Leveraging community-to-facility service provision to implement the World Health Organization HEARTS-D guidelines in Bangladesh for improving diabetes control and prevention. - PROJECT SUMMARY Type-2 diabetes (T2D) is rising at an alarming rate globally and in the United States (US). This rapid increase in the T2D burden has a particular impact on cities, where more than half the global populations currently live and where 3 out of 4 people with T2D reside. In response to this growing global challenge, the World Health Organization (WHO) has emphasized (a) the need for a sustained improvement in the detection, treatment, and control of T2D, and (b) a rapid implementation of the WHO’s evidence-based HEARTS module for tackling chronic diseases. However, currently, in most countries (including Bangladesh and the US), effective adoption of the WHO HEARTS module into routine urban primary care has been limited. These include suboptimal delivery mechanisms, poor uptake, a weak monitoring system, and inadequate capacities. To address this, we will evaluate a community-to-facility integrated strategy to implement the WHO HEARTS-Diabetes (D) module in the existing urban service delivery system in Bangladesh. First, we will develop and optimize a community-to-facility integrated strategy for adopting the WHO HEARTS-D module using Implementation Mapping. Guided by this approach, we will conduct mixed methods assessments to: (a) identify contextual factors, and (b) assess the implementation behavior of providers that may influence T2D care in cities. We will then develop and optimize a suitable implementation strategy that can achieve high coverage, access, and utilization of chronic T2D care through iterative cycles of mixed methods qualitative assessments, implementation, and outcome measurements. For this aim, study staff will select the key stakeholders, primary care providers, and community health workers as participants, based in 3 wards in Sylhet city of Bangladesh. Second, we will evaluate the impacts of the optimized community-to-facility integrated strategy on implementation outcomes. We will conduct a 2-arm, type 2, hybrid implementation-effectiveness randomized trial. The study will involve 20 municipal wards as clusters from Sylhet city (10 in each arm). This study compares the following strategies: (a) a community-to- facility integrated strategy for implementing the WHO HEARTS-D module and (b) a facility-only usual service delivery. We will evaluate the implementation process by relevant outcomes based on the RE-AIM framework components: reach, effectiveness, implementation, and maintenance. Third, we will compare the effectiveness of this strategy on T2D status. In a study sample of 5,000 randomly selected participants, we will compare improvements in the prevalence of controlled T2D, treatment uptake and adherence to glucose-lowering therapy, T2D complications, and awareness among participants in both study arms from baseline to end-line. Our study should guide policymakers into effective implementation and sustainment of the WHO HEARTS-D module that can be: (a) embedded within local organizational structures, and (b) adapted to the US and other similar global contexts.
