Sustainable Risk Research Articles

Public policies on sustainable flood risk management: Study cases of the Netherlands and Malawi

Background: This study compares flood management strategies in Malawi and the Netherlands, emphasizing their respective advantages and disadvantages. The Netherlands is renowned globally for its flood defense, prioritizing prevention, stakeholder involvement, and nature-based solutions through sophisticated infrastructure and proactive approaches. However, future challenges may arise from economic expansion and climate change pressures. In contrast, Malawi, despite having fewer resources, is making strides with its National Resilience Strategy, focusing on risk mitigation, sustainable agriculture, and early warning systems to combat flooding and hunger vulnerabilities. Yet, it faces significant issues with financing, management, and the long-term sustainability of community-based projects. Methods: This study utilized bibliometric analysis and a Systematic Literature Review (SLR), employing a comparative approach to evaluate Malawian and Dutch public policies on flooding disasters. The aim was to identify similarities and differences in their approaches to flood risk management. Findings: The Netherlands’ proactive flood management strategy, characterized by advanced infrastructure and integrated policy frameworks, is a model for high-capacity settings. Its emphasis on nature-based solutions and stakeholder engagement further strengthens its resilience. Malawi's approach, while resource-constrained, shows promise through its National Resilience Strategy, which targets risk reduction, sustainable agricultural practices, and robust early warning systems. Nevertheless, Malawi continues to grapple with financing, effective management, and the sustainability of its flood risk mitigation initiatives. Conclusion: The experiences of the Netherlands and Malawi illustrate the need for continuous policy adaptation and the challenges of managing flood risks in diverse socioeconomic contexts. This research clarifies the relative benefits of different flood control strategies and emphasizes the importance of tailored approaches to address the complexities of flood dangers. Both countries demonstrate the ongoing need for regulatory reform to enhance flood risk mitigation efforts. Novelty/Originality of this Study: This study uniquely compares the flood risk management policies of Malawi and the Netherlands, highlighting the differences between a developing nation's reactive, community-focused approach and a developed country's proactive, infrastructure-intensive strategy. By analyzing their respective strengths and weaknesses, it identifies potential improvements and opportunities for both nations to enhance their flood management and resilience.

Globalization and fiscal policy after financial crises

Has globalization affected the use of fiscal policy as a macroeconomic stabilization tool in response to financial crises? We study this question in an empirical model using different dimensions of globalization – political, social, and economic – and de facto and de jure measures of the different dimensions. By estimating Jordà (2005)-type local projections, we first document that higher political, social and economic globalization matter for the policy response to financial crises, producing more contractionary or austerity policies in terms of the high-employment surplus after distress. High initial debt-to-GDP ratios exacerbate to some extent the effects of globalization, producing additional fiscal austerity after financial distress. Second, we find that countries’ degree of policies and conditions that enable or restrict international flows and activities – hence policies “on paper” – matter most for the effects of globalization on the dynamics of fiscal policy after a financial distress, compared to the actual degree of such flows, that is, policies “in practice”. In total, using of fiscal policy as a macro stabilization tool in an environment of increased globalization appears to be restricted. Accommodation and reinforcement of debt externalities, fiscal spillovers and contagion ensuing from increased globalization may have contributed to policymakers’ concerns about debt sustainability and sovereign risk, thus influencing the fiscal policy response.

Multivariate Statistical Analysis of Cosmetics Due to Potentially Toxic/Heavy Metal(loid) Contamination: Source Identification for Sustainability and Human Health Risk Assessment

Multivariate Statistical Analysis of Cosmetics Due to Potentially Toxic/Heavy Metal(loid) Contamination: Source Identification for Sustainability and Human Health Risk Assessment

Congenital anomalies in pregnancies with overt and pregestational type 2 diabetes: a gray portrayal from a cohort in Brazil

