Background:
Recent decades have witnessed dramatic surges in the prevalence of non-communicable diseases (NCDs) such as diabetes mellitus (DM), particularly in low- and middle-income countries. Unfortunately, diagnosis, treatment, and control of DM often remain elusive, and complications common. One potential strategy, successfully used for HIV and TB, is the development of integrated care models that empower and capacitate front-line health workers (FLHWs).

Aims:
HealthRise, a global project focused on expanding access to care for underserved populations, has implemented community-based interventions in four countries with large and growing burdens of DM: Brazil, India, South Africa, and the United States. The project aims to strengthen health systems by improving the capacity of FLHWs and increasing coordination between primary health care and community services. A comprehensive monitoring and evaluation framework was established to measure the interventions’ impacts on rates of disease diagnosis, treatment, and control. Needs assessments were conducted as a baseline for the impact evaluation; baseline results are presented here.

Methods:
Within each country, diverse sub-geographies representing high or increasing burden of DM were selected through local collaboration. Needs assessments were designed to assess supply- and demand-side barriers influencing the continuum of care from diagnosis, to treatment and control. Mixed methods were applied utilizing primary and secondary data sources; the former largely in India and South Africa, the latter in Brazil and the United States. Results are presented descriptively.

Results:
The prevalence of DM ranged from 5-9% across all sites.  The prevalence of DM risk factors among the general population was high in all countries, with the highest rates of hypertension and elevated BMIs in South Africa. More than 70% of individuals with DM reported a diagnosis, although many patients reported seeking care only after developing symptoms. Once diagnosed, patients were likely to initiate treatment, but successful management of conditions was challenging even in the highest-income populations. Qualitative data indicated that access to care was often challenging, particularly in poorer communities where travel time and costs posed significant barriers.  Furthermore, patients reported difficulties managing medications, adjusting behaviors, and monitoring their condition.  This was compounded by either a lack of community-based resources or poor coordination between these services and the health care system.

Discussion:
The overwhelming majority of patients with DM were aware of their disease status, and most initiated pharmacologic treatment. However, many patients faced barriers to continuous access, resulting in inadequate disease control. Our results suggest patients need more accessible and frequent support maintaining healthy lifestyles, maintaining treatment regimens, monitoring conditions, and adjusting treatment as necessary. HealthRise has launched interventions to address these gaps and improve outcomes by building community health worker capacity, integrating their work into the formal health care system, and empowering patients with support systems. Results of the final impact evaluation will provide further evidence on how community-based strategies can improve DM care across a wide range of settings.

Diabetes epidemiology, risk factors and barriers to care in four countries: initial findings from the HealthRise project