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Klingberg S, Adhikari B, Draper CE, Bosire E, Nyirenda D, Tiigah P, Mukumbang FC. 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. BMJ Glob Health 2024; 9:e013712. [PMID: 38341191 PMCID: PMC10862340 DOI: 10.1136/bmjgh-2023-013712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- Sonja Klingberg
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catherine E Draper
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Edna Bosire
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Deborah Nyirenda
- Community Engagement & Bioethics, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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Akter K, Kuddus A, Jeny T, Nahar T, Shaha S, Ahmed N, King C, Pires M, Haghparast-Bidgoli H, Azad K, Fottrell E, Morrison J. Stakeholder perceptions on scaling-up community-led interventions for prevention and control of non-communicable diseases in Bangladesh: a qualitative study. BMC Public Health 2023; 23:719. [PMID: 37081438 PMCID: PMC10116471 DOI: 10.1186/s12889-023-15551-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/28/2023] [Indexed: 04/22/2023] Open
Abstract
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.
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Affiliation(s)
- Kohenour Akter
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Tasnova Jeny
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Tasmin Nahar
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Sanjit Shaha
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Naveed Ahmed
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Carina King
- Karolinska Institutet, K9 Global Folkhälsa, K9 GPH Stålsby Lundborg Alfvén, Stockholm, 171 77, Sweden
| | - Malini Pires
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | | | - Kishwar Azad
- Diabetic Association of Bangladesh - Centre for Health Research and Implementation (BADAS-CHRI), BIRDEM, Ramna, Dhaka, 1000, Bangladesh
| | - Edward Fottrell
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Joanna Morrison
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Seal AJ, Mohamed HA, Stokes-Walter R, Mohamed S, Abdille AM, Yakowenko E, Sheikh Omar M, Jelle M. Use of an adapted participatory learning and action cycle to increase knowledge and uptake of child vaccination in internally displaced persons camps (IVACS): A cluster-randomised controlled trial. Vaccine 2023; 41:3038-3046. [PMID: 36906409 DOI: 10.1016/j.vaccine.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 01/27/2023] [Accepted: 02/05/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Vaccination is a key public health intervention that can reduce excess mortality in humanitarian contexts. Vaccine hesitancy is thought to be a significant problem requiring demand side interventions. Participatory Learning and Action (PLA) approaches have proven effective in reducing perinatal mortality in low income settings and we aimed to apply an adapted approach in Somalia. METHODS A randomised cluster trial was implemented in camps for internally displaced people near Mogadishu, from June to October 2021. An adapted PLA approach (hPLA) was used in partnership with indigenous 'Abaay-Abaay' women's social groups. Trained facilitators ran 6 meeting cycles that addressed topics of child health and vaccination, analysed challenges, and planned and implemented potential solutions. Solutions included a stakeholder exchange meeting involving Abaay-Abaay group members and services providers from humanitarian organisations. Data was collected at baseline and after completion of the 3 month intervention cycle. RESULTS Overall, 64.6% of mothers were group members at baseline and this increased in both arms during the intervention (p = 0.016). Maternal preference for getting young children vaccinated was >95% at baseline and did not change. The hPLA intervention improved the adjusted maternal/caregiver knowledge score by 7.9 points (maximum possible score 21) compared to the control (95% CI 6.93, 8.85; p < 0.0001). Coverage of both measles vaccination (MCV1) (aOR 2.43 95% CI 1.96, 3.01; p < 0.001) and completion of the pentavalent vaccination series (aOR 2.45 95% CI 1.27, 4.74; p = 0.008) also improved. However, adherence to timely vaccination did not (aOR 1.12 95% CI 0.39, 3.26; p = 0.828). Possession of a home-based, child health record card increased in the intervention arm from 18 to 35% (aOR 2.86 95% CI 1.35, 6.06; p = 0.006). CONCLUSION A hPLA approach, run in partnership with indigenous social groups, can achieve important changes in public health knowledge and practice in a humanitarian context. Further work to scale up the approach and address other vaccines and population groups is warranted.
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Fottrell E, King C, Ahmed N, Shaha SK, Morrison J, Pires M, Kuddus A, Nahar T, Haghparast-Bidgoli H, Khan AA, Azad K. Intermediate hyperglycaemia, diabetes and blood pressure in rural Bangladesh: five-year post-randomisation follow-up of the DMagic cluster-randomised controlled trial. Lancet Reg Health Southeast Asia 2023; 10:100122. [PMID: 36938333 PMCID: PMC10015271 DOI: 10.1016/j.lansea.2022.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
Abstract
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.
