Participatory learning and action to address type 2 diabetes in rural Bangladesh: a qualitative process evaluation

Cognitive function and associations with demographic, socioeconomic, health and behavioural factors among older adult men and women in rural Bangladesh: a population-based cross-sectional study

Background

Cognitive impairment has a major impact on health, quality of life and survival and its increasing burden presents a critical global health challenge. Empirical population-based studies of cognitive function and its association with demographic, socioeconomic, health and behavioural factors among older adults in low-resource setting are rare. This study describes the burden of cognitive impairment and associations with demographic, health and behavioural factors among older adults in rural Bangladesh.

Methods

We conducted a population-based cross-sectional study of a random sample of men and women aged 60 years and above in 96 rural villages in Bangladesh. Cognitive function was measured using the Bangla Adaptation of the Mini-mental State Examination (BAMSE), where higher score indicates higher function. Blood pressure, height and weight were measured using standard protocols and fasting glucose and 2-h oral glucose test were used to identify diabetes risk. Interviewer administered survey questionnaires assessed depressive symptoms, anxiety and self-reported health behaviours. Analyses were carried out separately for men and women and examined associations between sociodemographic, health and behaviour factors with BAMSE scores using robust Poisson regression.

Findings

Data were gathered from 403 (216 female, 187 male) eligible participants. More than 50% of the population had at least mild cognitive impairment and women had lower cognitive scores than men. Younger age, higher education, wealth, and literacy were significantly associated with higher BAMSE scores among women and men. Associations with marital status varied between men and women, with being married having a positive association with BAMSE among women, i.e. higher cognitive function (relative score ratio (95% CI) 1.08 (1.02, 1.15), p = 0.013), but no association among men (0.94 (0.87, 1.02), p = 0.13). No clear associations were observed with diabetes or hypertension, but overweight and obesity were associated with an increased BAMSE score among women (1.10 (1.02, 1.19), p = 0.011) but not men (1.01 (0.94, 1.10), p = 0.70). Moderate and severe depressive symptoms were associated with lower BAMSE scores among men (0.90 (0.82, 0.99), p = 0.037), but not women (0.94 (0.83, 1.06), p = 0.31). Physical activity was associated with a relative increase in BAMSE score (1.08 (1.01, 1.16), p = 0.020) among women, though no association was seen in men (1.01 (0.95, 1.07), p = 0.76). The consumption of betel was associated with lower BAMSE among women (0.94 (0.89, 1.00), p = 0.056), but there was no evidence of association among men (1.01 (0.96, 1.07), p = 0.61).

Interpretation

A large proportion of older adults in rural Bangladesh have impaired cognitive function and there are important gender differences in the distribution of cognitive scores and their association with demographic, socioeconomic, health and behavioural factors in this population. Improvement in health and social care systems, taking into account the specific social, economic and gender dimensions of the context, are needed to prevent and manage the burden of cognitive decline in rural Bangladesh.

Funding

This survey and analysis were part of the Bangladesh Diabetes Community-Led Awareness, Response and Evaluation (DClare) study funded by UKRI/MRC (MR/T023562/1) under the Global Alliance for Chronic Diseases Scale-Up Programme.

How did the context of COVID-19 affect the implementation and mechanisms of participatory learning and action to address type 2 diabetes? Mixed-methods research in rural Bangladesh

OBJECTIVES

Research indicates the effectiveness of participatory interventions to address rapid rises in type 2 diabetes in low-income countries. Understanding their transferability to different contexts is a priority. We aimed to analyse how the COVID-19 post-lockdown context and adjustments to a participatory learning and action intervention affected theorised mechanisms of effect in rural Bangladesh and to examine the broader implications of this context and intervention adjustments for developing optimal contexts for participatory interventions.

DESIGN

Mixed methods using longitudinal qualitative and quantitative observation data, focus group discussions and interviews with group and community members and project personnel. We used descriptive content analysis, guided by realist evaluation research questions about context, implementation and mechanisms. We used team reflection to enhance the rigour of our analysis.

SETTING

Cluster-randomised trial in Alfadanga upazila, Faridpur district, in the central region of Bangladesh. The intervention was implemented between January 2020 and December 2022, during the COVID-19 pandemic.

PARTICIPANTS

Participatory group members, community members and project personnel (n=32). Structured observations of participatory groups (n=1820) and unstructured observations of groups and their environments (n=15).

INTERVENTIONS

Participatory learning and action community groups of men and women implemented by community-based facilitators.

RESULTS

Due to COVID-19, the participatory learning and action (PLA) intervention was not implemented as planned, which had major effects on the time available to develop the intervention with communities. Communities learnt about diabetes and were motivated to address its causes at an individual level, but community action was a more challenging mechanism to trigger. The post-pandemic context made it difficult to build community rapport, and strategies to engage communities through home visits were challenging. Communities' prior negative experience in working together and in working with non-governmental organisations led to low community cohesion and low motivation to address diabetes collectively. This also resulted in expectations that the implementing organisation would implement community actions and incentivise attendance at meetings. This misalignment of expectations further disabled relationship building, and community strategies addressing the social causes of diabetes were largely not enacted.

