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
Authors: Ramani-Chander Anusha , Joshi Rohina , van Olmen Josefien , Wouters Edwin , Delobelle Peter , Vedanthan Rajesh , Miranda J Jaime , Oldenburg Brian , Sherwood Stephen , Rawal Lal B , Mash Robert James , Irazola Vilma Edith , Martens Monika , Lazo-Porras Maria , Liu Hueiming , Agarwal Gina , Waqa Gade , Marcolino Milena Soriano , Esandi Maria Eugenia , Ribeiro Antonio Luiz Pinho , Probandari Ari , González-Salazar Francisco , Shrestha Abha , Sujarwoto Sujarwoto , Levitt Naomi , Paredes Myriam , Sugishita Tomohiko , Batal Malek , Li Yuan , Haghparast-Bidgoli Hassan , Naanyu Violet , He Feng J , Zhang Puhong , Mfinanga Sayoki Godfrey , De Neve Jan-Walter , Daivadanam Meena , Siddiqi Kamran , Geldsetzer Pascal , Klipstein-Grobusch Kerstin , Huffman Mark D , Webster Jacqui , Ojji Dike , Beratarrechea Andrea , Tian Maoyi , Postma Maarten , Owolabi Mayowa O , Birungi Josephine , Antonietti Laura , Ortiz Zulma , Patel Anushka , Peiris David , Schouw Darcelle , Koot Jaap , Nakamura Keiko , Tampubolon Gindo , Thrift Amanda G 
Published: April 2022

IntroductionThere 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 analysisWe 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 TPand conduct multistakeholder qualitative interviews to gather data at T0and T1.We will undertake descriptive statistical analysis of TPdata and analyse T0and T1data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.Ethics and disseminationThe 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.