Evaluation of a scaling up strategy for noncommunicable diseases interventions using the RE-AIM framework –  A case study from Vietnam

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Koot, Johanna Vervoort, Zinzi Pardoel, Giang Nguyen Hoang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6311998/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality in Vietnam. The government has a strategic NCD plan in place, which puts emphasis on community-based prevention and screening and primary healthcare-based early diagnosis and treatment. The project Scaling-Up NCD Interventions in Southeast Asia (SUNI-SEA) implemented community-based screening in Intergenerational Solidarity Groups (ISHGs) and capacity building for early diagnosis and treatment in Commune Health Stations (CHSs). Through creating synergies between community and PHC the project aimed at scaling up NCD prevention and control in Vietnam. This paper presents the methodology for monitoring processes and results in scaling up NCD prevention and control in Vietnam, and lessons learned for global action in this field. Methods: The project used the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to develop quantitative and qualitative indicators for measuring the implementation. The project applied a sequential explanatory design to perform routine monitoring, surveys and in-depth interviews, leading to final conclusions. Results: The project managed to scale up NCD interventions successfully through horizonal scaling-up (reaching more people) and vertical scaling-up (increasing the package of services). Risk factors for diabetes and hypertension were identified in community-based screening, and early treatment started in CHSs. Health literacy of community members increased, and skills of health workers improved. The processes of scaling up were highly dependent on good communication and commitment of stakeholders (community members, community-based organisations, health workers, health managers), clear agreements on roles and responsibilities, as well as simple understandable interventions, with good protocols and guidelines. Technical support and continuous capacity building is required throughout the process. Organisational, financial and human resources constraints hamper scaling up. Conclusions: The RE-AIM framework is a suitable tool for measuring scaling up interventions. For application in routine situations, monitoring must be simplified. A sequential explanatory design helps to measure results and processes step by step. Barriers and facilitators for scaling-up NCD interventions were identified. Trial registration: NCT05239572 date 25 Oct 2023 Scaling up non-communicable diseases diabetes hypertension Vietnam RE-AIM sequential explanatory design community health primary healthcare Figures Figure 1 Figure 2 Figure 3 INTRODUCTION General introduction Noncommunicable diseases (NCDs), including diabetes and hypertension, represent a rapidly increasing global public health challenge, responsible for 41 million deaths annually, with disproportionate impacts on low- and middle-income countries ( 1 ). The increased morbidity and mortality of these diseases is mainly driven by rapid unplanned urbanisation, increase in unhealthy lifestyles and an ageing population( 2 ). In the Southeast Asian region, almost two thirds of all deaths are caused by NCDs ( 3 ). In Southeast Asia, Vietnam is one of the fastest ageing countries in the world and faces a significant NCD burden ( 4 ). Vietnam has national NCD strategies in place. Primary healthcare (PHC) services in Vietnam play a crucial role in the prevention and management of NCDs ( 5 , 6 ). These services are provided in Commune Health Stations (CHSs) and District Health Centres (DHCs)( 7 ). The national strategy emphasises the involvement of communities in preventive measures ( 8 ) as evidence shows that community-level interventions can effectively address NCDs such as hypertension and diabetes , ( 9 – 11 ). Intergenerational Self-Help Clubs (ISHCs) are currently active across Vietnam, contributing to these efforts at the community level ( 12 ). In Vietnam, NCD screening is applied to identify individuals at higher risk for NCDs or those already affected by them. Appropriate interventions can be offered to maintain health or improve health outcomes( 13 ). Incorporating local culture and context into the provided activities( 14 , 15 ) is important for the successful implementation of screening for NCDs and health promotion activities. ISHCs, with their broad range of activities and extensive reach, serve as a pivotal community-level platform for scaling up NCD screening, prevention, and early detection, particularly in underserved populations in Vietnam ( 16 ). Scaling-up The national strategy in Vietnam is implemented through a wide range of projects and interventions in the healthcare system. However, significant progress is still needed to achieve the strategy’s envisioned outcomes ( 17 – 19 ). While NCD screening and early treatment programmes are effective on a small scale, scaling them up nationwide is essential to meet the national strategy’s goals. This presents challenges, as NCD programmes are not always reaching the target populations, and limited awareness of NCDs can hinder scaling up ( 9 , 20 , 21 ). Scaling up from small-scale pilot projects to large-scale interventions involves two approaches: horizontal scaling up, which aims at reaching more people with existing services (for example, new ISHCs in other geographic areas that start providing screening) and vertical scaling up, which aims at increasing the services for people already reached (for example, adding NCD screening to already implemented health education programmes) ( 22 – 24 ). Both approaches are necessary to ensure comprehensive and sustainable scaling-up. SUNI SEA study The scaling up of NCD screening and prevention in Vietnam, as discussed in this paper, was part of the larger Horizon 2020 European Union funded project: Scaling-Up NCD Interventions in South-East Asia (SUNI-SEA). This 4.5-year (2019–2023) project was conducted in Indonesia, Myanmar, and Vietnam through a collaboration of ten consortium partners in Europe and Southeast Asia. The project performed intervention research into scaling up services for prevention and management of diabetes and hypertension, covering both community activities and PHC strengthening, intensifying collaboration between ISHCs and CHSs. The theoretical model of the intervention research is shown in Fig. 1 in which the synergy between community-based screening and health promotion and PHC-based diagnosis and treatment is depicted. Synergy is contributing to increase uptake of screening, enhance early diagnosis, and improve adherence to medical and non-medical treatment. In the figure, the socio-economic contextual factors influencing the NCD intervention are shown. Figure 1 SUNI-SEA project synergy model: interventions at the PHC facility and in the community In Vietnam, SUNI-SEA leveraged existing and ongoing ISHC and PHC activities around hypertension and diabetes prevention and management. Following a thorough situation analysis to identify the necessary steps for scaling-up, the SUNI-SEA Vietnam country team developed priority interventions to strengthen communities, healthcare organisations, and the NCD control programme in accordance with the model of fit of Korten ( 25 ) (Fig. 2 ). The model highlights the need for alignment between community needs, organisational capacities, and policy support and guided stakeholders in identifying and addressing the key factors necessary for successful scaling up of interventions. Figure 2 Priority intervention plan developed within the SUNI-SEA project in Vietnam To achieve scaling up, the project aimed to strengthen the management of community-based organisations (CBOs) i.e. ISHCs and Associations of the Elderly (AE)). There was also a focus on capacity building for volunteers in performing screening and keeping the screening records. In addition, the team supported patient groups in Vietnam to enhance peer support for lifestyle changes and treatment adherence. Community-based organisations were actively involved in monitoring the activities. For the NCD control programme the project developed and introduced a protocol for NCD screening and a community-based monitoring system to follow up those screened. Health education materials were developed and disseminated, electronic health records and electronic reporting formats were also created. Capacity building in healthcare organisations , was a key component, involving online courses and in-person training sessions to improve the capabilities of healthcare staff using simplified clinical guidelines. Also, organisations were supported with advocacy activities for resource mobilisation and building the commitment of decision-makers to sustain NCD interventions. The activities are described in other publications by the consortium ( 9 , 26 ). Measuring the scaling-up of the SUNI-SEA project was challenging due to the complexity of the contributing factors. In recent years, various models have been developed to address this complexity ( 27 ) In literature, the definition of scalability of interventions has been scrutinised ( 28 ) and tools for measuring scalability have been evaluated ( 29 ). However, there is limited literature that describes the full process of measuring scalability in practice. Aim of this study In this study, we report on processes and outcomes of the scaling up strategy applied in the SUNI-SEA project in Vietnam and identify facilitators and barriers to scaling-up as experienced by stakeholders in the community, in the health system, and policy makers. We reflect on the complex evaluation methodology of scaling-up activities. MATERIALS AND METHODS Setting As part of the larger SUNI-SEA project the scaling up strategy was implemented in 59 ISHCs in Ninh Binh and Hai Phong provinces in Vietnam and in 114 CHSs and 7 DHCs serving the communes and districts where ISHCs were established. Identified stakeholders were the ISHC members and community volunteers, implementers in the health system, like PHC health staff and local health managers, district and provincial health authorities in Ninh Binh and Hai Phong provinces, as well as managers of CBOs and policy makers in the health and wellbeing of elderly in Vietnam. Framework and indicators for evaluation of scaling up To evaluate scaling-up activities, we used the (updated) RE-AIM ( 30 , 31 ) framework, allowing a nuanced understanding of both impact and sustainability of scaling-up ( 26 ). RE-AIM systematically examines five dimensions of individual and organisational level outcomes, namely: Reach, Effectiveness, Adoption, Implementation, and Maintenance. It has an explicit focus on the design, dissemination, and implementation processes that can either facilitate or impede success in achieving broad and equitable population-based impact. The RE-AIM framework applies a mixed method approach of quantitative data and qualitative data collection to better understand how and why results are achieved. The RE-AIM framework is widely used in public health development programmes and is appreciated because it provides a structure to systematically evaluate impact and processes ( 31 ). Within the SUNI-SEA project, descriptions for each of the RE-AIM dimensions of results and process topics for the given definitions were formulated in the inception phase of the project. (See Table 1 for summary). Table 1 RE-AIM indicators and monitoring topics RE-AIM dimension Description of the dimension Result topics Process topics Reach Individually : People in communities and health services who participated in the prevention programmes, and assessment of who was more likely to participate and why. Health system : the extent to which programmes were covering all areas they were supposed to cover. Individually : Number of ISHC members screened for NCD risk factors. Persons reached : in communities (ISHCs) and in health facilities (service providers). Organisations involved in communities and the health system. Geographic coverage of planned districts. Creation of synergy of the health system and community : (see Fig. 1 ) Improving collaboration between ISHCs and CHSs and DHCs. Development of mutual understanding of services and referrals between communities and CHSs. Mapping of advocacy activities : Efforts to reach CBOs, health managers, policy makers to bring them on board in expansion of the programme. Effectiveness Individually : The outcome and impact of the programme, including potential negative effects, quality of life, and economic outcomes. Health system : Quality assurance throughout the project and attitudes towards perceived effects on targeted outcomes at the end of the programme. Individually : Number and percentages of persons diagnosed with illness risk factors and persons referred. Health workers capable of diagnosis and treatment. Improved knowledge and behaviour of ISHC members because of the interventions. Organisationally : Number of health facilities operating according to national standards. Individually : Processes of increasing health literacy of community members, ability to make decisions about their own health. Organisationally : Development processes of policies to implement prevention and screening of NCSs in communities. Economically : Increasing knowledge into costs and benefits of scaling up, as an investment case for improving health. Adoption Individually : At the participant level characteristics of those who participated and those who were hesitant, including their reasons for hesitation. Health system : At the organisation level characteristics of organisations and implementation sites, including those invited to participate and their organisations, and reasons for adoption or non-adoption. Individually : Number of persons who participated in the ISHCs throughout the project. Number of community volunteers active throughout the project. Organisationally : Number of organisations that committed to the project after invitation. Electronic medical record functional and number of persons with completed report. Context : Gaining insights about and experience with contextual barriers. Engagement : Developing cooperation and involvement of stakeholders and readiness to get involved in the implementation. Implementation Individually : The intervention agent’s fidelity to the various elements of the protocol, including consistency of delivery as intended and time required. Health system : This also includes the training of staff, using checklists, recording of adaptations made, and the costs of the implementation. Screening : Number of screening activities performed in ISHCs. Number of community reports submitted. ISHC boards : Number of training sessions delivered for ISHC boards and volunteers on health education and NCD prevention. Health system : Health education materials developed. Number of health education and information sessions organised in health facilities and ISHCs. Treatment : Improving adherence to policy and new NCD guidelines implemented. Prevention : Development and planning of community activities on NCD prevention and control, health education and promotion activities. Maintenance The ongoing of interventions to sustain the effectiveness (outcome and impact) at the individual level of participants/patients, on programme-level, organisations embedding these programmes into their routine operations and budgets and on regional/national level policy that makes optimal reach and implementation possible Contracts : Number of contracts between the health sector and AEs signed for continuation. Commitment : Planning process for continuation of activities, contracts for service delivery. Table 1 RE-AIM indicators and monitoring topics Data collection, monitoring, and evaluation of the implementation process The research team applied a mixed method approach in three steps to measure the formulated RE-AIM indicators. Quantitative and qualitative data were integrated using a sequential explanatory design ( 32 ). First , we performed quantitative monitoring and evaluation activities throughout the course of the project through routine data collection and specific surveys. We incorporated the data in the above shown indicator framework. We first analysed the quantitative measurable results of the project. See Table 2 . Second , based on the RE-AIM framework, we produced a topic list for measuring the scale-up processes as perceived by different stakeholders (communities, CBOs, mass organisations, healthcare managers, policy makers). We conducted in total 58 in-depth interviews (IDIs) with one or more interviewees. At the provincial level, two IDIs (one per province) were conducted with representatives from the Provincial Department of Health and relevant functional divisions, as well as representatives from the Centre for Disease Control (part of provincial health structure). At the district level, seven IDIs (one per district across seven districts) were conducted with representatives from the DHC and relevant units involved in the prevention and management of hypertension and diabetes. At the commune level, IDIs were conducted with: ( 1 ) heads of all CHSs located in the commune where ISHCs were established (seven IDIs, one per district across seven districts); ( 2 ) CHS staff members (21 IDIs, one per commune across three communes per district across seven districts); and ( 3 ) hypertension/diabetes patients (21 IDIs, one per commune across three communes per district across seven districts). The researchers took notes in some meetings and recorded and transcribed discussions in other meetings. They entered the results of the consultation in the comprehensive RE-AIM framework matrix. Third , we conducted an evaluation meeting with the Vietnamese team and the international researchers from Myanmar, Indonesia, and Europe. In this meeting, final facilitators and challenges for scaling up NCD interventions were formulated. An international expert in qualitative research guided the focus group discussions, and a second expert took notes during the meeting. Table 2 Quantitative data collection in SUNI-SEA Quantitative data collection title Data collected Number respondents Time or period Baseline and endline community surveys Knowledge, attitudes, and practices of ISHC members 897 ISHC members and 813 control participants First quarter 2021 – First quarter 2023 Surveys capacity building ISHC volunteers Pre-test and post-test knowledge and follow-up survey one year after training 59 persons Various periods from 2021 to 2022 Baseline and endline patient surveys Knowledge, attitude, and practices of patients regarding hypertension and diabetes self-management, service utilization and treatment adherence 1 008 patients (baseline) and 745 patients (endline) First quarter 2021 - Fourth quarter 2022 PHC staff survey – Baseline and Endline survey Knowledge, attitude, and practices of PHC staff regarding hypertension and diabetes management 102 PHC staff First quarter 2021 - Fourth quarter 2022 Electronic screening records in communities Two sessions of screening with measurement of blood pressure, body mass index, risk factors NCDs 3 485 persons During 2022 Activity reporting ISHCs, HelpAge staff Screening sessions, health education sessions, meetings with health officials 59 ISHCs 114 CHSs From last quarter 2021 until first quarter 2023 Cost-effectiveness analysis Cost data of community activities (screening health education) and PHC treatment data 59 ISHCs 114 CHSs 2023 Health facility survey The availability of resources for NCD management, service provision. 