CONCLUSION

PLA has optimal effects when time is available to build trust and social cohesion. These are contextual elements and mechanisms that need to be activated to enable critical reflection and community action to develop an enabling environment to address type 2 diabetes.

TRIAL REGISTRATION NUMBER

ISRCTN42219712.

Changes in pre-diabetes and diabetes prevalence and diabetes self-management behaviors across socioeconomic spectra in rural southwest China: 2013-2022

BACKGROUND

This study aimed to uncover the changing prevalence of pre-diabetes and diabetes as well as diabetes self-management behaviors across socioeconomic gradients in rural southwest China.

METHODS

A two-wave, community-based, cross-sectional survey was conducted. A total of 7,747 and 7,536 individuals aged ≥ 35 years, residing in rural southwest China, were selected using a three-stage stratified random sampling method. Demographic characteristics and self-management behaviors were collected through face-to-face interviews, and physical indicators were measured through on-site examinations. An individual socioeconomic position (SEP) index was constructed using principal component analysis based on three variables: education, annual household income, and access to medical services.

RESULTS

In 2022, the overall prevalence of pre-diabetes and diabetes (15.7% and 7.6%) were lower than in 2013 (18.3% and 8.2%) (P < 0.05). This decline was also observed in subgroups including women, those aged 45-54 years, those of Han ethnicity, those with a high educational level, those with a high annual household income, and those with good access to medical services and high SEP (P < 0.05). In contrast, higher rates were found among ethnic minorities, those with low annual household income, and those with low SEP. The overall rate of compliance with anti-diabetic medications or insulin injection was higher in 2022 (95.9%) compared to 2013 (76.5%), with the largest relative increase occurring among participants with a low level of education and income, poor access to medical services, and low SEP (P < 0.01). The proportion of individuals having taken measures to control diabetes was lower in 2022 (39.7%) compared to 2013 (53.3%) (P < 0.01). This lower rate was also observed among the subgroups categorized by sex, education, and income level, in the Han majority, and among participants with good access to medical services and high SEP (P < 0.05). Furthermore, while the overall rate of regular self-monitoring of blood glucose did not differ between the two survey years (41.8% and 44.7%, P > 0.05), a higher rate was uncovered among patients with low education level, low annual household income, poor access to medical services, and low SEP in 2022 compared to 2013 (P < 0.05).

CONCLUSIONS

The prevalence of pre-diabetes and diabetes, as well as the rate of taking measures to control diabetes, were lower among the rural Chinese adult population in 2022 compared with 2013. However, compliance with anti-diabetes medications or insulin injections was higher. Additionally, socioeconomic disparities are associated with these Changes.

Acceptability of a community health worker-led health literacy intervention on lifestyle modification among hypertensive and diabetes patients in the City of Harare, Zimbabwe

Working with community health workers is a vital strategy to improve health at a community level in low- and middle-income countries. Our study assessed the acceptability of a community health worker-led health literacy intervention on lifestyle modification among hypertensive and diabetes patients in the City of Harare, Zimbabwe. The intervention consisted of face-to-face individual educational sessions and support visits, delivered by trained community health workers at either the patient's home or the primary care clinic. We embedded this qualitative study within a cluster randomized trial, which assessed the intervention's effectiveness. Data were gathered through in-depth interviews with 3 community health nurses and 25 patients as well as 3 focus group discussions with CHWs. We analyzed the data manually using the deductive analysis method based on a coding framework structured according to the Theoretical Framework for Acceptability. Participants expressed optimism and anxiety regarding the intervention. All community nurses and CHWs believed that the intervention was effective in improving adherence to recommended lifestyle modifications and overall health outcomes among the patients. Patients felt that the intervention was ethically sound. All community health workers and community nurses reported a clear understanding of the intervention's goals and methods. Some patients felt that some aspects of the intervention needed to be improved. There was a consensus that the benefits associated with the intervention outweighed the costs. Some patients reported that they were not confident in participating in the intervention because some of the recommended lifestyle modifications were beyond their control. Whilst there were positive sentiments regarding the intervention's potential to empower patients and improve health outcomes, challenges related to patients' perceived burdens must be addressed. Future iterations of the intervention should focus on enhancing support for CHWs and ensuring that patients' preferences are catered for.

People with pulmonary tuberculosis in primary health care: social networks and repercussions of illness

OBJECTIVE

to analyze the perceptions of people with pulmonary tuberculosis about their social support networks and the repercussions of becoming ill.

METHOD

a qualitative, descriptive study, conducted with 41 individuals undergoing treatment for pulmonary tuberculosis, in Primary Health Care units in two Brazilian capitals: Belém/Pará and Campo Grande/Mato Grosso do Sul. Semi-structured individual interviews were carried out from July to December 2019. The thematic content analysis technique was applied.

