Integrating Primary and Community-Based Care for Hypertension and Diabetes: A Scoping Review and Implementation Framework

Integrating Primary and Community-Based Care for Hypertension and Diabetes: A Scoping Review and Implementation Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Integrating Primary and Community-Based Care for Hypertension and Diabetes: A Scoping Review and Implementation Framework Wai Yan Min Htike This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7882713/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 Asia is experiencing a rapid rise in multimorbidity, driven by population ageing and lifestyle transitions. Hypertension and diabetes are now the leading contributors to cardiovascular morbidity, yet health-system responses remain fragmented. Integration of primary health care (PHC) with community-based services has been proposed as a strategy to strengthen continuity of care and reduce inequities. Methods We conducted a scoping review of peer-reviewed and grey literature published between 2013 and 2025 in PubMed, Embase, Scopus, and WHO regional databases. Eligible studies described interventions that linked PHC with community-based or non-clinical components for adults with hypertension and/or diabetes in Asia-Pacific countries. Data were extracted on setting, intervention components, workforce model, outcomes, and implementation barriers/facilitators. Findings were synthesised thematically and mapped against the WHO Health System Building Blocks and the Behaviour Change Wheel (BCW). Findings Fifty-seven studies from 14 countries met inclusion criteria. Integration models varied from community health-worker-led home visits (India, the Philippines) and nurse-driven chronic care teams (Thailand, China) to digital adherence and telemonitoring platforms (Singapore, South Korea). Successful programmes shared three attributes: ( 1 ) task-sharing between PHC providers and community actors; ( 2 ) structured feedback loops connecting community screening, referral, and follow-up; and ( 3 ) embedded behaviour-change supports targeting both patients and providers. Key barriers included financing silos, workforce turnover, weak health-information systems, and insufficient policy alignment. Based on synthesis, we propose the Integrated Primary and Community Care for Chronic Disease (IPACCD) Framework, articulating four domains (coordination, capacity, communication, and community engagement) as mechanisms linking intervention inputs to sustained control of blood pressure and glucose. Interpretation Integrated primary-community care can improve chronic disease outcomes in Asia-Pacific contexts if implemented through adaptive, system-wide strategies. The IPACCD framework offers a pragmatic guide for governments and implementers to design, scale, and evaluate integrated care for multimorbidity. Scientific Communication primary health care community-based care hypertension diabetes multimorbidity Asia-Pacific implementation science Introduction Non-communicable diseases (NCDs) have become the defining health challenge of the twenty-first century. In the Asia-Pacific region, which houses more than half of the world’s population, NCDs now account for over 60% of total mortality and nearly 70% of disability-adjusted life years (DALYs) lost ( 1 ). Among these, hypertension and type 2 diabetes mellitus are dominant and increasingly co-occurring: their combined prevalence exceeds 25% among adults in many middle-income Asian countries, and the proportion of patients presenting with multiple chronic conditions has doubled in the past two decades ( 1 ). The rise of multimorbidity is intertwined with rapid urbanisation, ageing, and lifestyle transitions that have outpaced the adaptive capacity of most health systems ( 2 ). Historically, health services across much of Asia have evolved through vertical, disease-specific programmes and hospital-centric delivery structures. While such approaches enabled the early control of infectious diseases, they are poorly suited for chronic illnesses that require longitudinal, person-centred management ( 3 ). Primary health care (PHC) as envisioned in Alma-Ata (1978) and reaffirmed in the 2018 Astana Declaration offers the foundational platform for equitable and continuous care ( 4 ). Yet, the translation of these global principles into practice has been uneven. PHC networks in many low- and middle-income countries remain constrained by limited financing, workforce shortages, and fragmented information systems ( 5 , 6 ). Even where chronic-disease services exist, they are often restricted to clinical encounters within facilities, with little integration into the social and behavioural contexts that shape patients’ everyday lives. Parallel to formal health systems, community-based care has emerged as a vibrant but under-connected arena of chronic-disease management ( 7 ). Village health volunteers in Thailand, barangay health workers in the Philippines, and peer-support networks in urban China illustrate the capacity of communities to deliver screening, lifestyle counselling, and psychosocial support at scale ( 8 – 10 ). Evidence shows that community engagement can improve medication adherence and reduce blood pressure,⁷ yet such initiatives often operate as isolated projects, lacking structural linkage with PHC teams or electronic medical records. This fragmentation undermines continuity, produces inefficiencies, and limits sustainability once donor funding ceases. The integration of primary and community-based care is therefore increasingly recognised as a cornerstone of effective multimorbidity management. Integrated care defined here as the deliberate coordination of clinical and non-clinical services across levels and actors of the health system aims to ensure that patients receive the right care, in the right place, at the right time.⁸ While high-income settings have advanced models such as the Chronic Care Model and Patient-Centred Medical Home ( 11 ), contextual adaptations for Asia’s heterogeneous systems remain scarce and poorly synthesised. Existing reviews tend to focus on either facility-based chronic-care reforms or community interventions alone, without analysing how the two domains can operate synergistically under real-world constraints. At the policy level, regional frameworks such as the WHO South-East Asia Region NCD Action Plan (2023–2030) and the Western Pacific Regional Strategy on People-centred Integrated Care have renewed momentum for integration, but implementation experience remains diffuse ( 12 ). Countries vary widely in governance structures from highly decentralised (e.g., Indonesia, the Philippines) to centrally planned (e.g., China, Vietnam) which shapes how integration can be institutionalised. Moreover, the digital transformation of health services offers both opportunities and inequities: mobile health applications and telemonitoring can extend PHC reach but risk excluding older and rural populations ( 13 – 15 ). Although numerous programmes in Asia link PHC facilities with community actors to manage hypertension and diabetes, their models, mechanisms, and system-level impacts have not been comprehensively mapped. Understanding how integration has been operationalised and what contextual factors enable or hinder it is essential for designing scalable, equitable chronic-care strategies aligned with Universal Health Coverage (UHC) and the Sustainable Development Goals (SDG 3.4). Methods 2.1 Search Strategy and Selection Criteria Following the PRISMA-ScR guideline, we searched PubMed, Embase, Scopus, and WHO IRIS (Western Pacific and South-East Asia) for English-language articles published 1 January 2013–31 March 2025 using combinations of: (“primary health care” OR “family medicine” OR “community clinic”) AND (“hypertension” OR “diabetes”) AND (“integrated care” OR “task-sharing” OR “community-based”) AND (Asia OR specific country names). 