40 CHSs First quarter 2021 – First quarter 2023 The steps are shown in Fig. 3 . Figure 3 Monitoring and Evaluation process in the SUNI-SEA project Quantitative data For the quantitative monitoring, a set of instruments was put in place, addressing the topics of the RE-AIM framework. Baseline and endline surveys were conducted among community members to measure changes of knowledge, attitudes, and practices over time. Several surveys were conducted to measure specific project activities, like capacity building of ISHC members, and training of volunteers and health workers. Continuous (routine) data collection was done through electronic health records maintained by ISHC volunteers. Publications of part of the surveys are available ( 9 , 33 – 35 ). Table 2 Quantitative data collection in SUNI-SEA Ethical considerations The SUNI-SEA project adhered to privacy protection rules, using varied methods to safeguard participant data depending on the study phase. Ethical approval was granted by the Institutional Ethical Review Board of Hanoi School of Public Health, with the number 485/2019/YTCC-HD3, on November 13, 2019. Extension was granted on April 25, 2023, with approval number 196/2023/YTCC-HD3. All participants signed informed consent forms. The studies involving human participants were reviewed and approved by HelpAge International. The patients/participants provided their written informed consent to participate in this study. In case the participants were researchers from the SUNI-SEA consortium, ethical review and approval were waved. RESULTS We first report on the results of step 1 and step 2 (Fig. 2 ) of the quantitative data collected and the consecutive qualitative analysis of the process of scaling up, following the RE-AIM framework. REACH - Results: Persons reached in communities (ISHCs) and in health facilities (service providers). Over an 18-month period, 3,485 individuals participated in 59 ISHCs in Ninh Binh and Hai Phong provinces in Vietnam. NCD screening was conducted twice in all ISHCs, with 94% of members participating, and 96% of those attending both screening rounds. A control group of 205 non-ISHC members were screened in CHSs. Organisations engaged The project engaged a range of organisations within the community and health system, including 114 CHSs, 7 DHCs and two provincial health departments. During the project, 86.7% of the CHSs in Ninh Binh and 81.3% in Hai Phong supported NCD screening in ISHCs. The Centres for Disease Control (part of the district health office) also contributed to the project and later adapted the materials for use in other health centres. Geographic coverage of planned districts. All 7 targeted districts of two provinces were covered and DHC staff participated in supervision and support. REACH - Process: Synergy of the health system and mapping of advocacy activities. In the process of creating synergy between the different stakeholders, we found that communication and (systems that support) collaboration were the main topics mentioned in interviews. Stakeholders identified commitment and open communication between ISHCs and CHSs as crucial for successful collaboration. Because their mandates are complementary, ISHCs and CHSs can mutually reinforce their respective activities, according to interviewees. Productive communication between ISHCs’ volunteers or boards and CHSs’ staff/management fosters collaboration. Conversely, poor communication directly impedes joint activities. For example, the referral process of persons with NCD risks between ISHCs and CHS is informal, as there is no regular referral mechanism between community groups and public health services. To foster sustainable collaboration between ISHCs and CHSs, beyond individual motivation and organisational capacity, support from external stakeholders, including AEs and local DHCs, is necessary. In several districts, these collaborations were formalised in collaboration agreements between governmental organisations and CBOs. CHS staff in Ninh Binh “The ISHC operates in a very organised manner. They have obtained permission from the local People's Committee to collaborate with the local health centre. Every month, representatives from CHS come to support the club to measure blood pressure and weight for older people during their club activities. They provide guidance for individuals with hypertension to visit the health centre for examination and medication. Having this club throughout the city would be great, as it would attract more participants.” Chairperson of ISHC, female “…. A better and closer collaboration between ISHC and CHS supports the screening at the ISHC. It brings a lot of benefits to ISHC. The health volunteers are very happy, they learn a lot from the health staff and build trust with club members”. EFFECTIVENESS - Results Individually During all screening sessions in ISHCs in total 978 persons were identified with a high risk for hypertension and 228 with a high risk for diabetes. In Ninh Binh in CHSs, 146 persons were diagnosed with high blood pressure and another 64 persons in Hai Phong. For diabetes, these numbers were 56 and 28 respectively. Health workers demonstrated substantial improvement in performance, increasing their average scores on diagnosis and treatment knowledge from 62–76% and protocol adherence from 19–56%. A set of handbooks for self-management of diabetes and hypertension was developed and distributed to community volunteers, and peer support groups were created. Following the intervention, 82% of ISHC members reported improved health behaviours due to group activities, while 79% of patients in peer support groups in CHSs reported improved treatment adherence. A survey showed that adherence to treatment of anti-hypertensive medicines increased from 25.6–35.9% among ISHC members. Improved knowledge and behaviours of ISHC members because of the interventions: Baseline and endline surveys were conducted with 897 ISHC members and 813 control participants. Significant improvements were observed in knowledge of NCD risk factors among ISHC members and adherence to physical activity recommendations. After the intervention, ISHC members were able to name more risk factors, symptoms, and complications of both diabetes and hypertension. Similar trends were seen in other knowledge indicators. There were fewer people with high blood pressure amongst ISHC members. However, there were not many significant differences between ISHC members and control group related to diagnosis and health behaviours. We only found differences in ever being diagnosed with hypertension, complying with physical activity guidelines, and knowing the recommended amount of salt intake. Smoking, for example, did not reduce. Organisationally : Number of health facilities operating according to national standards: the Vietnamese clinical guidelines were rewritten in simplified formats for lower-level trained health workers and made available. Desktop treatment instructions were disseminated in 114 CHSs. 126 staff members were trained in diagnosis and treatment of NCDs. In 90.5% of CHSs in Ninh Binh and 55.9% of CHSs in Hai Phong, proactive hypertension diagnosis and treatment were offered to visiting patients. EFFECTIVENESS – Process Increased health literacy. As a result of the interventions that have been implemented and scaled up, health literacy of community members and therefore their ability to take decisions about their own health has improved. Community members indicated that they know more about NCDs and the availability of health services, in case they are identified with high risks for diabetes or high blood pressure. Community members were better able to understand received leaflets and communicate about organised interventions. The possibility to ask questions to visiting CHS staff was very helpful for the community members. Therefore, CHSs could organise their activities more effectively. Club member, male "…. I was classified as prehypertension through the first screening event of the ISHC. After that, I was advised by the health volunteers on how to change my diet (reduce salt intake, increase my intake of green vegetables), drink enough water (1.5-2 litres per day), reduce alcohol and tobacco, and increase exercise and sports. Every month when I attend club meetings, health volunteers also help to check my blood pressure. Now my blood pressure is stable and there is no sign of increasing, my weight has also decreased a bit. I feel good now." Implemented policies . The existing policy mechanisms that are promoting social welfare and healthcare programmes for older people are highly appreciated by local AEs. These policy mechanisms support the stakeholders, like AEs, ISHCs and CHSs, in implementing further activities on topics like prevention of diabetes and high blood pressure. The cooperation between CHSs and ISHCs is not only leading to health benefits for older people (regular health check-ups and screening for non-communicable diseases) but also support CHSs in their task of managing people's health in their catchment area. Challenges in the financial mechanisms for providing healthcare services, such as the availability of medicines and supplies, health insurance reimbursement, are still present, according to interviewees and need to be addressed when developing policies further in the future. Health leader, male “ … the cooperation between the health sector and AE, ISHCs has been achieving high efficiency and performing well in health management in the community. This is a practical and meaningful model that needs to be maintained and replicated to meet the healthcare needs of older people, helping to reduce the burden for the health sector. We considered ISHC health volunteers as an extended arm of the health sector in communities”. CHS staff in Hai Phong “In the past, the training only focused on discussing the disease and its complications. There was no emphasis on treatment, only on counselling and care. However, now there is a shift towards treatment, which the doctors prefer. Previously, the training focused on regulations, guidelines, monitoring, and updating software information. Currently, the training includes skills such as patient communication, medication usage, and patient nutrition. Such training programmes can be conducted annually, providing a refresher and ensuring that knowledge is not forgotten, while also updating participants on new knowledge.” Costs of scaling up. According to the AEs, part of the success of the implemented interventions lies in the fact that they are low cost, simple interventions and are closely linked to regular activities and household chores. They are suitable for the community’s lifestyle in Vietnam. Due to the low costs of the health-related activities, it is easier for the ISHCs to cover the costs from their existing funding sources in the current system of healthcare financing. If that is not the case, many ISHC leaders are capable of raising the additional funds that are needed for the implementation of the interventions. ADOPTION – Results : Community: A training programme for ISHC volunteers and board members was developed and implemented. In the first training round 420 volunteers, ISHC boards, and stakeholders participated and in the second round 550 participated. Health education materials were developed and disseminated in communities. The ISHC health volunteers and management boards were able to implement the screening and health promotion activities autonomously. PHC staff: Training of health workers on NCDs and health education had a significant positive impact on hypertension management at CHSs. PHC staff improved their practices, particularly in health education and monitoring, in accordance with Ministry of Health guidelines. CHS doctors expanded the range of health education topics for patients, focusing on healthy diet and lifestyle modifications. This resulted in increased patient engagement with CHS services, including counselling, clinical examinations, and health education. Consequently, patients showed significant improvements in their knowledge of hypertension risk factors and medication adherence and adopted healthier lifestyle practices, such as improved medication adherence, blood pressure self-monitoring, reduced salt intake, and increased physical activity. ADOPTION – Process Knowledge about and experience with contextual barriers and cooperation and involvement of stakeholders and readiness to get involved in the implementation. Building trust between partners and within the community was crucial in the process, requiring dedicated effort and time from all involved. Transparency by healthcare organisations in both activity planning and communication proved to be a key factor in their success. The ISHCs in the community have the capacity of building trust in the community, according to PHC staff. When all are clear on who has what role, it is easier to implement healthcare activities, especially for older people. Establishing a strong link between CHSs and ISHCs, with CHS staff providing advisory support to ISHC management, was found to be especially effective. CHS staff in Ninh Binh “To facilitate the intervention, we need to have a good plan from the city or provincial level, CHS can propose to the committee to establish a directive that guides the coordination among various stakeholders. With the committee's guidance, the organisations and sectors will actively participate in the collaboration. Since we don't have active village health workers in the urban commune, we rely on the team leader of the village to use a loudspeaker to announce to the community to come to the CHS. Secondly, the age group targeted by the project is mostly working individuals over the age of 40. We have collaborated with ISHC to deliver information to the community. It has been more effective in the village where there is a club compared areas without ISHCs as we have to visit each household individually. The local government is very attentive, and when we consult People's Committee, they are willing to provide assistance.” There are several barriers to overcome in establishing cooperation. Among others, lack of clear collaborating mechanisms and communication, lack of data-sharing, and lack of active engagement are seen by interviewees as problems. Effective cooperation depends partly on individual people, so mediating mechanisms needs to be in place. Respondents indicated that to overcome these barriers several steps can be taken. For example, formalising collaborations through official agreements and clearly defined operational procedures was suggested. Training for all partners involved is also important, as well as regular meetings between the (management of) involved partners. Although NCDs are a priority for the provincial department of health there is also a challenge on human resource level – getting enough (qualified) individuals involved is a challenge for all partners. Therefore, it is even more important to draft feasible plans together on how to implement the activities and for example ensure medication availability. ISHC Chairperson, female : “…my ISHC has mobilised support from departments, local authorities, and community members: 17 million VND (~ 700 EUR) to organise the year-end ceremony and more than 10 million VND (~ 400 EUR) to buy a television for the ISHC. Besides, ISHC also invites health staff, departments, and local authorities to attend and support the club's activities. The chairperson is very active in approaching and sharing with relevant stakeholders of the ISHC annual plan, activities, and events. So, our ISHC received support and has smoothly collaborated with the CHS, local authorities, etc. …”. IMPLEMENTATION - Results Community The number of screening sessions performed in ISHCs was 118, with 90% of the members participating. Health education materials were developed. 