ObjectiveTo describe the frequency and types of congenital anomalies and associated risk factors in Brazilian women with type 2 diabetes.MethodsIn this retrospective cohort study between 2005 and 2021, we included all pregnant participants with type 2 diabetes from the two major public hospitals in southern Brazil. We collected data from the electronic hospital records. Congenital anomalies were classified by the 10th revised International Classification of Diseases, Q chapter, enhanced by the EUROCAT registry classification, and categorized by type and gravity. We used multiple Poisson regression with robust estimates to estimate risks.ResultsAmong 648 participants, we excluded 19, and 62 were lost to follow-up; therefore, we included 567 participants. Overt diabetes arose in 191 participants (33.7%, 95% CI 30.0% – 38.0%). Less than 20% of the participants supplemented folate. Congenital anomalies occurred in 78 neonates (13.8%, CI 11.0 − 16.9%), 73 babies (93.6%) presented major anomalies, and 20 (10.5%) cases occurred in participants with overt diabetes. Cardiac anomalies were the most frequent (43 isolated and 12 combined). Pre-eclampsia was associated with an increased risk in the analyses including all women (adjusted RR 1.87 (95% CI 1.23–2.85), p = 0.003), but not in analyses including only women with an HbA1c measured up to the 14th gestational age. HbA1c, either measured at any time in pregnancy (adjusted RR 1.21 (95% CI 1.10–1.33), p < 0.001) or up to the first 14 weeks (adjusted RR 1.22, 95% CI 1.10–1.35, p < 0.001) was the only sustained risk factor. Risk factors such as maternal age, obesity, diabetes diagnosis, or use of antidiabetic medications were not associated with congenital anomalies.ConclusionWe found a high frequency of congenital anomalies associated with poor maternal glycemic control and revealed an almost universal lack of preconception care. An urgent call to action is mandatory for the reversal of this gray scenario.

Accounting curricula and climate-related sustainability: evidence from Australia and New Zealand universities

ABSTRACT To address climate-related sustainability risks, the global financial system has implemented standards that require entities to disclose information in their financial statements regarding governance processes, controls, and strategies for managing climate-related risks and opportunities. As a result, accountants require knowledge and skills for recording, reporting, measuring and advising on these matters. In response, our study investigates the extent to which climate-related sustainability topics are evident in accounting curricula at 42 Australian and New Zealand universities. Following data collection between November 2022 and April 2023, using contextual thematic analysis, we analyze 1520 subjects and their 7590 intended learning outcomes (ILOs) from 42 undergraduate and 40 postgraduate accounting courses. Findings show that climate-related sustainability is referenced in only 232 subjects and 355 ILOs. As such, since most subjects have only one ILO related to climate-related sustainability, the topic would seem to typically be addressed through adaptations to existing subjects. Further, given the significant number of universities with ≤4 subjects that make reference to climate-related sustainability topics, together with a focus on skills being evident in only 91 ILOs, our findings suggest that much remains to be done to develop accountants’ requisite knowledge and skills.

Communicative Framework Development for Construction Risk Governance: An Analysis of Risk and Trust Perception for Organizational Sustainability

In the construction industry, risk governance stems from the standardization of safety policies and procedures. Safety governance is typically communicated and enforced through a top-down, command-and-control approach. Procedures and policies are created at the top level and cascaded down to the work. Individual discretion in the workplace permits a choice for worker adherence to safety procedures. Through a literature review, this study identified risk perception as a significant variable in regulatory compliance and fidelity. Individual hazard assessments and risk behaviors are often based on subjective cognitive risk perceptions rather than organizational governance policy. In the current governance system, there is a misalignment of risk perceptions and failure in trust between the workforce and the regulatory process. This study examines the impact of risk perceptions on safety compliance and promotes a more participative risk governance process for sustainable construction practices. A participative framework model is proposed to help align worker risk perceptions with organizational governance through policy creation, policy compliance and stakeholder participation and feedback. Utilizing proper discourse and cyclical communication, the proposed framework aims to increase safety fidelity, compliance, and trust in the construction industry through a more inclusive and collaborative governance strategy.

