Living with depression and diabetes: A qualitative study in Bangladesh and Pakistan

Diabetes and depression are both serious health conditions. While their relationship is bidirectional and each condition adversely affects outcomes for the other, they are treated separately. In low and middle income countries, such as Bangladesh and Pakistan, health systems are already stretched and the integration of diabetes and depression care is rarely a priority. Within this context through interviews with patients, healthcare workers and policy makers the study explored: lived experiences of people living with depression and diabetes, current practice in mental health and diabetes care and barriers and perspectives on integrating a brief psychological therapy into diabetes care. The findings of the study included: differing patient and practitioner understandings of distress/depression, high levels of stigma for mental health and a lack of awareness and training on treating depression. While it was apparent there is a need for more holistic care and the concept of a brief psychological intervention appeared acceptable to participants, many logistical barriers to integrating a mental health intervention into diabetes care were identified. The study highlights the importance of context and of recognising drivers and understandings of distress when planning for more integrated mental and physical health services, and specifically when adapting and implementing a new intervention into existing services.

Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study

BACKGROUND

Depression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services.

METHODS

We conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains.

RESULTS

Reported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care.

CONCLUSIONS

Depression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.

Effectiveness and implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: Systematic review and meta-analysis

We evaluate the effectiveness of psychological interventions for depression in people with NCDs in South Asia and explore the individual, organizational, and policy-level barriers and facilitators for the implementation and scaling up of these interventions. Eight databases (and local web pages) were searched in May 2022. We conducted random effects models to evaluate the pooled effect of psychological interventions on depression in people with NCDs. We extracted the individual, organizational, and policy level barriers and facilitators. We found five randomized control trials, nine qualitative studies, and 35 policy documents that fitted the inclusion criteria. The pooled standardized mean difference in depression comparing psychological interventions with usual care was -2.31 (95% CI, -4.16 to -0.45; p = .015, I2 = 96.0%). We found barriers and facilitators to intervention delivery, mental health appears in the policy agenda in Bangladesh and Pakistan. However, there is a lack of policies relating to training in mental health for NCD health providers and a lack of integration of mental health care with NCD care. All of the psychological interventions reported to be effective in treating depression in this population. There are important delivery and policy barriers to the implementation and scaling up of psychological interventions for people with NCDs.

Participatory mental health interventions in low-income and middle-income countries: a realist review protocol

INTRODUCTION

The launch of the Movement for Global Mental Health brought long-standing calls for improved mental health interventions in low-and middle-income countries (LMICs) to centre stage. Within the movement, the participation of communities and people with lived experience of mental health problems is argued as essential to successful interventions. However, there remains a lack of conceptual clarity around 'participation' in mental health interventions with the specific elements of participation rarely articulated. Our review responds to this gap by exploring how 'participation' is applied, what it means and what key mechanisms contribute to change in participatory interventions for mental health in LMICs.

METHODS AND ANALYSIS

A realist review methodology will be used to identify the different contexts that trigger mechanisms of change, and the resulting outcomes related to the development and implementation of participatory mental health interventions, that is: what makes participation work in mental health interventions in LMICs and why? We augment our search with primary data collection in communities who are the targets of global mental health initiatives to inform the production of a programme theory on participation for mental health in LMICs.

ETHICS AND DISSEMINATION

Ethical approval for focus group discussions (FGDs) was obtained in each country involved. FGDs will be conducted in line with WHO safety guidance during the COVID-19 crisis. The full review will be published in an academic journal, with further papers providing an in-depth analysis on community perspectives on participation in mental health. The project findings will also be shared on a website, in webinars and an online workshop.

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.

Protocol for integrating mental health services into primary healthcare facilities: a qualitative study of the perspectives of patients, family members and healthcare providers in rural Bangladesh

INTRODUCTION

In Bangladesh, Non-communicable diseases (NCDs) account for 67% of all deaths. Mental health services are not available in routine healthcare at the primary facilities in Bangladesh. The protocol is for a qualitative study that seeks to understand the perceptions, beliefs and norms regarding common mental disorders (CMDs) among patients with NCD with and without CMDs to identify barriers to accessing mental health services in rural communities in Bangladesh. We also aim to explore the feasibility of integrating mental healthcare into routine NCD services at primary health facilities in rural Bangladesh.

