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 in most of low- and middle-income countries (LMIC). This
rapid increase in the T2D burden has a particular impact on cities, where more than half the LMIC 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 an equitable and sustained improvement in
the detection, treatment, and control of T2D, and (b) a rapid implementation of the WHO’s evidence-based
HEARTS-D module, which aims to improve service delivery for T2D in primary care facilities. However, currently,
in most LMICs (such as Bangladesh), effective adoption of the WHO HEARTS-D module into routine urban
primary care has been limited owing to substantial implementation barriers. These include suboptimal delivery
mechanisms, poor uptake, weak monitoring system, and inadequate capacities. To address this, we will evaluate
a community-to-facility integrated strategy to implement WHO HEARTS-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 (IM). Guided by the IM 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 T2D care, specifically for urban
poor populations, through iterative cycles of mixed methods qualitative assessments, implementation, and
outcome measurements. For this aim, trained study staff will select ~45 key stakeholders, primary care providers
and CHWs 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 a total of 20 municipal wards
as clusters from Sylhet city (10 in each arm). This cluster randomized trial will compare the following strategies:
(a) a community-to-facility integrated strategy for implementing the WHO HEARTS-D module and (b) a facility-
only service delivery strategy (without a community component). We will evaluate the implementation process
by defining relevant outcomes based on the RE-AIM framework components: reach, effectiveness,
implementation, and maintenance. Third, we will compare the effectiveness of this integrated strategy on T2D
status. Based on a study sample of 5,000 randomly selected participants, we will aim to compare improvements
in the prevalence of controlled T2D status, treatment uptake and adherence to glucose-lowering therapy, T2D
complications and awareness among participants in both study arms, from baseline to end-line. Our should guide
the policymakers into effective implementation and sustainment of WHO HEARTS-D module that can be: (a)
embedded within local organizational structures, and (b) adapted to similar contexts globally.
