Abstract
BackgroundDiabetes 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.MethodsWe 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.ResultsThe 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.ConclusionsThe 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 registrationRegistered at ISRCTN on 30th March 2016 (Retrospectively Registered) Registration number: ISRCTN41083256.
Highlights
An estimated 422 million people have diabetes and 75% of those are in low- and middle-income countries [1]
He believed that development of a critical consciousness about a shared context among marginalised groups was a precondition for positive behaviour change [5, 6]
Individual and group level mechanisms Health literacy and self-confidence Diabetic and non-diabetic attenders felt that group discussions helped develop their individual knowledge about the causes, symptoms and complications of diabetes, and how to prevent, test for and control diabetes: “I ate fried snacks a lot before and enjoyed eating them, but after I found out that they are unhealthy I do not buy them.” (Attender women 020FGD)
Summary
An estimated 422 million people have diabetes and 75% of those are in low- and middle-income countries [1]. A collaboration between the Diabetic Association of Bangladesh and the University College London Institute for Global Health conducted a qualitative process evaluation (PE) [4] of a community mobilisation intervention of groups practicing participatory learning and action (PLA) [5,6,7]. The PLA intervention was inspired by the philosophy of Paulo Freire He believed that development of a critical consciousness about a shared context among marginalised groups was a precondition for positive behaviour change [5, 6]. Diabetes is 7th largest cause of death worldwide, and prevalence is increasing rapidly in low-and middle-income countries. We conducted a participatory learning and action (PLA) intervention with community groups in rural Bangladesh which was evaluated through a cluster randomised controlled trial. We present findings from qualitative process evaluation research to explore how this intervention was effective
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