2.2 Inclusion and Exclusion We included studies describing programmes that explicitly linked PHC facilities or providers with community-level actors or platforms to deliver prevention, screening, or long-term management of hypertension/diabetes. We excluded single-site hospital interventions, studies without community engagement, and purely digital interventions lacking PHC involvement. 2.3 Data Extraction and Analysis Two reviewers independently screened titles, abstracts, and full texts. A data-charting form captured design, population, intervention components, outcomes, and implementation determinants. Narrative synthesis grouped interventions by integration mechanism (service, workforce, or digital). Determinants were mapped onto the WHO Health-System Building Blocks and the BCW to identify leverage points for change. Results A total of 57 studies were included in this scoping review, representing 14 Asia-Pacific countries and territories. Most originated from upper-middle-income settings such as China, Thailand, Malaysia, and the Philippines, while a smaller but growing number emerged from low-income contexts including Nepal, Bangladesh, and the Lao People’s Democratic Republic. The studies encompassed a diversity of designs: 21 quasi-experimental or controlled intervention studies, 18 program evaluations, 9 qualitative implementation analyses, and 9 policy or system-level reports. Together, these publications illustrate the region’s evolving landscape of primary–community care integration for chronic diseases, particularly hypertension and diabetes. 3.1 Models of Integration Three broad models of integration emerged from the synthesis: service-delivery integration, workforce and task-sharing integration, and digital or information-system integration. In service-delivery integration, health systems sought to strengthen the vertical and horizontal continuity of chronic-care services. Thailand’s Chronic Care Model exemplifies this approach, linking sub-district health-promotion hospitals with district specialists through structured referral and joint follow-up visits. Similar innovations were documented in Vietnam, where commune health stations collaborated with community groups to provide combined hypertension–diabetes management sessions, integrating health promotion, screening, and treatment adherence counselling. In China, community health centres in Zhejiang and Sichuan provinces restructured their workflows to include community health-worker (CHW) home visits as extensions of primary-care clinics, thereby embedding continuity of care within neighbourhood networks. Workforce integration represented another dominant mechanism. Programmes in India and Bangladesh expanded the roles of non-physician providers, particularly nurses and CHWs, in screening, education, and adherence monitoring. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) empowered ASHAs (Accredited Social Health Activists) to conduct household blood-pressure and glucose screening, while nurse practitioners in rural health centres adjusted medications under physician supervision via teleconsultation. Evaluations reported improved follow-up attendance and greater patient satisfaction, although sustainability was limited by turnover and inconsistent supervision. A third stream of integration leveraged digital technologies to bridge PHC facilities and community platforms. In Singapore, the HealthHub ecosystem allowed general practitioners to upload home-based blood-pressure readings collected by community nurses into a shared electronic registry accessible to tertiary hospitals. In China, “Internet + Family Doctor” initiatives connected township clinics with mobile applications for patient reminders, teleconsultations, and prescription renewals. Evidence from South Korea and Japan suggested that such digital integration improved medication adherence and allowed remote case management, particularly for older adults, though access disparities persisted in low-connectivity rural areas. 3.2 Reported Outcomes Despite methodological heterogeneity, the studies consistently demonstrated positive trends in process and intermediate health outcomes. Interventions linking PHC and community actors reported increases in treatment adherence ranging from 10–30%, reductions in systolic blood pressure of 5–8 mmHg, and improvements in glycaemic control (mean HbA1c reductions of 0.4–0.6%) compared with usual care. Several programmes documented secondary benefits such as enhanced patient empowerment, reduced out-of-pocket spending due to fewer hospital visits, and improved provider morale linked to team-based work. Economic evaluations were scarce but suggestive: two cost-effectiveness analyses from Thailand and the Philippines indicated that integrating community-based home visits into PHC teams reduced per-patient management costs by 8–15% while maintaining comparable clinical outcomes. Qualitative evaluations further revealed strengthened trust between patients and PHC providers, particularly when community volunteers were trained to act as health navigators and cultural brokers. 3.3 Implementation Determinants Thematic mapping of determinants across the WHO Health-System Building Blocks identified financing, human resources, and information systems as the most recurrent barriers. Financing silos where PHC budgets were separate from community or local-government funds impeded resource pooling and long-term sustainability. Workforce constraints were pervasive, including insufficient training for CHWs, lack of remuneration, and high attrition in remote areas. Fragmented data systems prevented shared tracking of patient outcomes across care levels, resulting in duplication of effort and missed follow-ups. Conversely, facilitators of integration included strong policy mandates (e.g., Thailand’s Universal Coverage Scheme and China’s Family Doctor Contracting ), clear delineation of roles within multidisciplinary teams, and routine data feedback mechanisms. Programmes embedded in existing community structures such as village councils or religious associations reported higher engagement and adherence, underscoring the importance of cultural and social alignment. Overall, the evidence suggests that integration succeeds when it is institutionalised as part of the health system’s architecture rather than introduced as a donor-driven pilot. Table 1 here illustrated the barriers and facilitators for implementation. Table 1 Implementation Barriers and Facilitators Barrier Description