Financial Sustainability and Corporate Credit Risk: Moderating Role of Earnings Management

Financial Sustainability and Corporate Credit Risk: Moderating Role of Earnings Management

Mitigating Financial Risks in Sustainable Public–Private Partnership Infrastructure Projects: A Quantitative Analysis

Economic recession from the coronavirus outbreak continues to have negative rippling effects on local and international financial investments in public–private partnership (PPP) projects in Ghana, a developing country. Together with poor reports on operating cash-inflows for PPP projects such as those covering schools, hospitals, railways, fishing harbors, cocoa warehouses, recreational parks and affordable housing, there is an urgent need to develop and institutionalise sustainable and robust financial risk management measures. These measures are meant to mitigate financial losses, promote sustainability practices and prolong the longevity of infrastructure developments within PPP pacts. Therefore, this study aims to assess the mitigation measures of PPP infrastructure management in Ghana. Primary data from survey questionnaires were utilised in this study, with the data obtained from PPP practitioners and experts. Data were grouped into project type, sectors and practitioners of PPP projects to aid the analysis using tools such as the Kruskal–Wallis test, the Mann–Whitney U test and factor analysis. The results demonstrate sustainable and green finance, the innovative skills and competencies of project teams, green financial risk models and inclusive cost reduction strategies as crucial to minimising financial risks in PPP project delivery. These findings have significant implications for PPP practitioners and researchers in Ghana and similar developing countries to understand and develop measures to respond to financial risks for sustainable PPP project development and future research studies.

Evaluating the Efficacy of Coronary Sinus Reducer Implantation in the Management of Refractory Angina: A Systematic Review and Meta-Analysis.

The coronary sinus reducer (CSR), a minimally invasive device, has emerged as a promising alternative for improving myocardial perfusion in these patients. This meta-analysis evaluated the effectiveness of CSR implantation in patients with refractory angina. A comprehensive search of PubMed, EMBASE, and Web of Science databases identified 10 relevant studies with a pooled sample size of 799 patients. The analysis focused on changes in the Canadian Cardiovascular Society (CCS) classification score, Seattle Angina Questionnaire (SAQ) score, and six-minute walk distance (6MWD) from baseline to follow-up. Results showed significant improvements across all measured outcomes. CCS scores decreased significantly post-CSR implantation, indicating reduced angina severity. SAQ scores improved across all domains, including physical limitation, anginal stability, anginal frequency, treatment satisfaction, and quality of life, suggesting enhanced overall well-being. The 6MWD also increased significantly, reflecting improved functional capacity. These findings highlight CSR's potential as an effective treatment option for patients with refractory angina who have exhausted traditional therapies. CSR implantation appears to alleviate angina symptoms, improve quality of life, and enhance exercise tolerance. Future research should prioritize larger, multi-center randomized controlled trials to validate these findings. Long-term follow-up studies are needed to assess sustained benefits and potential risks.

Developing a transdisciplinary tool for water risk management and decision-support in Ontario, Canada

Extant literature reveals limited examination of risk management strategies and tools to support decision-making for sustainable water management in the private sector in Ontario, Canada. Moreover, a gap persists in understanding how water risks are prioritized and managed in the private sector. Addressing these gaps, this transdisciplinary study applied a novel normative-analytical risk governance theoretical framework to water security risks, which combines analytical risk estimation with normative priorities and insights of practitioners, to examine contextually-attuned water risk management strategies and develop a decision-support tool. Using mixed methods, the study first employed a survey to elicit practitioner priorities for seven water risk indicators and investigated water risk management approaches. Then, interviews were conducted to obtain in-depth understanding about the priorities, strategies, opportunities, and role of trust in water risk management. The study found that a combination of regulatory, voluntary, and multi-stakeholder participatory approaches is needed, contingent on the severity of water risks, sector, location, and context. Moreover, the criteria of flexibility, efficiency, strategic incentives, and economic and regulatory signals, are essential. Finally, using secondary data analysis, the study integrated interdisciplinary risk data with practitioner priorities to develop a first-of-a-kind decision-support tool for water risk management in Ontario, ‘WATR-DST’. WATR-DST is an automated tool that applies the study’s findings and assists multi-sector water-related decisions, practices, and investments by providing contextually-attuned risk information in a user-friendly format. Based on the user inputs (location, sector, and source type), it displays the severity of seven water risks, qualitative themes under public and media attention, and recommends water risk management strategies. Thus, the study contributes to knowledge in sustainability management, risk analysis, and environmental management by demonstrating the novel application of the normative-analytical framework for water risk management in the private sector. WATR-DST is a key contribution envisioned to improve multi-sector water-related decisions in Ontario.

