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

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.

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

“…However, people were also selective about the messages they shared with others, and perceived messages delivered in group discussions to be inherently more valuable and trustworthy than those delivered by mobile messages. This resonates with findings from the qualitative process evaluation of the DMagic trial that the group discussions gave confidence to members of the community who were illiterate and that their credibility was heightened with others in their community if they had attended a group meeting (Morrison et al, 2019). This points to the role of group and community interactions in the way individuals perceive the value of their own individual actions and behaviors (Howarth et al, 2004).…”

“…The group also strengthened their social network, which enabled them to collectively interact with others to change behaviors. Both the VPA and process evaluation research showed that the groups addressed social norms, creating an enabling social context within the household and community to enact healthy behaviors ( Morrison et al, 2019 ).…”

“…A range of message formats was used, including information giving, dramas, and songs. All content was based on formative research and behavior change theories and was reviewed by medical experts ( Jennings et al, 2019 ; Morrison et al, 2019 ).…”

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

“…We will conduct a mixed methods process evaluation following the UK Medical Research Council guidelines to describe the intervention implementation and develop the theory of how the intervention can affect health outcomes in this context [ 25 ]. The intervention and trial design has used the extensive formative and process evaluation research from the DMagic trial [ 18 , 19 ]. A process evaluation officer will collect qualitative data on how the intervention is working through (1) group observations throughout the intervention and (2) semi-structured and key informant interviews and group discussions in case study communities at two time points during the intervention.…”

“…A process evaluation officer will collect qualitative data on how the intervention is working through (1) group observations throughout the intervention and (2) semi-structured and key informant interviews and group discussions in case study communities at two time points during the intervention. We will develop our hypothesis that health literacy is improved by the intervention [ 19 ] by integrating questions on health literacy in our survey tools [ 26 ]. We will also develop our hypothesis about the intervention effect on diabetes stigma through qualitative research and four quantitative questions asked to self-reported diabetics in the individual questionnaires.…”