Project Overview of SMART2D

Our goal is to fill those gaps by strengthening capacity for T2DM care through proven strategies like task-shifting and expanding care networks in three settings: a rural community in a low-income country (Uganda), an urban township in a middle-income country (South Africa), and socioeconomically disadvantaged groups in a high-income country (Sweden).

Background

Type 2 diabetes mellitus (T2DM) is increasingly contributing to the global burden of disease; the most dramatic epidemiological shift will take place in sub-Saharan Africa. The formal health systems, especially in low- and middle-income countries, may be overwhelmed by the magnitude of the T2DM burden. The economic cost of managing diabetes is high, health care professionals are often more focused on medical care rather than prevention, and the systems often suffer from weak health policies and guidelines, a lack of human resources and medicines, and inadequate coverage of service delivery. They are often poorly accessible, acceptable, available, affordable or adequate, results in the poor prevention and management of T2DM.

Developing and expanding the reach of the health systems down to the community level is one approach to tackling the epidemic. There is convincing evidence that lifestyle interventions can prevent or delay the onset of T2DM for those with pre-diabetes and delay the onset of complications for those with T2DM. In this situation, it is more appropriate to look at an individual in terms of his or her family, community and environment, rather than as a singular patient dependent on a medical provider. Approaches that include community outreach components to those who cannot access the health system are appropriate. Indeed, community-directed and community empowerment strategies with established care structures at a grassroots level have already been successfully developed and tested in some sub-Saharan settings. Borrowing these ideas for the management and prevention of T2DM would be highly relevant and cost-effective.

By setting the study in three different contexts - a rural area in a low-income country (Uganda), an urban township in a middle-income country (South Africa), and socioeconomically disadvantaged populations in a high-income country (Sweden) - each of which has its own strengths and weaknesses in diabetes care, allows for reciprocal learning between the settings. Through collaborative work and shared learning, the gaps of one setting may be filled by the strengths of another. Potentially effective interventions exist for T2DM, but innovations in delivery systems are required to realize their potential.

Our aim is to strengthen capacity for T2DM prevention and management through task-shifting among health care providers and community health workers, and expanding care networks through community-based peer support groups, by targeting three populations in different settings.

Objectives

Our objectives are to develop cross-lessons between the low-, middle- and high-income countries; to formulate facility and community strategies to improve access and adherence to prevention and management interventions for T2DM, and implement these strategies through a controlled study design; and to engage in policy dialogue throughout the process.

Methods

Through literature reviews, formative studies, and lessons learned from other projects and experiences, we will first gain contextual evidence for understanding notions of health and wellbeing, understanding current healthcare practices and potential for change, and understanding dietary and physical activity practices, barriers, and facilitators. During this time and throughout the project, we will also perform cross-learning site exchanges to maximize reciprocal learning.

From our formative studies, we will develop facility and community based strategies for prevention and management, such as expanding care networks through peer support. We will implement a facility only strategy arm versus a facility + community strategy arm using a controlled study design. Finally, the impact will be evaluated for disease outcomes and health system and equity related outcomes.

We will also perform continuous policy dialogue with stakeholders in all three settings throughout the project to maximize the impact of our findings.

Time

The four-year project will run from 2015 to 2019.

Funding

This project is funded by the Horizon 2020 Framework Programme of the European Union.