174 health education and communication sessions were organised in ISHCs with 85% of members participating. 600 manuals for self-management of risk factors were distributed to the volunteers and board members of ISHCs. 3 500 health booklets and 7 300 health information leaflets were disseminated. 59 banners with health messages were put up in communities. Health system The intervention led to a dramatic increase in community screening for hypertension and diabetes at CHSs, as evidenced by a health facility survey. Hypertension screening coverage among CHSs increased more than three times, from 26–80%, while diabetes screening more than tripled, rising from 21–67%. This resulted in a substantial increase in the number of newly diagnosed hypertension and diabetes cases within their catchment areas. IMPLEMENTATION - Process Adherence to policy and new NCD guidelines implemented. In practice, the CHS staff follows the national guideline on diagnosis, treatment, and management of common NCDs at CHS (Decision 5904/2019/TT-BYT issued by Ministry of Health). This guideline includes, among other things, guidance on health communication and screening and treatment of hypertension and diabetes. Training is helping health staff and community volunteers in gaining knowledge and experience with diagnosing and treating according to the methods set out in the guideline. The practice is not yet aligned to the policy. For example, the provision of required medicines for treatment at PHC level is insufficient. Also, infrastructural and financial barriers are experienced in the implementation process. CHS head “Firstly, it is important to regularly update training materials and provide training not only for CHS personnel but also for village health workers. Secondly, to ensure effective implementation and management, there should be a sufficient budget allocated to CHSs to provide resources and create favourable conditions for NCD activities, especially for those who have specialised training to guide others at CHSs. As for medication supply, although there is currently no shortage, it is crucial to maintain a consistent and sufficient supply, ensuring that there are reserves in case of unexpected shortages to serve the community”. Community activities for NCD prevention and control, health education, and health promotion activities. Collaboration agreements on the CHSs/ISHCs level are very instrumental, but also between district AEs and DHCs. Also, guidance, direction, and support from the district health office to DHCs and CHSs leads to smoother implementation processes. Creating networks of ISHCs to exchange experiences was instrumental to strengthening activities across the network. The local health managers and health authorities indicate that ISHCs should be considered as an extended arm of the healthcare sector, and vice versa. Provincial Department of Health in Ninh Binh “At this time, the priority is to establish a financial mechanism to ensure the payment for healthcare services through health insurance. The medical examination fees have not reimbursed for CHSs since 2018, which did not create the motivation of CHS staff in provision of health services. Secondly, ensuring an adequate supply of medications in terms of quantity and variety is crucial. It requires more decisive guidance and implementation from the high-level health authorities” MAINTENANCE - Results The project staff conducted in total 10 meetings with health authorities, local government organisations, and interest groups to discuss the progress and sustainability of the project, leading to agreements on the way forward. Cost-effectiveness: The current cost-effectiveness evaluation suggests that although there is need for a substantial investment in preventive activities such as screening, health education, and added treatment of hypertension and diabetes, potential savings in prevented complications of hypertension and diabetes could make this investment worth its value. Number of contracts signed for continuation: Both the Ninh Binh and Hai Phong AEs signed collaboration agreements with Provincial Department of Health for the continuation of the governmental support to ISHCs in implementing health care activities, especially in NCD screening. The Ninh Binh AE signed a contract with a commercial company for sponsoring ISHC healthcare activities and NCD screening after the end of the project. By the end of the project, two collaboration agreements at the district level (District AEs and DHCs) were signed. The Ninh Binh AE collaborated with the Provincial Department of Health and had vertical directions to the district level in all eight districts to sign the collaboration agreement in 2023 in order to support healthcare activities in ISHCs. The Government of Vietnam decided to increase the number of ISHCs from the current 500 to countrywide 6,000. MAINTENANCE – Process In the previous paragraphs of RE-AIM many helping and hindering factors already have been mentioned that also relate to the sustainable implementation of the activities. The main helping factors that are identified are availability of related policies including formal collaboration agreements, capacity building, availability of SUNI-SEA tools and acknowledging the role of ISHC’s and their volunteers in this process of creating a sustainable and maintainable NCD’s intervention program. It is hindering when there is low awareness of the specific roles of community-based organisations and ISHC’s in healthcare, when there is a lack of monitoring and supervision at the implemented activities and when there is no adequate availability of volunteers, staff (human resource problems) and finances to keep the activities going. District health manager “However, there is concern that once the programme ends, the clubs might cease their activities. Therefore, the involvement of the local government is necessary to sustain the model, with healthcare playing a role in advising the People's Committee for their active participation. The direction should come from the top-down. The involvement of the local government is needed to provide motivation for the healthcare sector. I have already presented the plan to the People's Committee .” Final conclusions on facilitators and barriers of scaling up NCD interventions per RE-AIM domain In the end of project meeting of the consortium (step 3) a final discussion on the processes and results described above took place. The main points of this discussion are summarised in an overview of helping and hindering factors when scaling up interventions aimed NCD prevention. The factors are shown in Table 3 below. The findings were widely disseminated and were used in other studies ( 36 ). Table 3 Facilitators and barriers for scaling up NCD interventions Facilitators Barriers REACH • Related policies mentioning responsibility and role of health sectors in support ISHC and ISHC scale up, including collaboration agreements between the health sector and local AEs-ISHCs • Mobilisation and engagement of key stakeholders (local government, health, AE, ISHC) by organizing stakeholder meetings leading to commitment and feeling responsible • Acceptance / willingness of ISHC members towards synergy approach • CHS attending training for ISHC health volunteers • Low commitment of local government, health sector, and AEs in some areas • Limited resources: both human resource and financial • Lack of communication between ISHC and CHS due to no formal mechanism for reporting and feedback, both two-ways EFFECTIVENESS • Capacity building: including training and regular technical support • Good and easy to understand training and information-, education-, and communication materials • Low costs of interventions • Interventions are simple and suitable for community’s cultural lifestyle • COVID: limited time and overload of the health sector, irregular technical support from HelpAge and local AE staff • Financial mechanisms for providing healthcare services (such as medicines) • Lack of younger members in community volunteers and ISHC management boards • Lack of communication skills of community health volunteers and ISHC management boards in the implementation of NCD prevention and health education for ISHC members ADOPTION • CHS staff being advisors of the management board of ISHC • Regular updating/communication and information sharing between ISHCs and local authorities • Formal collaboration agreement • No communication and information sharing between ISHCs and local authorities • No formal collaboration agreement/mechanism • No concrete implementation plan that was discussed with the CHS leader in advance which hindered CHS to allocate time and personnel (consensus about timeline and collaborative activities is needed) • Depending on enthusiasm and responsibility of ISHC’s management IMPLEMENTATION • Simplified format of guidelines • Capacity building for both ISHC and PHC: improving knowledge, communication, self-confidence • Availability of policy in place including formal collaboration agreement • No follow-up or monitoring of existing policy implementation • Financial mechanisms for providing healthcare services (such as medicines) • Human resource: insufficient health personnel MAINTENANCE • Availability of related policies including having a formal collaboration agreement • Capacity building • Availability of tools developed in the project • Acknowledging the role of ISHC and volunteers • Low awareness of role of CBO/ISHCs in health care • Lack of monitoring and supervision • An adequate availability of human resource and financing (is more a precondition) Table 3 Facilitators and barriers for scaling up NCD interventions Discussion In this study, we reported the process and outcomes of the SUNI-SEA project and identified facilitators and barriers to scaling-up community-based and PHC-based interventions for prevention, early detection and control of NCDs in Vietnam. We applied a sequential explanatory design to our monitoring and evaluation methodology based on the RE-AIM framework. We first analysed quantitative results of the implementation research and used these results and the perspectives of stakeholders to get insights into the processes, facilitators, and barriers of scaling up. This resulted in a comprehensive overview of relevant factors for the process of scaling-up projects globally, at the community level, PHC level, health management level, and policy level. The findings were discussed within a broader research team and resulted in a concrete set of key points of attention grouped according to the RE-AIM domains. These insights contribute to the global discourse on scaling up community-based health interventions. The findings from this study provide valuable insights into scaling up community-based and PHC-based NCD interventions beyond Vietnam, particularly in decentralised healthcare systems globally. Many LMICs face similar challenges in NCD prevention, including limited resources, fragmented health governance, and the lack of sustainable financing mechanisms. The success of Vietnam’s approach, leveraging existing community networks, formalising partnerships between community-based organisations and PHC facilities, and integrating interventions into national policies, offers several lessons for other contexts. First, the SUNI-SEA project demonstrated that establishing clear agreements between community-based organisations and PHC facilities facilitated sustained collaboration. A similar approach has been used in Brazil’s Family Health Strategy, where community health workers are formally integrated into PHC teams, ensuring continuity of care and systematic NCD prevention efforts ( 37 ). Other LMICs could benefit from clear governance frameworks that define the role of CBOs in NCD prevention. Second, digital health innovations present opportunities but require infrastructure investment, provider training, and policy alignment. Vietnam’s electronic screening records faced interoperability and digital literacy challenges, similar to those encountered in India’s National Digital Health Mission (NDHM) ( 38 ). Addressing these barriers will be critical for scaling digital health solutions in decentralised systems. Third, policy commitment plays a decisive role in the successful expansion of community-based NCD interventions. Vietnam’s strong national policies supporting community-led health initiatives were a key enabler of scale-up. In contrast, many decentralised health systems lack explicit policy frameworks that mandate NCD prevention at the community level. To address this, advocacy strategies used in Vietnam, such as engaging mass organisations, could be adapted in other cultural and governance settings. For example, in several African and Latin American countries, faith-based organisations and municipal health councils play similar community leadership roles and could serve as effective channels for community-driven NCD programs ( 39 , 40 ). We concluded that increasing the reach of the complex interventions, requires the commitment of all stakeholders, ranging from community to policymakers, and continuous interaction among stakeholders to make the synergy approach work. Furthermore, to increase effectiveness, we implemented interventions that were simple, affordable, and accompanied by continuous capacity building for health care providers and community members. In addition, diversifying the backgrounds, ages, and genders of health volunteers and ISHC boards leveraged the quality of activity at the community level. For improved adoption of the community-based intervention, formal agreements between healthcare organisations and CBOs, based on transparent operational plans, were crucial. Implementation can be enhanced by clear governmental policies, sustainable financing mechanisms and practical guidelines for implementers. Finally, the maintenance of community-based interventions was ensured by integrating them into existing policies and practices and by establishing clearly defined roles and responsibilities of community-based organisations in implementation and monitoring. By fostering stakeholder engagement, simplifying interventions, establishing formal agreements, strengthening implementation mechanisms, and ensuring policy integration and community ownership, programmes can achieve broader reach, greater effectiveness, and long-term sustainability. The sequential explanatory design proved to be adequate for analysing complex interventions at the community level, within healthcare organisations, and in NCD prevention and control programmes. The RE-AIM framework proved effective in capturing the multidimensional impacts of scaling-up efforts. It is the most frequently used framework in evaluating scaling up programmes ( 41 ). By applying the RE-AIM framework within a sequential explanatory design, we were able to evaluate over 20 project sub-activities across various areas under umbrella unified framework. The integration of quantitative analysis followed by qualitative interpretation of findings provided a contextualised understanding of the outcomes as recommended by Toyon ( 42 ). The robust analytic structure of RE-AIM, along with clear instructions on how to capture the consultations with stakeholders, ensured reliability and validity of the findings. As a result, we were able to answer the questions of “what” and “how” the scaling up was done. Our approach of phased analysing outcomes and processes through quantitative and qualitative methods, was also advocated by the Medical Research Council for evaluating complex health interventions ( 43 – 45 ). The participatory approach, which actively engaged implementing stakeholders, yielded a wealth of insights into the factors influencing scale-up and the broader context in which it occurred. Rathod et al. identified seven key elements for the successful scaling-up of complex health interventions ( 41 ): Integration of the complex health intervention into national or local policy Capacity building and training, in particular cascade training (i.e. train the trainer) approaches as well as cascade facilitation Resource support (e.g., appointment of staff) Quality improvement and monitoring (e.g., benchmarking against quality criteria) Cultivating partnership and collaboration (e.g., peer-support networks) Transfer of ownership (e.g., shifting to external facilitation) Ongoing advocacy and communication (e.g., based on impact evaluation) All the seven key elements in scaling-up projects were present in the SUNI-SEA project. Vietnam has clear policies and strategies concerning the control of NCDs and community engagement in prevention efforts. Vietnam's decentralised health system enabled tailored approaches at the provincial level, fostering local ownership of interventions. However, this structure requires commitment of local