Role of Diversification on Financial Sustainability and Credit Risk of Asian Microfinance Institutions

This paper investigates the role of diversification with respect to financial sustainability and credit risk. This study has extended the discussion from banking to microfinance institutions (MFIs) having dual objective of both financial and social nature to eradicate poverty. Asia being the hub of microfinance, is selected for understanding the scenario. Role of diversification is determined with respect to revenue, product, geographical and asset perspective. Risk is measured with the help of credit risk; z-score and Portfolio at risk (30 days) while operational self- sustainability is employed to understand microfinance sustainability. The approach of generalized method of moment (GMM) is employed for panel data analysis for a sample of 313 Asian microfinance from time period 2012-2019. The findings present significant impacts of various dimensions of diversification for sustainability of microfinance institutions and found more risk comes with more diversification. Further MFIs can mitigate their risk with the help of strategy of group lending. This study suggests that, all MFIs generate income through both financial and non-financial services that led to expansion of their social outreach and decrease their operational cost and hence, sustainability. The findings are helpful for practitioner and policy makers to adapt strategies of diversification for sustainability of MFIs.

STATISTICAL METHODS FOR MANAGING RISKS IN PLANNING FOREIGN ECONOMIC AND LOGISTICS ACTIVITIES FOR SUSTAINABLE DEVELOPMENT OF THE ENTERPRISE

The article examines the topical issue of risk management in foreign economic and logistics activities, which is closely related to the enterprise’s chosen strategy and ensures its sustainable development. The study considers the issue of developing a hedging strategy using statistical methods since adequate forecasting allows predicting the impact of external environment factors on the exchange rate, which will allow the enterprise to timely predict and mitigate the risks in foreign economic and logistics activities. The authors have used general scientific and special methods of systemic and structural analysis to clarify the directions of sustainable performance and risk management tools; formulate the goals and steps in choosing a strategy of hedging; compare the methods of foreign exchange rate risk hedging and perform correlation and regression analysis of factors that impact exchange rate under crisis conditions. The purpose of the paper is to study the specifics of ensuring the sustainable performance of an enterprise using statistical methods in risk management for planning foreign economic and logistics activities. The authors have proposed a definition of a hedging strategy based on the concepts, approaches, and ideas of asset and/or investment management with the aim of reducing loss through hedging instruments, whose feasibility can be substantiated by statistical methods. It has been found that the formation and successful implementation of a hedging strategy requires the use of statistical analysis in order to timely predict fluctuations in exchange rates. The findings of the research were tested based on the performance of PrJSC "Linde Gas Ukraine". In the strategy of hedging the exchange rate risks, it has been proposed to simultaneously open a foreign currency deposit and take a loan in the national currency to replenish the company's working capital. The perspective of further research is the implementation of the proposed hedging strategy and assessment of its effectiveness.