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Key Words
- ADS, Appraisal of Diabetes Scale
- BADAS, Diabetic Association of Bangladesh
- BMI, Body Mass Index
- Bangladesh
- CVD, Cardiovascular disease(s)
- Cardiovascular risk
- Cluster randomised controlled trial
- Community intervention
- Control
- DBP, Diastolic blood pressure
- DDS, Dietary Diversity Score
- Diabetes
- GAD-7, Generalised Anxiety Disorder Assessment
- IQR, Inter-quartile range
- NCD, Non-communicable disease(s)
- PHQ-9, Patient Health Questionnaire 9
- PLA, Participatory Learning and Action
- PP, Pulse pressure
- Prevention
- Rural
- SBP, Systolic blood pressure
- T2DM, Type-2 diabetesmellitus
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Affiliation(s)
- Edward Fottrell
- UCL Institute for Global Health, University College London, London, UK
- Corresponding author. UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Naveed Ahmed
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Sanjit Kumer Shaha
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Joanna Morrison
- UCL Institute for Global Health, University College London, London, UK
| | - Malini Pires
- UCL Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Tasmin Nahar
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A.K. Azad Khan
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Centre for Health Research & Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
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Lazo-Porras M, Liu H, Ouyang M, Yin X, Malavera A, Bressan T, Guzman-Vilca WC, Pacheco N, Benito M, Miranda JJ, Moore G, Chappuis F, Perel P, Beran D. Process evaluation of complex interventions in non-communicable and neglected tropical diseases in low- and middle-income countries: a scoping review. BMJ Open 2022; 12:e057597. [PMID: 36581963 PMCID: PMC9438086 DOI: 10.1136/bmjopen-2021-057597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The aim of this review is to map out the use of process evaluation (PE) in complex interventions that address non-communicable diseases (NCDs) and neglected tropical diseases (NTDs) to identify gaps in the design and conduct, as well as strengths, limitations and implications, of this type of research in low- and middle-income countries (LMICs). DESIGN Scoping review of PE studies of complex interventions implemented in LMICs. Six databases were searched focused on studies published since 2008. DATA SOURCES Embase, PubMed, EbscoHost, Web of Science (WOS), Virtual Health Library (VHL) Regional Portal and Global Index Medicus: Regional Indexes AIM (AFRO), LILACS (AMRO/PAHO), IMEMR (EMRO), IMSEAR (SEARO), WPRIM (WPRO) Global Index Regional Indexes, MEDLINE, SciELO. ELIGIBILITY CRITERIA Studies conducted in LMICs on PEs of randomised controlled trials (RCTs) and non-RCTs published between January 2008 and January 2020. Other criteria were studies of interventions for people at risk or having physical and mental NCDs, and/or NTDs, and/or their healthcare providers and/or others related to achieve better health for these two disease groups. Studies were excluded if they were not reported in English or Spanish or Portuguese or French, not peer-reviewed articles, not empirical research and not human research. DATA EXTRACTION AND SYNTHESIS Data extracted to be evaluated were: available evidence in the utilisation of PE in the areas of NCDs and NTDs, including frameworks and theories used; methods applied to conduct PEs; and in a subsample, the barriers and facilitators to implement complex interventions identified through the PE. Variables were extracted and categorised. The information was synthesised through quantitative analysis by reporting frequencies and percentages. Qualitative analysis was also performed to understand facilitators and barriers presented in these studies. The implications for PEs, and how the information from the PE was used by researchers or other stakeholders were also assessed in this approach. RESULTS 303 studies were identified, 79% were for NCDs, 12% used the label 'PE', 27% described a theory or framework for the PE, and 42% used mixed methods to analyse their findings. Acceptability, barriers and facilitators to implement the interventions, experiences and perceptions, and feasibility were the outcomes most frequently evaluated as part of the PEs. Barriers and facilitators themes identified were contextual factors, health system factors, human resources, attitudes and policy factors. CONCLUSIONS PEs in NCDs and NTDs are used in LMICs with a wide variety of methods. This review identified many PEs that were not labelled by the authors as such, as well as a limited application of PE-related theories and frameworks, and heterogeneous reporting of this type of study.