authorities. Successful implementation depended on the commitment of local authorities. In districts with limited health resources or lower levels of commitment from local authorities’ implementation was more challenging. A notable aspect of Vietnam's community-based healthcare system is the role of mass organisations in community-based healthcare. In this project, the Vietnamese AE played a leverage role of initiating and maintaining community-based screening and health promotion activities ( 46 ). Lessons from Vietnam underscore the need for clear coordination mechanisms in decentralised health systems and involving CBOs in implementation. Capacity building was a crucial success factor during the project. Our findings indicate that the adaptation of training materials to local contexts, along with technical support, were essential. During the project general guidelines for cultural adaptation of training were developed, which were cited several times ( 14 ). However, it is crucial that capacity building remains an ongoing effort with refresher courses and supervision. Long-term sustainability will require embedding these efforts within Vietnam’s health system, rather than limiting them to specific projects ( 34 ). The project introduced electronic health records for monitoring and supervising community-based screening activities, which contributed to digital innovation in healthcare but also revealed key challenges in Vietnam’s digital transformation ( 35 , 47 ). Despite these advancements, persistent barriers such as digital literacy gaps, infrastructure limitations, and data integration issues remain. The project successfully facilitated formal agreements between healthcare organisations and branches of the Vietnamese AE, further strengthening community-health collaborations. Additionally, advocacy efforts contributed to the expansion of the ISHC model nationwide, reaching 6 000 communities in Vietnam. However, achieving sustainable and resilient healthcare systems capable of addressing evolving NCD challenges remains a work in progress ( 48 ). The SUNI-SEA project provided critical inputs to scaling up community-based and PHC-based NCD interventions in Vietnam and generated new knowledge on establishing synergies. However, for sustaining the results long term will require strengthening of PHC, improving human resources, and ensuring financial sustainability and reliable medical supply chains. Strengths and limitations The research into scaling up community- and PHC-based NCD interventions benefited from multiple data sources, including several surveys, routine data collection programmes, and consultations with a wide range of stakeholders in the SUNI-SEA implementation research project. This multi-source approach offered a comprehensive spectrum of information and insights into the outcomes and processes of the scaling-up. It was possible to manage the phased approach of quantitative and qualitative data analysis based on the intervention theory and the RE-AIM framework. However, the effort of managing this complex monitoring was huge and only affordable in a research setting. Documentation of all findings of the over 20 specific interventions (listed in Fig. 2 ) was not always complete. With the travel restrictions due to COVID-19 and language barriers, in-depth interviews were mostly done by researchers directly involved in the implementation research. Socially acceptable responses may therefore have been given in some instances. Not all interviews were transcribed in full, and some information may have gone missing in the summaries of meetings. Due to the COVID-19 pandemic, there were various delays, which resulted in a short implementation time. The short implementation time was insufficient to allow for the various physiological changes required to assess the impact on health indicators. It also explains why we mostly observed changes in knowledge, as this is the most proximal element in our theory of change; it is too early to accurately assess the full impact of the intervention on the other outcomes. Implications for practice and research The SUNI-SEA project created screening protocols, clinical guidelines, teaching and health education materials, which are disseminated through the Global Alliance of Chronic Diseases and through HelpAge International and can be used globally. These resources may need adaptation to local conditions, when used in other countries. While the lessons learned are valuable and applicable in other contexts, the specific organisational and political context of Vietnam in relation to CBOs and mass organisations, was a contributing factor to successful scaling-up. Further research is needed in understanding scaling-up mechanisms in other countries. Conclusion The sequential explanatory design of monitoring of complex scaling up of community- and PHC-based NCD interventions, using the project’s theoretical model and the RE-AIM framework proved viable in the SUNI-SEA project. This study demonstrates that successful scaling up of community-based and PHC-based NCD interventions requires a multi-faceted approach addressing all five RE-AIM dimensions. The project was successful in incorporating key elements of scaling up health interventions and could draw important lessons for further strengthening NCD prevention and control in Vietnam and globally. Further steps are needed for simplifying the RE-AIM methodology and integrating it into regular health systems. Abbreviations AE Association of the Elderly CBO Community-based organization CHS Commune Health Station DHC District Health Centre IDI In-depth Interview ISHC Inter-generational solidarity club MoH Ministry of Health NCD Non-communicable disease NGO Non-governmental organization PHC Primary Healthcare RE-AIM Reach Effectiveness Adoption Implementation Maintenance SUNI-SEA Scaling Up NCD interventions in Southeast Asia VND Vietnamese Dong WHO World Health Organization Declarations Ethical Approval The SUNI-SEA project adhered to privacy protection rules, using varied methods to safeguard participant data depending on the study phase. The project adhered to the standards as set in the Declaration of Helsinki. Ethical approval was granted by the Institutional Ethical Review Board of Hanoi School of Public Health, with the number 485/2019/YTCC-HD3, on November 13, 2019. Extension was granted on April 25, 2023, with approval number 196/2023/YTCC-HD3. All participants signed informed consent forms. Persons unable to sign a declaration were not included in the study. All personal information was anonymized before data analysis was performed. Data The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Part of the quantitative data was previously published in articles referenced in this article. Qualitative research was not previously used in other publications. Consent for publication Not applicable Competing Interests The authors declare no conflict of interest Funding/Acknowledgements This work has been supported by the European Union under the research and innovation programme [grant agreement No:825026], call SC1-BHC-16-2018 Global Alliance for Chronic Diseases (GACD) - Scaling-up of evidence-based health interventions at population level for the prevention and management of hypertension and/or diabetes, soliciting for research in Low- and Middle-Income Countries (LMIC). The funding source was not involved in the data collection, data analysis, manuscript writing and publication. All authors made a critical contribution to the process of conceptualisation, data collection, analysis and writing up of the results. Author contribution statement JK: concept, data analysis, draft, revision. JV: concept, data analysis, draft, revision. ZP: concept, data analysis, draft, revision. GNH: data collection, data analysis, draft, revision. 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As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6311998","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453057633,"identity":"37884cec-e9ab-4dde-8a8a-394dad7507dd","order_by":0,"name":"Jaap A.R. 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Pardoel","email":"","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":false,"prefix":"","firstName":"Zinzi","middleName":"","lastName":"Pardoel","suffix":""},{"id":453057636,"identity":"715c2b0a-f43b-4b08-bc43-001714f2e0ee","order_by":3,"name":"Giang Nguyen Hoang","email":"","orcid":"","institution":"Health Strategy and Policy Institute, Ministry of Health, Hanoi, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Giang","middleName":"Nguyen","lastName":"Hoang","suffix":""},{"id":453057637,"identity":"58ae144c-3c95-4600-bd3c-c6a1dbfb0590","order_by":4,"name":"Thang Nguyen Thi","email":"","orcid":"","institution":"Health Strategy and Policy Institute, Ministry of Health, Hanoi, Vietnam","correspondingAuthor":false,"prefix":"","firstName":"Thang","middleName":"Nguyen","lastName":"Thi","suffix":""},{"id":453057638,"identity":"dbf52c7f-146d-4672-96c6-27f2fb10cc0c","order_by":5,"name":"Lan Nguyen Thi 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International, health department, Chiang Mai, Thailand","correspondingAuthor":false,"prefix":"","firstName":"Caitlin","middleName":"","lastName":"Wald","suffix":""},{"id":453057645,"identity":"9fbe56db-bf78-42e5-a2ef-907fd4303569","order_by":9,"name":"Manna Alma","email":"","orcid":"","institution":"University Medical Center Groningen","correspondingAuthor":false,"prefix":"","firstName":"Manna","middleName":"","lastName":"Alma","suffix":""}],"badges":[],"createdAt":"2025-03-26 11:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6311998/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6311998/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82311230,"identity":"47bffbbe-87dd-4a05-a114-f54f769318f9","added_by":"auto","created_at":"2025-05-09 01:54:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":483474,"visible":true,"origin":"","legend":"\u003cp\u003eSUNI-SEA project synergy model: interventions at the PHC facility and in the community\u003c/p\u003e","description":"","filename":"Figure1suniseasynergymodel.png","url":"https://assets-eu.researchsquare.com/files/rs-6311998/v1/7747d43190b8c1a16867e5ec.png"},{"id":82311853,"identity":"c8395c88-cdea-4fcb-8e5f-551af8745a89","added_by":"auto","created_at":"2025-05-09 02:02:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":293187,"visible":true,"origin":"","legend":"\u003cp\u003ePriority intervention plan developed within the SUNI-SEA project in Vietnam\u003c/p\u003e","description":"","filename":"Figure2KortenmodelactionsVietnam.png","url":"https://assets-eu.researchsquare.com/files/rs-6311998/v1/ec10b8bddc5d9bc640602fb1.png"},{"id":82311852,"identity":"590aa076-d311-4426-9fec-9bac06dfea64","added_by":"auto","created_at":"2025-05-09 02:02:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1040341,"visible":true,"origin":"","legend":"\u003cp\u003eMonitoring and Evaluation process in the SUNI-SEA project\u003c/p\u003e","description":"","filename":"figure3evaluationmodel.png","url":"https://assets-eu.researchsquare.com/files/rs-6311998/v1/de2a9367c4df1470964414cf.png"},{"id":84072567,"identity":"0c1ddf27-9718-466b-b4c1-6338baae1fa8","added_by":"auto","created_at":"2025-06-06 12:32:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3427859,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6311998/v1/cf89d1b9-c460-4ada-816a-373ed646cc96.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of a scaling up strategy for noncommunicable diseases interventions using the RE-AIM framework – A case study from Vietnam","fulltext":[{"header":"INTRODUCTION","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eGeneral introduction\u003c/h2\u003e \u003cp\u003eNoncommunicable diseases (NCDs), including diabetes and hypertension, represent a rapidly increasing global public health challenge, responsible for 41\u0026nbsp;million deaths annually, with disproportionate impacts on low- and middle-income countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The increased morbidity and mortality of these diseases is mainly driven by rapid unplanned urbanisation, increase in unhealthy lifestyles and an ageing population(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In the Southeast Asian region, almost two thirds of all deaths are caused by NCDs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Southeast Asia, Vietnam is one of the fastest ageing countries in the world and faces a significant NCD burden (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Vietnam has national NCD strategies in place. Primary healthcare (PHC) services in Vietnam play a crucial role in the prevention and management of NCDs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These services are provided in Commune Health Stations (CHSs) and District Health Centres (DHCs)(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The national strategy emphasises the involvement of communities in preventive measures (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) as evidence shows that community-level interventions can effectively address NCDs such as hypertension and diabetes\u003csup\u003e,\u003c/sup\u003e(\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Intergenerational Self-Help Clubs (ISHCs) are currently active across Vietnam, contributing to these efforts at the community level (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In Vietnam, NCD screening is applied to identify individuals at higher risk for NCDs or those already affected by them. Appropriate interventions can be offered to maintain health or improve health outcomes(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Incorporating local culture and context into the provided activities(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) is important for the successful implementation of screening for NCDs and health promotion activities. ISHCs, with their broad range of activities and extensive reach, serve as a pivotal community-level platform for scaling up NCD screening, prevention, and early detection, particularly in underserved populations in Vietnam (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eScaling-up\u003c/h2\u003e \u003cp\u003eThe national strategy in Vietnam is implemented through a wide range of projects and interventions in the healthcare system. However, significant progress is still needed to achieve the strategy\u0026rsquo;s envisioned outcomes (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). While NCD screening and early treatment programmes are effective on a small scale, scaling them up nationwide is essential to meet the national strategy\u0026rsquo;s goals. This presents challenges, as NCD programmes are not always reaching the target populations, and limited awareness of NCDs can hinder scaling up (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eScaling up from small-scale pilot projects to large-scale interventions involves two approaches: horizontal scaling up, which aims at reaching more people with existing services (for example, new ISHCs in other geographic areas that start providing screening) and vertical scaling up, which aims at increasing the services for people already reached (for example, adding NCD screening to already implemented health education programmes) (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Both approaches are necessary to ensure comprehensive and sustainable scaling-up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSUNI SEA study\u003c/h3\u003e\n\u003cp\u003eThe scaling up of NCD screening and prevention in Vietnam, as discussed in this paper, was part of the larger Horizon 2020 European Union funded project: Scaling-Up NCD Interventions in South-East Asia (SUNI-SEA). This 4.5-year (2019\u0026ndash;2023) project was conducted in Indonesia, Myanmar, and Vietnam through a collaboration of ten consortium partners in Europe and Southeast Asia. The project performed intervention research into scaling up services for prevention and management of diabetes and hypertension, covering both community activities and PHC strengthening, intensifying collaboration between ISHCs and CHSs.\u003c/p\u003e \u003cp\u003eThe theoretical model of the intervention research is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e in which the synergy between community-based screening and health promotion and PHC-based diagnosis and treatment is depicted. Synergy is contributing to increase uptake of screening, enhance early diagnosis, and improve adherence to medical and non-medical treatment. In the figure, the socio-economic contextual factors influencing the NCD intervention are shown.