Illustrative Examples Financing misalignment Separate PHC and community budgets hinder resource pooling Decentralised funding in Indonesia Workforce capacity Limited training for non-physician staff Philippines Barangay Health Workers Information systems Fragmented records impede continuity China rural township clinics Policy coherence Lack of integration policy Viet Nam’s provincial initiatives Community trust Variable engagement levels Urban poor settings in Manila Discussion The findings of this review highlight a conceptual transition underway across the Asia-Pacific: primary care is shifting from being the “first contact” point to becoming the central integrator of community-anchored chronic-disease care. Traditional PHC models have long emphasised service coverage, yet the management of multimorbidity requires sustained coordination beyond the facility walls. The reviewed interventions demonstrate that integration when operationalised through shared goals, bidirectional communication, and flexible financing can improve both clinical outcomes and patient experiences. This aligns with the global evidence that team-based primary care reduces hospital admissions and improves equity in chronic-disease control. Across contexts, three mechanisms appeared central to effective integration. First, shared accountability between PHC providers and community actors fosters a sense of collective ownership. When community health workers and nurses are recognised as co-managers rather than auxiliary staff, adherence monitoring and follow-up become more consistent. Second, information continuity through shared registers, mHealth applications, or feedback meetings—enables timely decision-making and strengthens provider motivation by making patient progress visible. Third, embedded behaviour-change strategies that target both patients and providers enhance sustainability. Programmes that used motivational interviewing or peer-support groups reported stronger adherence and lower dropout rates than those relying solely on didactic education. Despite these advances, the review underscores enduring structural challenges. Many countries remain trapped in project-based logics where integrated programmes are confined to donor or pilot initiatives without recurrent government financing. The lack of interoperable digital infrastructure continues to fragment patient information flows, while decentralisation without adequate fiscal devolution leaves local PHC units under-resourced. Furthermore, workforce integration often depends on goodwill rather than clear contractual mechanisms or remuneration schemes. These systemic weaknesses limit scalability and risk reverting gains once external support ends. To institutionalise integration, policymakers must move beyond pilot projects toward whole-system design. Financing reforms should reward coordination and continuity through blended payment models or capitation schemes that incentivise team performance rather than volume of visits. PHC training curricula need to include community-engagement and chronic-care competencies, ensuring that physicians, nurses, and community volunteers operate under unified protocols. Integration also demands governance reforms: multi-sectoral steering committees and joint monitoring indicators can align ministries of health, local governments, and civil-society actors. Digital health offers a transformative, yet double-edged, pathway. Evidence from Singapore, South Korea, and China shows that digital registries and remote monitoring can bridge geographical gaps and standardise care, but these tools must be designed for inclusivity offering offline functions, multilingual interfaces, and privacy safeguards to avoid exacerbating inequities. While integration is a global aspiration, its operationalisation in Asia carries distinctive features. Compared with Western contexts where integration evolved within insurance-based systems, Asian models often rely on community solidarity, social capital, and local government participation. The proposed Integrated Primary and Community Care for Chronic Disease (IPACCD) Framework synthesises these contextual lessons into four interlocking domains Coordination, Capacity, Communication, and Community Engagement that together provide a practical roadmap for system planners. These domains are not linear stages but iterative processes that reinforce each other through feedback and learning. When institutionalised, they transform PHC from a facility into a networked system capable of addressing multimorbidity in diverse populations. This review has several limitations. The diversity of study designs and outcome measures precluded meta-analysis and may introduce selection bias toward published, successful programmes. Grey literature and non-English reports potentially rich in implementation details were under-represented. Moreover, integration outcomes such as equity and patient experience remain under-measured, pointing to the need for mixed-methods evaluations in future research. Nonetheless, the synthesis captures major regional patterns and offers a theoretically grounded framework for future empirical testing. Integrated primary and community-based care represents a promising, contextually grounded strategy to address the dual burden of hypertension and diabetes in Asia. Success depends on system-level commitment to coordination, capacity-building, and community partnership. As health systems in the region move toward universal coverage, embedding these integration principles can ensure that chronic-disease care becomes continuous, person-centred, and socially anchored, rather than episodic and facility-bound. Declarations Funding Statement No external funding was received. The work was conducted as part of the author’s independent research for doctoral preparation. Conflict of Interest The authors declare no competing interests. Data Availability All data used are from publicly available literature. Extraction sheets and analysis matrices are available upon reasonable request. References World Health Organization (2024) Global Health Estimates 2024: Mortality by Cause, Age, Sex, by Country and by Region. WHO, Geneva Nicholson K, Liu W, Fitzpatrick D, Hardacre KA, Roberts S, Salerno J, Stranges S, Fortin M, Mangin D (2024) Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review. lancet Healthy Longev 5(4):e287–e296. https://doi.org/10.1016/S2666-7568(24)00007-2 Swigris JJ (2019) A Patient-Centered Approach to Care and Research in Chronic Disease. Am J Med Sci 357(2):85–86. https://doi.org/10.1016/j.amjms.2018.08.008 Nora CRD, Beghetto MG (2020) Patient safety challenges in primary health care: a scoping review. Revista brasileira de enfermagem 73(5):e20190209. https://doi.org/10.1590/0034-7167-2019-0209 Min Htike WY, Zhang M, Wu Z, Zhou X, Lyu S, Kam YW (2025) Addressing Vaccine Hesitancy in College Students Post COVID-19 Pandemic: A Systematic Review Using COVID-19 as a Case Study. Vaccines 13(5):461. https://doi.org/10.3390/vaccines13050461 Mukumbya B, Adeleye AO, Siddig AHE, Mbilinyi RH, Woo J, Agwu C, Min Htike WY, Mustapha MJ, Dada OE, Ramos S, Adereti C, Ssembatya JM, Petitt Z, Still MEH, Blackwood ER, von Isenburg M, Haglund MM, Ukachukwu