IntroductionAs non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme’s endline evaluation.MethodsThe evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients’ biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time.ResultsAlmost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges.ConclusionsFindings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

BackgroundThe HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs).MethodsThis mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach.Results46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs.ConclusionIn this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Background Community-based health interventions are increasingly viewed as models of care that can bridge healthcare gaps experienced by underserved communities in the United States (US). With this study, we sought to assess the impact of such interventions, as implemented through the US HealthRise program, on hypertension and diabetes among underserved communities in Hennepin, Ramsey, and Rice Counties, Minnesota. Methods and findings HealthRise patient data from June 2016 to October 2018 were assessed relative to comparison patients in a difference-in-difference analysis, quantifying program impact on reducing systolic blood pressure (SBP) and hemoglobin A1c, as well as meeting clinical targets (< 140 mmHg for hypertension, < 8% Al1c for diabetes), beyond routine care. For hypertension, HealthRise participation was associated with SBP reductions in Rice (6.9 mmHg [95% confidence interval: 0.9–12.9]) and higher clinical target achievement in Hennepin (27.3 percentage-points [9.8–44.9]) and Rice (17.1 percentage-points [0.9 to 33.3]). For diabetes, HealthRise was associated with A1c decreases in Ramsey (1.3 [0.4–2.2]). Qualitative data showed the value of home visits alongside clinic-based services; however, challenges remained, including community health worker retention and program sustainability. Conclusions HealthRise participation had positive effects on improving hypertension and diabetes outcomes at some sites. While community-based health programs can help bridge healthcare gaps, they alone cannot fully address structural inequalities experienced by many underserved communities.

BackgroundImpairment in mnemonic discrimination is a hallmark feature of the very early stages of Alzheimer’s Disease (AD) and is associated with aberrant hippocampal function. Carriers of an Apolipoprotein (APOE) e4 gene, the most well‐established risk factor for AD, show differences in hippocampal function from youth. The cognitive consequences of altered brain activation in this group, however, remain poorly understood.MethodsAn online web‐platform has been developed – the APOE Memory Bank, which presents a collection of in‐depth behavioural tasks targeting hippocampal (object and spatial mnemonic discrimination) and non‐hippocampal cognitive processes (prospective memory, working memory and executive control). Cognitively healthy adults (aged 45–65 years) were invited to take part from the NIHR BioResource database. Selection processes have ensured a well‐matched, equivalent sample of e4 carriers and non‐carriers.ResultsFour hundred and twenty‐one participants have provided data to the APOE Memory bank to date. Ongoing, pre‐registered analyses will test if APOE e4 carriers show alterations in their ability to discriminate objects in memory, and if genotype differences in the cognitive processes supporting successful mnemonic discrimination underpin disparities. The sample is enriched with a high proportion of homozygous e4 carriers, providing a novel examination of gene‐dose effects at scale.ConclusionsEstablishing which cognitive processes are sensitive to the detrimental effects of APOE e4 will advance understanding of how genotype differences in brain development confer vulnerability in this high‐risk group. To date, indices of mnemonic discrimination have been used to discriminate preclinical or prodromal AD. This research provides a novel test of whether, in mid‐life, a web‐based object mnemonic discrimination task can differentiate risk for subsequent cognitive impairment. Identifying non‐invasive, easy‐to‐administer risk markers will advance future avenues of prophylactic, personalised intervention

Background: Brazil HealthRise community-based program focused on improving technologies for care coordination, developing the local workforce, and identifying and educating individuals with hypertension and diabetes. Objectives: To assess the impact of HealthRise on hypertension and diabetes management among patients in the region of Teofilo Otoni (TO) and in the city of Vitoria da Conquista (VC). Methods: Grantees routinely collected patient-level clinical in intervention areas from March 2017 to December 2018; endline qualitative interviews were conducted with patients, providers, administrators, and policymakers in both intervention and comparison sites. Paired t-tests were employed to measure the potential impact of the program on reducing systolic blood pressure (SBP) and hemoglobin A1c (HbA1c) between baseline and endline, and on increasing the percentage of enrollees meeting clinical targets (SBP < 140 mmHg for hypertension; < 8% HbA1c for diabetes). We analyzed qualitative data using thematic coding. Results: Across sites, 2,764 hypertension patients and 244 diabetes patients were followed through endline. Participants experienced reductions in SBP in TO (-1.9 mmHg [-3.1;-0.7]) and VC (-4,2 mmHg [-5.2;-3.1]); more hypertension patients met treatment targets in these locations (TO: +3.9 percentage-points [0.4;7.2]; VC: +10.5 percentage-points [7.81;13.2]) by endline. HbA1c decreased in TO (-0.6 [-0.9;-0.4]) and VC (-0.9 [-1.4;-0.5]), and more individuals presented HbA1c < 8% by endline (TO: +10.2 percentage-points [3.8, 16.6]; VC: +25 percentage-points [12.2, 37.8]). Qualitative data pointed to overall enthusiasm for new technologies and care routine implemented by HealthRise, but challenges regarding program implementation, integration with other levels of care, and social determinants of health persisted. Conclusions: Program showed positive effects on hypertension and diabetes outcomes. Community-based health interventions can help bridge healthcare gaps, but their full impact will remain limited until multisectoral policies and actions address underlying structural and social determinants of health more effectively.