METHODS AND ANALYSIS

This study will be conducted at the outpatient departments in two subdistrict hospitals and one district hospital in Munshiganj district in Bangladesh. We will purposefully select patients with hypertension and diabetes from the patient inventory generated from a recently completed randomised control trial titled 'Control of Blood Pressure and Risk Attenuation Bangladesh, Pakistan, Sri Lanka' in two subdistricts in Munshiganj district in Bangladesh. The selected participants will be screened for CMD using the Depression, Anxiety and Stress Scale - 21 Items (DASS-21) over the telephone. Sixty in-depth interviews with patients and family members, 8-10 key informant interviews with healthcare providers and 2 focus group discussions with community health workers will be held following consent.The study is conceptualised under Levesque et al's framework. Thematic analysis will be applied following the study objectives and key issues, and commonly emerging topics generated by the data. The findings will be presented anonymously to corroborate the interpretation.

ETHICS AND DISSEMINATION

Approval has been obtained from the Institutional Review Board at icddr,b (PR-19108) and the University of York (HSRGC/2020/382/F). Written informed consent or audio recording consent form in Bangla will be obtained. For dissemination, we will invite representatives of the collaborating institutions to share the findings in national or international conferences and peer-reviewed journals.

Improving access to diabetes care for children: An evaluation of the changing diabetes in children project in Kenya and Bangladesh

BACKGROUND

The changing diabetes in children (CDiC) project is a public-private partnership implemented by Novo Nordisk, to improve access to diabetes care for children with type 1 diabetes. This paper outlines the findings from an evaluation of CDiC in Bangladesh and Kenya, assessing whether CDiC has achieved its objectives in each of six core program components.

RESEARCH DESIGN AND METHODS

The Rapid Assessment Protocol for Insulin Access (RAPIA) framework was used to analyze the path of insulin provision and the healthcare infrastructure in place for diagnosis and treatment of diabetes. The RAPIA facilitates a mixed-methods approach to multiple levels of data collection and systems analysis. Information is collected through questionnaires, in-depth interviews and focus group discussions, site visits, and document reviews, engaging a wide range of stakeholders (N = 127). All transcripts were analyzed thematically.

RESULTS

The CDiC scheme provides a stable supply of free insulin to children in implementing facilities in Kenya and Bangladesh, and offers a comprehensive package of pediatric diabetes care. However, some elements of the CDiC program were not functioning as originally intended. Transitions away from donor funding and toward government ownership are a particular concern, as patients may incur additional treatment costs, while services offered may be reduced. Additionally, despite subsidized treatment costs, indirect costs remain a substantial barrier to care.

CONCLUSION

Public-private partnerships such as the CDiC program can improve access to life-saving medicines. However, our analysis found several limitations, including concerns over the sustainability of the project in both countries. Any program reliant on external funding and delivered in a high-turnover staffing environment will be vulnerable to sustainability concerns.

Care-seeking and managing diabetes in rural Bangladesh: a mixed methods study

Background

Type 2 diabetes mellitus poses a major health challenge worldwide and in low-income countries such as Bangladesh, however little is known about the care-seeking of people with diabetes. We sought to understand the factors that affect care-seeking and diabetes management in rural Bangladesh in order to make recommendations as to how care could be better delivered.

Methods

Survey data from a community-based random sample of 12,047 adults aged 30 years and above identified 292 individuals with a self-reported prior diagnosis of diabetes. Data on health seeking practices regarding testing, medical advice, medication and use of non-allopathic medicine were gathered from these 292 individuals. Qualitative semi-structured interviews and focus group discussions with people with diabetes and semi-structured interviews with health workers explored care-seeking behaviour, management of diabetes and perceptions on quality of care. We explore quality of care using the WHO model with the following domains: safe, effective, patient-centred, timely, equitable and efficient.