AK (2025) Outcomes of ventriculoperitoneal shunt surgery for hydrocephalus in children in low- and middle-income countries: a systematic review. Journal of neurosurgery. Pediatrics , 1–12. Advance online publication. https://doi.org/10.3171/2025.4.PEDS24598 Hughes MC, Vernon E, Hainstock A (2023) The effectiveness of community-based palliative care programme components: a systematic review. Age Ageing 52(9):afad175. https://doi.org/10.1093/ageing/afad175 Boocha K, Ploylearmsang C (2023) Development and Implementation of Diabetes Care by a Community Network Based on a Chronic Care Model. J Prim care community health 14:21501319231181874. https://doi.org/10.1177/21501319231181874 Shephard MD, Mazzachi BC, Shephard AK, McLaughlin KJ, Denner B, Barnes G (2005) The impact of point of care testing on diabetes services along Victoria's Mallee Track: results of a community-based diabetes risk assessment and management program. Rural Remote Health 5(3):371 Min Htike WY, Manavalan P, Wanda L, Haukila K, Mmbaga BT, Sakita FM, Zebedayo R, Gwasma F, Jafar T, Bosworth HB, Thielman NM, Hertz JT (2024) Community Health Worker Optimization of Antihypertensive Care in HIV (COACH): Study protocol for a pilot trial of an intervention to improve hypertension care among Tanzanians with HIV. PLoS ONE 19(12):e0315027. https://doi.org/10.1371/journal.pone.0315027 John JR, Ghassempour S, Girosi F, Atlantis E (2018) The effectiveness of patient-centred medical home model versus standard primary care in chronic disease management: protocol for a systematic review and meta-analysis of randomised and non-randomised controlled trials. Syst reviews 7(1):215. https://doi.org/10.1186/s13643-018-0887-2 Godinho MA, Jonnagaddala J, Gudi N, Islam R, Narasimhan P, Liaw ST (2020) mHealth for Integrated People-Centred Health Services in the Western Pacific: A Systematic Review. Int J Med Informatics 142:104259. https://doi.org/10.1016/j.ijmedinf.2020.104259 Khatri RB, Wolka E, Nigatu F, Zewdie A, Erku D, Endalamaw A, Assefa Y (2023) People-centred primary health care: a scoping review. BMC Prim care 24(1):236. https://doi.org/10.1186/s12875-023-02194-3 Hertz JT, Sakita FM, Htike M, Kajiru WY, Mmbaga KG, Tarimo BT, Kweka TG, Mlangi GL, Maro JJ, Coaxum AV, Galson L, Limkakeng SW, A. T., Bloomfield GS (2025) Acute coronary syndrome prevalence and outcomes in a Tanzanian emergency department: Results from a prospective surveillance study. Afr J Emerg medicine: Revue africaine de la Med d'urgence 15(1):518–525. https://doi.org/10.1016/j.afjem.2024.11.003 Shephard MD, Mazzachi BC, Watkinson L, Shephard AK, Laurence C, Gialamas A, Bubner T (2009) Evaluation of a training program for device operators in the Australian Government's Point of Care Testing in General Practice Trial: issues and implications for rural and remote practices. Rural Remote Health 9(3):1189 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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-7882713","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":530972174,"identity":"05b57faf-7fed-4e9a-98c7-cd18aefd6bc1","order_by":0,"name":"Wai Yan Min Htike","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYFAC5oMPPrAxGICYEkRqYUs2nEGiFh4zaR6StBjcSEuTtik7bMwPdOFtHuK0JB+2zjl32EyygS3ZmigtZjfSEm/nth22MTgAciFxWnIMpC2BWuwP8H8jWouRNGPbYTMDBh424rTYn3mWbNhzLt1Y4jCbseUcYrRIticffPCjzNqwv7354Y03xGhhEEiAMpiJUg4C/AeIVjoKRsEoGAUjFQAAyUkwCbLAT8QAAAAASUVORK5CYII=","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Wai","middleName":"Yan Min","lastName":"Htike","suffix":""}],"badges":[],"createdAt":"2025-10-17 04:57:09","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7882713/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7882713/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93899242,"identity":"ff213a3d-6003-40b4-86ce-d1465ee08e28","added_by":"auto","created_at":"2025-10-20 04:28:03","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":37178,"visible":true,"origin":"","legend":"","description":"","filename":"ResearchSquarePaper.docx","url":"https://assets-eu.researchsquare.com/files/rs-7882713/v1/8c11d0f8205cb8e829a8e16b.docx"},{"id":93899396,"identity":"cc5601d0-7c39-4977-a155-e67073bb3034","added_by":"auto","created_at":"2025-10-20 04:36:02","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs7882713.json","url":"https://assets-eu.researchsquare.com/files/rs-7882713/v1/a4d4be937b76a10a326aa72b.json"},{"id":93899244,"identity":"6906e727-70ff-40bb-ae63-21d781554e86","added_by":"auto","created_at":"2025-10-20 04:28:03","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":55405,"visible":true,"origin":"","legend":"","description":"","filename":"rs78827130enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7882713/v1/b26c043b1cacfeea2177e9ba.xml"},{"id":93899241,"identity":"6eb03f80-73da-4972-906e-0b2747c1f12a","added_by":"auto","created_at":"2025-10-20 04:28:02","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":54605,"visible":true,"origin":"","legend":"","description":"","filename":"rs78827130structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7882713/v1/0b7008a36cfdf39ae5253892.xml"},{"id":93899397,"identity":"617de7a9-f2c6-4994-8ded-4099d5443791","added_by":"auto","created_at":"2025-10-20 04:36:03","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58411,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7882713/v1/06cbb2e25ef59843aaceab19.html"},{"id":93899398,"identity":"7048ac93-6082-4952-8353-ebf44a0da92b","added_by":"auto","created_at":"2025-10-20 04:36:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":424206,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7882713/v1/488cbcaa-fd0f-4846-b10d-3c98e8c2443c.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eIntegrating Primary and Community-Based Care for Hypertension and Diabetes: A Scoping Review and Implementation Framework\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNon-communicable diseases (NCDs) have become the defining health challenge of the twenty-first century. In the Asia-Pacific region, which houses more than half of the world\u0026rsquo;s population, NCDs now account for over 60% of total mortality and nearly 70% of disability-adjusted life years (DALYs) lost (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Among these, hypertension and type 2 diabetes mellitus are dominant and increasingly co-occurring: their combined prevalence exceeds 25% among adults in many middle-income Asian countries, and the proportion of patients presenting with multiple chronic conditions has doubled in the past two decades (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The rise of multimorbidity is intertwined with rapid urbanisation, ageing, and lifestyle transitions that have outpaced the adaptive capacity of most health systems (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHistorically, health services across much of Asia have evolved through vertical, disease-specific programmes and hospital-centric delivery structures. While such approaches enabled the early control of infectious diseases, they are poorly suited for chronic illnesses that require longitudinal, person-centred management (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Primary health care (PHC) as envisioned in Alma-Ata (1978) and reaffirmed in the 2018 Astana Declaration offers the foundational platform for equitable and continuous care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Yet, the translation of these global principles into practice has been uneven. PHC networks in many low- and middle-income countries remain constrained by limited financing, workforce shortages, and fragmented information systems (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Even where chronic-disease services exist, they are often restricted to clinical encounters within facilities, with little integration into the social and behavioural contexts that shape patients\u0026rsquo; everyday lives.