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003eSUNI-SEA project synergy model: interventions at the PHC facility and in the community\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn Vietnam, SUNI-SEA leveraged existing and ongoing ISHC and PHC activities around hypertension and diabetes prevention and management. Following a thorough situation analysis to identify the necessary steps for scaling-up, the SUNI-SEA Vietnam country team developed priority interventions to strengthen communities, healthcare organisations, and the NCD control programme in accordance with the model of fit of Korten (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The model highlights the need for alignment between community needs, organisational capacities, and policy support and guided stakeholders in identifying and addressing the key factors necessary for successful scaling up of interventions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ePriority intervention plan developed within the SUNI-SEA project in Vietnam\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo achieve scaling up, the project aimed to strengthen the \u003cem\u003emanagement of community-based organisations (CBOs)\u003c/em\u003e i.e. ISHCs and Associations of the Elderly (AE)). There was also a focus on capacity building for volunteers in performing screening and keeping the screening records. In addition, the team supported patient groups in Vietnam to enhance peer support for lifestyle changes and treatment adherence. Community-based organisations were actively involved in monitoring the activities. For the \u003cem\u003eNCD control programme\u003c/em\u003e the project developed and introduced a protocol for NCD screening and a community-based monitoring system to follow up those screened. Health education materials were developed and disseminated, electronic health records and electronic reporting formats were also created. Capacity building in \u003cem\u003ehealthcare organisations\u003c/em\u003e, was a key component, involving online courses and in-person training sessions to improve the capabilities of healthcare staff using simplified clinical guidelines. Also, organisations were supported with advocacy activities for resource mobilisation and building the commitment of decision-makers to sustain NCD interventions. The activities are described in other publications by the consortium (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMeasuring the scaling-up of the SUNI-SEA project was challenging due to the complexity of the contributing factors. In recent years, various models have been developed to address this complexity (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) In literature, the definition of scalability of interventions has been scrutinised (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and tools for measuring scalability have been evaluated (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, there is limited literature that describes the full process of measuring scalability in practice.\u003c/p\u003e\n\u003ch3\u003eAim of this study\u003c/h3\u003e\n\u003cp\u003eIn this study, we report on processes and outcomes of the scaling up strategy applied in the SUNI-SEA project in Vietnam and identify facilitators and barriers to scaling-up as experienced by stakeholders in the community, in the health system, and policy makers. We reflect on the complex evaluation methodology of scaling-up activities.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eAs part of the larger SUNI-SEA project the scaling up strategy was implemented in 59 ISHCs in Ninh Binh and Hai Phong provinces in Vietnam and in 114 CHSs and 7 DHCs serving the communes and districts where ISHCs were established.\u003c/p\u003e \u003cp\u003e Identified stakeholders were the ISHC members and community volunteers, implementers in the health system, like PHC health staff and local health managers, district and provincial health authorities in Ninh Binh and Hai Phong provinces, as well as managers of CBOs and policy makers in the health and wellbeing of elderly in Vietnam.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFramework and indicators for evaluation of scaling up\u003c/h2\u003e \u003cp\u003eTo evaluate scaling-up activities, we used the (updated) RE-AIM (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) framework, allowing a nuanced understanding of both impact and sustainability of scaling-up (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). RE-AIM systematically examines five dimensions of individual and organisational level outcomes, namely: Reach, Effectiveness, Adoption, Implementation, and Maintenance. It has an explicit focus on the design, dissemination, and implementation processes that can either facilitate or impede success in achieving broad and equitable population-based impact. The RE-AIM framework applies a mixed method approach of quantitative data and qualitative data collection to better understand how and why results are achieved. The RE-AIM framework is widely used in public health development programmes and is appreciated because it provides a structure to systematically evaluate impact and processes (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin the SUNI-SEA project, descriptions for each of the RE-AIM dimensions of results and process topics for the given definitions were formulated in the inception phase of the project. (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for summary).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRE-AIM indicators and monitoring topics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE-AIM dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription of the dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResult topics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProcess topics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: People in communities and health services who participated in the prevention programmes, and assessment of who was more likely to participate and why.\u003c/p\u003e \u003cp\u003e\u003cb\u003eHealth system\u003c/b\u003e: the extent to which programmes were covering all areas they were supposed to cover.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: Number of ISHC members screened for NCD risk factors.\u003c/p\u003e \u003cp\u003e\u003cb\u003ePersons reached\u003c/b\u003e: in communities (ISHCs) and in health facilities (service providers).\u003c/p\u003e \u003cp\u003e\u003cb\u003eOrganisations involved\u003c/b\u003e in communities and the health system.\u003c/p\u003e \u003cp\u003e\u003cb\u003eGeographic coverage\u003c/b\u003e of planned districts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eCreation of synergy of the health system and community\u003c/b\u003e: (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Improving collaboration between ISHCs and CHSs and DHCs. Development of mutual understanding of services and referrals between communities and CHSs.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMapping of advocacy activities\u003c/b\u003e: Efforts to reach CBOs, health managers, policy makers to bring them on board in expansion of the programme.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEffectiveness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: The outcome and impact of the programme, including potential negative effects, quality of life, and economic outcomes.\u003c/p\u003e \u003cp\u003e\u003cb\u003eHealth system\u003c/b\u003e: Quality assurance throughout the project and attitudes towards perceived effects on targeted outcomes at the end of the programme.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: Number and percentages of persons diagnosed with illness risk factors and persons referred. Health workers capable of diagnosis and treatment.\u003c/p\u003e \u003cp\u003eImproved knowledge and behaviour of ISHC members because of the interventions.\u003c/p\u003e \u003cp\u003e\u003cb\u003eOrganisationally\u003c/b\u003e: Number of health facilities operating according to national standards.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: Processes of increasing health literacy of community members, ability to make decisions about their own health.\u003c/p\u003e \u003cp\u003e\u003cb\u003eOrganisationally\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eDevelopment processes of policies to implement prevention and screening of NCSs in communities.\u003c/p\u003e \u003cp\u003e\u003cb\u003eEconomically\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eIncreasing knowledge into costs and benefits of scaling up, as an investment case for improving health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdoption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: At the participant level characteristics of those who participated and those who were hesitant, including their reasons for hesitation.\u003c/p\u003e \u003cp\u003e\u003cb\u003eHealth system\u003c/b\u003e: At the organisation level characteristics of organisations and implementation sites, including those invited to participate and their organisations, and reasons for adoption or non-adoption.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: Number of persons who participated in the ISHCs throughout the project.\u003c/p\u003e \u003cp\u003eNumber of community volunteers active throughout the project.\u003c/p\u003e \u003cp\u003e\u003cb\u003eOrganisationally\u003c/b\u003e: Number of organisations that committed to the project after invitation.\u003c/p\u003e \u003cp\u003eElectronic medical record functional and number of persons with completed report.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eContext\u003c/b\u003e: Gaining insights about and experience with contextual barriers.\u003c/p\u003e \u003cp\u003e\u003cb\u003eEngagement\u003c/b\u003e: Developing cooperation and involvement of stakeholders and readiness to get involved in the implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIndividually\u003c/b\u003e: The intervention agent\u0026rsquo;s fidelity to the various elements of the protocol, including consistency of delivery as intended and time required.\u003c/p\u003e \u003cp\u003e\u003cb\u003eHealth system\u003c/b\u003e: This also includes the training of staff, using checklists, recording of adaptations made, and the costs of the implementation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eScreening\u003c/b\u003e: Number of screening activities performed in ISHCs. Number of community reports submitted.\u003c/p\u003e \u003cp\u003e\u003cb\u003eISHC boards\u003c/b\u003e: Number of training sessions delivered for ISHC boards and volunteers on health education and NCD prevention.\u003c/p\u003e \u003cp\u003e\u003cb\u003eHealth system\u003c/b\u003e: Health education materials developed. Number of health education and information sessions organised in health facilities and ISHCs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e: Improving adherence to policy and new NCD guidelines implemented.\u003c/p\u003e \u003cp\u003e\u003cb\u003ePrevention\u003c/b\u003e: Development and planning of community activities on NCD prevention and control, health education and promotion activities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintenance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe ongoing of interventions to sustain the effectiveness (outcome and impact) at the individual level of participants/patients, on programme-level, organisations embedding these programmes into their routine operations and budgets and on regional/national level policy that makes optimal reach and implementation possible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eContracts\u003c/b\u003e: Number of contracts between the health sector and AEs signed for continuation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eCommitment\u003c/b\u003e: Planning process for continuation of activities, contracts for service delivery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003eRE-AIM indicators and monitoring topics\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection, monitoring, and evaluation of the implementation process\u003c/h3\u003e\n\u003cp\u003eThe research team applied a mixed method approach in three steps to measure the formulated RE-AIM indicators. Quantitative and qualitative data were integrated using a sequential explanatory design (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFirst\u003c/b\u003e, we performed quantitative monitoring and evaluation activities throughout the course of the project through routine data collection and specific surveys. We incorporated the data in the above shown indicator framework. We first analysed the quantitative measurable results of the project. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSecond\u003c/b\u003e, based on the RE-AIM framework, we produced a topic list for measuring the scale-up processes as perceived by different stakeholders (communities, CBOs, mass organisations, healthcare managers, policy makers). We conducted in total 58 in-depth interviews (IDIs) with one or more interviewees. At the provincial level, two IDIs (one per province) were conducted with representatives from the Provincial Department of Health and relevant functional divisions, as well as representatives from the Centre for Disease Control (part of provincial health structure). At the district level, seven IDIs (one per district across seven districts) were conducted with representatives from the DHC and relevant units involved in the prevention and management of hypertension and diabetes. At the commune level, IDIs were conducted with: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) heads of all CHSs located in the commune where ISHCs were established (seven IDIs, one per district across seven districts); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) CHS staff members (21 IDIs, one per commune across three communes per district across seven districts); and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) hypertension/diabetes patients (21 IDIs, one per commune across three communes per district across seven districts). The researchers took notes in some meetings and recorded and transcribed discussions in other meetings. They entered the results of the consultation in the comprehensive RE-AIM framework matrix.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eThird\u003c/b\u003e, we conducted an evaluation meeting with the Vietnamese team and the international researchers from Myanmar, Indonesia, and Europe. In this meeting, final facilitators and challenges for scaling up NCD interventions were formulated. An international expert in qualitative research guided the focus group discussions, and a second expert took notes during the meeting.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuantitative data collection in SUNI-SEA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eQuantitative data collection title\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eData collected\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNumber respondents\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eTime or period\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline and endline community surveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge, attitudes, and practices of ISHC members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e897 ISHC members and 813 control participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst quarter 2021 \u0026ndash; First quarter 2023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurveys capacity building ISHC volunteers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test and post-test knowledge and follow-up survey one year after training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVarious periods from 2021 to 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline and endline patient surveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge, attitude, and practices of patients regarding hypertension and diabetes self-management, service utilization and treatment adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 008 patients (baseline) and 745 patients (endline)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst quarter 2021 - Fourth quarter 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHC staff survey \u0026ndash; Baseline and Endline survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge, attitude, and practices of PHC staff regarding hypertension and diabetes management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 PHC staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst quarter 2021 - Fourth quarter 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectronic screening records in communities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo sessions of screening with measurement of blood pressure, body mass index, risk factors NCDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 485 persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDuring 2022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity reporting ISHCs, HelpAge staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScreening sessions, health education sessions, meetings with health officials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 ISHCs\u003c/p\u003e \u003cp\u003e114 CHSs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrom last quarter 2021 until first quarter 2023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost-effectiveness analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCost data of community activities (screening health education) and PHC treatment data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 ISHCs\u003c/p\u003e \u003cp\u003e114 CHSs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth facility survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe availability of resources for NCD management, service provision.