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Affiliation(s)
- Maria Lazo-Porras
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Hueiming Liu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Xuejun Yin
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Wilmer Cristobal Guzman-Vilca
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- Sociedad Científica de Estudiantes de Medicina Cayetano Heredia (SOCEMCH), Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Niels Pacheco
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Melissa Benito
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Graham Moore
- DECIPHer, UKCRC Centre of Excellence, Cardiff University, Cardiff, UK
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Pablo Perel
- Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
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Pires M, Shaha S, King C, Morrison J, Nahar T, Ahmed N, Jennings HM, Akter K, Haghparast-Bidgoli H, Khan AKA, Costello A, Kuddus A, Azad K, Fottrell E. 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. J Epidemiol Community Health 2022; 76:586-594. [PMID: 35277436 PMCID: PMC9118071 DOI: 10.1136/jech-2021-217293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Malini Pires
- Institute for Global Health, University College London, London, UK
| | - Sanjit Shaha
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Joanna Morrison
- Institute for Global Health, University College London, London, UK
| | - Tasmin Nahar
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Naveed Ahmed
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Kohenour Akter
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - A K Azad Khan
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Anthony Costello
- Institute for Global Health, University College London, London, UK
| | - Abdul Kuddus
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Centre for Health Research and Implementation, Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, London, UK
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Schleiff MJ, Aitken I, Alam MA, Damtew ZA, Perry HB. Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education. Health Res Policy Syst 2021; 19:113. [PMID: 34641898 PMCID: PMC8506097 DOI: 10.1186/s12961-021-00757-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the sixth of our 11-paper supplement entitled "Community Health Workers at the Dawn of New Era". Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize. METHODS We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs. RESULTS The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs. CONCLUSION Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training-not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.
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Affiliation(s)
- Meike J. Schleiff
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Iain Aitken
- Management Sciences for Health, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Henry B. Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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van der Merwe M, D'Ambruoso L, Witter S, Twine R, Mabetha D, Hove J, Byass P, Tollman S, Kahn K. Collective reflections on the first cycle of a collaborative learning platform to strengthen rural primary healthcare in Mpumalanga, South Africa. Health Res Policy Syst 2021; 19:66. [PMID: 33874951 PMCID: PMC8054125 DOI: 10.1186/s12961-021-00716-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Frontline managers and health service providers are constrained in many contexts from responding to community priorities due to organizational cultures focused on centrally defined outputs and targets. This paper presents an evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme-a collaborative learning platform embedded in the local health system in Mpumalanga, South Africa-for strengthening of rural primary healthcare (PHC) systems. The programme aims to address exclusion from access to health services by generating and acting on research evidence of practical, local relevance. METHODS Drawing on existing links in the provincial and national health systems and applying rapid, participatory evaluation techniques, we evaluated the first action-learning cycle of the VAPAR programme (2017-19). We collected data in three phases: (1) 10 individual interviews with programme stakeholders, including from government departments and parastatals, nongovernmental organizations and local communities; (2) an evaluative/exploratory workshop with provincial and district Department of Health managers; and (3) feedback and discussion of findings during an interactive workshop with national child health experts. RESULTS Individual programme stakeholders described early outcomes relating to effective research and stakeholder engagement, and organization and delivery of services, with potential further contributions to the establishment of an evidence base for local policy and planning, and improved health outcomes. These outcomes were verified with provincial managers. Provincial and national stakeholders identified the potential for VAPAR to support engagement between communities and health authorities for collective planning and implementation of services. Provincial stakeholders proposed that this could be achieved through a two-way integration, with VAPAR stakeholders participating in routine health planning and review activities and frontline health officials being involved in the VAPAR process. Findings were collated into a revised theory of change. CONCLUSIONS The VAPAR learning platform was regarded as a feasible, acceptable and relevant approach to facilitate cooperative learning and community participation in health systems. The evaluation provides support for a collaborative learning platform within routine health system processes and contributes to the limited evaluative evidence base on embedded health systems research.
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Affiliation(s)
- Maria van der Merwe
- , White River, South Africa.
- Centre for Global Development, School of Education, University of Aberdeen, Aberdeen, Scotland.
