Bridging Income Generation with Group Integrated Care (BIGPIC)

Background

Cardiovascular disease is the leading cause of mortality worldwide, and >80% of CVD deaths occurring in low and middle income countries. Diabetes and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with Diabetes. Reducing CVD risk in people with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. This project focused on two innovative strategies to improve health outcomes: group medical visits and microfinance.

Aims

Aim 1: Identify the contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction, using a combination of qualitative research methods: 1) baraza (traditional community gathering) form of inquiry; and 2) focus group discussions among individuals with diabetes or at increased risk for diabetes, microfinance group members, and rural health workers.

Subsidiary aim 1.1: Use identified facilitators and barriers to develop a contextually and culturally appropriate integrated group medical visit-microfinance model to reduce CVD risk among individuals with diabetes or at increased risk of diabetes. We will assess this model’s acceptability and feasibility by conducting focus group discussions with patients, microfinance group members, and health workers.

Aim 2: Evaluate the effectiveness of group medical visits and microfinance groups for CVD risk reduction among individuals with diabetes or at increased risk for diabetes, by conducting a four-arm cluster randomized trial comparing: 1) usual clinical care; 2) usual clinical care plus microfinance groups only; 3) group medical visits only (no microfinance); and 4) group medical visits integrated into microfinance groups. The primary outcome measure will be one-year change in systolic blood pressure (SBP), and a key secondary outcome will be change in QRISK2 CVD risk score, which has been validated for Black Africans.

Subsidiary Aim 2.1: Conduct mediation analysis to evaluate the influence of changes in social network characteristics on intermediate factors and intervention outcomes and moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of interventions.

Aim 3: Evaluate the incremental cost-effectiveness of each intervention arm of the trial, in terms of costs per unit decrease in SBP, per percent change in CVD risk score, and per disability-adjusted life year saved.

This research project aimed to add to the existing knowledge base on innovative, scalable, and sustainable strategies for reducing CVD risk in diabetes and other chronic diseases in LMICs and other low-resource settings. If proven to be effective, the team aimed to expand the approach beyond the trial, thus ensuring that this research will have a significant and positive health impact on a larger population.

Project plan

The objective of our project was to utilize a transdisciplinary implementation research approach to address the challenge of reducing CVD risk in low-resource settings. The central hypothesis was: group medical visits integrated into microfinance groups could be effective and cost-effective in reducing CVD risk among individuals with diabetes and at increased risk for diabetes in western Kenya, and that the key modifiable CVD risk factor to be addressed is BP. The team hypothesized that group medical visits and microfinance could each reduce CVD risk, but the integration of group medical visits and microfinance would yield the largest gains. The team further hypothesized that changes in social network characteristics could mediate the impact of interventions on the primary outcome, and that baseline social network characteristics could moderate the impact of interventions.

Impact

The BIGPIC project demonstrated that implementation of a contextualized care delivery model to tackle cardiovascular disease in rural Kenya could have an impact on health. The intervention led to significant improvements in linkage to care and a reduction in blood pressure for participants. The project was awarded scale up funding through the National Heart, Lung and Blood Institute (NHLBI) in order to support continuation of the project.

Publications and output

GACD have also published an end-of-programme report providing a comprehensive summary of the programme and outcomes.