Bridging Income Generation With Group Integrated Care

NCT02501746 | Completed DMC

• 2 other identifiers: 18-012601R01HL125487
• Study Type: interventional
• Target: 2,890
• Locations: 1 country
• Sites: 1

Brief Summary

Specific Aims: Bridging Income Generation with GrouP Integrated Care (BIGPIC) Over 80% of cardiovascular disease (CVD) deaths occur in low- and middle-income countries (LMICs). Diabetes, a major risk factor for CVD, is also responsible for substantial morbidity and mortality in LMICs. Elevated blood pressure (BP) increases CVD risk among individuals with diabetes and pre-diabetes; BP control is therefore a powerful way to reduce CVD risk. Cost-effective, culturally appropriate, and context-specific approaches are critical. Two promising strategies to improve health outcomes are group medical visits and microfinance. Both can increase quality of care, clinician-patient trust, self-efficacy, health savings, self-confidence, group cohesion, and social support. While these strategies have been successful in other contexts, their impact on CVD risk reduction among diabetics and pre-diabetics in low-resource settings is not known. In partnership with the Government of Kenya, the Academic Model Providing Access to Healthcare (AMPATH) Partnership has expanded its clinical scope of work to include diabetes and hypertension. AMPATH has piloted group care and microfinance initiatives among patients with chronic diseases with promising early results. Both strategies are feasible, as is integration of group medical visits into microfinance groups. However, the effectiveness of these strategies individually, and in combination, on improving CVD risk is not known. Thus, the objective of this proposal is to utilize a transdisciplinary implementation research approach to address the challenge of reducing CVD risk in low-resource settings. The central hypothesis is: group medical visits integrated into microfinance groups will 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 research team hypothesize that group medical visits and microfinance may each reduce CVD risk, but the integration of group medical visits and microfinance will yield the largest gains. Also further hypothesize is that changes in social network characteristics may mediate the impact of interventions on the primary outcome, and that baseline social network characteristics may moderate the impact of interventions. To test these hypotheses and achieve the overall objectives, the following specific aims will be pursued: 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. This model's acceptability and feasibility will be assessed 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 will 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 investigators are poised to expand the approach beyond the trial, thus ensuring that this research will have a significant and positive health impact on a larger population.

Conditions

Cardiovascular Disease; Diabetes

Keywords

Group medical care; Microfinance; Hypertension; Community-based intervention; Global health

Outcome Measures

Primary Outcomes (1)

• Change in Systolic Blood Pressure

  Change in Systolic Blood Pressure at 12 months as compared to baseline

  Baseline and 12 months

Secondary Outcomes (1)

• Change in cardiovascular disease (CVD) risk Score

  Baseline and 12 months

Study Arms (4)

Usual Clinical Care (UC)

ACTIVE COMPARATOR

This will be the current standard of care delivered by the AMPATH CDM Program, in accordance with the management protocol for diabetes and hypertension.

Other: Usual Clinical Care

Usual clinical care plus microfinance groups only (MF)

EXPERIMENTAL

Usual clinical care as described above. In addition, participants will be encouraged to create microfinance groups organized and supported by AMPATH's Safety Net Program.

Other: Usual Clinical Care; Other: Microfinance Groups

Group medical visits only (GMV)

EXPERIMENTAL

Participants randomized to this arm will be invited to create a group that will attend monthly group medical visits at the rural health facility. Each group medical visit will be staffed by both the rural clinician and the local CHW (educator). Groups will consist of the same patients at each of 12 monthly visits. Each visit will begin with the measurement of fasting blood glucose and resting electronic BP, as well as the ascertainment of medication regimens for BP and diabetes, and extent of adherence to the prescribed regimen.

Other: Group Medical Visits

GMV integrated into GMV-MF

EXPERIMENTAL

Clinical care will be provided in the form of group medical visits, and the participants will be actively recruited to create microfinance groups. Thus, the monthly group medical visit will be integrated into the microfinance groups, wherein the visit will consist of an initial microfinance portion, followed by the group medical visit.

Other: Group Medical Visits

Interventions

Usual Clinical Care OTHER

Non-hypertensive diabetic individuals will not be pharmacologically treated for BP reduction; those with BP 120-139/80-89 will be advised on lifestyle changes to reduce BP as recommended by the 2013 Standards of Medical Care in Diabetes. Care will be provided to each individual at the rural health facility by a rural clinician mentored by the CDM Program, including regular monthly consultation, vital signs, physical examination, and prescriptions. CHWs will assist with linkage and retention of patients to the care program, and provide health education. The 12-month follow-up BP will be measured in the rural health facility, in order to mimic real-world practice. If the patient does not present to the rural health facility for the 12-month visit, the local CHW will trace the patient at home and will check the 12-month BP at that time, again consistent with real-world conditions.

Also known as: UC

Usual Clinical Care (UC); Usual clinical care plus microfinance groups only (MF)

Group Medical Visits OTHER

The CHW will facilitate a group discussion about a self-care or health education topic chosen by the group while the rural clinician reviews the BP, sugar, and adherence data to determine a clinical recommendation as per the CDM clinical algorithm. which is communicated to each individual patient privately by the rural clinician in a five-minute "breakout time". The rural clinician will not change the regimen for non adherence but instead will use the breakout time to assess barriers to adherence and try to help the patient identify solutions to those barriers.The breakout time can also be used to perform a physical examination or other assessments as clinically required. After all patients have had individual consultations with the rural clinician, the entire group re-convenes for a closing session, which consists of a question-and-answer period and determination of the next session's self-care or health education topic.