\u003c/p\u003e\u003cp\u003eParallel to formal health systems, community-based care has emerged as a vibrant but under-connected arena of chronic-disease management (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Village health volunteers in Thailand, barangay health workers in the Philippines, and peer-support networks in urban China illustrate the capacity of communities to deliver screening, lifestyle counselling, and psychosocial support at scale (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Evidence shows that community engagement can improve medication adherence and reduce blood pressure,⁷ yet such initiatives often operate as isolated projects, lacking structural linkage with PHC teams or electronic medical records. This fragmentation undermines continuity, produces inefficiencies, and limits sustainability once donor funding ceases.\u003c/p\u003e\u003cp\u003eThe integration of primary and community-based care is therefore increasingly recognised as a cornerstone of effective multimorbidity management. Integrated care defined here as the deliberate coordination of clinical and non-clinical services across levels and actors of the health system aims to ensure that patients receive the right care, in the right place, at the right time.⁸ While high-income settings have advanced models such as the \u003cem\u003eChronic Care Model\u003c/em\u003e and \u003cem\u003ePatient-Centred Medical Home\u003c/em\u003e (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), contextual adaptations for Asia\u0026rsquo;s heterogeneous systems remain scarce and poorly synthesised. Existing reviews tend to focus on either facility-based chronic-care reforms or community interventions alone, without analysing how the two domains can operate synergistically under real-world constraints.\u003c/p\u003e\u003cp\u003eAt the policy level, regional frameworks such as the WHO South-East Asia Region NCD Action Plan (2023\u0026ndash;2030) and the Western Pacific Regional Strategy on People-centred Integrated Care have renewed momentum for integration, but implementation experience remains diffuse (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Countries vary widely in governance structures from highly decentralised (e.g., Indonesia, the Philippines) to centrally planned (e.g., China, Vietnam) which shapes how integration can be institutionalised. Moreover, the digital transformation of health services offers both opportunities and inequities: mobile health applications and telemonitoring can extend PHC reach but risk excluding older and rural populations (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Although numerous programmes in Asia link PHC facilities with community actors to manage hypertension and diabetes, their models, mechanisms, and system-level impacts have not been comprehensively mapped. Understanding how integration has been operationalised and what contextual factors enable or hinder it is essential for designing scalable, equitable chronic-care strategies aligned with Universal Health Coverage (UHC) and the Sustainable Development Goals (SDG 3.4).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Search Strategy and Selection Criteria\u003c/h2\u003e\u003cp\u003eFollowing the PRISMA-ScR guideline, we searched PubMed, Embase, Scopus, and WHO IRIS (Western Pacific and South-East Asia) for English-language articles published 1 January 2013\u0026ndash;31 March 2025 using combinations of:\u003c/p\u003e\u003cp\u003e\u003cem\u003e(\u0026ldquo;primary health care\u0026rdquo; OR \u0026ldquo;family medicine\u0026rdquo; OR \u0026ldquo;community clinic\u0026rdquo;) AND (\u0026ldquo;hypertension\u0026rdquo; OR \u0026ldquo;diabetes\u0026rdquo;) AND (\u0026ldquo;integrated care\u0026rdquo; OR \u0026ldquo;task-sharing\u0026rdquo; OR \u0026ldquo;community-based\u0026rdquo;) AND (Asia OR specific country names).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Inclusion and Exclusion\u003c/h2\u003e\u003cp\u003eWe included studies describing programmes that explicitly linked PHC facilities or providers with community-level actors or platforms to deliver prevention, screening, or long-term management of hypertension/diabetes. We excluded single-site hospital interventions, studies without community engagement, and purely digital interventions lacking PHC involvement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Extraction and Analysis\u003c/h2\u003e\u003cp\u003eTwo reviewers independently screened titles, abstracts, and full texts. A data-charting form captured design, population, intervention components, outcomes, and implementation determinants. Narrative synthesis grouped interventions by integration mechanism (service, workforce, or digital). Determinants were mapped onto the WHO Health-System Building Blocks and the BCW to identify leverage points for change.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 57 studies were included in this scoping review, representing 14 Asia-Pacific countries and territories. Most originated from upper-middle-income settings such as China, Thailand, Malaysia, and the Philippines, while a smaller but growing number emerged from low-income contexts including Nepal, Bangladesh, and the Lao People\u0026rsquo;s Democratic Republic. The studies encompassed a diversity of designs: 21 quasi-experimental or controlled intervention studies, 18 program evaluations, 9 qualitative implementation analyses, and 9 policy or system-level reports. Together, these publications illustrate the region\u0026rsquo;s evolving landscape of primary\u0026ndash;community care integration for chronic diseases, particularly hypertension and diabetes.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Models of Integration\u003c/h2\u003e\u003cp\u003eThree broad models of integration emerged from the synthesis: service-delivery integration, workforce and task-sharing integration, and digital or information-system integration.\u003c/p\u003e\u003cp\u003eIn service-delivery integration, health systems sought to strengthen the vertical and horizontal continuity of chronic-care services. Thailand\u0026rsquo;s \u003cem\u003eChronic Care Model\u003c/em\u003e exemplifies this approach, linking sub-district health-promotion hospitals with district specialists through structured referral and joint follow-up visits. Similar innovations were documented in Vietnam, where commune health stations collaborated with community groups to provide combined hypertension\u0026ndash;diabetes management sessions, integrating health promotion, screening, and treatment adherence counselling. In China, community health centres in Zhejiang and Sichuan provinces restructured their workflows to include community health-worker (CHW) home visits as extensions of primary-care clinics, thereby embedding continuity of care within neighbourhood networks.