RESULTS

among the participants, 21 (51.22%) were from Belém and 20 (48.78%) from Campo Grande. Males (n=23/56.10%), age group from 21 to 40 years old (n=16/39.02%), unemployed status (n=28/68.29%) and who did not receive social benefits (n=23/56.10%) predominated. Three thematic categories emerged, presenting perceptions about social networks and the types of support they offer, the impact of the disease on family budget and its impact on work activities.

FINAL CONSIDERATIONS

social support networks were characterized by the diversity of people and family or emotional ties maintained with the participants, as well as the diversity of types of support. In this context, they found the necessary human support to face the impact of the illness and deal with their socioeconomic condition.

Public health education using social learning theory: a systematic scoping review

BACKGROUND

Public health education (PHE) in social environments plays a crucial role in mitigating the impact of public health events, especially with the recent surge in global incidents. Social learning theory (SLT) provides a strong theoretical foundation for implementing PHE. The objective of this study is to conduct a systematic scoping review of PHE using SLT, synthesizing the target populations, types of research, main findings, and future directions.

METHODS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR) guidelines. We conducted a comprehensive search of five electronic databases (Web of Science, Scopus, PubMed, ProQuest, and APA PsycInfo) for English articles related to PHE using SLT. Two reviewers independently screened the titles and abstracts. Descriptive statistics were utilized to analyze the characteristics of the articles included in the study, followed by a comprehensive narrative analysis of the results.

RESULTS

Research on PHE using SLT mainly focuses on adolescents, students, special patients, and vulnerable populations. The study sample includes seven research types and nine commonly used experimental methods. Four modes of PHE using SLT are identified, along with four types of summarized research results.

CONCLUSION

PHE research based on SLT can be prioritized for preventing widespread infectious diseases, spreading fundamental public health information, and assisting patients with particular illnesses. To enhance the implementation of PHE, researchers and policymakers should integrate online and offline health education resources, ensure the accessibility of up-to-date information, and leverage digital technologies in PHE. More highly interactive and participatory health education courses will be established in social learning environments to encourage public participation in PHE.

Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India

Addressing undernutrition requires strategies that remove barriers to health for all. We adapted an intervention from the 'UPAVAN' trial to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. In UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and nutrition-sensitive agricultural (NSA) topics. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response system. We assessed feasibility, acceptability, and equity of m-UPAVAN using a convergent parallel mixed-methods design. m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. In Feb-Mar 2021, we invited 1000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, we randomly sampled 200 mothers each month for five months for phone surveys to monitor progress against targets. Feasibility targets were met if >70% received videos/audios and >50% watched/listened at least once. Acceptability targets were met if >75% of those watching/listening liked the videos/audios and <20% opted out of the intervention. We investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). Of the 810 mothers we reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and inclusive, and that mobile approaches provide important complementarity. We conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. Investments are needed in developing and testing hybrid NSA interventions.

Enhanced or hindered research benefits? A realist review of community engagement and participatory research practices for non-communicable disease prevention in low- and middle-income countries

INTRODUCTION

Community engagement and participatory research are widely used and considered important for ethical health research and interventions. Based on calls to unpack their complexity and observed biases in their favour, we conducted a realist review with a focus on non-communicable disease prevention. The aim was to generate an understanding of how and why engagement or participatory practices enhance or hinder the benefits of non-communicable disease research and interventions in low- and middle-income countries.

METHODS

We retroductively formulated theories based on existing literature and realist interviews. After initial searches, preliminary theories and a search strategy were developed. We searched three databases and screened records with a focus on theoretical and empirical relevance. Insights about contexts, strategies, mechanisms and outcomes were extracted and synthesised into six theories. Five realist interviews were conducted to complement literature-based theorising. The final synthesis included 17 quality-appraised articles describing 15 studies.

RESULTS

We developed six theories explaining how community engagement or participatory research practices either enhance or hinder the benefits of non-communicable disease research or interventions. Benefit-enhancing mechanisms include community members' agency being realised, a shared understanding of the benefits of health promotion, communities feeling empowered, and community members feeling solidarity and unity. Benefit-hindering mechanisms include community members' agency remaining unrealised and participation being driven by financial motives or reputational expectations.

CONCLUSION

Our review challenges assumptions about community engagement and participatory research being solely beneficial in the context of non-communicable disease prevention in low- and middle-income countries. We present both helpful and harmful pathways through which health and research outcomes are affected. Our practical recommendations relate to maximising benefits and minimising harm by addressing institutional inflexibility and researcher capabilities, managing expectations on research, promoting solidarity in solving public health challenges and sharing decision-making power.

Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study

BACKGROUND

Engaging communities is an important component of multisectoral action to address the growing burden of non-communicable diseases (NCDs) in low- and middle-income countries. We conducted research with non-communicable disease stakeholders in Bangladesh to understand how a community-led intervention which was shown to reduce the incidence of type 2 diabetes in rural Bangladesh could be scaled-up.

