Effectiveness of a Female Community Health Volunteer-Delivered Intervention in Reducing Blood Glucose Among Adults With Type 2 Diabetes: An Open-Label, Cluster Randomized Clinical Trial

Advancing diabetes primary care education and knowledge in Nepal: A scoping review and case study discussion

AIMS

Diabetes mellitus (DM) is a chronic disorder of insulin and glucose metabolism. It affects more than 463 million people worldwide and is expected to reach 700 million by 2045. In the Southeast Asian region, the prevalence of DM has tripled to 115 million due to rapid urbanization, unhealthy diet, sedentary lifestyles, and genetic factors. In Nepal, a developing country, DM affects 8.5% of adults, with an alarming increase in recent years. Lack of diabetes education and limited populational adoption of behavioural changes further hamper care.

METHODS

In the present study, we performed a scoping review to determine the status of awareness, attitudes, and knowledge about diabetes in the Nepalese population with a focus on the educational initiatives that have been implemented. We also conducted a two-week international case study discussion among medical students to brainstorm viable intervention strategies.

RESULTS

Our findings indicate that limited data is available on the level of education or initiatives to improve knowledge and practice among healthcare professionals and community members. Targeted studies of people with diabetes also present heterogeneous results due to differences in the sample population, geographic location, education, age, and gender. Accordingly, we propose five interrelated education-based strategies that leverage existing networks to expand community outreach and engagement, improve system resilience, and improve health outcomes.

CONCLUSIONS

Effective education for healthcare professionals, community, and patients with diabetes is vital in improving diabetes outcomes in Nepal and South Asia. Collaboration, funding, and evaluation are key areas needing reform.

Female community health volunteers' experience in navigating social context while providing basic diabetes services in western Nepal: Social capital and beyond from systems thinking

The global burden of non-communicable diseases (NCDs) has led to an increased mobilization of community health workers (CHWs) in the prevention and management of NCDs, particularly in resource-poor settings. However, little is known about the experiences of CHWs as they navigate the complex social context while proving home-based NCD management. This study aims to explore the experiences of female community health volunteers (FCHVs) in a community-based pilot project in western Nepal, specially regarding the social challenges they face while delivering basic type 2 diabetes (T2D) services. Using a qualitative phenomenological approach, the study conducted two focus group discussions and nine in-depth interviews with a total of 14 and 9 FCHVs, respectively. Social Capital theory was employed to understand the sociological aspects. The findings shed light on the challenges encountered by FCHVs in expanding their social networks, building trust, and fostering reciprocity among T2D intervention recepients. Notably, social trust was a significant challenge, compounded by power dynamics related to gender and socioeconomic status. FCHVs managed to overcome these challenges through their perseverance, self-motivation, and leaveraging their strong bonding and linking social capital. The recognition they received from the community played a crucial role in sustaining their motivation. The study highlights the importance of FCHVs' strong social capital, supported by available resources and personal motivation, in overcoming social obstacles. It is imperative for community health interventions to anticipate challenges across various elements of social capital to ensure the long-term retention and motivation of CHWs. Establishing appropriate support systems that address personal motivating factors and the strengthen social capital is essential.

Effectiveness of a dietician-led intervention in reducing glycated haemoglobin among people with type 2 diabetes in Nepal: a single centre, open-label, randomised controlled trial

Background

Nutrition education and counselling are considered a cornerstone for the management of type 2 diabetes (T2D). However, there is limited research related to the management of T2D through dietary approach, particularly in low-income and middle-income countries (LMICs) like Nepal. This study assessed the effectiveness of a dietician-led dietary intervention in reducing glycated haemoglobin (HbA1c) levels among people with T2D.

Methods

An open-label, two-armed, hospital-based, randomised controlled trial was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Participants were randomly assigned to either dietician-led dietary intervention group (n = 78) or usual care control group (n = 78). People with type 2 diabetes with HbA1c >6.5% and aged 24-64 years were included in the study. The primary outcome was a change in HbA1c level over six months, and secondary outcomes included changes in biochemical and clinical parameters, Problem Areas in Diabetes (PAID) score, diabetic knowledge, dietary adherence, and macronutrient intake level. Data were analysed using an intention-to-treat approach. This trial is registered with ClinicalTrials.gov, NCT04267367.

Findings

Between August 15, 2021 and February 25, 2022, 156 people with type 2 diabetes were recruited for the study, of which 136 participants completed the trial. At six months of follow-up, compared to baseline values, the mean HbA1c (%) level decreased in the intervention group by 0.48 (95% CI: -0.80 to -0.16), while it increased in the control group by 0.22 (95% CI: -0.21 to 0.66). In an adjusted model, the reduction in HbA1c (%) levels for the intervention was 0.61 (95% CI: -1.04 to -0.17; p = 0.006). In addition, fasting blood glucose was decreased by 18.96 mg/dL (95% CI: -36.12 to -1.81; p = 0.031) after the intervention. The intervention resulted in the reduction of BMI, waist and hip circumference, PAID score, dietary adherence, and macronutrient intake in the intervention group compared to the control group.