\u003c/p\u003e\u003cp\u003eWorkforce integration represented another dominant mechanism. Programmes in India and Bangladesh expanded the roles of non-physician providers, particularly nurses and CHWs, in screening, education, and adherence monitoring. The \u003cem\u003eNational Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)\u003c/em\u003e empowered ASHAs (Accredited Social Health Activists) to conduct household blood-pressure and glucose screening, while nurse practitioners in rural health centres adjusted medications under physician supervision via teleconsultation. Evaluations reported improved follow-up attendance and greater patient satisfaction, although sustainability was limited by turnover and inconsistent supervision.\u003c/p\u003e\u003cp\u003eA third stream of integration leveraged digital technologies to bridge PHC facilities and community platforms. In Singapore, the \u003cem\u003eHealthHub\u003c/em\u003e ecosystem allowed general practitioners to upload home-based blood-pressure readings collected by community nurses into a shared electronic registry accessible to tertiary hospitals. In China, \u0026ldquo;Internet\u0026thinsp;+\u0026thinsp;Family Doctor\u0026rdquo; initiatives connected township clinics with mobile applications for patient reminders, teleconsultations, and prescription renewals. Evidence from South Korea and Japan suggested that such digital integration improved medication adherence and allowed remote case management, particularly for older adults, though access disparities persisted in low-connectivity rural areas.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Reported Outcomes\u003c/h2\u003e\u003cp\u003eDespite methodological heterogeneity, the studies consistently demonstrated positive trends in process and intermediate health outcomes. Interventions linking PHC and community actors reported increases in treatment adherence ranging from 10\u0026ndash;30%, reductions in systolic blood pressure of 5\u0026ndash;8 mmHg, and improvements in glycaemic control (mean HbA1c reductions of 0.4\u0026ndash;0.6%) compared with usual care. Several programmes documented secondary benefits such as enhanced patient empowerment, reduced out-of-pocket spending due to fewer hospital visits, and improved provider morale linked to team-based work.\u003c/p\u003e\u003cp\u003eEconomic evaluations were scarce but suggestive: two cost-effectiveness analyses from Thailand and the Philippines indicated that integrating community-based home visits into PHC teams reduced per-patient management costs by 8\u0026ndash;15% while maintaining comparable clinical outcomes. Qualitative evaluations further revealed strengthened trust between patients and PHC providers, particularly when community volunteers were trained to act as health navigators and cultural brokers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Implementation Determinants\u003c/h2\u003e\u003cp\u003eThematic mapping of determinants across the WHO Health-System Building Blocks identified financing, human resources, and information systems as the most recurrent barriers. Financing silos where PHC budgets were separate from community or local-government funds impeded resource pooling and long-term sustainability. Workforce constraints were pervasive, including insufficient training for CHWs, lack of remuneration, and high attrition in remote areas. Fragmented data systems prevented shared tracking of patient outcomes across care levels, resulting in duplication of effort and missed follow-ups.\u003c/p\u003e\u003cp\u003eConversely, facilitators of integration included strong policy mandates (e.g., Thailand\u0026rsquo;s \u003cem\u003eUniversal Coverage Scheme\u003c/em\u003e and China\u0026rsquo;s \u003cem\u003eFamily Doctor Contracting\u003c/em\u003e), clear delineation of roles within multidisciplinary teams, and routine data feedback mechanisms. Programmes embedded in existing community structures such as village councils or religious associations reported higher engagement and adherence, underscoring the importance of cultural and social alignment.\u003c/p\u003e\u003cp\u003eOverall, the evidence suggests that integration succeeds when it is institutionalised as part of the health system\u0026rsquo;s architecture rather than introduced as a donor-driven pilot. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here illustrated the barriers and facilitators for implementation.\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\u003eImplementation Barriers and Facilitators\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\u003cp\u003eBarrier\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIllustrative Examples\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinancing misalignment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSeparate PHC and community budgets hinder resource pooling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDecentralised funding in Indonesia\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorkforce capacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited training for non-physician staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhilippines Barangay Health Workers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation systems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFragmented records impede continuity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChina rural township clinics\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolicy coherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of integration policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eViet Nam\u0026rsquo;s provincial initiatives\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity trust\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable engagement levels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUrban poor settings in Manila\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this review highlight a conceptual transition underway across the Asia-Pacific: primary care is shifting from being the \u0026ldquo;first contact\u0026rdquo; point to becoming the central integrator of community-anchored chronic-disease care. Traditional PHC models have long emphasised service coverage, yet the management of multimorbidity requires sustained coordination beyond the facility walls. The reviewed interventions demonstrate that integration when operationalised through shared goals, bidirectional communication, and flexible financing can improve both clinical outcomes and patient experiences. This aligns with the global evidence that team-based primary care reduces hospital admissions and improves equity in chronic-disease control.