METHODS

We purposively sampled any actor who could have an interest in the intervention, or that could affect or be affected by the intervention. We interviewed central level stakeholders from donor agencies, national health policy levels, public, non-governmental, and research sectors to identify scale-up mechanisms. We interviewed community health workers, policy makers, and non-governmental stakeholders, to explore the feasibility and acceptability of implementing the suggested mechanisms. We discussed scale-up options in focus groups with community members who had attended a community-led intervention. We iteratively developed our data collection tools based on our analysis and re-interviewed some participants. We analysed the data deductively using a stakeholder analysis framework, and inductively from codes identified in the data.

RESULTS

Despite interest in addressing NCDs, there was a lack of a clear community engagement strategy at the government level, and most interventions have been implemented by non-governmental organisations. Many felt the Ministry of Health and Family Welfare should lead on community engagement, and NCD screening and referral has been added to the responsibilities of community health workers and health volunteers. Yet there remains a focus on reproductive health and NCD diagnosis and referral instead of prevention at the community level. There is potential to engage health volunteers in community-led interventions, but their present focus on engaging women for reproductive health does not fit with community needs for NCD prevention.

CONCLUSIONS

Research highlighted the need for a preventative community engagement strategy to address NCDs, and the potential to utilise existing cadres to scale-up community-led interventions. It will be important to work with key stakeholders to address gender issues and ensure flexibility and responsiveness to community concerns. We indicate areas for further implementation research to develop scaled-up models of community-led interventions to address NCDs.

How Did People with Prediabetes Who Attended the Diabetes Prevention Education Program (DiPEP) Experience Making Lifestyle Changes? A Qualitative Study in Nepal

Diabetes can be prevented through lifestyle modification in the prediabetic phase. A group-based lifestyle intervention called 'Diabetes Prevention Education Program' (DiPEP) was tested recently in Nepal. The present study aimed to explore experiences of making lifestyle changes among people with prediabetes participating in the DiPEP. This qualitative study, with semi-structured interviews of 20 participants, was conducted 4-7 months following DiPEP intervention. Data analysis was performed by thematic analysis. The results included four themes, understanding that diabetes could be prevented, lifestyle changes made, hurdles to overcome, and experiencing benefits leading to sustained change. Some participants said they felt relieved to know that they had a chance to prevent diabetes. The participants talked mostly about making changes in diet (reducing carbohydrate intake) and physical activity (starting exercises). Obstacles mentioned included a lack of motivation and a lack of family support to implement changes. Experiencing benefits such as weight loss and reduced blood sugar levels were reported to lead them to maintain the changes they had made. Understanding that diabetes could be prevented was a key motivator for implementing changes. The benefits and hurdles experienced by the participants of the present study can be taken into consideration while designing lifestyle intervention programs in similar settings.

Intermediate hyperglycaemia, diabetes and blood pressure in rural Bangladesh: five-year post-randomisation follow-up of the DMagic cluster-randomised controlled trial

Background

The DMagic trial showed that participatory learning and action (PLA) community mobilisation delivered through facilitated community groups, and mHealth voice messaging interventions improved diabetes knowledge in Bangladesh and the PLA intervention reduced diabetes occurrence. We assess intervention effects three years after intervention activities stopped.

Methods

Five years post-randomisation, we conducted a cross-sectional survey among a random sample of adults aged ≥30-years living in the 96 DMagic villages, and a cohort of individuals identified with intermediate hyperglycaemia at the start of the DMagic trial in 2016. Primary outcomes were: 1) the combined prevalence of intermediate hyperglycaemia and diabetes; 2) five-year cumulative incidence of diabetes among the 2016 cohort of individuals with intermediate hyperglycaemia. Secondary outcomes were: weight, BMI, waist and hip circumferences, blood pressure, knowledge and behaviours. Primary analysis compared outcomes at the cluster level between intervention arms relative to control.

Findings

Data were gathered from 1623 (82%) of the randomly selected adults and 1817 (87%) of the intermediate hyperglycaemia cohort. 2018 improvements in diabetes knowledge in mHealth clusters were no longer observable in 2021. Knowledge remains significantly higher in PLA clusters relative to control but no difference in primary outcomes of intermediate hyperglycaemia and diabetes prevalence (OR (95%CI) 1.23 (0.89, 1.70)) or five-year incidence of diabetes were observed (1.04 (0.78, 1.40)). Hypertension (0.73 (0.54, 0.97)) and hypertension control (2.77 (1.34, 5.75)) were improved in PLA clusters relative to control.

Interpretation

PLA intervention effect on intermediate hyperglycaemia and diabetes was not sustained at 3 years after intervention end, but benefits in terms of blood pressure reduction were observed.

Funding

Medical Research Council UK: MR/M016501/1 (DMagic trial); MR/T023562/1 (DClare study), under the Global Alliance for Chronic Diseases (GACD) Diabetes and Scale-up Programmes, respectively.