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 CHSs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst quarter 2021 \u0026ndash; First quarter 2023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe steps are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003eMonitoring and Evaluation process in the SUNI-SEA project\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eQuantitative data\u003c/h3\u003e\n\u003cp\u003eFor the quantitative monitoring, a set of instruments was put in place, addressing the topics of the RE-AIM framework. Baseline and endline surveys were conducted among community members to measure changes of knowledge, attitudes, and practices over time. Several surveys were conducted to measure specific project activities, like capacity building of ISHC members, and training of volunteers and health workers. Continuous (routine) data collection was done through electronic health records maintained by ISHC volunteers. Publications of part of the surveys are available (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003eQuantitative data collection in SUNI-SEA\u003c/b\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003eThe SUNI-SEA project adhered to privacy protection rules, using varied methods to safeguard participant data depending on the study phase. Ethical approval was granted by the Institutional Ethical Review Board of Hanoi School of Public Health, with the number 485/2019/YTCC-HD3, on November 13, 2019. Extension was granted on April 25, 2023, with approval number 196/2023/YTCC-HD3. All participants signed informed consent forms. The studies involving human participants were reviewed and approved by HelpAge International. The patients/participants provided their written informed consent to participate in this study. In case the participants were researchers from the SUNI-SEA consortium, ethical review and approval were waved.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe first report on the results of step 1 and step 2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) of the quantitative data collected and the consecutive qualitative analysis of the process of scaling up, following the RE-AIM framework.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eREACH - Results:\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePersons reached\u003c/b\u003e in communities (ISHCs) and in health facilities (service providers). Over an 18-month period, 3,485 individuals participated in 59 ISHCs in Ninh Binh and Hai Phong provinces in Vietnam. NCD screening was conducted twice in all ISHCs, with 94% of members participating, and 96% of those attending both screening rounds. A control group of 205 non-ISHC members were screened in CHSs.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOrganisations engaged\u003c/strong\u003e \u003cp\u003eThe project engaged a range of organisations within the community and health system, including 114 CHSs, 7 DHCs and two provincial health departments. During the project, 86.7% of the CHSs in Ninh Binh and 81.3% in Hai Phong supported NCD screening in ISHCs. The Centres for Disease Control (part of the district health office) also contributed to the project and later adapted the materials for use in other health centres.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eGeographic coverage\u003c/b\u003e of planned districts. All 7 targeted districts of two provinces were covered and DHC staff participated in supervision and support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eREACH - Process:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSynergy of the health system and mapping of advocacy activities.\u003c/b\u003e In the process of creating synergy between the different stakeholders, we found that communication and (systems that support) collaboration were the main topics mentioned in interviews. Stakeholders identified commitment and open communication between ISHCs and CHSs as crucial for successful collaboration. Because their mandates are complementary, ISHCs and CHSs can mutually reinforce their respective activities, according to interviewees. Productive communication between ISHCs\u0026rsquo; volunteers or boards and CHSs\u0026rsquo; staff/management fosters collaboration. Conversely, poor communication directly impedes joint activities. For example, the referral process of persons with NCD risks between ISHCs and CHS is informal, as there is no regular referral mechanism between community groups and public health services.\u003c/p\u003e \u003cp\u003eTo foster sustainable collaboration between ISHCs and CHSs, beyond individual motivation and organisational capacity, support from external stakeholders, including AEs and local DHCs, is necessary. In several districts, these collaborations were formalised in collaboration agreements between governmental organisations and CBOs.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCHS staff in Ninh Binh\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The ISHC operates in a very organised manner. They have obtained permission from the local People's Committee to collaborate with the local health centre. Every month, representatives from CHS come to support the club to measure blood pressure and weight for older people during their club activities. They provide guidance for individuals with hypertension to visit the health centre for examination and medication. Having this club throughout the city would be great, as it would attract more participants.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eChairperson of ISHC, female\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;. A better and closer collaboration between ISHC and CHS supports the screening at the ISHC. It brings a lot of benefits to ISHC. The health volunteers are very happy, they learn a lot from the health staff and build trust with club members\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEFFECTIVENESS - Results\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eIndividually\u003c/strong\u003e \u003cp\u003eDuring all screening sessions in ISHCs in total 978 persons were identified with a high risk for hypertension and 228 with a high risk for diabetes. In Ninh Binh in CHSs, 146 persons were diagnosed with high blood pressure and another 64 persons in Hai Phong. For diabetes, these numbers were 56 and 28 respectively. Health workers demonstrated substantial improvement in performance, increasing their average scores on diagnosis and treatment knowledge from 62\u0026ndash;76% and protocol adherence from 19\u0026ndash;56%.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eA set of handbooks for self-management of diabetes and hypertension was developed and distributed to community volunteers, and peer support groups were created. Following the intervention, 82% of ISHC members reported improved health behaviours due to group activities, while 79% of patients in peer support groups in CHSs reported improved treatment adherence. A survey showed that adherence to treatment of anti-hypertensive medicines increased from 25.6\u0026ndash;35.9% among ISHC members.\u003c/p\u003e \u003cp\u003eImproved knowledge and behaviours of ISHC members because of the interventions: Baseline and endline surveys were conducted with 897 ISHC members and 813 control participants. Significant improvements were observed in knowledge of NCD risk factors among ISHC members and adherence to physical activity recommendations. After the intervention, ISHC members were able to name more risk factors, symptoms, and complications of both diabetes and hypertension. Similar trends were seen in other knowledge indicators. There were fewer people with high blood pressure amongst ISHC members. However, there were not many significant differences between ISHC members and control group related to diagnosis and health behaviours. We only found differences in ever being diagnosed with hypertension, complying with physical activity guidelines, and knowing the recommended amount of salt intake. Smoking, for example, did not reduce.\u003c/p\u003e \u003cp\u003e\u003cb\u003eOrganisationally\u003c/b\u003e: Number of health facilities operating according to national standards: the Vietnamese clinical guidelines were rewritten in simplified formats for lower-level trained health workers and made available. Desktop treatment instructions were disseminated in 114 CHSs. 126 staff members were trained in diagnosis and treatment of NCDs. In 90.5% of CHSs in Ninh Binh and 55.9% of CHSs in Hai Phong, proactive hypertension diagnosis and treatment were offered to visiting patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEFFECTIVENESS \u0026ndash; Process\u003c/h2\u003e \u003cp\u003e \u003cb\u003eIncreased health literacy.\u003c/b\u003e As a result of the interventions that have been implemented and scaled up, health literacy of community members and therefore their ability to take decisions about their own health has improved. Community members indicated that they know more about NCDs and the availability of health services, in case they are identified with high risks for diabetes or high blood pressure. Community members were better able to understand received leaflets and communicate about organised interventions. The possibility to ask questions to visiting CHS staff was very helpful for the community members. Therefore, CHSs could organise their activities more effectively.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClub member, male\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\"\u0026hellip;. I was classified as prehypertension through the first screening event of the ISHC. After that, I was advised by the health volunteers on how to change my diet (reduce salt intake, increase my intake of green vegetables), drink enough water (1.5-2 litres per day), reduce alcohol and tobacco, and increase exercise and sports. Every month when I attend club meetings, health volunteers also help to check my blood pressure. Now my blood pressure is stable and there is no sign of increasing, my weight has also decreased a bit. I feel good now.\"\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eImplemented policies\u003c/b\u003e. The existing policy mechanisms that are promoting social welfare and healthcare programmes for older people are highly appreciated by local AEs. These policy mechanisms support the stakeholders, like AEs, ISHCs and CHSs, in implementing further activities on topics like prevention of diabetes and high blood pressure. The cooperation between CHSs and ISHCs is not only leading to health benefits for older people (regular health check-ups and screening for non-communicable diseases) but also support CHSs in their task of managing people's health in their catchment area. Challenges in the financial mechanisms for providing healthcare services, such as the availability of medicines and supplies, health insurance reimbursement, are still present, according to interviewees and need to be addressed when developing policies further in the future.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealth leader, male\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo; \u0026hellip; the cooperation between the health sector and AE, ISHCs has been achieving high efficiency and performing well in health management in the community. This is a practical and meaningful model that needs to be maintained and replicated to meet the healthcare needs of older people, helping to reduce the burden for the health sector. We considered ISHC health volunteers as an extended arm of the health sector in communities\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCHS staff in Hai Phong\u003c/strong\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;In the past, the training only focused on discussing the disease and its complications. There was no emphasis on treatment, only on counselling and care. However, now there is a shift towards treatment, which the doctors prefer. Previously, the training focused on regulations, guidelines, monitoring, and updating software information. Currently, the training includes skills such as patient communication, medication usage, and patient nutrition. Such training programmes can be conducted annually, providing a refresher and ensuring that knowledge is not forgotten, while also updating participants on new knowledge.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eCosts of scaling up.\u003c/b\u003e According to the AEs, part of the success of the implemented interventions lies in the fact that they are low cost, simple interventions and are closely linked to regular activities and household chores. They are suitable for the community\u0026rsquo;s lifestyle in Vietnam. Due to the low costs of the health-related activities, it is easier for the ISHCs to cover the costs from their existing funding sources in the current system of healthcare financing. If that is not the case, many ISHC leaders are capable of raising the additional funds that are needed for the implementation of the interventions.\u003c/p\u003e \u003cp\u003e\u003cb\u003eADOPTION \u0026ndash; Results\u003c/b\u003e: Community: A training programme for ISHC volunteers and board members was developed and implemented. In the first training round 420 volunteers, ISHC boards, and stakeholders participated and in the second round 550 participated. Health education materials were developed and disseminated in communities. The ISHC health volunteers and management boards were able to implement the screening and health promotion activities autonomously.\u003c/p\u003e \u003cp\u003ePHC staff: Training of health workers on NCDs and health education had a significant positive impact on hypertension management at CHSs. PHC staff improved their practices, particularly in health education and monitoring, in accordance with Ministry of Health guidelines. CHS doctors expanded the range of health education topics for patients, focusing on healthy diet and lifestyle modifications. This resulted in increased patient engagement with CHS services, including counselling, clinical examinations, and health education. Consequently, patients showed significant improvements in their knowledge of hypertension risk factors and medication adherence and adopted healthier lifestyle practices, such as improved medication adherence, blood pressure self-monitoring, reduced salt intake, and increased physical activity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eADOPTION \u0026ndash; Process\u003c/h2\u003e \u003cp\u003e \u003cb\u003eKnowledge about and experience with contextual barriers and cooperation and involvement of stakeholders and readiness to get involved in the implementation.\u003c/b\u003e Building trust between partners and within the community was crucial in the process, requiring dedicated effort and time from all involved. Transparency by healthcare organisations in both activity planning and communication proved to be a key factor in their success. The ISHCs in the community have the capacity of building trust in the community, according to PHC staff. When all are clear on who has what role, it is easier to implement healthcare activities, especially for older people. Establishing a strong link between CHSs and ISHCs, with CHS staff providing advisory support to ISHC management, was found to be especially effective.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCHS staff in Ninh Binh\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;To facilitate the intervention, we need to have a good plan from the city or provincial level, CHS can propose to the committee to establish a directive that guides the coordination among various stakeholders. With the committee's guidance, the organisations and sectors will actively participate in the collaboration. Since we don't have active village health workers in the urban commune, we rely on the team leader of the village to use a loudspeaker to announce to the community to come to the CHS. Secondly, the age group targeted by the project is mostly working individuals over the age of 40. We have collaborated with ISHC to deliver information to the community. It has been more effective in the village where there is a club compared areas without ISHCs as we have to visit each household individually. The local government is very attentive, and when we consult People's Committee, they are willing to provide assistance.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eThere are several barriers to overcome in establishing cooperation. Among others, lack of clear collaborating mechanisms and communication, lack of data-sharing, and lack of active engagement are seen by interviewees as problems. Effective cooperation depends partly on individual people, so mediating mechanisms needs to be in place. Respondents indicated that to overcome these barriers several steps can be taken. For example, formalising collaborations through official agreements and clearly defined operational procedures was suggested. Training for all partners involved is also important, as well as regular meetings between the (management of) involved partners. Although NCDs are a priority for the provincial department of health there is also a challenge on human resource level \u0026ndash; getting enough (qualified) individuals involved is a challenge for all partners. Therefore, it is even more important to draft feasible plans together on how to implement the activities and for example ensure medication availability.