Also known as: GMV

GMV integrated into GMV-MF; Group medical visits only (GMV)

Microfinance Groups OTHER

The rural clinician and the CHW will organize a meeting with AMPATH's Safety Net Program representatives, who will introduce the concept of microfinance groups, the potential benefits, and encourage the formation of new groups to meet monthly. The microfinance groups need to incorporate an element of self-selection and self-formation, so that individuals have the freedom to choose with whom they will create a group. The groups are therefore formed voluntarily, and usually along geographical boundaries, which facilitates participation, retention, and meeting logistics.

Also known as: MF

Usual clinical care plus microfinance groups only (MF)

Eligibility Criteria

• Age: 35 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Adults in the CDM Program who:
• Have diabetes (fasting glucose ≥ 7 mmol/L);
• Are at increased risk for developing diabetes (impaired fasting glucose (fasting glucose 5.6 - 6.9 mmol/L);
• Have an elevated Leicester Risk Assessment score (≥ 7)

You may not qualify if:

• Acute illness requiring immediate medical attention;
• Terminal illness;
• Refusal to provide informed consent;
• Individuals who are pregnant or have HIV will be excluded, (automatically referred to a higher level of care within the AMPATH care system).
• Participation in the trial will not be contingent upon membership in a group. An intention-to-treat analysis will be conducted and the denominator in each cluster will include all eligible individuals who consent, irrespective of whether they are in a group, thus minimizing selection bias.

Sponsors & Collaborators

• NYU Langone Health: lead
• Moi University College of Health Sciences: collaborator
• Brown University: collaborator
• Duke University: collaborator
• Purdue University: collaborator
• National Heart, Lung, and Blood Institute (NHLBI): collaborator
• Icahn School of Medicine at Mount Sinai: collaborator

Study Sites (1)

Moi University College of Health Sciences

Eldoret, Kenya

Location

Related Publications (6)

• Chay J, Su RJ, Kamano JH, Andama B, Bloomfield GS, Delong AK, Horowitz CR, Menya D, Mugo R, Orango V, Pastakia SD, Wanyonyi C, Vedanthan R, Finkelstein EA. Cost-effectiveness of group medical visits and microfinance interventions versus usual care to manage hypertension in Kenya: a secondary modelling analysis of data from the Bridging Income Generation with Group Integrated Care (BIGPIC) trial. Lancet Glob Health. 2024 Aug;12(8):e1331-e1342. doi: 10.1016/S2214-109X(24)00188-8.

  PMID: 39030063 DERIVED

• Gala P, Kamano JH, Vazquez Sanchez M, Mugo R, Orango V, Pastakia S, Horowitz C, Hogan JW, Vedanthan R. Cross-sectional analysis of factors associated with medication adherence in western Kenya. BMJ Open. 2023 Sep 5;13(9):e072358. doi: 10.1136/bmjopen-2023-072358.

  PMID: 37669842 DERIVED

• Pillsbury MKM, Mwangi E, Andesia J, Njuguna B, Bloomfield GS, Chepchumba A, Kamano J, Mercer T, Miheso J, Pastakia SD, Pathak S, Thakkar A, Naanyu V, Akwanalo C, Vedanthan R. Human-centered implementation research: a new approach to develop and evaluate implementation strategies for strengthening referral networks for hypertension in western Kenya. BMC Health Serv Res. 2021 Sep 3;21(1):910. doi: 10.1186/s12913-021-06930-2.

  PMID: 34479556 DERIVED

• Ruchman SG, Delong AK, Kamano JH, Bloomfield GS, Chrysanthopoulou SA, Fuster V, Horowitz CR, Kiptoo P, Matelong W, Mugo R, Naanyu V, Orango V, Pastakia SD, Valente TW, Hogan JW, Vedanthan R. Egocentric social network characteristics and cardiovascular risk among patients with hypertension or diabetes in western Kenya: a cross-sectional analysis from the BIGPIC trial. BMJ Open. 2021 Sep 2;11(9):e049610. doi: 10.1136/bmjopen-2021-049610.

  PMID: 34475172 DERIVED

• Vedanthan R, Kamano JH, Chrysanthopoulou SA, Mugo R, Andama B, Bloomfield GS, Chesoli CW, DeLong AK, Edelman D, Finkelstein EA, Horowitz CR, Manyara S, Menya D, Naanyu V, Orango V, Pastakia SD, Valente TW, Hogan JW, Fuster V. Group Medical Visit and Microfinance Intervention for Patients With Diabetes or Hypertension in Kenya. J Am Coll Cardiol. 2021 Apr 27;77(16):2007-2018. doi: 10.1016/j.jacc.2021.03.002.

  PMID: 33888251 DERIVED

• Leung CL, Naert M, Andama B, Dong R, Edelman D, Horowitz C, Kiptoo P, Manyara S, Matelong W, Matini E, Naanyu V, Nyariki S, Pastakia S, Valente T, Fuster V, Bloomfield GS, Kamano J, Vedanthan R. Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya. BMC Health Serv Res. 2020 May 12;20(1):415. doi: 10.1186/s12913-020-05199-1.

  PMID: 32398131 DERIVED

MeSH Terms

Conditions

Cardiovascular Diseases; Diabetes Mellitus; Hypertension

Condition Hierarchy (Ancestors)

Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases; Vascular Diseases

Study Officials

• Rajesh Vedanthan, MD, MPH

  NYU Langone Health

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: OTHER
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: July 15, 2015
• First Posted: July 17, 2015
• Study Start: February 6, 2017
• Primary Completion: December 29, 2019
• Study Completion: December 29, 2019
• Last Updated: June 17, 2020

Record last verified: 2020-06

Locations

KE (1)