Using participatory action research to reimagine community mental health services in Colombia: a mixed-method study protocol

INTRODUCTION

Mental healthcare systems are challenged by how they hear and respond to what marginalised communities experience as drivers of mental distress. In Colombia, this challenge intersects with wider challenges facing post-conflict reconstruction. Our pilot study will explore the feasibility and acceptability of a participatory approach to developing community-led participatory interventions for community mental health systems strengthening and mental health improvement, in two sites in Caquetá, Colombia.

METHODS AND ANALYSIS

The project is divided into three distinct phases aligned with community participatory action research cycles: diagnostic, intervention and evaluation. This allows us to use a participatory approach to design a community-led, bottom-up intervention for mental health systems strengthening and the promotion of mental health and well-being.The diagnostic phase explores local understandings of mental health, mental distress and access to mental health services from community members and health providers. The intervention stage will be guided by a participatory Theory of Change process. Community priorities will inform the development of a participatory, learning and action (PLA) informed group intervention, with a community linkage forum. The pilot of the PLA intervention will be evaluated using MRC process evaluation guidelines.

ETHICS AND DISSEMINATION

This project has received ethical approval from two sources. Universidad de Los Andes (2021-1393) and the University College London (16127/005). Dissemination of findings will include academic publications, community forums, policy briefs and visual media (cartoons, pod casts and short films).

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

BACKGROUND

While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs).

METHODS AND FINDINGS

On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework.

CONCLUSIONS

Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Description of global innovative methods in developing the WHO Community Engagement Package

OBJECTIVES

Development of a Community Engagement Package composed of (1) database of community engagement (CE) experiences from different contexts, (2) CE learning package of lessons and tools presented as online modules, and (3) CE workshop package for identifying CE experiences to enrich the CE database and ensure regular update of learning resources. The package aims to guide practitioners to promote local action and enhance skills for CE.

SETTING AND PARTICIPANTS

The packages were co-created with diverse teams from WHO, Social Innovation in Health Initiative, UNICEF, community practitioners, and other partners providing synergistic contributions and bridging existing silos.

METHODS

The design process of the package was anchored on CE principles. Literature search was performed using standardised search terms through global and regional databases. Interviews with CE practitioners were also conducted.

RESULTS

A total of 356 cases were found to fit the inclusion criteria and proceeded to data extraction and thematic analysis. Themes were organised according to rationale, key points and insights, facilitators of CE and barriers to CE. Principles and standards of CE in various contexts served as a foundation for the CE learning package. The package comprises four modules organised by major themes such as mobilising communities, strengthening health systems, CE in health emergencies and CE as a driver for health equity.

CONCLUSION

After pilot implementation, tools and resources were made available for training and continuous collection of novel CE lessons and experiences from diverse socio-geographical contexts.

Understanding Community Participation in Rural Health Care: A Participatory Learning and Action Approach

Community participation is one of the founding pillars of primary health care. However, due to various reasons, we are yet to achieve complete integration of this component into the health system functioning in India. The objective of our study was to do a formative assessment of community participation in a rural healthcare setting by adopting participatory learning action (PLA). technique. The study participants included frontline health workers and members from local governing institutions of rural areas. The study design is qualitative in nature with a participatory approach. A number of three PLA techniques have been used as a part of this study to recognize available resources for community participation, address its barriers and facilitators, and finally devise a time-line-based action plan. Based on the this, a conceptual framework for community participation pertaining to the rural healthcare system has been developed. This study highlights the importance of understanding the psychosocial aspects of community participation among various stakeholders involved in rural health care. Lessons learned from this PLA study will be helpful in the integration of community-based participatory approach within grassroot level healthcare planning and service delivery.

Equity impact of participatory learning and action community mobilisation and mHealth interventions to prevent and control type 2 diabetes and intermediate hyperglycaemia in rural Bangladesh: analysis of a cluster randomised controlled trial

Background

A cluster randomised trial of mHealth and participatory learning and action (PLA) community mobilisation interventions showed that PLA significantly reduced the prevalence of intermediate hyperglycaemia and type 2 diabetes mellitus (T2DM) and the incidence of T2DM among adults in rural Bangladesh; mHealth improved knowledge but showed no effect on glycaemic outcomes. We explore the equity of intervention reach and impact.

Methods

Intervention reach and primary outcomes of intermediate hyperglycaemia and T2DM were assessed through interview surveys and blood fasting glucose and 2-hour oral glucose tolerance tests among population-based samples of adults aged ≥30 years. Age-stratified, gender-stratified and wealth-stratified intervention effects were estimated using random effects logistic regression.

Results

PLA participants were similar to non-participants, though female participants were younger and more likely to be married than female non-participants. Differences including age, education, wealth and marital status were observed between individuals exposed and those not exposed to the mHealth intervention.