Tourist Motivations to Adopt Sustainable Smart Hospitality: An Innovation Resistance Theory Perspective

This study aimed to assess the neglected conceptualization of smartness in the context of tourism and its probable consequences. Specifically, this study focused on investigating the relationships between sustainable smartness, usage barriers, value barriers, risk barriers, traditional barriers, image barriers, and tourists’ behavioral intentions regarding their stay in smart hotels. The conceptual model of this study is constructed based on innovation resistance theory. By engaging structural equation modeling (SEM) in Smart-PLS 3.2.8, we calculated data from 672 valid respondents. The findings demonstrate that smartness significantly affects usage, value, risk, and traditional and image barriers. Furthermore, we unearthed a significant effect of all barriers on tourists’ behavioral intentions.

A Bibliometric Review of the Relationship between Sustainability Accounting and Financial Risk

This study conducts a comprehensive bibliometric analysis of the field of sustainability accounting and financial risk management, examining thematic clusters, research trends, research opportunities, and author collaborations from 1990 to 2024. Through an extensive review of literature and citation data, key thematic areas such as integrated reporting, environmental risk, and the financial impact of ESG factors were identified. Temporal trend analysis revealed an increasing focus on transparency in sustainability disclosures and the integration of corporate social responsibility into corporate risk management. Opportunities for further research were highlighted in underexplored areas including green accounting and the incorporation of non-financial risks into financial sustainability frameworks. Additionally, an examination of author networks provided insight into the collaborative dynamics among leading scholars, identifying core research groups and potential areas for new interdisciplinary studies. This study provides a structured overview of the scholarly landscape, identifying pivotal trends and gaps, thereby setting a foundation for future academic inquiries and practical applications in sustainability and financial risk management.

The Effect of Service Quality and Islamic Financial Education on Customer Growth and Risk Profile in Islamic Microfinance Institutions in Central Java

This study examines the impact of Service Quality and Islamic Financial Education on Customer Growth and Risk Profile within Islamic microfinance institutions operating in Central Java. A quantitative approach utilizing Structural Equation Modeling-Partial Least Squares (SEM-PLS) was employed to analyze data collected from 130 respondents using Likert scale surveys. The measurement model and structural model were evaluated to assess the relationships among the variables. The results indicate significant positive associations between both Service Quality and Islamic Financial Education with Customer Growth and Risk Profile. Service Quality emerged as a critical factor influencing Customer Growth, while Islamic Financial Education was found to enhance Risk Profile management. These findings underscore the importance of enhancing service delivery and financial literacy initiatives in promoting sustainable growth and risk management in Islamic microfinance.

Multi-objective optimisation framework for Blue-Green Infrastructure placement using detailed flood model

Designing city-scale Blue-Green Infrastructure (BGI) for flood risk management requires detailed and robust methods. This is due to the complex interaction of flow pathways and the need to assess cost-benefit trade-offs for various BGI options. This study aims to find a cost-effective BGI placement scheme by developing an improved approach called the Cost OptimisatioN Framework for Implementing blue-Green infrastructURE (CONFIGURE). The optimisation framework integrates a detailed hydrodynamic flood simulation model with a multi-objective optimisation algorithm (Non-dominated Sorting Genetic Algorithm II). The use of a high-resolution flood simulation model ensures the explicit representation of BGI and other land use features to simulate flow pathways and surface flood risk accurately, while the optimisation algorithm guarantees achieving the best cost-benefit trade-offs for given BGI options. The current study uses the advanced CityCAT hydrodynamic flood model to evaluate the efficiency of the optimisation framework and the impact of location and size of permeable interventions on the optimisation process and subsequent cost-benefit trade-offs. This is achieved by dividing permeable surface areas into intervention zones of varying size and quantity. Furthermore, rainstorm events with 100-year and 30-year return periods are analysed to identify any common optimal solutions for different rainfall intensities. Depending on the number of intervention locations, the automated framework reliably achieves optimal BGI implementation solutions in a fraction of the time required to find the best solutions by trialling all possible options. Designing and optimising interventions with smaller sizes but many permeable zones save a good fraction of investment. However, such a design scheme requires more computational time to find optimal options. Furthermore, the optimal spatial configuration of BGI varies with different rainstorm severities, suggesting a need for careful selection of the rainstorm return period. Based on the results, CONFIGURE shows promise in devising sustainable urban flood risk management designs.