Results

People with diabetes who are aware of their diabetic status do seek care but access, particularly to specialist diabetes services, is hindered by costs, time, crowded conditions and distance. Locally available services, while more accessible, lack infrastructure and expertise. Women are less likely to be diagnosed with diabetes and attend specialist services. Furthermore costs of care and dissatisfaction with health care providers affect medication adherence.

Conclusion

People with diabetes often make a trade-off between seeking locally available accessible care and specialised care which is more difficult to access. It is vital that health services respond to the needs of patients by building the capacity of local health providers and consider practical ways of supporting diabetes care.

Trial registration

ISRCTN41083256. Registered on 30/03/2016.

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

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 .

Developing a theory-driven contextually relevant mHealth intervention

Background: mHealth interventions have huge potential to reach large numbers of people in resource poor settings but have been criticised for lacking theory-driven design and rigorous evaluation. This paper shares the process we developed when developing an awareness raising and behaviour change focused mHealth intervention, through applying behavioural theory to in-depth qualitative research. It addresses an important gap in research regarding the use of theory and formative research to develop an mHealth intervention.

Objectives: To develop a theory-driven contextually relevant mHealth intervention aimed at preventing and managing diabetes among the general population in rural Bangladesh.

Methods: In-depth formative qualitative research (interviews and focus group discussions) were conducted in rural Faridpur. The data were analysed thematically and enablers and barriers to behaviour change related to lifestyle and the prevention of and management of diabetes were identified. In addition to the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change we selected the Transtheoretical Domains Framework (TDF) to be applied to the formative research in order to guide the development of the intervention.

Results: A six step-process was developed to outline the content of voice messages drawing on in-depth qualitative research and COM-B and TDF models. A table to inform voice messages was developed and acted as a guide to scriptwriters in the production of the messages.

Conclusions: In order to respond to the local needs of a community in Bangladesh, a process of formative research, drawing on behavioural theory helped in the development of awareness-raising and behaviour change mHealth messages through helping us to conceptualise and understand behaviour (for example by categorising behaviour into specific domains) and subsequently identify specific behavioural strategies to target the behaviour.

Implementation and fidelity of a participatory learning and action cycle intervention to prevent and control type 2 diabetes in rural Bangladesh

Introduction

There is an urgent need to address the growing type 2 diabetes disease burden. 20–30% of adults in rural areas of Bangladesh have intermediate hyperglycaemia and about 10% have diabetes. We report on the implementation and fidelity of a Participatory Learning and Action (PLA) intervention, evaluated through a three-arm cluster randomised controlled trial which reduced the incidence of diabetes and intermediate hyperglycaemia in rural Bangladesh. PLA interventions have been effective in addressing population level health problems in low income country contexts, and therefore we sought to use this approach to engage communities to identify and address community barriers to prevention and control of type 2 diabetes.

Methods

We used a mixed methods approach collecting quantitative data through field reports and qualitative data through observations and focus group discussions. Through descriptive analysis, we considered fidelity to the participatory approach and implementation plans.

Results

One hundred twenty-two groups per month were convened by 16 facilitators and supervised by two coordinators. Groups worked through a four phase PLA cycle of problem identification, planning together, implementation and evaluation to address the risk factors for diabetes – diet, physical activity, smoking and stress. Groups reported a lack of awareness about diabetes prevention and control, the prohibitive cost of care and healthy eating, and gender barriers to exercise for women. Groups set targets to encourage physical activity, kitchen-gardening, cooking with less oil, and reduced tobacco consumption. Anti-tobacco committees operated in 90 groups. One hundred twenty-two groups arranged blood glucose testing and 74 groups organized testing twice. Forty-one women’s groups established funds, and 61 communities committed not to ridicule women exercising. Experienced and committed supervisors enabled fidelity to a participatory methodology. A longer intervention period and capacity building could enable engagement with systems barriers to behaviour change.

