Scaling-up community-led diabetes and NCD awareness and response in Bangladesh

Between 2016 and 2019, the DMagic (Diabetes Mellitus Action through community Groups or mHealth Information for better Control) project revealed a huge burden of diabetes risk in rural Bangladesh. It showed that a Participatory Learning and Action (PLA) method of community mobilisation directed at the general population significantly increased diabetes knowledge and awareness and resulted in large reductions in the prevalence and incidence of diabetes and intermediate hyperglycaemia. The impact was both highly cost effective and equitable. (See DMagic case study Action for better control of diabetes in Bangladesh).

The Diabetes: Community-led Awareness, Response and Evaluation (D:Clare) project (September 2019 to February 2024) led by University College London and the Centre for Health Research and Implementation at the Diabetic Association of Bangladesh, and in collaboration with Karolinska Intitutet, Sweden aimed to develop and test models for scaling-up the PLA community mobilisation intervention to prevent and control type-2 diabetes mellitus and non-communicable disease (NCD) risk in rural and urban Bangladesh.

 

PLA community mobilisation worked through facilitated community groups actively engaging communities in identifying health problems, designing and implementing solutions, and reflecting on their progress. The approach has proven effective across various health outcomes and settings.

The project team engaged with governmental, service providers and non-governmental stakeholders at the sub-district, district and national level to explore delivery mechanisms of PLA at scale, identifying contextual barriers and enablers, including those related to policy and systems. They also conducted a cluster randomised controlled trial and process evaluation to test the effectiveness of PLA when scaled-up across a sub-district with a population of 115,000, and explored the sustainability of PLA intervention activities and impacts in former DMagic communities. These findings informed the development and testing of lower-cost, sustainable intervention models in rural areas. Finally, the team adapted and piloted the PLA community interventions in an urban context.

Community and stakeholder engagement were important to all project activities. Regular consultations were held with national and district-level policymakers, service providers and Community Advisory Groups on all aspects of the project. At the national and district levels, the project team sought input and support from the Line Director for NCDs at the Bangladesh Ministry of Health and Family Welfare and from the Civil Surgeon of Faridpur District to develop the project application and protocol. Engagement with the Civil Surgeon was crucial throughout the project, fostering community and health service cooperation, especially during COVID-19. This included adapting project activities in response to the pandemic and collaborating with the Office of the Civil Surgeon to monitor population trends in COVID-19. Community Advisory Groups representing community leaders, such as religious leaders, teachers and elders were similarly vital to the project’s success, offering direct input on key decisions, including resuming field activities post-lockdown.

 

Stakeholder engagement shaped the implementation of the PLA intervention during COVID-19 and resulted in adaptation to intervention delivery and evaluation.

 

As the project ended, findings were openly discussed with stakeholders from the community, health system, and local government. Beyond the project’s period, the team continues to consult with district and community stakeholders on the perceived value, success and challenges of their work and the ongoing delivery of PLA efforts led by the Diabetic Association of Bangladesh, the nation’s largest non-governmental health service provider working closely with the Ministry of Health and Social Welfare.

Stakeholder engagement was a key focus of the research with the team aiming to understand the perceptions of scaling up the PLA intervention. Findings highlighted the importance of community engagement strategies to address NCDs nationally and the potential to utilise existing cadres to scale-up community-led interventions. Stakeholders emphasised a critical need to advocate for prevention as an integral part of a multisectoral action plan and to address implementation factors impacting gender equity in access to and effectiveness of strategies. Maintaining fidelity was highlighted as critical to ensure that interventions remain community-led and responsive to community needs.

The cluster randomised controlled trial showed that scaling-up the PLA intervention across Alfadanga sub-district in Faridpur resulted in significant increases in diabetes knowledge at the population level. However, there was no evidence of an effect on the prevalence of intermediate hyperglycaemia and diabetes. Process evaluation indicated intervention participation was lower in D:Clare compared to DMagic, with COVID-related adaptions potentially limiting communities’ ability to act on the diabetes knowledge and strategies developed during group meetings. Nevertheless, the PLA intervention resulted in important changes in population measures of blood pressure and hypertension. The trial’s findings support the continued development, implementation and evaluation of PLA for NCD prevention and control in resource-poor settings.

In 2021, the team revisited the DMagic study areas, and found that all PLA groups that started during the study had ended within five-years of the project. However, important positive health impacts persisted, including significantly higher levels of diabetes knowledge and awareness and positive impacts on population blood pressure in PLA-exposed villages compared to control. As part of the D:Clare project’s goal of developing and testing sustainable models of PLA delivery, the team pilot tested an adapted approach to intervention delivery using locally-recruited ‘NCD Mobilisers’ to facilitate PLA groups whilst offering cost-recovery community-based NCD risk screening. Preliminary testing in a sample of former DMagic communities shows great promise for sustained intervention delivery. The Diabetic Association of Bangladesh has continued implementing this model beyond the D:Clare project period.

Detailed formative research and adaptation of the PLA process for urban settings in Bangladesh resulted in significant changes in intervention design and delivery. This research overlapped with a related MRC-funded project on contextual awareness, response and evaluation to diabetes in urban Ghana and informed pilot PLA intervention implementation in these contexts. In Bangladesh, adaptations included greater emphasis on strategies tackling the barriers to physical activity, particularly for women. Pilot testing of these strategies has informed a new GACD project focusing on participatory interventions for NCD prevention in Faridpur, Bangladesh and Kathmandu, Nepal which will run from 2024-2027 (GACD Healthy Cities project HC06).

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This research was funded by the Medical Research Council (MRC-UKRI) and the National Institute for Health and Care Research (NIHR) under the Global Alliance for Chronic Diseases (GACD) Scale Up Research Programme.

To access publications relating to this project, see GACD’s publications webpage (under Scale Up Research Programme publications, Project SU16).

For more information about this project, please contact Professor Ed Fottrell, University College London, United Kingdom.