilizes innovated methods (a step-wise model of diabetes prevention with lifestyle and metformin added when needed; inclusion of individuals with isolated glucose tolerance, impaired fasting glucose, and both; classes team-taught by professionals and trained community educators) with the goals of increasing diabetes prevention, community acceptability, and long-term dissemination and sustainability of the program. The study outcomes are: diabetes incidence (primary measure of effectiveness), cost-effectiveness, changes in anthropometric measures, plasma lipids, blood pressure, blood glucose, and HbA(1c,) Program acceptability and sustainability will be assessed using a mixed methods approach. CONCLUSION: D-CLIP, a low-cost, community-based, research program, addresses the key components of translational research and can be used as a model for prevention of chronic diseases in other low and middle-income country settings.