Interpretation

The dietician-led intervention improved glycaemic control, improved macronutrient intake, and clinical outcomes among people with type 2 diabetes. The dietician-led intervention may be considered for diabetes management in LMICs.

Funding

The research was funded by the University Grants Commission (UGC), Nepal.

Culturally Tailored Dietary Interventions for Improving Glycaemic Control and Preventing Complications in South Asians with Type 2 Diabetes: Success and Future Implications

Glycaemic control is the basis of type 2 diabetes mellitus (T2DM) management and is crucial for preventing diabetes microvascular and macrovascular complications. The South Asian population is at higher risk of T2DM and resultant cardiovascular disease, peripheral vascular disease and death compared to Caucasians. Effective diabetes care has been deemed challenging in this population, but little is known about the usefulness of lifestyle interventions in improving glycaemic control and reducing complications. This narrative review aims to explore the efficacy of lifestyle interventions targeted to South Asians with T2DM in inducing clinically relevant improvements in HbA1c levels at such levels that reduce the risk of diabetes complications. A search of the literature using six databases (MEDLINE (EBSCOhost), PubMed, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials and Scopus) identified dietary-based, physical-activity-based and education-based interventions that aimed to manage T2DM in South Asians. Results showed that dietary and physical activity interventions (duration 3-12 months) have been effective in generating a clinically relevant decrease in HbA1c levels (≥0.5%) in South Asians with T2DM and could potentially assist in reducing diabetes complications. Education-based interventions produced small effects on glycaemic control. These outcomes support the development of comparable longer-term randomised clinical trials combining dietary and physical activity interventions with the aim to provide further evidence on specific interventions that can lower complications and ensure effective diabetes care in a high-risk population.

The hypertension and hyperlipidemia status among type 2 diabetic patients in the community and influencing factors analysis of glycemic control

OBJECTIVE

To understand the prevalence of hypertension and hyperlipidaemia as well as the current status of glycaemic control and its influencing factors among type 2 diabetes mellitus patients in the community in South China, and to provide recommendations for the prevention and control of diabetes.

METHODS

Questionnaires, physical examinations and laboratory tests were conducted on patients with type 2 diabetes mellitus who participated in the National Basic Public Health Service Programme in Guangzhou in 2020. The chi-square test, t-test and multi-factor unconditional logistic regression analysis were performed using R 4.1.2 software.

RESULT

Among 127,423 type 2 diabetic patients in Guangzhou, 57,695 achieved glycemic control standards, with a glycemic control rate of 45.28%.In this study, the proportion of T2DM patients with hypertension and hyperlipidaemia together was 27.79%, The percentage of T2DM patients with hypertension alone and hyperlipidaemia alone was 28.34% and 20.53% respectively, and the rate of no complications was 23.34%. There was a statistically significant difference in the rate of glycaemic control between the different disease combination states (P < 0.05). The glycaemic control rate was 47.67% in diabetic patients without hypertension and hyperlipidaemia, 52.54% and 37.24% in those with combined hypertension alone and hyperlipidaemia alone respectively, compared to 41.80% in diabetic patients with hypertension and hyperlipidaemia. After adjusting for all covariates, multivariate analysis showed that combined hypertension alone was associated with good glycaemic control (OR 0.817, 95% CI 0.791, 0.843, P < 0.001),when using comorbid T2DM as a control group, combined hyperlipidaemia alone, combined hypertension and hyperlipidaemia were associated with poor glycaemic control (OR 1.521, 95% CI 1.470,1.574, P < 0.001 and OR 1.250, 95% CI 1.211,1.291, P < 0.001), Subgroup analyses as well as multifactorial unconditional logistic regression analyses showed that patients with type 2 diabetes who were overweight and obese, smoked, drank alcohol, had a diagnosis of diabetes for ≥ 6 years, had fair or poor adherence and had a family history of diabetes had lower rates of glycaemic control.

CONCLUSION

The results of this study showed that the co-morbidity of hypertension and hyperlipidaemia was high and prevalent among diabetic patients in Guangzhou. Moreover, glycaemic control of T2DM patients with hyperlipidaemia was lower than other diabetic patients. Obesity and overweight, poor lifestyle and dietary habits are also major factors affecting the treatment and control of T2D patients in this region. Therefore, comprehensive measures should be actively taken to control blood glucose levels in type 2 diabetic patients by also incorporating lipid management into the community and strictly controlling lipid levels.