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- National Health Service (NHS) Grampian, Aberdeen, Scotland
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Byass
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Tollman
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
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9
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King C, Pires M, Ahmed N, Akter K, Kuddus A, Copas A, Haghparast-Bidgoli H, Morrison J, Nahar T, Shaha SK, Khan AKA, Azad K, Fottrell E. 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. Trials 2021; 22:235. [PMID: 33781315 PMCID: PMC8006505 DOI: 10.1186/s13063-021-05167-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/02/2021] [Indexed: 02/27/2023] Open
Abstract
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.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Malini Pires
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Andrew Copas
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
| | | | - Joanna Morrison
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | | | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- Institute for Global Health, University College London, 30 Guildford Street, London, WC1N 1EH UK
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Liu F, Guo Y, Liu Y, Chen G, Wang Y, Xue X, Liu S, Huo W, Mao Z, Hou Y, Lu Y, Wang C, Xiang H, Li S. Associations of long-term exposure to PM 1, PM 2.5, NO 2 with type 2 diabetes mellitus prevalence and fasting blood glucose levels in Chinese rural populations. Environ Int 2019; 133:105213. [PMID: 31654916 PMCID: PMC6853163 DOI: 10.1016/j.envint.2019.105213] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/19/2019] [Accepted: 09/22/2019] [Indexed: 05/07/2023]
Abstract
OBJECTIVES To evaluate the associations between long-term exposure to particulate matter with an aerodynamic diameter ≤1.0 μm and ≤2.5 μm (PM1 and PM2.5), nitrogen dioxide (NO2) and type 2 diabetes prevalence and fasting blood glucose levels in Chinese rural populations. MATERIAL AND METHODS A total of 39, 259 participants were enrolled in The Henan Rural Cohort study. Questionnaires and medical examination were conducted from July 2015 to September 2017 in rural areas of Henan province, China. Three-year average residential exposure levels of PM1, PM2.5, NO2 for each subject were estimated by a spatiotemporal model. Logistic regression and linear regression models were applied to estimate the associations between PM1, PM2.5, NO2 exposure and type 2 diabetes prevalence and fasting blood glucose levels. RESULTS The mean 3-year residential exposure concentrations of PM1, PM2.5 and NO2 was 57.4 μg/m3, 73.4 μg/m3 and 39.9 μg/m3, respectively. Higher exposure concentrations of PM1, PM2.5, NO2 by 1 μg/m3 was positively related to a 4.0% (95%CIs: 1.026, 1.054), 6.8% (1.052, 1.084) and 5.0% (1.039, 1.061) increase in odds of type 2 diabetes in the final adjusted models. Besides, a 1 μg/m3 increase of PM1, PM2.5 and NO2 was related to a 0.020 mmol/L (95%CIs: 0.014, 0.026), 0.036 mmol/L (95%CIs: 0.030, 0.042) and 0.030 mmol/L (95%CIs: 0.026, 0.034) mmol/L higher fasting blood glucose levels. CONCLUSIONS Higher exposure concentrations of air pollutants were positively related to the increased odds of type 2 diabetes, as well as higher fasting blood glucose levels in Chinese rural populations.
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Affiliation(s)
- Feifei Liu
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China
| | - Yuming Guo
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Epidemiology and Biostatistics, School of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Yisi Liu
- Department of Environmental and Occupational Health Sciences, University of Washington, 1959 NE Pacific Street, Seattle, USA
| | - Gongbo Chen
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China
| | - Yuxin Wang
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China
| | - Xiaowei Xue
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China
| | - Suyang Liu
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China
| | - Wenqian Huo
- Department of Epidemiology and Biostatistics, School of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Zhenxing Mao
- Department of Epidemiology and Biostatistics, School of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Yitan Hou
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China
| | - Yuanan Lu
- Environmental Health Laboratory, Department of Public Health Sciences, University Hawaii at Manoa, 1960 East West Rd, Biomed Bldg, D105 Honolulu, USA
| | - Chongjian Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Zhengzhou University, Zhengzhou, Henan, China.
| | - Hao Xiang
- Department of Global Health, School of Health Sciences, Wuhan University, 115# Donghu Road, Wuhan, China.
