Morrison Joanna, Akter Kohenour, Jennings Hannah Maria, Kuddus Abdul, Nahar Tasmin, King Carina, Shaha Sanjit Kumer, Ahmed Naveed, Haghparast-Bidgoli Hassan, Costello Anthony, Khan A K Azad, Azad Kishwar, Fottrell Edward
1University College London Institute for Global Health, London, UK.
Diabetic Association of Bangladesh, Dhaka, Bangladesh.
Glob Health Res Policy. 2019 Jul 5;4:19. doi: 10.1186/s41256-019-0110-6. eCollection 2019.
There is an urgent need to address the growing type 2 diabetes disease burden. 20-30% of adults in rural areas of Bangladesh have intermediate hyperglycaemia and about 10% have diabetes. We report on the implementation and fidelity of a Participatory Learning and Action (PLA) intervention, evaluated through a three-arm cluster randomised controlled trial which reduced the incidence of diabetes and intermediate hyperglycaemia in rural Bangladesh. PLA interventions have been effective in addressing population level health problems in low income country contexts, and therefore we sought to use this approach to engage communities to identify and address community barriers to prevention and control of type 2 diabetes.
We used a mixed methods approach collecting quantitative data through field reports and qualitative data through observations and focus group discussions. Through descriptive analysis, we considered fidelity to the participatory approach and implementation plans.
One hundred twenty-two groups per month were convened by 16 facilitators and supervised by two coordinators. Groups worked through a four phase PLA cycle of problem identification, planning together, implementation and evaluation to address the risk factors for diabetes - diet, physical activity, smoking and stress. Groups reported a lack of awareness about diabetes prevention and control, the prohibitive cost of care and healthy eating, and gender barriers to exercise for women. Groups set targets to encourage physical activity, kitchen-gardening, cooking with less oil, and reduced tobacco consumption. Anti-tobacco committees operated in 90 groups. One hundred twenty-two groups arranged blood glucose testing and 74 groups organized testing twice. Forty-one women's groups established funds, and 61 communities committed not to ridicule women exercising. Experienced and committed supervisors enabled fidelity to a participatory methodology. A longer intervention period and capacity building could enable engagement with systems barriers to behaviour change.
Our complex intervention was implemented as planned and is likely to be valid in similar contexts given the flexibility of the participatory approach to contextually specific barriers to prevention and control of type 2 diabetes. Fidelity to the participatory approach is key to implementing the intervention and effectively addressing type 2 diabetes in a low-income country.
迫切需要应对日益加重的2型糖尿病疾病负担。孟加拉国农村地区20%-30%的成年人患有血糖偏高，约10%的人患有糖尿病。我们报告了一项参与式学习与行动（PLA）干预措施的实施情况及实施的保真度，该干预措施通过一项三臂整群随机对照试验进行评估，该试验降低了孟加拉国农村地区糖尿病和血糖偏高的发病率。PLA干预措施在解决低收入国家的人群健康问题方面已取得成效，因此我们试图采用这种方法让社区参与，以识别并消除2型糖尿病预防和控制的社区障碍。
我们采用混合方法，通过实地报告收集定量数据，并通过观察和焦点小组讨论收集定性数据。通过描述性分析，我们考量了对参与式方法和实施计划的保真度。
16名促进者每月召集122个小组，并由两名协调员进行监督。各小组经历了一个四阶段的PLA循环，即问题识别、共同规划、实施和评估，以解决糖尿病的风险因素——饮食、体育活动、吸烟和压力。各小组报告称，对糖尿病预防和控制缺乏认识，护理和健康饮食成本过高，以及女性运动存在性别障碍。各小组设定了目标，以鼓励体育活动、家庭菜园种植、少用油烹饪以及减少烟草消费。90个小组设立了反烟草委员会。122个小组安排了血糖检测，74个小组组织了两次检测。41个妇女小组设立了基金，61个社区承诺不嘲笑锻炼的妇女。经验丰富且敬业的监督员确保了对参与式方法的保真度。更长的干预期和能力建设可以促使解决行为改变的系统障碍。
我们的复杂干预措施按计划实施，鉴于参与式方法在应对2型糖尿病预防和控制的具体背景障碍方面具有灵活性，该措施在类似背景下可能有效。对参与式方法的保真度是在低收入国家实施干预措施并有效应对2型糖尿病的关键。
