Bridging Income Generation With Group Integrated Care (BIGPIC)

The Academic Model Providing Access to Healthcare Partnership (AMPATH) was initiated in Kenya in 2001. In 2009, AMPATH was designated as a Center of Excellence for Cardiovascular and Pulmonary Disease Research by the NHLBI, and the program's research portfolio includes CVD, diabetes, and risk factors. Population-based prevalence of diabetes and hypertension in Kenya is not well known, and estimates vary according to technique, definitions, and geography. Prevalence rates range from 1% to 12% for diabetes, and 5% to 24% for hypertension. The lower ranges of these figures are self-reported disease and likely underestimate true prevalence due to low awareness of and screening for chronic diseases in this region.

In response to this substantial and growing burden of diabetes and hypertension, AMPATH has formed a Chronic Disease Management (CDM) Program , and established productive partnerships with the Kenyan government and local communities, in order to optimize care delivery for chronic diseases, such as diabetes and hypertension. AMPATH has a Memorandum of Understanding with the Kenyan Ministry of Public Health and Sanitation and the Ministry of Medical Services to test and evaluate innovative approaches to chronic disease management. The CDM Program developed a robust diabetes and hypertension management protocol derived from the International Diabetes Federation, World Health Organization (WHO), and Joint National Commission 7 and 8 guidelines for diabetes and hypertension management, using drugs contained in the Kenyan national formulary. The CDM program's interventions are delivered at Ministry of Health facilities with associated personnel. In addition, AMPATH has developed innovative, community-based solutions to ensure a consistent and secure supply of essential medicines. The CDM Program has enrolled over 2,000 patients with diabetes and 3,100 patients with hypertension, who are being cared for at nine rural health centers and 30 rural dispensaries. However, achieving BP control has been challenging; preliminary analysis of CDM Program data indicates that despite an average reduction in systolic BP (SBP) of 9.3 mmHg, only 30-40% of the CDM patient population have controlled BP. Thus, the program is actively seeking out innovative approaches to optimize care delivery and outcomes for patients.

AMPATH is also sensitive to the economic reality of its catchment population, recognizing that the average daily income for a substantial proportion of its clients is less than one US dollar per day. AMPATH has created a Safety Net Program to improve the economic security of clients without encouraging dependency, by promoting income-generating activities. The program has conducted preliminary work organizing microfinance groups, initially starting with HIV patients and pregnant women, and recently expanding to patients with diabetes and hypertension. Based on the model of Village-Level Savings and Loan Associations, AMPATH's microfinance program is a client-driven model that involves the creation of community savings groups. Thus, microfinance group members mobilize and manage their own savings, provide interest-bearing loans to group members, offer a limited form of financial insurance, and contribute to a social fund that is used in cases of emergency or welfare issues of group members. AMPATH also provides group members specific training on agribusiness, entrepreneurship, financial literacy, accounting, marketing, and group dynamics, to support engagement in sustainable income-generating activities. Since the program was launched in November 2010, there have been a total of 9,969 clients (83.8% female, 16.2% male), 508 groups, cumulative deposits of over $250,000 and social fund of nearly $23,000. The microfinance program has increased group membership by 14% with a retention rate of over 98%. An impact evaluation of the microfinance program revealed that group members have increased their monthly income by 10% and increased their weekly expenditure on food per household by 18%.

This research project will be conducted within the AMPATH catchment area, in six Divisions in western Kenya, each of which is geographically and administratively divided into Community Units (CUs) of approximately 6,000 individuals: Burnt Forest (4 CUs), Chulaimbo (8), Endebess (4), Kapsara (6), Matunda (4), and Moi's Bridge (6). Each Division has rural health facilities (rural health centers and rural dispensaries) staffed by clinical officers (mid-level practitioners) and nurses, while CHWs are in the villages. There has been a longstanding positive relationship among AMPATH, healthcare providers, and the communities. The CDM program has an established presence in all these communities.

Conceptual Framework Both microfinance and group medical visits can improve health outcomes through many mechanisms. The research team hypothesize that both interventions can cause changes in social network characteristics, leading to improved intermediate factors (diet, physical activity, medication adherence, and retention in care), ultimately yielding CVD risk reduction. It is also possible that both interventions can impact the intermediate factors and health outcomes independent of social network characteristics. Likewise, changes in social network characteristics may mediate the relationship between the interventions and CVD risk reduction independent of the intermediate factors. In addition, the interventions may be related to the health outcomes by other independent pathways. Finally, baseline differences in social network characteristics may moderate the impact of microfinance and group medical visits on CVD risk reduction.