A community health worker will visit older adults in Sri Lanka, check their blood pressure and blood sugar, and lead group sessions on mindfulness and exercise. This matters because one in three older adults in South Asia has both a cardiometabolic condition (like diabetes or heart disease) and a mental health disorder (like depression or anxiety). These combined conditions worsen each other, yet no existing low-cost programme addresses both at once. The earlier COBRA trial cut blood pressure but ignored mental health and diabetes. This project fills that gap by adding mental health screening, behavioural activation therapy, and physician training to the existing community-worker model. If successful, the programme could be rolled out across Sri Lanka and other low- and middle-income countries through existing health networks. It would give older adults a single, integrated service for their physical and mental health, reducing stigma and delayed care. The trial will also generate cost-effectiveness data that governments need to justify national adoption. The intervention aligns with Sri Lanka’s National Policy for Elders, making policy uptake more likely.
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Cardiometabolic diseases are major contributors to disability and death in low- and middle-income countries (LMICs), especially in older adults in South Asia. Common mental health disorders, especially anxiety and depression, are the second leading cause of disability in LMICs and have a bidirectional link to cardiometabolic diseases. The presence of multimorbid (defined as two or more) cardiometabolic and mental health disorders (CaMMHD) further heightens the risk of adverse outcomes. Additionally, in South Asia, multimorbid CaMMHD are associated with stigma and delayed health seeking with devastating consequences. Our MRC-funded successful COBRA intervention trial demonstrated the effectiveness and cost-effectiveness of a community health worker (CHW)-led intervention in South Asia, focusing primarily on reducing blood pressure (BP). However, it did not explicitly address issues related to diabetes or mental health. Moreover, COBRA did not focus on the importance of community engagement and social integration, particularly important to address the needs of the elderly in whom adverse outcomes are amplified by neurocognitive decline, social isolation and loneliness. Our proposed innovation, "COBRA Holistic Senior (COBRA-HS)” aims to address these gaps. Using extensive community engagement, we will transform COBRA into COBRA-HS to address these broad health needs of the elderly. COBRA-HS will include a) multistakeholder coalition committee to refine the intervention and catalyse social support b) trained CHW-led home CaMMHD monitoring and referrals; c) holistic lifestyle group sessions that combine behavioural activation therapy, mindfulness with lifestyle advice and physical education and d) physicians trained in multimorbid CaMMHD care. Importantly, COBRA-HS is designed to be low cost and scalable through local partnerships and established networks. To test COBRA-HS we will use a convergent, mixed-method, type 2 hybrid effectiveness-implementation study including a cluster randomized controlled trial guided by appropriate frameworks focused on equity and sustainability. We will enrol 1600 adults, aged 60 or older (>50% women) with multimorbid CaMMHD in 40 communities randomized 1:1 to COBRA-HS or usual care, followed for 18 months during and 6 months after the intervention. An embedded qualitative process evaluation will be conducted with 180 stakeholders. The Aims are: In older adults living in low-income communities in Sri Lanka: 1: To identify the contextual social, environmental and health systems barriers, facilitators, co-adapt, and determine the acceptability of innovative “COBRA-HS." 2A: To evaluate whether “COBRA-HS” intervention is more effective than usual care in improving the primary composite outcome of mental health (Hopkins Symptoms Checklist (HSCL))-25 score and cardiometabolic (glycated haemoglobin, BP) indices in older adults with multimorbid CaMMHD over 18 months. We will also assess several secondary (vascular, social, pharmacologic, and mental health) and process (behavioural) outcomes. 2B: To assess the reach, adoption, implementation fidelity, maintenance, acceptability, and experiences of stakeholders with “COBRA-HS” during the intervention, and its sustainability 6 months post-intervention. 3: To determine the incremental cost-effectiveness of COBRA-HS compared with usual care on quality-adjusted life-years gained from the health system and societal perspectives. Our team has an extensive track record of research capacity strengthening and policy advocacy. The proposed intervention is aligned with the recent National Policy for Elders' in Sri Lanka, enhancing its timeliness, scalability, and sustainability. If successful, COBRA-HS could serve as the vanguard approach for managing multimorbid CaMMHD and reducing suffering among older adults in Sri Lanka, and potentially many other LMICs, aligning with the Sustainable Development Goals (SDG) goals and MRC’s mission.
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