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

Diabetes is a foremost health challenges facing policy makers 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 deft 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 in diabetes self-management programmes by utilising secondary data from ongoing process evaluations of diabetes self-management programmes in LMICs; the GUIDES trial (gestational diabetes in Uganda and Thailand), and the DSME-T (type 2 diabetes in Thailand).
The aims of this project will be to:
a) Identify which BCTs have been used in diabetes self-management programmes in LMICs, and how effective these techniques have been in the LMIC contexts.
b) Establish the determinants of effectiveness of diabetes self-management programmes in India and Uganda in terms of intervention implementation, context and behaviour change mechanisms.
c) Investigate how context influences the applicability and acceptability of BCTs in diabetes self-management programmes in LMICs.
d) Develop and validate a questionnaire to measure participants attitudes to BCTs in interventions.

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 qualitative and quantitative data collected by the GUIDES research teams in India and Uganda 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). This data will be triangulated across the trial sites. Following this, I will synthesise and compare qualitative data on the use of BCTs in the GUIDES and DSME-T trials to identify similarities and differences between the contexts. Finally, I will develop a questionnaire on participant's attitudes towards BCTs. Using data on reliability and validity of this questionnaire which will be collected by collaborators in Thailand, I will use statistical methods such as factor analysis to validate this questionnaire.
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" in my first term and will seek training during my project on mixed-methods research.
b) This project involves working with interdisciplinary teams, including healthcare professionals and policy makers in trial countries to communicate relevant findings. This is in line with the MRC priority of interdisciplinary skills.
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