China Hypertension and Diabetes Care Cascade Study

Hypertension and type 2 diabetes present substantial challenges to the Chinese health system. A nationwide survey revealed a hypertension prevalence of 37.2% among Chinese adults over 35, with only 44.7% aware of their diagnosis and a mere 30.1% receiving antihypertensive treatment, resulting in an overall control rate of 7.2% [1]. Similarly, diabetes prevalence in 2018 stood at 12.9%, with awareness and treatment rates of 37% and 33%, respectively [2]. Achieving hypertension and diabetes control is conditional on successful progression through screening, diagnosis, management, and control-a continuum demanding care continuity. The care cascade analysis, originally devised for communicable diseases (i.e., HIV and tuberculosis), offers a systematic approach that dissects disease management into a series of interconnected service delivery stages [3, 4]. This method evaluates patient progression, unveiling critical drop-offs between each stage. Despite existing population-based surveys detailing the awareness, prevalence and treatment of hypertension and diabetes in China, few studies provide a systematic diagnosis of what happens between stages and devise interventions tailored to each stage of the care cascade.

This implementation study aims to identify priorities and formulate strategies to overcome health service delivery bottlenecks associated with hypertension and diabetes in rural China. Leveraging implementation frameworks, the study seeks to unravel the complexities embedded within the care cascade, paving the way for targeted interventions. Addressing the nuanced dynamics of the care cascade, this research will provide indispensable insights for optimising healthcare delivery in resource-limited settings, ultimately informing global perspectives on chronic disease management.

The overall aim of this study is to enhance the control of hypertension and diabetes in rural China through a systematic assessment and improvement of the care cascade, specifically:

1. To describe the cascade gap and identify barriers and facilitators at each cascade stage.
2. To develop practical interventions through stakeholder co-design.
3. To assess the effectiveness of developed interventions and evaluate implementation strategies.

This is a hybrid design implementation study using mixed methods and integrates diverse implementation theories, models, and frameworks. The theoretical model synthesises the process model, determinant framework, and evaluation framework under the theory of implementation science (Figure 1). The Consolidated Framework for Implementation Research (CFIR) framework identifies multilevel factors influencing implementation. The chronic care model (CCM) is used to inform intervention development. The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework is used to assess interventions across multiple dimensions. Normalisation Process Theory (NPT) is applied to measure elements critical for successful implementation and integration into routine work.