Improving the effectiveness of diabetes self-management programmes in low-and middle-income countries through behaviour change approaches

Diabetes is a foremost health challenge in many low-and middle-income countries (LMICs). Self-management programmes offer a potentially cost-effective intervention to improve diabetes self-management in LMICs. However, there is limited evidence on how effective self-management programmes are in LMIC contexts.

Behaviour change techniques (BCTs) are widely used tools to develop and describe behaviour change interventions for health behaviour in high-income countries (HICs) and are commonly employed in diabetes self-management programmes. However, there remains a lack of evidence on the use of BCTs in LMICs, making it unclear how applicable these tools are in these contexts. A variety of differences may exist in patient's values, experiences and beliefs in LMICs compared to HICs where BCTs have primarily been tested and categorised. It is unclear whether or how these factors may impact the functioning of BCTs in the LMIC context, or how this may impact on the effectiveness of interventions in these settings. The relevance of BCTs used in existing self-management programmes to LMIC contexts needs to be determined in order to maximise effectiveness. Therefore, this project will examine how context influences the effectiveness and acceptability of BCTs for diabetes self-management.

Project aims:
a) Identify the BCTs that have been used in diabetes self-management programmes in LMICs and explore their effectiveness.
b) Establish the determinants of effectiveness of a diabetes self-management programme in India and Uganda in terms of intervention implementation, context and behaviour change mechanisms.
c) Explore the acceptability of BCTs for healthcare professionals caring for people with diabetes globally.
d) Develop and validate a questionnaire to measure patient's attitudes to BCTs.

I will conduct a systematic review of the literature on diabetes self-management programmes in LMICs and the BCTs used. This will help to guide the rest of the project. I will then use data collected as part of a trial of educational films for improving screening and self-management of gestational diabetes in India and Uganda (GUIDES) to conduct a mixed-methods process evaluation of the GUIDES trial. This will consider factors based on the MRC framework for process evaluations: context, implementation and mechanisms (including BCTs). I have additionally developed a questionnaire on people with diabetes' attitudes towards BCTs for diabetes management behaviours. Using data on reliability and validity of this questionnaire which has been collected by collaborators in Thailand, I will use statistical methods to validate this questionnaire. This questionnaire will then be modified and used to collect data on the acceptability of BCTs for healthcare professionals involved in the care of people with diabetes globally. Results of this questionnaire will be analysed to identify similarities and differences in the acceptability of BCTs in different settings. Semi-structured interviews with healthcare professionals will be conducted to explore this further (focusing on countries where the questionnaire data suggests that differences in BCT acceptability exists).

Skills gained
a) This project will involve mixed-methods analysis, including quantitative analysis of large data sets and validation of a questionnaire. This will develop my quantitative skills in line with the MRC priority. To support this, I have taken the LSHTM MSc module "Statistics for Epidemiology and Population Health" and a Methodical training course on "Advanced Mixed Methods Research".
b) This project involves working with interdisciplinary teams, including healthcare professionals and policy makers in trial countries to communicate relevant findings.
c) This project is also in line with the MRC research themes of global health and implementation research as it seeks to support the effective implementation of intervention.