PLA reduced the prevalence of T2DM and intermediate hyperglycaemia in all age, gender and wealth strata. Reductions in 2-year incidence of T2DM of at least 51% (0.49, 95% CI 0.26 to 0.92) were observed in all strata except among the oldest and least poor groups. mHealth impact on glycaemic outcomes was observed only among the youngest group, where a 47% reduction in the 2-year incidence of T2DM was observed (0.53, 95% CI 0.28 to 1.00).

Conclusion

Large impacts of PLA across all strata indicate a highly effective and equitable intervention. mHealth may be more suitable for targeting higher risk, younger populations.

Trial registration number

ISRCTN41083256.

Participatory learning and action (PLA) to improve health outcomes in high-income settings: a systematic review protocol

INTRODUCTION

Participatory learning and action (PLA) is a form of group reflection and learning with documented efficacy in low-income countries to improve social and health outcomes. PLA represents both a learning philosophy and a practical framework that could be applied to a variety of contexts. To date, PLA has not been widely implemented within high-income countries (HICs) to improve health and health-related outcomes. We aim to synthesise the literature currently available by means of a systematic review to form a foundation for future applications of PLA methodology in HICs.

METHODS AND ANALYSIS

Two reviewers will independently search predefined terms in the following electronic bibliographic databases: MEDLINE, EMBASE, CINAHL and Cochrane Library. The search terms will encompass PLA and PDSA (Plan-Do-Study-Act) projects, as well as studies using the Triple/Quadruple Aim model. We will include randomised controlled trials that incorporate online or face-to-face components using the PLA/PDSA methodology. Our data will be extracted into a standardised prepiloted form with subsequent narrative review according to the SWiM (Synthesis Without Meta-Analysis) guidelines.

ETHICS AND DISSEMINATION

No ethics approval is required for this study. The results of this study will be submitted for publication in a leading peer-reviewed academic journal in this field. Additionally, a report will be produced for the funders of this review, which can be viewed for free on their website.

PROSPERO REGISTRATION NUMBER

CRD42020187978.

Efficacy of Residential, Group-Based, Intensive Holistic Lifestyle Intervention Among Type-2 Diabetes Patients - A Single Group Pre- And Post-intervention Study

Background The present study assessed the efficacy of the residential, group-based, intensive holistic lifestyle intervention on glycaemic control. Materials and methods A one-group pre and post-intervention study was conducted among 145 people with diabetes for a period of one year from February 2019 to January 2020. The study population underwent "Brahma Kumaris Raja Yoga lifestyle" intervention. Outcome variables were changes in HbA1c levels and anthropometric parameters (like weight, BMI, etc.). Paired t-test was used to compare normally distributed numeric variables. Results The mean age was 52.39±5.79 years, with a male-female ratio close to 1:1. Mean HbA1c at baseline was 9.06±2.1%. The mean weight and BMI were 71.03±12.84 kg and 28.28±4.83kg/m2, respectively. Mean HbA1c value had shown a reduction of 1.60% (95%CI 1.17 to 1.90, p <0.001) at three months and 1.58% (95% CI 1.13-1.87, p<0.001) reduction at a six-month follow-up. Between the third and sixth months, there was no significant change in the HbA1c value. Mean weight reduced by 0.79 kg (95% CI 0.08-1.08, p=0.023) at six-month follow-up and mean BMI decreased by 0.31 units from baseline to three months (95% CI 0.05-0.56, p=0.017). A statistically significant reduction was observed in waist circumference at the third month (MD=1.61 95% CI =0.95 to 2.28, P<0.001) and sixth month (MD=1.53, 95% CI 0.82-2.25, p<0.001) follow-up. Conclusion This residential, group-based, intensive holistic lifestyle intervention showed a significant decrease in HbA1c levels and anthropometric parameters at three- and six-months follow-up, thereby improving the overall health and wellbeing of people with diabetes.

Lifestyle Interventions through Participatory Research: A Mixed-Methods Systematic Review of Alcohol and Other Breast Cancer Behavioural Risk Factors

Breast cancer is one of the most frequently diagnosed cancers in women globally. Sex and advancing age represent the dominant risk factors, with strong evidence of alcohol as a modifiable risk factor. The carcinogenic nature of alcohol has been known for over twenty years; however, this has failed to translate into significant behavioural, practice, or policy change. As a result, women have not benefitted from this research and, by extension, have been exposed to unnecessary breast cancer risk. Participatory research presents a solution to research translation in public health through the collaboration of impacted populations with academics in research. This systematic review examines peer-reviewed research studies where participants were involved in the research process and the outcomes related to breast cancer prevention (either alcohol or broader lifestyle modification). Seven of the eight studies reported positive effects, and the collaboration between academic researchers and impacted populations may have supported positive outcomes. Women were receptive and responsive to participatory approaches, and their participation is important to address socially entrenched behaviours such as alcohol consumption. Participatory research presents opportunities for future interventions to improve (or address) modifiable risk factors for breast cancer.