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eISHC Chairperson, female\u003c/b\u003e: \u003cem\u003e\u0026ldquo;\u0026hellip;my ISHC has mobilised support from departments, local authorities, and community members: 17\u0026nbsp;million VND (~\u0026thinsp;700 EUR) to organise the year-end ceremony and more than 10\u0026nbsp;million VND (~\u0026thinsp;400 EUR) to buy a television for the ISHC. Besides, ISHC also invites health staff, departments, and local authorities to attend and support the club's activities. The chairperson is very active in approaching and sharing with relevant stakeholders of the ISHC annual plan, activities, and events. So, our ISHC received support and has smoothly collaborated with the CHS, local authorities, etc. \u0026hellip;\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eIMPLEMENTATION - Results\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCommunity\u003c/strong\u003e \u003cp\u003eThe number of screening sessions performed in ISHCs was 118, with 90% of the members participating. Health education materials were developed. 174 health education and communication sessions were organised in ISHCs with 85% of members participating. 600 manuals for self-management of risk factors were distributed to the volunteers and board members of ISHCs. 3 500 health booklets and 7 300 health information leaflets were disseminated. 59 banners with health messages were put up in communities.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealth system\u003c/strong\u003e \u003cp\u003eThe intervention led to a dramatic increase in community screening for hypertension and diabetes at CHSs, as evidenced by a health facility survey. Hypertension screening coverage among CHSs increased more than three times, from 26\u0026ndash;80%, while diabetes screening more than tripled, rising from 21\u0026ndash;67%. This resulted in a substantial increase in the number of newly diagnosed hypertension and diabetes cases within their catchment areas.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eIMPLEMENTATION - Process\u003c/h2\u003e \u003cp\u003e\u003cb\u003e Adherence to policy and new NCD guidelines implemented.\u003c/b\u003e In practice, the CHS staff follows the national guideline on diagnosis, treatment, and management of common NCDs at CHS (Decision 5904/2019/TT-BYT issued by Ministry of Health). This guideline includes, among other things, guidance on health communication and screening and treatment of hypertension and diabetes. Training is helping health staff and community volunteers in gaining knowledge and experience with diagnosing and treating according to the methods set out in the guideline.\u003c/p\u003e \u003cp\u003eThe practice is not yet aligned to the policy. For example, the provision of required medicines for treatment at PHC level is insufficient. Also, infrastructural and financial barriers are experienced in the implementation process.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCHS head\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Firstly, it is important to regularly update training materials and provide training not only for CHS personnel but also for village health workers. Secondly, to ensure effective implementation and management, there should be a sufficient budget allocated to CHSs to provide resources and create favourable conditions for NCD activities, especially for those who have specialised training to guide others at CHSs. As for medication supply, although there is currently no shortage, it is crucial to maintain a consistent and sufficient supply, ensuring that there are reserves in case of unexpected shortages to serve the community\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eCommunity activities for NCD prevention and control, health education, and health promotion activities.\u003c/b\u003e Collaboration agreements on the CHSs/ISHCs level are very instrumental, but also between district AEs and DHCs. Also, guidance, direction, and support from the district health office to DHCs and CHSs leads to smoother implementation processes. Creating networks of ISHCs to exchange experiences was instrumental to strengthening activities across the network. The local health managers and health authorities indicate that ISHCs should be considered as an extended arm of the healthcare sector, and vice versa.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eProvincial Department of Health in Ninh Binh\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;At this time, the priority is to establish a financial mechanism to ensure the payment for healthcare services through health insurance. The medical examination fees have not reimbursed for CHSs since 2018, which did not create the motivation of CHS staff in provision of health services. Secondly, ensuring an adequate supply of medications in terms of quantity and variety is crucial. It requires more decisive guidance and implementation from the high-level health authorities\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMAINTENANCE - Results\u003c/h2\u003e \u003cp\u003eThe project staff conducted in total 10 meetings with health authorities, local government organisations, and interest groups to discuss the progress and sustainability of the project, leading to agreements on the way forward.\u003c/p\u003e \u003cp\u003eCost-effectiveness: The current cost-effectiveness evaluation suggests that although there is need for a substantial investment in preventive activities such as screening, health education, and added treatment of hypertension and diabetes, potential savings in prevented complications of hypertension and diabetes could make this investment worth its value.\u003c/p\u003e \u003cp\u003eNumber of contracts signed for continuation: Both the Ninh Binh and Hai Phong AEs signed collaboration agreements with Provincial Department of Health for the continuation of the governmental support to ISHCs in implementing health care activities, especially in NCD screening. The Ninh Binh AE signed a contract with a commercial company for sponsoring ISHC healthcare activities and NCD screening after the end of the project. By the end of the project, two collaboration agreements at the district level (District AEs and DHCs) were signed. The Ninh Binh AE collaborated with the Provincial Department of Health and had vertical directions to the district level in all eight districts to sign the collaboration agreement in 2023 in order to support healthcare activities in ISHCs. The Government of Vietnam decided to increase the number of ISHCs from the current 500 to countrywide 6,000.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eMAINTENANCE \u0026ndash; Process\u003c/h2\u003e \u003cp\u003eIn the previous paragraphs of RE-AIM many helping and hindering factors already have been mentioned that also relate to the sustainable implementation of the activities. The main helping factors that are identified are availability of related policies including formal collaboration agreements, capacity building, availability of SUNI-SEA tools and acknowledging the role of ISHC\u0026rsquo;s and their volunteers in this process of creating a sustainable and maintainable NCD\u0026rsquo;s intervention program. It is hindering when there is low awareness of the specific roles of community-based organisations and ISHC\u0026rsquo;s in healthcare, when there is a lack of monitoring and supervision at the implemented activities and when there is no adequate availability of volunteers, staff (human resource problems) and finances to keep the activities going.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDistrict health manager\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;However, there is concern that once the programme ends, the clubs might cease their activities. Therefore, the involvement of the local government is necessary to sustain the model, with healthcare playing a role in advising the People's Committee for their active participation. The direction should come from the top-down. The involvement of the local government is needed to provide motivation for the healthcare sector. I have already presented the plan to the People's Committee\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eFinal conclusions on facilitators and barriers of scaling up NCD interventions per RE-AIM domain\u003c/h2\u003e \u003cp\u003eIn the end of project meeting of the consortium (step 3) a final discussion on the processes and results described above took place. The main points of this discussion are summarised in an overview of helping and hindering factors when scaling up interventions aimed NCD prevention. The factors are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below. The findings were widely disseminated and were used in other studies (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFacilitators and barriers for scaling up NCD interventions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacilitators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eREACH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Related policies mentioning responsibility and role of health sectors in support ISHC and ISHC scale up, including collaboration agreements between the health sector and local AEs-ISHCs\u003c/p\u003e \u003cp\u003e\u0026bull; Mobilisation and engagement of key stakeholders (local government, health, AE, ISHC) by organizing stakeholder meetings leading to commitment and feeling responsible\u003c/p\u003e \u003cp\u003e\u0026bull; Acceptance / willingness of ISHC members towards synergy approach\u003c/p\u003e \u003cp\u003e\u0026bull; CHS attending training for ISHC health volunteers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Low commitment of local government, health sector, and AEs in some areas\u003c/p\u003e \u003cp\u003e\u0026bull; Limited resources: both human resource and financial\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of communication between ISHC and CHS due to no formal mechanism for reporting and feedback, both two-ways\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEFFECTIVENESS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Capacity building: including training and regular technical support\u003c/p\u003e \u003cp\u003e\u0026bull; Good and easy to understand training and information-, education-, and communication materials\u003c/p\u003e \u003cp\u003e\u0026bull; Low costs of interventions\u003c/p\u003e \u003cp\u003e\u0026bull; Interventions are simple and suitable for community\u0026rsquo;s cultural lifestyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; COVID: limited time and overload of the health sector, irregular technical support from HelpAge and local AE staff\u003c/p\u003e \u003cp\u003e\u0026bull; Financial mechanisms for providing healthcare services (such as medicines)\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of younger members in community volunteers and ISHC management boards\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of communication skills of community health volunteers and ISHC management boards in the implementation of NCD prevention and health education for ISHC members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eADOPTION\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; CHS staff being advisors of the management board of ISHC\u003c/p\u003e \u003cp\u003e\u0026bull; Regular updating/communication and information sharing between ISHCs and local authorities\u003c/p\u003e \u003cp\u003e\u0026bull; Formal collaboration agreement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; No communication and information sharing between ISHCs and local authorities\u003c/p\u003e \u003cp\u003e\u0026bull; No formal collaboration agreement/mechanism\u003c/p\u003e \u003cp\u003e\u0026bull; No concrete implementation plan that was discussed with the CHS leader in advance which hindered CHS to allocate time and personnel (consensus about timeline and collaborative activities is needed)\u003c/p\u003e \u003cp\u003e\u0026bull; Depending on enthusiasm and responsibility of ISHC\u0026rsquo;s management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIMPLEMENTATION\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Simplified format of guidelines\u003c/p\u003e \u003cp\u003e\u0026bull; Capacity building for both ISHC and PHC: improving knowledge, communication, self-confidence\u003c/p\u003e \u003cp\u003e\u0026bull; Availability of policy in place including formal collaboration agreement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; No follow-up or monitoring of existing policy implementation\u003c/p\u003e \u003cp\u003e\u0026bull; Financial mechanisms for providing healthcare services (such as medicines)\u003c/p\u003e \u003cp\u003e\u0026bull; Human resource: insufficient health personnel\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMAINTENANCE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Availability of related policies including having a formal collaboration agreement\u003c/p\u003e \u003cp\u003e\u0026bull; Capacity building\u003c/p\u003e \u003cp\u003e\u0026bull; Availability of tools developed in the project\u003c/p\u003e \u003cp\u003e\u0026bull; Acknowledging the role of ISHC and volunteers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Low awareness of role of CBO/ISHCs in health care\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of monitoring and supervision\u003c/p\u003e \u003cp\u003e\u0026bull; An adequate availability of human resource and financing (is more a precondition)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003eFacilitators and barriers for scaling up NCD interventions\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we reported the process and outcomes of the SUNI-SEA project and identified facilitators and barriers to scaling-up community-based and PHC-based interventions for prevention, early detection and control of NCDs in Vietnam. We applied a sequential explanatory design to our monitoring and evaluation methodology based on the RE-AIM framework. We first analysed quantitative results of the implementation research and used these results and the perspectives of stakeholders to get insights into the processes, facilitators, and barriers of scaling up. This resulted in a comprehensive overview of relevant factors for the process of scaling-up projects globally, at the community level, PHC level, health management level, and policy level. The findings were discussed within a broader research team and resulted in a concrete set of key points of attention grouped according to the RE-AIM domains. These insights contribute to the global discourse on scaling up community-based health interventions.\u003c/p\u003e \u003cp\u003eThe findings from this study provide valuable insights into scaling up community-based and PHC-based NCD interventions beyond Vietnam, particularly in decentralised healthcare systems globally. Many LMICs face similar challenges in NCD prevention, including limited resources, fragmented health governance, and the lack of sustainable financing mechanisms. The success of Vietnam\u0026rsquo;s approach, leveraging existing community networks, formalising partnerships between community-based organisations and PHC facilities, and integrating interventions into national policies, offers several lessons for other contexts. First, the SUNI-SEA project demonstrated that establishing clear agreements between community-based organisations and PHC facilities facilitated sustained collaboration. A similar approach has been used in Brazil\u0026rsquo;s Family Health Strategy, where community health workers are formally integrated into PHC teams, ensuring continuity of care and systematic NCD prevention efforts (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Other LMICs could benefit from clear governance frameworks that define the role of CBOs in NCD prevention. Second, digital health innovations present opportunities but require infrastructure investment, provider training, and policy alignment. Vietnam\u0026rsquo;s electronic screening records faced interoperability and digital literacy challenges, similar to those encountered in India\u0026rsquo;s National Digital Health Mission (NDHM) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Addressing these barriers will be critical for scaling digital health solutions in decentralised systems. Third, policy commitment plays a decisive role in the successful expansion of community-based NCD interventions. Vietnam\u0026rsquo;s strong national policies supporting community-led health initiatives were a key enabler of scale-up. In contrast, many decentralised health systems lack explicit policy frameworks that mandate NCD prevention at the community level. To address this, advocacy strategies used in Vietnam, such as engaging mass organisations, could be adapted in other cultural and governance settings. For example, in several African and Latin American countries, faith-based organisations and municipal health councils play similar community leadership roles and could serve as effective channels for community-driven NCD programs (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe concluded that increasing the reach of the complex interventions, requires the commitment of all stakeholders, ranging from community to policymakers, and continuous interaction among stakeholders to make the synergy approach work. Furthermore, to increase effectiveness, we implemented interventions that were simple, affordable, and accompanied by continuous capacity building for health care providers and community members. In addition, diversifying the backgrounds, ages, and genders of health volunteers and ISHC boards leveraged the quality of activity at the community level. For improved adoption of the community-based intervention, formal agreements between healthcare organisations and CBOs, based on transparent operational plans, were crucial. Implementation can be enhanced by clear governmental policies, sustainable financing mechanisms and practical guidelines for implementers. Finally, the maintenance of community-based interventions was ensured by integrating them into existing policies and practices and by establishing clearly defined roles and responsibilities of community-based organisations in implementation and monitoring. By fostering stakeholder engagement, simplifying interventions, establishing formal agreements, strengthening implementation mechanisms, and ensuring policy integration and community ownership, programmes can achieve broader reach, greater effectiveness, and long-term sustainability. The sequential explanatory design proved to be adequate for analysing complex interventions at the community level, within healthcare organisations, and in NCD prevention and control programmes. The RE-AIM framework proved effective in capturing the multidimensional impacts of scaling-up efforts. It is the most frequently used framework in evaluating scaling up programmes (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). By applying the RE-AIM framework within a sequential explanatory design, we were able to evaluate over 20 project sub-activities across various areas under umbrella unified framework. The integration of quantitative analysis followed by qualitative interpretation of findings provided a contextualised understanding of the outcomes as recommended by Toyon (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The robust analytic structure of RE-AIM, along with clear instructions on how to capture the consultations with stakeholders, ensured reliability and validity of the findings. As a result, we were able to answer the questions of \u0026ldquo;what\u0026rdquo; and \u0026ldquo;how\u0026rdquo; the scaling up was done. Our approach of phased analysing outcomes and processes through quantitative and qualitative methods, was also advocated by the Medical Research Council for evaluating complex health interventions (\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). The participatory approach, which actively engaged implementing stakeholders, yielded a wealth of insights into the factors influencing scale-up and the broader context in which it occurred.