Original Investigation
Group Medical Visit and Microfinance Intervention for Patients With Diabetes or Hypertension in Kenya

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Abstract

Background

Incorporating social determinants of health into care delivery for chronic diseases is a priority.

Objectives

The goal of this study was to evaluate the impact of group medical visits and/or microfinance on blood pressure reduction.

Methods

The authors conducted a cluster randomized trial with 4 arms and 24 clusters: 1) usual care (UC); 2) usual care plus microfinance (MF); 3) group medical visits (GMVs); and 4) GMV integrated into MF (GMV-MF). The primary outcome was 1-year change in systolic blood pressure (SBP). Mixed-effects intention-to-treat models were used to evaluate the outcomes.

Results

A total of 2,890 individuals (69.9% women) were enrolled (708 UC, 709 MF, 740 GMV, and 733 GMV-MF). Average baseline SBP was 157.5 mm Hg. Mean SBP declined −11.4, −14.8, −14.7, and −16.4 mm Hg in UC, MF, GMV, and GMV-MF, respectively. Adjusted estimates and multiplicity-adjusted 98.3% confidence intervals showed that, relative to UC, SBP reduction was 3.9 mm Hg (−8.5 to 0.7), 3.3 mm Hg (−7.8 to 1.2), and 2.3 mm Hg (−7.0 to 2.4) greater in GMV-MF, GMV, and MF, respectively. GMV and GMV-MF tended to benefit women, and MF and GMV-MF tended to benefit poorer individuals. Active participation in GMV-MF was associated with greater benefit.

Conclusions

A strategy combining GMV and MF for individuals with diabetes or hypertension in Kenya led to clinically meaningful SBP reductions associated with cardiovascular benefit. Although the significance threshold was not met in pairwise comparison hypothesis testing, confidence intervals for GMV-MF were consistent with impacts ranging from substantive benefit to neutral effect relative to UC. Incorporating social determinants of health into care delivery for chronic diseases has potential to improve outcomes. (Bridging Income Generation With Group Integrated Care [BIGPIC]; NCT02501746)

Key Words

diabetes
group medical visits
hypertension
Kenya
microfinance
social determinants of health

Abbreviations and Acronyms

AMPATH
Academic Model Providing Access to Healthcare Partnership
BP
blood pressure
CVD
cardiovascular disease
DBP
diastolic blood pressure
GMV
group medical visit
LMICs
low- and middle-income countries
MF
microfinance
SBP
systolic blood pressure
UC
usual care

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Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.

K.M. Venkat Narayan, MD, MSc, MBA, served as the Guest Associate Editor for this paper. Javed Butler, MD, MPH, MBA, served as the Guest Editor-in-Chief for this paper.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Drs. Hogan and Fuster contributed equally to this work as senior authors.