| | - Shanshan Li
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Morrison J, Akter K, Jennings HM, Nahar T, Kuddus A, Shaha SK, Ahmed N, King C, Haghparast-Bidgoli H, Costello A, Khan AKA, Azad K, Fottrell E. Participatory learning and action to address type 2 diabetes in rural Bangladesh: a qualitative process evaluation. BMC Endocr Disord 2019; 19:118. [PMID: 31684932 PMCID: PMC6830002 DOI: 10.1186/s12902-019-0447-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Diabetes is 7th largest cause of death worldwide, and prevalence is increasing rapidly in low-and middle-income countries. There is an urgent need to develop and test interventions to prevent and control diabetes and develop the theory about how such interventions can be effective. We conducted a participatory learning and action (PLA) intervention with community groups in rural Bangladesh which was evaluated through a cluster randomised controlled trial. There was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA group compared with the control group. We present findings from qualitative process evaluation research to explore how this intervention was effective. METHODS We conducted group interviews and focus group discussions using photovoice with purposively sampled group attenders and non-attenders, and intervention implementers. Data were collected before the trial analysis. We used inductive content analysis to generate theory from the data. RESULTS The intervention increased the health literacy of individuals and communities - developing their knowledge, capacity and self-confidence to enact healthy behaviours. Community, household and individual capacity increased through social support and social networks, which then created an enabling community context, further strengthening agency and enabling community action. This increased opportunities for healthy behaviour. Community actions addressed lack of awareness about diabetes, gendered barriers to physical activity and lack of access to blood glucose testing. The interaction between the individual, household, and community contexts amplified change, and yet there was limited engagement with macro level, or 'state', barriers to healthy behaviour. CONCLUSIONS The participatory approach enabled groups to analyse how context affected their ability to have healthy behaviours and participants engaged with issues as a community in the ways that they felt comfortable. We suggest measuring health literacy and social networks in future interventions and recommend specific capacity strengthening to develop public accountability mechanisms and health systems strengthening to complement community-based interventions. TRIAL REGISTRATION Registered at ISRCTN on 30th March 2016 (Retrospectively Registered) Registration number: ISRCTN41083256 .
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Affiliation(s)
- Joanna Morrison
- University College London Institute for Global Health, London, UK
| | | | | | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Carina King
- University College London Institute for Global Health, London, UK
| | | | - Anthony Costello
- University College London Institute for Global Health, London, UK
| | | | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- University College London Institute for Global Health, London, UK
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Morrison J, Jennings H, Akter K, Kuddus A, Mannell J, Nahar T, Shaha SK, Ahmed N, Haghparast-Bidgoli H, Costello A, Khan AKA, Azad K, Fottrell E. Gendered perceptions of physical activity and diabetes in rural Bangladesh: a qualitative study to inform mHealth and community mobilization interventions. WHO South East Asia J Public Health 2019; 8:104-111. [PMID: 31441446 DOI: 10.4103/2224-3151.264855] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Diabetes prevalence is increasing rapidly in Bangladesh, and there is an urgent need to promote preventive behaviours for type 2 diabetes, such as maintaining a healthy body weight, eating healthily, avoiding tobacco and being active for 150 minutes per week. Methods We used a qualitative methodology informed by the capability, opportunity, motivation theory of behaviour change to explore the factors affecting physical activity among men and women in rural Bangladesh. We conducted semi-structured interviews and focus group discussions with 64 purposively sampled participants with and without diabetes, and five health workers. From the results of descriptive content analysis, we identified key capabilities, opportunities and motivations to engage with in our mHealth and community mobilization interventions. Results Men and women without diabetes lacked awareness about the need to remain physically active to prevent diabetes, and most felt that their activity levels were sufficient. Housework was not commonly perceived as physical activity among all respondents. These knowledge and capability gaps could be addressed through mHealth messaging and community mobilization providing information on sufficiency and types of physical activity to prevent and control diabetes. Men were physically active while working outside the home, whereas women felt unsafe and conspicuous, and were constrained by family commitments and social expectations of appropriate behaviour. Women engaged in strategies to protect their own and their family’s reputations. These opportunity factors affecting physical activity indicated the need for strategies developed through participatory processes to challenge unhealthy gender norms and increase women’s safety. Conclusion Formative research data can enable the development of contextually relevant interventions. Data show that mHealth interventions should consider gendered barriers to physical activity, tailoring information to meet men’s and women’s needs, and that community mobilization interventions should enable unhealthy, gendered community norms to be challenged. Participatory interventions can enable communities to push the boundaries of socially acceptable behaviours to increase physical activity, helping to prevent and control diabetes.
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Affiliation(s)
- Joanna Morrison
- .University College London Institute for Global Health, London, United Kingdom
| | - Hannah Jennings
- .University College London Institute for Global Health, London, United Kingdom
| | | | - Abdul Kuddus
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Jenevieve Mannell
- .University College London Institute for Global Health, London, United Kingdom
| | - Tasmin Nahar
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | | | - Anthony Costello
- .University College London Institute for Global Health, London, United Kingdom
| | - A K Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Kishwar Azad
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Edward Fottrell
- .University College London Institute for Global Health, London, United Kingdom
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