"Must you make an app?" A qualitative exploration of socio-technical challenges and opportunities for designing digital maternal and child health solutions in Soweto, South Africa

Participatory and digital health approaches have the potential to create solutions to health issues and related inequalities. A project called Co-Designing Community-based ICTs Interventions for Maternal and Child Health in South Africa (CoMaCH) is exploring such solutions in four different sites across South Africa. The present study captures initial qualitative research that was carried out in one of the urban research sites in Soweto. The aim was twofold: 1) to develop a situation analysis of existing services and the practices and preferences of intended end-users, and 2) to explore barriers and facilitators to utilising digital health for community-based solutions to maternal and child health from multiple perspectives. Semi-structured interviews were conducted with 28 participants, including mothers, other caregivers and community health workers. Four themes were developed using a framework method approach to thematic analysis: coping as a parent is a priority; existing services and initiatives lack consistency, coverage and effective communication; the promise of technology is limited by cost, accessibility and crime; and, information is key but difficult to navigate. Solutions proposed by participants included various digital-based and non-digital channels for accessing reliable health information or education; community engagement events and social support; and, community organisations and initiatives such as saving schemes or community gardens. This initial qualitative study informs later co-design phases, and raises ethical and practical questions about participatory intervention development, including the flexibility of researcher-driven endeavours to accommodate community views, and the limits of digital health solutions vis-à-vis material needs and structural barriers to health and wellbeing.

Engaging communities in non-communicable disease research and interventions in low- and middle-income countries: a realist review protocol

INTRODUCTION

Engaging communities and intended beneficiaries at various stages of health research is a recommended practice. The contribution of community engagement to non-communicable disease research in low- and middle-income countries has not yet been extensively studied or synthesised. This protocol describes the steps towards generating an understanding of community engagement in the context of non-communicable disease research, prevention and health promotion using a realist review approach. A realist lens enables a rich explanatory approach to causation while capturing complexity, and an openness to multiple outcomes, including unintended consequences. The review will thus develop an understanding of community engagement without assuming that such practices result in more ethical research or effective interventions.

METHODS AND ANALYSIS

We propose a realist approach aiming to examine how, why, under what circumstances and for whom community engagement works or does not work. The iterative review steps include clarifying the review scope; searching for evidence; appraising studies and extracting data; synthesising evidence and drawing conclusions; and disseminating, implementing and evaluating the findings. Principles of meta-narrative review (pragmatism, pluralism, historicity, contestation, reflexivity and peer review) are employed to ensure practicable and contextualised review outputs. The proposed review will draw on theoretical and empirical literature beyond specific diseases or settings, but with a focus on informing non-communicable disease research and interventions in low- and middle-income countries. The synthesis of existing literature will be complemented by qualitative realist interviews and stakeholder consultation. Through drawing on multiple types of evidence and input from both experts and intended beneficiaries, the review will provide critical and pragmatic insights for research and community engagement in low- and middle-income countries.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of the Witwatersrand. Dissemination will include traditional academic channels, institutional communications, social media and discussions with a wide range of stakeholders.

Classroom, club or collective? Three types of community-based group intervention and why they matter for health

Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.

Learning from a diabetes mHealth intervention in rural Bangladesh: what worked, what did not and what next?

There is an urgent need for population-based interventions to slow the growth of the diabetes epidemic in low-and middle-income countries. We tested the effectiveness of a population-based mHealth voice messaging intervention for T2DM prevention and control in rural Bangladesh through a cluster randomised controlled trial. mHealth improved knowledge and awareness about T2DM but there was no detectable effect on T2DM occurrence. We conducted mixed-methods research to understand this result. Exposure to messages was limited by technological faults, high frequency of mobile phone number changes, message fatigue and (mis)perceptions that messages were only for those who had T2DM. Persistent social norms, habits and desires made behaviour change challenging, and participants felt they would be more motivated by group discussions than mHealth messaging alone. Engagement with mHealth messages for T2DM prevention and control can be increased by (1) sending identifiable messages from a trusted source (2) using participatory design of mHealth messages to inform modelling of behaviours and increase relevance to the general population (3) enabling interactive messaging. mHealth messaging is likely to be most successful if implemented as part of a multi-sectoral, multi-component approach to address T2DM and non-communicable disease risk factors.

A funfair without the candy floss: engaging communities to prevent diabetes in Nepal

OBJECTIVES

The World Health Organization estimates that 422 million people have diabetes, three-quarters of whom live in low- and middle-income countries. Global action plans to address non-communicable diseases (NCDs) recognise the centrality of community engagement to create an enabling environment within which to address risk factors.

STUDY DESIGN

In this article, we describe and critically reflect on a cocreated community engagement approach to address type 2 diabetes in the southern plains of Nepal. We coproduced the engagement approach with 40 artists from the Janakpur Women's Development Centre to create an environment for dialogue about diabetes and NCD risk between artists and the general public.