Exploring sustainable watershed flood risks management: An innovative TFAHP-TOPSIS methodology in the Georges River Basin, Australia

Floods occur frequently in low-lying coastal and riverine areas, making it crucial to effectively identify the distribution of flood risks in flood-prone areas. Traditional risk assessment models based on Multiple-Criteria Decision-Making (MCDM) method have limitations in both accuracy and effectiveness, particularly in identifying potential risks in watershed floodplains. To refine the flood measurement process, an optimized integrated MCDM model is proposed in this paper. Taking the Georges River Basin in Australia is chosen as an example, twelve risk indicators were identified, considering factors related to hazard, exposure, and vulnerability. To more accurately describe the characteristics of watershed floods, the flood hazard indicators were separated into sub-basins. The Triangular Fuzzy Analytic Hierarchy Process (TFAHP) is employed to optimize the weight calculation, and in combination with the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS), the spatial distribution of flood risks was determined. The results indicate that high-risk areas are concentrated in the central-eastern part of Liverpool, the eastern part of Fairfield, and the central part of Bankstown-Canterbury. Medium to very-high potential risk areas identified by the integrated TFAHP-TOPSIS model are 17.3 % more than the single TFAHP method and 12.7 % more than the TOPSIS method, indicating that the integrated model performs better in identifying potential risks in floodplains. The results can provide decision support for disaster prevention strategies making in flood-prone areas.

Learning Dynamic Multimodal Network Slot Concepts from the Web for Forecasting Environmental, Social and Governance Ratings

Dynamic multimodal networks are networks with node attributes from different modalities where the attributes and network relationships evolve across time, i.e., both networks and multimodal attributes are dynamic; for example, dynamic relationship networks between companies that evolve across time due to changes in business strategies and alliances, which are associated with dynamic company attributes from multiple modalities such as textual online news, categorical events, and numerical financial-related data. Such information can be useful in predictive tasks involving companies. Environmental, social, and governance (ESG) ratings of companies are important for assessing the sustainability risks of companies. The process of generating ESG ratings by expert analysts is, however, laborious and time-intensive. We thus explore the use of dynamic multimodal networks extracted from the web for forecasting ESG ratings. Learning such dynamic multimodal networks from the web for forecasting ESG ratings is, however, challenging due to its heterogeneity and the low signal-to-noise ratios and non-stationary distributions of web information. Human analysts cope with such issues by learning concepts from past experience through relational thinking and scanning for such concepts when analyzing new information about a company. In this article, we propose the Dynamic Multimodal Slot Concept Attention-based Network (DynScan) model. DynScan utilizes slot attention mechanisms together with slot concept alignment and disentanglement loss functions to learn latent slot concepts from dynamic multimodal networks to improve performance on ESG rating forecasting tasks. DynScan is evaluated on forecasting tasks on six datasets, comprising three ESG ratings across two sets of companies. Our experiments show that DynScan outperforms other state-of-the-art models on these forecasting tasks. We also visualize the slot concepts learned by DynScan on five synthetic datasets and three real-world datasets and observe distinct and meaningful slot concepts being learned by DynScan across both synthetic and real-world datasets.

Sourcing cobalt in the Democratic Republic of the Congo for a responsible net-zero transition: Incentives, risks and stakeholders

