Implementation determinants and community-based prevention for cardiometabolic disease in Mozambique: a pilot study

SUMMARY/ABSTRACT
The burden of noncommunicable diseases (NCDs), including cardiometabolic disease, is increasing globally,
particularly in low- and middle-income countries (LMICs). NCDs are responsible for an estimated 35% of all
deaths in sub-Saharan Africa, and in Mozambique nearly 60% of all DALYs are attributable to NCDs and injury.
The prevalence of hypertension (HTN) and type II diabetes (T2D) are on the rise, from 33.1% in 2005 to 38.9%
in 2015 for HTN and 2.9% to 7.4% for T2D across the same period. Effective strategies to meet the growing
disease burden that can be integrated into – and scaled through – health systems and disease-specific platforms,
like those for HIV, are needed. Similarly, little information exists on effective, population-based primordial
prevention of cardiometabolic in LMIC community-based settings, including efforts to intervene in the relationship
between an individual's environment, health behaviors, and risk factors for HTN and T2D. In recent years, several
implementation research studies have applied the Systems Analysis and Improvement Approach (SAIA) to
optimize care cascades for preventing mother-to-child HIV transmission (R01HD0757; PI: Sherr), addressing
HTN among people with HIV (SAIA-HTN, R01HL142412, PI: Gimbel; SCALE SAIA-HTN, 1UG3HL156390-
01/UH3HL156390,PI: Mocumbi/Gimbel), and to pilot T2D care optimization within facilities where SAIA-HTN has
been implemented, coupled with food environment assessments and Citizen Science-based nutritional
education modules in three institutional cafeterias. This F31 proposal will leverage the data gathered under these
studies to conduct formative research to characterize determinants for effective implementation of integrated
care for T2D, HTN, and HIV embedded within ongoing health systems strengthening efforts in public sector
facilities in Mozambique. We will also conduct pilot research to determine possible associations between
community-based participatory education modules and changes in diet. We will evaluate barriers, facilitators,
and organizational readiness to deliver medical services for T2D alongside integrated HTN and HIV services
(Aim 1), leveraging qualitative data gathered through interviews and focus group discussions among
stakeholders in two Mozambican health facilities and organizational readiness for implementing change (ORIC)
assessments. In Aim 2, we will leverage data collected in food intake questionnaires administered under the
parent study to assess the presence of longitudinal or dose-response relationships between exposure to
community education modules and food intake. This formative research will contribute to scarce evidence for
effective systems approaches to treat and prevent cardiometabolic disease in LMICs. This research plan will
provide the F31 candidate rigorous predoctoral training including 1) application of implementation science
frameworks for qualitative research, 2) development of participatory research methods, and 3) advanced
statistical analyses using quantitative data for implementation science.

Grant Number: 5F31HL175834-02
NIH Institute/Center: NIH
Principal Investigator: Amanda Brumwell