Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study

Global Alliance for Chronic Diseases Upscaling Working Group Collaborators, Anusha Ramani-Chander, Rohina Joshi, Josefien van Olmen, Edwin Wouters, Peter Delobelle, Rajesh Vedanthan, J. Jaime Miranda, Brian Oldenburg, Stephen Sherwood, Lal B. Rawal, Robert James Mash, Vilma Edith Irazola, Monika Martens, Maria Lazo-Porras, Hueiming Liu, Gina Agarwal, Gade Waqa, Milena Soriano Marcolino, Maria Eugenia EsandiAntonio Luiz Pinho Ribeiro, Ari Probandari, Francisco González-Salazar, Abha Shrestha, Sujarwoto Sujarwoto, Naomi Levitt, Myriam Paredes, Tomohiko Sugishita, Malek Batal, Yuan Li, Hassan Haghparast-Bidgoli, Violet Naanyu, Feng J. He, Puhong Zhang, Sayoki Godfrey Mfinanga, Jan Walter De Neve, Meena Daivadanam, Kamran Siddiqi, Pascal Geldsetzer, Kerstin Klipstein-Grobusch, Mark D. Huffman, Jacqui Webster, Dike Ojji, Andrea Beratarrechea, Maoyi Tian, Maarten Postma, Mayowa O. Owolabi, Josephine Birungi, Laura Antonietti, Zulma Ortiz, Jaap Koot, Amanda G. Thrift

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INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.

METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.

ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Original languageEnglish
Article numbere053122
Number of pages10
JournalBMJ Open
Issue number4
Publication statusPublished - 18-Apr-2022


  • health services administration & management
  • protocols & guidelines
  • public health

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