Village Health Volunteers as Peer Supports for DM type 2 Patients
Boosaba Sanguanprasit TIP-PHC HSD, WHO/SEARO
Co-investigators: • Assoc. Prof. Prasit Leerapan • Asst. Prof. Pimsurang Taechaboonsermsak • Asst. Prof. Rewadee Jongsuwat Field Researchers: • Mr. Chatchawal • Mr. Narintr •Mr. Theerawut Thammakul •Mrs. Salinee Fangsoongnern
Supported by: Peer for Progress, the American Academy of Family Physicians Foundation
Outline for presentation 1. DM Situations 2. Peer supports 3. Project: • • • • •
Objectives Methods Results Success factors Challenges
1. DM situations
Diabetes Mellitus type 2 in Thailand, 1991 - 2009
3.2 mil people affected
7 6 5 4 3 2 1 0 1991
1996 Year
2009
DM patients: • 70 – 80 % can’t control blood sugar levels • 13.4% had complications High risk groups • 32.2% overweight • 8.8% obese • 34.3% raised BP • 7.3% raised blood glucose • 56.1% raised blood cholesterol Source: WHO, NCD Country profiles 2011
Results from preliminary survey • Patients:
– 94.6% had FBS ≥100 mg/dl, 12% FBS ≥200 mg/dl – 28.6% overweight and 15.6% obese – About two-third had inappropriate eating behaviours
• VHVs: – 60 % had visited patients at home – Not good at supporting/facilitating patients for behavioural change – 52% overweight and 22.8% obese
• Current DM projects – DM screening – Health education – Referral services
Institute of Medicine definition: “the systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.” IOM. Priority Areas for National Action: Transforming Health Care Quality. Washington DC: National Academies Press, 2003, p 52.
Key functions of peer include: (i) assistance in daily management; (ii) social and emotional support to encourage sustained self management and coping with negative emotions; (iii) linkage to clinical care and community resources; and (iv) ongoing support
3. Project Objectives: To build capacity of village health volunteers (VHVs) in motivating DM fype2 patients to develop and maintain self management behaviors
Measurement: • Process measures: • Perceived susceptibility, severity of complications. • Perceived benefits. • Perceived self efficacy • Perceived levels of supports received • Behavioral endpoints: • Health behaviours: diets, exercise, foot care • Physiologic endpoints: • HbA1C • FBS • BMI • Psychosocial outcomes: • Quality of life (WHO quality of life-BREF)
Select Provinces
Select project areas
Preliminary survey
Select Provinces
Pre test
Manual development
Training VHVs
Implementation and follow up
Post test
VHV selection criteria: • having ≥ 3 DM patients • be able to read and write • willing to participate in the project • be able to complete the program
Patient selection criteria: • having diabetes type 2 • age between 35 – 75 years; • FBS ≤ 300 ≥ 30 mg/dl; • systolic BP 130 – 180 mmHg.
Inclusive curriculum development Participants: patients, VHVs, health staff, researchers • Organize workshop to discuss contents and methods • curriculum include: – knowledge about DM and management; – proper diets and exercise for diabetes patients; – assessment of the patients
• classification of patients’ readiness to behavioral change • collaborative goal setting and action plans; • problem solving techniques.
VHV training • 20 VHVs and 6 health staffs • Using participatory learning • Capacity building – Planning and goal setting – Supporting: motivation, feedback, networking – Problem solving – Coping skills
Implementation
Sustainable Health behavioural change continuum
inactive
Knowledge & Perception
Self Efficacy
Motivation
intervention
intention
Supports/regulate
action
Supports/regulate
sustained
Self efficacy
Outcome expectancies
goals
planning
initiation
maintenance
recovery Risk perception
Health Action Process Approach Schwarzer & Fuchs, 1996
Providing information to: Increase knowledge and perceptions: • Susceptibility - what will happen • Severity • Benefits, if change
Messages must: • values, social and cultural appropriate • appropriate for education and age of target groups
Building self efficacy Skill and confidence development: demonstration, practice, reinforcement • Planning • Goal setting: specific, timebound, attainable, measurable, progressi ve • Problem solving and Coping • Leadership
Supporting and regulating behaviors – Peer support – Networking – Providing feedbacks – supportive/conducive environment – Culturally and socially appropriate
Inclusive and participative planning
Demonstration and practice
Peer support
Reinforcement
Supportive environment
Building Sense of Community
Community Organic Garden
Working together, culturally and socially appropriate
Results
Knowledge and perception: before and after intervention 30 25
Experimental group
20 15 10 5 0 Knowledge
Susceptibility
Severity Pre
Post
benefit
Self Efficacy 30 25 20 15
Comparison group
10 5 0 Knowledge
Susceptibility
Severity Pre
Post
benefit
Self Efficacy
Health Behaviours: Before and after intervention Experimental group
50 45 40 35 30 25 20 15 10 5 0 Behaviours
Eating Pre
Post 40 35
Comparison group
30 25 20 15 10 5 0 Behaviours
Eating Pre
Post
Physiological measures: experimental and comparison groups FBS
HBA1C
BMI
Pre
Post
Pre
Post
Pre
Post
148.53
140.12
8.25
7.71
26.5
24.9
Comparison 129.8
127.7
7.5
8.0
25.2
25.7
Experiment
Perceived support and quality of life: before and after intervention
Experimental group
60 50 40 30 20 10 0 Support
QOL Pre
Post
47 46 45 44
Comparison group
43 42 41 40 39 38 37 Support
QOL Pre
Post
Effective empowerment strategies: Built on and reinforced authentic participation, ensure autonomy in decision-making, sense of community and local bonding. WHO Regional Office for Europe’s Health Evidence Network (HEN), February 2006
Key success factors • Kinship: VHVs long existed in the community and related to patients. • Strong connection between VHVs and health staff • Caring attitude and commitment of VHVs • Patient network: support each other • VHV network: sharing and supporting each other. • Initiatives and creativity to make activities fun and attractive • Fearless environment and sense of community
Challenges • Patients doubted VHV credibility and resisted their advice. • VHVs’ educating and empowering skills need to be refreshed and reinforced • Seasonal variations: planting, harvesting seasons. • Dealing with adamant, severe diabetes cases who lose hope • Most rural Thais don’t like reading (manual)
Sawasdee, Thank you