Net-zero technologies and the electrification of transport rely heavily on cobalt-containing equipment. Growing demand for cobalt entails environmental, social and economic sustainability risks of cobalt mining, particularly artisanal and small-scale mining (ASM) in the Democratic Republic of the Congo (DRC). Many studies have raised the importance of motivating stakeholders to source cobalt responsibly. Through a systematic literature review, we identify nine sustainability risks that need to be addressed in the cobalt supply chain, analyse measures for incentivising responsible cobalt sourcing, and map links between the sustainability risks and the measures, to elaborate on the engagement of downstream stakeholders and identify methodological gaps. We group such measures into four incentive mechanisms, where integrating ASM into the cobalt supply chain while further formalising the ASM sector (Incentive Mechanism III) is the key to addressing most sustainability risks. Further deconstructing Incentive Mechanism III demonstrates that upstream stakeholders and governments shoulder most responsibility for its implementation. Engagement of downstream companies (such as electric vehicle manufacturers) is inadequate, given their significant influence both on consumers and on the cobalt supply chain. To engage downstream stakeholders more actively, we recommend establishing dedicated ASM funding pools and providing training for ASM communities.

Effect of a multicomponent quality improvement strategy on sustained achievement of diabetes care goals and macrovascular and microvascular complications in South Asia at 6.5 years follow-up: Post hoc analyses of the CARRS randomized clinical trial.

Diabetes control is poor globally and leads to burdensome microvascular and macrovascular complications. We aimed to assess post hoc between-group differences in sustained risk factor control and macrovascular and microvascular endpoints at 6.5 years in the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomized trial. This parallel group individual randomized clinical trial was performed at 10 outpatient diabetes clinics in India and Pakistan from January 2011 through September 2019. A total of 1,146 patients with poorly controlled type 2 diabetes (HbA1c ≥8% and systolic BP ≥140 mm Hg and/or LDL-cholesterol ≥130 mg/dL) were randomized to a multicomponent quality improvement (QI) strategy (trained nonphysician care coordinator to facilitate care for patients and clinical decision support system for physicians) or usual care. At 2.5 years, compared to usual care, those receiving the QI strategy were significantly more likely to achieve multiple risk factor control. Six clinics continued, while 4 clinics discontinued implementing the QI strategy for an additional 4-year follow-up (overall median 6.5 years follow-up). In this post hoc analysis, using intention-to-treat, we examined between-group differences in multiple risk factor control (HbA1c <7% plus BP <130/80 mm Hg and/or LDL-cholesterol <100 mg/dL) and first macrovascular endpoints (nonfatal myocardial infarction, nonfatal stroke, death, revascularization [angioplasty or coronary artery bypass graft]), which were co-primary outcomes. We also examined secondary outcomes, namely, single risk factor control, first microvascular endpoints (retinopathy, nephropathy, neuropathy), and composite first macrovascular plus microvascular events (which also included amputation and all-cause mortality) by treatment group and whether QI strategy implementation was continued over 6.5 years. At 6.5 years, assessment data were available for 854 participants (74.5%; n = 417 [intervention]; n = 437 [usual care]). In terms of sociodemographic and clinical characteristics, participants in the intervention and usual care groups were similar and participants at sites that continued were no different to participants at sites that discontinued intervention implementation. Patients in the intervention arm were more likely to exhibit sustained multiple risk factor control than usual care (relative risk: 1.77; 95% confidence interval [CI], 1.45, 2.16), p < 0.001. Cumulatively, there were 233 (40.5%) first microvascular and macrovascular events in intervention and 274 (48.0%) in usual care patients (absolute risk reduction: 7.5% [95% CI: -13.2, -1.7], p = 0.01; hazard ratio [HR] = 0.72 [95% CI: 0.61, 0.86]), p < 0.001. Patients in the intervention arm experienced lower incidence of first microvascular endpoints (HR = 0.68 [95% CI: 0.56, 0.83), p < 0.001, but there was no evidence of between-group differences in first macrovascular events. Beneficial effects on microvascular and composite vascular outcomes were observed in sites that continued, but not sites that discontinued the intervention. In urban South Asian clinics, a multicomponent QI strategy led to sustained multiple risk factor control and between-group differences in microvascular, but not macrovascular, endpoints. Between-group reductions in vascular outcomes at 6.5 years were observed only at sites that continued the QI intervention, suggesting that practice change needs to be maintained for better population health of people with diabetes. ClinicalTrials.gov NCT01212328.