METHODS

We used participatory action research to produce contextually relevant interactive methods and materials. Methods included artists' peer research to inform creative workshops, a drama performed in 19 villages and a two-day funfair in a public park. We used qualitative and participatory methods to analyse the effect of this engagement and reflect on lessons learned.

RESULTS

Around 2000 people saw the drama, and around 4000 people attended the funfair. Community dialogue about prevention of diabetes was facilitated by drama and through games and songs at the funfair. Artists grew confident to interact with their peers and drama audiences about the causes of diabetes and prevention strategies. Despite crowds at the funfair, it was difficult to reach women because the venue was often used by men and boys, and patriarchal norms prevent women from free movement. Village interactions were able to engage a more mixed audience.

CONCLUSION

Innovative, asset-based community engagement about diabetes and other NCDs at scale is possible through locating, building on and strengthening community resources to address local health issues. Engagement could be enhanced by considering the gendered nature of community engagement spaces and by increasing opportunities for interaction between artists and the general public through more intimate and large-scale events.

Community participatory learning and action cycle groups to reduce type 2 diabetes in Bangladesh (D:Clare trial): study protocol for a stepped-wedge cluster randomised controlled trial

BACKGROUND

An estimated 463 million people globally have diabetes, with the prevalence growing in low-and middle-income settings, such as Bangladesh. Given the need for context-appropriate interventions to prevent type 2 diabetes mellitus (T2DM), the 'Diabetes: Community-led Awareness, Response and Evaluation' (D:Clare) trial will rigorously evaluate the replication and scale-up of a participatory learning and action (PLA) cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control.

METHODS

This is a stepped-wedge cluster randomised controlled trial, with integrated process and economic evaluations, conducted from March 2020 to September 2022. The trial will evaluate a community-based four-phase PLA cycle intervention focused on prevention and control of T2DM implemented over 18 months, against a control of usual care. Twelve clusters will be randomly allocated (1:1) to implement the intervention at project month 1 or 12. The intervention will be evaluated through three cross-sectional surveys at months 1, 12 and 24. The trial will be conducted in Alfadanga Upazila, Faridpur district, with an estimated population of 120,000. Clusters are defined as administrative geographical areas, with approximately equal populations. Each of the six unions in Alfadanga will be divided into two clusters, forming 12 clusters in total. Given the risk of inter-cluster contamination, evaluation surveys will exclude villages in border areas. Participants will be randomly sampled, independently for each survey, from a population census conducted in January 2020. The primary outcome is the combined prevalence of intermediate hyperglycaemia and T2DM, measured through fasting and 2-h post-glucose load blood tests. A total of 4680 participants provide 84% power to detect a 30% reduction in the primary outcome, assuming a baseline of 30% and an ICC of 0.07. The analysis will be by intention-to-treat, comparing intervention and control periods across all clusters, adjusting for geographical clustering.

DISCUSSION

This study will provide further evidence of effectiveness for community-based PLA to prevent T2DM at scale in a rural Bangladesh setting. However, we encountered several challenges in applying the stepped-wedge design to our research context, with particular consideration given to balancing seasonality, timing and number of steps and estimation of partial versus full effect.

TRIAL REGISTRATION

ISRCTN: ISRCTN42219712 . Registered on 31 October 2019.

Knowledge and practices of Primary Care professionals on diabetic neuropathy: study of social representations

OBJECTIVES

to analyze the knowledge and practices of Primary Health Care professionals about diabetic neuropathy through their social representations.

METHODS

a qualitative, descriptive study, anchored in the procedural aspect of the Theory of Social Representations. It was carried out in four Family Health Units in Belém-Pará, with 31 professionals from four health teams. Data were produced by individual semi-structured interviews, and the corpus was submitted to content analysis.

RESULTS

two thematic categories were defined, showing the participants' understanding and imagination about neuropathy, as well as the biopsychosocial repercussions of this complication in patients' daily lives. The multidisciplinary practices developed in the context of disease treatment/prevention and the consequences of this performance were also shown.

FINAL CONSIDERATIONS

professionals' representations are anchored in neuropathy occurrence due to the deficient standard of care for themselves by patients, which results in the team's surpassing care attitude as an alternative to illness' challenges.

Visual Participatory Analysis: A Qualitative Method for Engaging Participants in Interpreting the Results of Randomized Controlled Trials of Health Interventions

This article contributes to the field of mixed methods by introducing a new method for eliciting participant perspectives of the quantitative results of randomized controlled trials. Participants are rarely asked to interpret trial results, obscuring potentially valuable information about why a trial either succeeds or fails. We introduce a unique method called visual participatory analysis and discuss the insights gained in its use as part of a trial to prevent risk and reduce the prevalence of diabetes in Bangladesh. Findings highlight benefits such as elucidating contextualized explanations for null results and identifying causal mechanisms, as well as challenges around communicating randomized controlled trial methodologies to lay audiences. We conclude that visual participatory analysis is a valuable method to use after a trial.