Effect of a female community health volunteer-delivered intervention to increase cervical cancer screening uptake in Nepal: a cluster randomized controlled trial

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A community-based cluster randomized controlled trial.

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An FCHV-delivered intervention increased cervical cancer screening uptake.

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Screening uptake among women aged 30–60 years in a semi-urban area of Nepal.

This study aimed to assess the effect of Female Community Health Volunteer (FCHV)-delivered intervention to increase cervical cancer screening uptake among Nepalese women. A community-based, open-label, 2-group, cluster randomized controlled trial (CRCT) was conducted in a semi-urban setting in Western Nepal. Fourteen clusters (1:1) were randomly assigned to the intervention group, which received a 12-month intervention delivered by FCHVs or the control group (usual care). Between April and June 2019, 690 women aged 30–60 years were recruited for CRCT during the baseline survey. A follow-up assessment was conducted after the completion of the 12 months intervention. The primary outcome was the change in cervical cancer screening from baseline to 12-month follow-up. Of 690 women, 646 women completed the trial. 254 women in the intervention group and 385 women in the control group were included in the primary outcome analysis. There was a significant increase in cervical cancer screening uptake in the intervention group [relative risk (RR), 1.48; 95 % confidence interval (CI) 1.32, 1.66; P < 0.01)], compared to the control group. The secondary outcome was the change in median knowledge score among women that increased from 2 [interquartile range (IQR) 1–4] (baseline) to 6 [IQR 3–9] (follow-up) in the intervention group. However, the median knowledge score remained almost the same among women in the control group 2 [IQR 1–5] to 3 [IQR 2–5]. Our study findings reported that an FCHV-delivered intervention significantly increased cervical cancer screening uptake among women living in a semi-urban setting in Nepal.

Trial registration: ClinicalTrials.gov NCT03808064.

Poor glycemic control, cardiovascular disease risk factors and their clustering among patients with type 2 diabetes mellitus: A cross-sectional study from Nepal

Background

Cardiovascular disease (CVD) is the most common complication of diabetes mellitus (DM). To prevent morbidity and mortality among patients with type 2 diabetes mellitus (T2DM), optimization of glycemic status and minimizing CVD risk factors is essential. As Nepal has limited data on these CVD risk parameters, we assessed the prevalence of poor glycemic control, CVD risk factors, and their clustering among patients with T2DM.

Methods

Using a cross-sectional study design, we collected data of 366 patients with T2DM. We applied a multistage cluster sampling technique and used the WHO STEPS tools. Binary logistic and Poisson regression was applied to calculate odds and prevalence ratio of clustering of risk factors, considering P< 0.05 statistically significant.

Results

The mean age of participants was 54.5±10.7 years and 208 (57%) were male. The prevalence of poor glycemic control was 66.4% (95% C.I: 61.5–71.2). The prevalence of smoking, alcohol users, inadequate fruit and vegetables intake and physical inactivity were 18% (95% C.I:14 to 21.9), 14.8% (95% C.I:11.1 to 18.4), 98.1% (95% C.I: 96.7–99.4), and 9.8% (95% C.I:6.7–12.8), respectively. Overall, 47.3% (95% C.I: 42.1–52.4) were overweight and obese, 59% (95% C.I: 52.9–63) were hypertensive, and 68% (95% C.I: 63.2–72.7) had dyslipidemia. Clustering of two, three, four, five and more than five risk factors was 12.6%, 30%, 30%,19%, and 8.7%, respectively. Four or more risk factors clustering was significantly associated with gender, age, level of education, T2DM duration, and use of medication. Risk factors clustering was significantly higher among males and users of anti-diabetic medications with prevalence ratio of 1.14 (95% C.I:1.05–1.23) and 1.09 (95% C.I: 1.09–1.18)], respectively.

Conclusions

The majority of the patients with T2DM had poor glycemic control and CVD risk factors. Policies and programs focused on the prevention and better management of T2DM and CVD risk factors should be implemented to reduce mortality in Nepal.

Health Information Sources Influencing Health Literacy in Different Social Contexts across Age Groups in Northern Thailand Citizens

Health literacy is an essential social determinant of health and has been associated with positive health outcomes. While many sources of health information are widely available, people of different ages also have diverse social contexts and preferences for health information sources. This study aimed to identify health information sources and socio-demographics influencing health literacy in different social contexts across age groups: 15–29 years (young), 30–59 years (middle-age), and ≥60 years (elderly). We obtained secondary data from a cross-sectional study in northern Thailand from March to August 2019. Multivariate linear regression with age group subgroup analysis was used to determine factors associated with general health literacy by the Thai version of the health literacy questionnaire. Receiving health information from physicians was significantly associated with higher general health literacy in young (β 6.45, 95%CI 0.44–12.45; p = 0.035) and elderly (β 5.18, 95%CI 1.84–8.52; p = 0.002) groups, while receiving health information from health volunteers was significantly associated with a higher general health literacy in the middle-aged (β 2.89, 95%CI 0.38–5.39; p = 0.024) group. Although younger participants showed more frequent access to health information via the media than the other age groups, there were no media sources significantly linked with their general health literacy. Health information from physicians is a vital source of health information.