Conclusion

Our complex intervention was implemented as planned and is likely to be valid in similar contexts given the flexibility of the participatory approach to contextually specific barriers to prevention and control of type 2 diabetes. Fidelity to the participatory approach is key to implementing the intervention and effectively addressing type 2 diabetes in a low-income country.

Effectiveness and safety of herbal medicines for induction of labour: a systematic review and meta-analysis

OBJECTIVE

The use of herbal medicines for induction of labour (IOL) is common globally and yet its effects are not well understood. We assessed the efficacy and safety of herbal medicines for IOL.

DESIGN

Systematic review and meta-analysis of published literature.

DATA SOURCES

We searched in MEDLINE, AMED and CINAHL in April 2017, updated in June 2018.

ELIGIBILITY CRITERIA

We considered experimental and non-experimental studies that compared relevant pregnancy outcomes between users and non-user of herbal medicines for IOL.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by two reviewers using a standardised form. A random-effects model was used to synthesise effects sizes and heterogeneity was explored through I2 statistic. The risk of bias was assessed using 'John Hopkins Nursing School Critical Appraisal Tool' and 'Cochrane Risk of Bias Tool'.

RESULTS

A total of 1421 papers were identified through the searches, but only 10 were retained after eligibility and risk of bias assessments. The users of herbal medicine for IOL were significantly more likely to give birth within 24 hours than non-users (Risk Ratio (RR) 4.48; 95% CI 1.75 to 11.44). No significant difference in the incidence of caesarean section (RR 1.19; 95% CI 0.76 to 1.86), assisted vaginal delivery (RR 0.73; 95% CI 0.47 to 1.14), haemorrhage (RR 0.84; 95% CI 0.44 to 1.60), meconium-stained liquor (RR 1.20; 95% CI 0.65 to 2.23) and admission to nursery (RR 1.08; 95% CI 0.49 to 2.38) was found between users and non-users of herbal medicines for IOL.

CONCLUSIONS

The findings suggest that herbal medicines for IOL are effective, but there is inconclusive evidence of safety due to lack of good quality data. Thus, the use of herbal medicines for IOL should be avoided until safety issues are clarified. More studies are recommended to establish the safety of herbal medicines.

Associations between the use of herbal medicines and adverse pregnancy outcomes in rural Malawi: a secondary analysis of randomised controlled trial data

Background

The use of herbal medicines during pregnancy is very high globally and previous studies have pointed out possible associations with adverse pregnancy outcomes. Nevertheless, the safety of herbal medicines in pregnancy is under-explored in low-income countries experiencing high maternal and neonatal complications. We investigated the associations between self-reported use of Mwanamphepo (a group of herbal medicines commonly used to induce or hasten labour) and adverse maternal and neonatal outcomes in rural Malawi.

Methods

We conducted a cross-sectional analysis of secondary household data relating to 8219 births that occurred between 2005 and 2010 in Mchinji district, Malawi. The data were collected as part of a cluster-randomised controlled trial (RCT) that evaluated community interventions designed to reduce maternal and neonatal mortality. Data were gathered on maternity history, demographic characteristics, pregnancy outcomes and exposure to Mwanamphepo. Associations between self-reported use of Mwanamphepo and maternal morbidity as well as neonatal death or morbidity were examined using mixed-effects models, adjusted for relevant covariates. All analyses were also adjusted for the clustered nature of the survey.

Results

Of the 8219 births, Mwanamphepo was used in 2113 pregnancies, representing an estimated prevalence of 25.7%. The self-reported use of Mwanamphepo was significantly associated with increased occurrence of maternal morbidity and neonatal death or morbidity. Specifically, the odds of maternal morbidity were 28% higher among self-reported users than non-users of Mwanamphepo (AOR = 1.28; 95% CI = 1.09–1.50) and the probabilities of neonatal death or morbidity were 22% higher (AOR =1.22; 95% CI = 1.06–1.40) among neonates whose mother reportedly used Mwanamphepo than those who did not.

