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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


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