Contribution of community health care volunteers in facilitating mobilization for diabetes and hypertension screening among the general population residing in urban puducherry - An operational research study

Introduction:

Non-communicable diseases (NCDs) have contributed to almost half of the global disease burden. Many countries have experimented with Community Health Volunteers (CHVs) to provide necessary care for NCDs. We aimed at evaluating the contribution of CHVs in mobilizing adults for the Diabetes and Hypertension screening in a selected Primary Health Centre (PHC) of Puducherry, India.

Methodology:

A community-based operational research study was conducted, where five volunteers from each of the 13 anganwadis functioning under the PHC were chosen as study participants. They were interviewed before enrolment for willingness. Four batches of sensitization and training sessions were conducted to provide the necessary training. CHVs were then given 3 months to mobilize the individuals for NCD screening. This model was evaluated using the Theoretical underpinning technique.

Results:

Of the total 85 CHVs suggested, around 65 (76.5%) showed willingness for rendering services. Approximately 32 (49.2%) discontinued during the initial weeks of the intervention due to various reasons. The remaining CHVs could reach 363/1470 (24.7%), eligible individuals, among them, 303 (83.5) were convinced to visit the health centre for screening. From the total members who were screened, approximately 52 (17%) and 31 (10%) were diagnosed to have diabetes and hypertension respectively and were initiated on treatment as per national guidelines.

Conclusion:

About half of the CHVs who volunteered, remained till the end and effectively contributed to a screening of NCDs. The involved volunteers aided in improvising the NCD coverage under the PHC.

Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.

Role of female community health volunteers in ischemic stroke prevention, identification, referral and rehabilitation in Nepal

For the past three decades, female community health volunteers (FCHVs) have been at the forefront of Nepal's health map and have contributed significantly to its improving health indicators such as maternal mortality rate and infant mortality rate. Given the changing epidemiology of Nepal and the shift of burden from communicable to non-communicable diseases (NCDs), it is important to revitalize their role with the changing times. The prevalence of ischemic stroke in Nepal is on the rise. However, very few people make it to the hospital within the time frame for thrombolysis and the patient's knowledge about ischemic stroke seems to play a major part. FCHVs can play a significant role in improving ischemic stroke care by raising awareness about the condition, its risk factors, and informing the public about the need for timely treatment. They can help screen for common risk factors such as obesity, hypertension and diabetes as well as monitor for treatment in previously diagnosed individuals. Randomized controlled trials have shown to yield favorable results in NCDs with engagement of FCHVs. With proper training and support, they can play an important role in improving ischemic stroke care in low- and middle-income countries like Nepal.

Community health workers at the dawn of a new era: 5. Roles and tasks

BACKGROUND

This is the fifth of our 11-paper supplement on "Community Health Workers at the Dawn of a New Era." When planning new community health worker (CHW) roles or expanding existing roles, programme planners need to analyse global and local research evidence and evidence-based guidance on the effectiveness and safety of relevant tasks performed by CHWs.

METHODS

In this paper, we explore key areas of consideration when selecting roles and tasks; present current knowledge regarding these issues; and suggest how decision-makers could consider these issues when assigning tasks in their setting. This paper draws on the chapter "Community Health Worker Roles and Tasks" in Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, as well as on a recently published compendium of 29 case studies of national CHW programmes and on recently published literature pertaining to roles and tasks of CHWs.

RESULTS

This paper provides a list of questions that aim to help programme planners think about important issues when determining CHW roles and tasks in their setting. Planners need to assess whether the recommended roles and tasks are considered acceptable and appropriate by their target population and by the CHWs themselves and those who support them. Planners also need to think about the practical and organizational implications of each task for their particular setting with regard to training requirements, health systems support, work location, workload, and programme costs.

CONCLUSION

When planning CHW roles and tasks, planners, programme implementers, and policy-makers should draw from global guidance and research evidence, but they also need to engage with the experiences, needs, and concerns of local communities and health workers. By drawing from both sources of information, they will stand a better chance of developing programmes that are effective in achieving their goals while remaining acceptable to those affected by them, feasible to implement, and sustainable over time.