The Bangladesh D:CLARE Project (Diabetes: Community-Led Awareness, Response and Evaluation)

We recently completed a population health experiment in rural Bangladesh where we found that a diabetes-focused participatory community mobilisation intervention whereby ordinary community members themselves identify, prioritise and address threats to their health reduced the burden of diabetes and the risk of diabetes (known as 'intermediate hyperglycaemia') in these villages by more than 60% relative to villages where no intervention took place. Furthermore, among individuals who were at higher risk of developing diabetes, those living in community mobilisation villages were almost 60% less likely to develop the disease over two years compared to those who lived in villages where no intervention took place. These findings and our robust methods of evaluation give us confidence that exposure to the community mobilisation intervention caused this reduction in the burden of intermediate hyperglycaemia and diabetes. Furthermore, the low-cost, social intervention is cost-effective and can lead to savings in health care expenditure. Based on these findings, we wish to scale-up our intervention to cover a much larger population. Working with the Diabetic Association of Bangladesh, who will implement the intervention across a population of 215,000 people, UCL will apply epidemiological, economic, social and implementation science methods to better understand the processes, costs and impact of implementation at such a large scale. Further, we will evaluate the sustainability of groups when direct intervention from the Diabetic Association of Bangladesh is withdrawn and evaluate whether observed improvements in health last over a period of three years. Finally, a core component of our project will be engagement with governmental and non-governmental stakeholders in Bangladesh and globally to share our findings and to explore opportunities for longer-term, larger-scale implementation of the intervention.

Our DMagic trial of monthly group meetings led by lay facilitators who guided participants through a Participatory, Learning and Action (PLA) cycle focused on diabetes prevention and control in rural Bangladesh. Through a four-phase cycle, community members: 1) identified local behavioural, social and environmental threats to their health and prioritised areas for action; 2) planned strategies to address these threats; 3) implemented their chosen strategies, which typically included greater awareness-raising, local exercise groups, or
lobbying markets for better access to healthy foods; and 4) evaluated the success of these strategies. Facilitators were locally recruited men and women who received one week's training in group facilitation and in the basics of diabetes prevention and control. Using robust measurements we compared population prevalence of intermediate hyperglycaemia and diabetes between intervention and control villages. After 18 months of intervention, the prevalence of diabetes and intermediate hyperglycaemia was 65% lower in intervention villages compared to control villages. Further, among individuals identified with intermediate hyperglycaemia before the intervention, the cumulative two-year incidence of diabetes was more than 60% lower in intervention villages.

The robust evidence of impact of our low-cost, social intervention demands replication and scale-up in Bangladesh. This research will roll out the intervention across six Unions in Faridpur district, as well as all the control villages from our aforementioned trial. In total, the scaled-up intervention will cover a population of approximately 215,000 people.

We will characterise PLA implementation and impact of the intervention at scale using qualitative, economic and quantitative methods, engage with national stakeholders to identify optimal intervention delivery mechanisms, and develop strategies to strengthen scale-up systems across Bangladesh and the region.

The D:CLARE project specifically address Sustainable Development Goals of ensuring healthy lives and promoting wellbeing, with particular emphasis on goal 3.4 - reducing premature mortality from non-communicable diseases. We will target three key development priorities to achieve this:

Broad stakeholder engagement using a range of communication techniques will motivate action on the basis of the evidence generated. We will co-create scale-up delivery systems with stakeholders, enhance capacity and motivation to scale-up PLA interventions to significantly reduce the burden of risk factors and intermediate hyperglycaemia and diabetes in Bangladesh. In addition to the proven awareness raising impacts of our intervention, our population survey methods will significantly increase self-awareness of disease status and capacity to control blood sugar among individuals for whom diabetes was previously undetected and was inadequately controlled. We will strengthen the evidence base for PLA, and enhance the efficiency of the intervention as well as develop insight into the medium to long-term equity and sustainability of intervention actions and effects. We will develop an in-depth understanding of the context, systems and stakeholders for further scale-up of PLA, and we will build capacity of district and national authorities, health systems and non-governmental organisations to respond to the diabetes epidemic.