\u003c/p\u003e \u003cp\u003eRathod et al. identified seven key elements for the successful scaling-up of complex health interventions (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIntegration of the complex health intervention into national or local policy\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCapacity building and training, in particular cascade training (i.e. train the trainer) approaches as well as cascade facilitation\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eResource support (e.g., appointment of staff)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eQuality improvement and monitoring (e.g., benchmarking against quality criteria)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCultivating partnership and collaboration (e.g., peer-support networks)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTransfer of ownership (e.g., shifting to external facilitation)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOngoing advocacy and communication (e.g., based on impact evaluation)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAll the seven key elements in scaling-up projects were present in the SUNI-SEA project. Vietnam has clear policies and strategies concerning the control of NCDs and community engagement in prevention efforts. Vietnam's decentralised health system enabled tailored approaches at the provincial level, fostering local ownership of interventions. However, this structure requires commitment of local authorities. Successful implementation depended on the commitment of local authorities. In districts with limited health resources or lower levels of commitment from local authorities\u0026rsquo; implementation was more challenging.\u003c/p\u003e \u003cp\u003eA notable aspect of Vietnam's community-based healthcare system is the role of mass organisations in community-based healthcare. In this project, the Vietnamese AE played a leverage role of initiating and maintaining community-based screening and health promotion activities (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Lessons from Vietnam underscore the need for clear coordination mechanisms in decentralised health systems and involving CBOs in implementation.\u003c/p\u003e \u003cp\u003eCapacity building was a crucial success factor during the project. Our findings indicate that the adaptation of training materials to local contexts, along with technical support, were essential. During the project general guidelines for cultural adaptation of training were developed, which were cited several times (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, it is crucial that capacity building remains an ongoing effort with refresher courses and supervision. Long-term sustainability will require embedding these efforts within Vietnam\u0026rsquo;s health system, rather than limiting them to specific projects (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe project introduced electronic health records for monitoring and supervising community-based screening activities, which contributed to digital innovation in healthcare but also revealed key challenges in Vietnam\u0026rsquo;s digital transformation (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Despite these advancements, persistent barriers such as digital literacy gaps, infrastructure limitations, and data integration issues remain.\u003c/p\u003e \u003cp\u003e The project successfully facilitated formal agreements between healthcare organisations and branches of the Vietnamese AE, further strengthening community-health collaborations. Additionally, advocacy efforts contributed to the expansion of the ISHC model nationwide, reaching 6 000 communities in Vietnam. However, achieving sustainable and resilient healthcare systems capable of addressing evolving NCD challenges remains a work in progress (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). The SUNI-SEA project provided critical inputs to scaling up community-based and PHC-based NCD interventions in Vietnam and generated new knowledge on establishing synergies. However, for sustaining the results long term will require strengthening of PHC, improving human resources, and ensuring financial sustainability and reliable medical supply chains.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe research into scaling up community- and PHC-based NCD interventions benefited from multiple data sources, including several surveys, routine data collection programmes, and consultations with a wide range of stakeholders in the SUNI-SEA implementation research project. This multi-source approach offered a comprehensive spectrum of information and insights into the outcomes and processes of the scaling-up. It was possible to manage the phased approach of quantitative and qualitative data analysis based on the intervention theory and the RE-AIM framework. However, the effort of managing this complex monitoring was huge and only affordable in a research setting. Documentation of all findings of the over 20 specific interventions (listed in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) was not always complete. With the travel restrictions due to COVID-19 and language barriers, in-depth interviews were mostly done by researchers directly involved in the implementation research. Socially acceptable responses may therefore have been given in some instances. Not all interviews were transcribed in full, and some information may have gone missing in the summaries of meetings. Due to the COVID-19 pandemic, there were various delays, which resulted in a short implementation time. The short implementation time was insufficient to allow for the various physiological changes required to assess the impact on health indicators. It also explains why we mostly observed changes in knowledge, as this is the most proximal element in our theory of change; it is too early to accurately assess the full impact of the intervention on the other outcomes.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eImplications for practice and research\u003c/h2\u003e \u003cp\u003e The SUNI-SEA project created screening protocols, clinical guidelines, teaching and health education materials, which are disseminated through the Global Alliance of Chronic Diseases and through HelpAge International and can be used globally. These resources may need adaptation to local conditions, when used in other countries.\u003c/p\u003e \u003cp\u003eWhile the lessons learned are valuable and applicable in other contexts, the specific organisational and political context of Vietnam in relation to CBOs and mass organisations, was a contributing factor to successful scaling-up. Further research is needed in understanding scaling-up mechanisms in other countries.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe sequential explanatory design of monitoring of complex scaling up of community- and PHC-based NCD interventions, using the project\u0026rsquo;s theoretical model and the RE-AIM framework proved viable in the SUNI-SEA project. This study demonstrates that successful scaling up of community-based and PHC-based NCD interventions requires a multi-faceted approach addressing all five RE-AIM dimensions. The project was successful in incorporating key elements of scaling up health interventions and could draw important lessons for further strengthening NCD prevention and control in Vietnam and globally. Further steps are needed for simplifying the RE-AIM methodology and integrating it into regular health systems.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssociation of the Elderly\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity-based organization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommune Health Station\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrict Health Centre\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn-depth Interview\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInter-generational solidarity club\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-communicable disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-governmental organization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary Healthcare\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE-AIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReach Effectiveness Adoption Implementation Maintenance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSUNI-SEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScaling Up NCD interventions in Southeast Asia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVND\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVietnamese Dong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe SUNI-SEA project adhered to privacy protection rules, using varied methods to safeguard participant data depending on the study phase. The project adhered to the standards as set in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Institutional Ethical Review Board of Hanoi School of Public Health, with the number 485/2019/YTCC-HD3, on November 13, 2019. Extension was granted on\u0026nbsp;April 25, 2023, with approval number 196/2023/YTCC-HD3.\u0026nbsp;All participants signed informed consent forms. Persons unable to sign a declaration were not included in the study. All personal information was anonymized before data analysis was performed.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eData\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003ePart of the quantitative data was previously published in articles referenced in this article. Qualitative research was not previously used in other publications.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare no conflict of interest\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003eFunding/Acknowledgements\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis work has been supported by the European Union under the research and innovation programme [grant agreement No:825026], call SC1-BHC-16-2018 Global Alliance for Chronic Diseases (GACD) - Scaling-up of evidence-based health interventions at population level for the prevention and management of hypertension and/or diabetes, soliciting for research in Low- and Middle-Income Countries (LMIC). The funding source was not involved in the data collection, data analysis, manuscript writing and publication. All authors made a critical contribution to the process of conceptualisation, data collection, analysis and writing up of the results.\u003c/p\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor contribution statement\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eJK: concept, data analysis, draft, revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJV: concept, data analysis, draft, revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZP: concept, data analysis, draft, revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGNH: data collection, data analysis, draft, revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNTT: data collection, data analysis, draft, revision.\u003c/p\u003e\n\u003cp\u003eLNTP: data collection, data analysis, draft, revision.\u003c/p\u003e\n\u003cp\u003eDNT: data collection, data analysis, draft, revision.\u003c/p\u003e\n\u003cp\u003eTNTT: data collection, data analysis, draft, revision.\u003c/p\u003e\n\u003cp\u003eCL: data collection, data analysis, draft, revision.\u003c/p\u003e\n\u003cp\u003eMA: concept, data analysis, draft, revision\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO, Factsheet. 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The Partnership for Health System Sustainability and Resilience (PHSSR). 2021.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Scaling up, non-communicable diseases, diabetes, hypertension, Vietnam, RE-AIM, sequential explanatory design, community health, primary healthcare","lastPublishedDoi":"10.21203/rs.3.rs-6311998/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6311998/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eNon-communicable diseases (NCDs) are the leading cause of morbidity and mortality in Vietnam. The government has a strategic NCD plan in place, which puts emphasis on community-based prevention and screening and primary healthcare-based early diagnosis and treatment. The project Scaling-Up NCD Interventions in Southeast Asia (SUNI-SEA) implemented community-based screening in Intergenerational Solidarity Groups (ISHGs) and capacity building for early diagnosis and treatment in Commune Health Stations (CHSs). Through creating synergies between community and PHC the project aimed at scaling up NCD prevention and control in Vietnam.\u003c/p\u003e\n\u003cp\u003eThis paper presents the methodology for monitoring processes and results in scaling up NCD prevention and control in Vietnam, and lessons learned for global action in this field.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe project used the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to develop quantitative and qualitative indicators for measuring the implementation. The project applied a sequential explanatory design to perform routine monitoring, surveys and in-depth interviews, leading to final conclusions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe project managed to scale up NCD interventions successfully through horizonal scaling-up (reaching more people) and vertical scaling-up (increasing the package of services). Risk factors for diabetes and hypertension were identified in community-based screening, and early treatment started in CHSs. Health literacy of community members increased, and skills of health workers improved.\u003c/p\u003e\n\u003cp\u003eThe processes of scaling up were highly dependent on good communication and commitment of stakeholders (community members, community-based organisations, health workers, health managers), clear agreements on roles and responsibilities, as well as simple understandable interventions, with good protocols and guidelines. Technical support and continuous capacity building is required throughout the process. Organisational, financial and human resources constraints hamper scaling up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe RE-AIM framework is a suitable tool for measuring scaling up interventions. For application in routine situations, monitoring must be simplified. A sequential explanatory design helps to measure results and processes step by step. Barriers and facilitators for scaling-up NCD interventions were identified.\u003c/p\u003e\n\u003cp\u003eTrial registration: NCT05239572 date 25 Oct 2023\u003c/p\u003e","manuscriptTitle":"Evaluation of a scaling up strategy for noncommunicable diseases interventions using the RE-AIM framework – A case study from Vietnam","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 01:54:06","doi":"10.21203/rs.3.rs-6311998/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81d70bf9-5ced-40a8-b905-3c96c303b3c5","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-06T12:23:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 01:54:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6311998","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6311998","identity":"rs-6311998","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}