Conclusion

The use of Mwanamphepo was associated with adverse pregnancy outcomes in rural Malawi. Thus, herbal medicines may not be safe in pregnancy. Where possible, pregnant women should be discouraged from using herbal medicines of unconfirmed safety and those who report to have used should be closely monitored by health professionals. The study was limited by the self-report of exposure and unavailability of data relating to some possible confounders.

Food or medicine? The food-medicine interface in households in Sylhet

ETHNOPHARMACOLOGICAL RELEVANCE

Bangladesh has a rich traditional plant-medicine use, drawing on Ayurveda and Unami medicine. How these practices translate into people׳s homes and lives vary. Furthermore, the overlap between food and medicine is blurred and context-specific. This paper explores the food-medicine interface as experienced by Bengali women in their homes, in the context of transnational and generational changes.

AIM AND OBJECTIVES

The aim is to explore the overlap of food and medicines in homes of Bengali women in Sylhet. The objectives are to explore the influences on medicinal plant practice and to scrutinise how catagories of food and medicine are decided.

MATERIAL AND METHODS

The paper draws on in-depth ethnographic research conducted in Sylhet, North-east Bangladesh as part of a wider project looking at food and medicine use among Bengali women in both the UK and Bangladesh. Methods included participant observation, unstructured interviews and semi-structured interviews with a total of thirty women.

RESULTS

The study indicates that the use of plants as food and medicine is common among Bengali women in Sylhet. What is consumed as a food and/or a medicine varies between individuals, generations and families. The use and perceptions of food-medicines is also dependent on multiple factors such as age, education and availability of both plants and biomedicine. Where a plant may fall on the food-medicine spectrum depends on a range of factors including its purpose, consistency and taste.

CONCLUSIONS

Previous academic research has concentrated on the nutritional and pharmacological properties of culturally constructed food-medicines (Etkin and Ross, 1982; Owen and Johns, 2002, Pieroni and Quave, 2006). However, our findings indicate a contextualisation of the food-plant spectrum based on both local beliefs and wider structural factors, and thus not necessarily characteristics intrinsic to the products׳ pharmacological or nutritional properties. The implications of this research are of both academic relevance and practical importance to informing health services.

Food, home and health: the meanings of food amongst Bengali Women in London

BACKGROUND

This paper explores the nature of food and plants and their meanings in a British Bengali urban context. It focuses on the nature of plants and food in terms of their role in home making, transnational connections, generational change and concepts of health.

METHODS

An ethnographic approach to the research was taken, specific methods included participant observation, focus group discussions and semi-structured interviews. Thirty women of Bengali origin were mostly composed of "mother" and "daughter" pairs. The mothers were over 45 years old and had migrated from Bangladesh as adults and their grown-up daughters grew up in the UK.

RESULTS

Food and plants play an important role in the construction of home "here" (London) while continuing to connect people to home "there" (Sylhet). This role, however, changes and is re-defined across generations. Looking at perceptions of "healthy" and "unhealthy" food, particularly in the context of Bengali food, multiple views of what constitutes "healthy" food exist. However, there appeared to be little two-way dialogue about this concept between the research participants and health professionals. This seems to be based on "cultural" and power differences that need to be addressed for a meaningful dialogue to occur.

CONCLUSION

In summary, this paper argues that while food is critical to the familial spaces of home (both locally and globally), it is defined by a complex interplay of actors and wider meanings as illustrated by concepts of health and what constitutes Bengali food. Therefore, we call for greater dialogue between health professionals and those they interact with, to allow for an enhanced appreciation of the dynamic nature of food and plants and the diverse perceptions of the role that they play in promoting health.

A Hexagonal (Wurtzite) Form of Silicon

The existence of a hexagonal (wurtzite) form of silicon, similar to that form of diamond (carbon) observed in meteorites and in the laboratory, has been identified by x-ray diffraction in reaction-bonded silicon nitride containing unreacted silicon. The presence of this phase is due to stresses created in the silicon by the nitridation reaction.