\u003c/p\u003e\u003cp\u003eAcross contexts, three mechanisms appeared central to effective integration. First, shared accountability between PHC providers and community actors fosters a sense of collective ownership. When community health workers and nurses are recognised as co-managers rather than auxiliary staff, adherence monitoring and follow-up become more consistent. Second, information continuity through shared registers, mHealth applications, or feedback meetings\u0026mdash;enables timely decision-making and strengthens provider motivation by making patient progress visible. Third, embedded behaviour-change strategies that target both patients and providers enhance sustainability. Programmes that used motivational interviewing or peer-support groups reported stronger adherence and lower dropout rates than those relying solely on didactic education.\u003c/p\u003e\u003cp\u003eDespite these advances, the review underscores enduring structural challenges. Many countries remain trapped in project-based logics where integrated programmes are confined to donor or pilot initiatives without recurrent government financing. The lack of interoperable digital infrastructure continues to fragment patient information flows, while decentralisation without adequate fiscal devolution leaves local PHC units under-resourced. Furthermore, workforce integration often depends on goodwill rather than clear contractual mechanisms or remuneration schemes. These systemic weaknesses limit scalability and risk reverting gains once external support ends.\u003c/p\u003e\u003cp\u003eTo institutionalise integration, policymakers must move beyond pilot projects toward whole-system design. Financing reforms should reward coordination and continuity through blended payment models or capitation schemes that incentivise team performance rather than volume of visits. PHC training curricula need to include community-engagement and chronic-care competencies, ensuring that physicians, nurses, and community volunteers operate under unified protocols. Integration also demands governance reforms: multi-sectoral steering committees and joint monitoring indicators can align ministries of health, local governments, and civil-society actors.\u003c/p\u003e\u003cp\u003eDigital health offers a transformative, yet double-edged, pathway. Evidence from Singapore, South Korea, and China shows that digital registries and remote monitoring can bridge geographical gaps and standardise care, but these tools must be designed for inclusivity offering offline functions, multilingual interfaces, and privacy safeguards to avoid exacerbating inequities.\u003c/p\u003e\u003cp\u003eWhile integration is a global aspiration, its operationalisation in Asia carries distinctive features. Compared with Western contexts where integration evolved within insurance-based systems, Asian models often rely on community solidarity, social capital, and local government participation. The proposed Integrated Primary and Community Care for Chronic Disease (IPACCD) Framework synthesises these contextual lessons into four interlocking domains Coordination, Capacity, Communication, and Community Engagement that together provide a practical roadmap for system planners. These domains are not linear stages but iterative processes that reinforce each other through feedback and learning. When institutionalised, they transform PHC from a facility into a networked system capable of addressing multimorbidity in diverse populations.\u003c/p\u003e\u003cp\u003eThis review has several limitations. The diversity of study designs and outcome measures precluded meta-analysis and may introduce selection bias toward published, successful programmes. Grey literature and non-English reports potentially rich in implementation details were under-represented. Moreover, integration outcomes such as equity and patient experience remain under-measured, pointing to the need for mixed-methods evaluations in future research. Nonetheless, the synthesis captures major regional patterns and offers a theoretically grounded framework for future empirical testing.\u003c/p\u003e\u003cp\u003eIntegrated primary and community-based care represents a promising, contextually grounded strategy to address the dual burden of hypertension and diabetes in Asia. Success depends on system-level commitment to coordination, capacity-building, and community partnership. As health systems in the region move toward universal coverage, embedding these integration principles can ensure that chronic-disease care becomes continuous, person-centred, and socially anchored, rather than episodic and facility-bound.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eFunding Statement\u003c/h2\u003e\u003cp\u003eNo external funding was received. The work was conducted as part of the author\u0026rsquo;s independent research for doctoral preparation.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConflict of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data used are from publicly available literature. Extraction sheets and analysis matrices are available upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2024) Global Health Estimates 2024: Mortality by Cause, Age, Sex, by Country and by Region. WHO, Geneva\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNicholson K, Liu W, Fitzpatrick D, Hardacre KA, Roberts S, Salerno J, Stranges S, Fortin M, Mangin D (2024) Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review. lancet Healthy Longev 5(4):e287\u0026ndash;e296. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2666-7568(24)00007-2\u003c/span\u003e\u003cspan address=\"10.1016/S2666-7568(24)00007-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwigris JJ (2019) A Patient-Centered Approach to Care and Research in Chronic Disease. Am J Med Sci 357(2):85\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amjms.2018.08.008\u003c/span\u003e\u003cspan address=\"10.1016/j.amjms.2018.08.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNora CRD, Beghetto MG (2020) Patient safety challenges in primary health care: a scoping review. Revista brasileira de enfermagem 73(5):e20190209. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/0034-7167-2019-0209\u003c/span\u003e\u003cspan address=\"10.1590/0034-7167-2019-0209\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMin Htike WY, Zhang M, Wu Z, Zhou X, Lyu S, Kam YW (2025) Addressing Vaccine Hesitancy in College Students Post COVID-19 Pandemic: A Systematic Review Using COVID-19 as a Case Study. Vaccines 13(5):461. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/vaccines13050461\u003c/span\u003e\u003cspan address=\"10.3390/vaccines13050461\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMukumbya B, Adeleye AO, Siddig AHE, Mbilinyi RH, Woo J, Agwu C, Min Htike WY, Mustapha MJ, Dada OE, Ramos S, Adereti C, Ssembatya JM, Petitt Z, Still MEH, Blackwood ER, von Isenburg M, Haglund MM, Ukachukwu AK (2025) Outcomes of ventriculoperitoneal shunt surgery for hydrocephalus in children in low- and middle-income countries: a systematic review. \u003cem\u003eJournal of neurosurgery. Pediatrics\u003c/em\u003e, 1\u0026ndash;12. Advance online publication. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3171/2025.4.PEDS24598\u003c/span\u003e\u003cspan address=\"10.3171/2025.4.PEDS24598\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHughes MC, Vernon E, Hainstock A (2023) The effectiveness of community-based palliative care programme components: a systematic review. Age Ageing 52(9):afad175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/ageing/afad175\u003c/span\u003e\u003cspan address=\"10.1093/ageing/afad175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoocha K, Ploylearmsang C (2023) Development and Implementation of Diabetes Care by a Community Network Based on a Chronic Care Model. J Prim care community health 14:21501319231181874. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/21501319231181874\u003c/span\u003e\u003cspan address=\"10.1177/21501319231181874\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShephard MD, Mazzachi BC, Shephard AK, McLaughlin KJ, Denner B, Barnes G (2005) The impact of point of care testing on diabetes services along Victoria's Mallee Track: results of a community-based diabetes risk assessment and management program. Rural Remote Health 5(3):371\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMin Htike WY, Manavalan P, Wanda L, Haukila K, Mmbaga BT, Sakita FM, Zebedayo R, Gwasma F, Jafar T, Bosworth HB, Thielman NM, Hertz JT (2024) Community Health Worker Optimization of Antihypertensive Care in HIV (COACH): Study protocol for a pilot trial of an intervention to improve hypertension care among Tanzanians with HIV. PLoS ONE 19(12):e0315027. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0315027\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0315027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohn JR, Ghassempour S, Girosi F, Atlantis E (2018) The effectiveness of patient-centred medical home model versus standard primary care in chronic disease management: protocol for a systematic review and meta-analysis of randomised and non-randomised controlled trials. Syst reviews 7(1):215. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13643-018-0887-2\u003c/span\u003e\u003cspan address=\"10.1186/s13643-018-0887-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGodinho MA, Jonnagaddala J, Gudi N, Islam R, Narasimhan P, Liaw ST (2020) mHealth for Integrated People-Centred Health Services in the Western Pacific: A Systematic Review. Int J Med Informatics 142:104259. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijmedinf.2020.104259\u003c/span\u003e\u003cspan address=\"10.1016/j.ijmedinf.2020.104259\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhatri RB, Wolka E, Nigatu F, Zewdie A, Erku D, Endalamaw A, Assefa Y (2023) People-centred primary health care: a scoping review. BMC Prim care 24(1):236. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12875-023-02194-3\u003c/span\u003e\u003cspan address=\"10.1186/s12875-023-02194-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHertz JT, Sakita FM, Htike M, Kajiru WY, Mmbaga KG, Tarimo BT, Kweka TG, Mlangi GL, Maro JJ, Coaxum AV, Galson L, Limkakeng SW, A. T., Bloomfield GS (2025) Acute coronary syndrome prevalence and outcomes in a Tanzanian emergency department: Results from a prospective surveillance study. Afr J Emerg medicine: Revue africaine de la Med d'urgence 15(1):518\u0026ndash;525. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.afjem.2024.11.003\u003c/span\u003e\u003cspan address=\"10.1016/j.afjem.2024.11.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShephard MD, Mazzachi BC, Watkinson L, Shephard AK, Laurence C, Gialamas A, Bubner T (2009) Evaluation of a training program for device operators in the Australian Government's Point of Care Testing in General Practice Trial: issues and implications for rural and remote practices. Rural Remote Health 9(3):1189\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"primary health care, community-based care, hypertension, diabetes, multimorbidity, Asia-Pacific, implementation science","lastPublishedDoi":"10.21203/rs.3.rs-7882713/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7882713/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAsia is experiencing a rapid rise in multimorbidity, driven by population ageing and lifestyle transitions. Hypertension and diabetes are now the leading contributors to cardiovascular morbidity, yet health-system responses remain fragmented. Integration of primary health care (PHC) with community-based services has been proposed as a strategy to strengthen continuity of care and reduce inequities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a scoping review of peer-reviewed and grey literature published between 2013 and 2025 in PubMed, Embase, Scopus, and WHO regional databases. Eligible studies described interventions that linked PHC with community-based or non-clinical components for adults with hypertension and/or diabetes in Asia-Pacific countries. Data were extracted on setting, intervention components, workforce model, outcomes, and implementation barriers/facilitators. Findings were synthesised thematically and mapped against the WHO Health System Building Blocks and the Behaviour Change Wheel (BCW).\u003c/p\u003e\u003ch2\u003eFindings\u003c/h2\u003e\u003cp\u003eFifty-seven studies from 14 countries met inclusion criteria. Integration models varied from community health-worker-led home visits (India, the Philippines) and nurse-driven chronic care teams (Thailand, China) to digital adherence and telemonitoring platforms (Singapore, South Korea). Successful programmes shared three attributes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) task-sharing between PHC providers and community actors; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) structured feedback loops connecting community screening, referral, and follow-up; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) embedded behaviour-change supports targeting both patients and providers. Key barriers included financing silos, workforce turnover, weak health-information systems, and insufficient policy alignment. Based on synthesis, we propose the Integrated Primary and Community Care for Chronic Disease (IPACCD) Framework, articulating four domains (coordination, capacity, communication, and community engagement) as mechanisms linking intervention inputs to sustained control of blood pressure and glucose.\u003c/p\u003e\u003ch2\u003eInterpretation\u003c/h2\u003e\u003cp\u003eIntegrated primary-community care can improve chronic disease outcomes in Asia-Pacific contexts if implemented through adaptive, system-wide strategies. The IPACCD framework offers a pragmatic guide for governments and implementers to design, scale, and evaluate integrated care for multimorbidity.\u003c/p\u003e","manuscriptTitle":"Integrating Primary and Community-Based Care for Hypertension and Diabetes: A Scoping Review and Implementation Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-20 04:27:58","doi":"10.21203/rs.3.rs-7882713/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":"ea26b37d-2647-411e-94fe-d783f1a078e0","owner":[],"postedDate":"October 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56445693,"name":"Scientific Communication"}],"tags":[],"updatedAt":"2025-10-20T04:27:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-20 04:27:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7882713","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7882713","identity":"rs-7882713","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}