The Bangladesh D:CLARE Project (Diabetes: Community-Led Awareness, Response and Evaluation)
Lead Research Organisation:
University College London
Department Name: Institute for Global Health
Abstract
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we will evaluate the sustainability of groups when direct intervention from the Diabetic Association of Bangladesh is withdrawn and evaluate whether observed improvements in health last over a period of three years.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.
Technical Summary
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.
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.
Planned Impact
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.
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.
Publications
King C
(2022)
Changes in non-communicable diseases, diet and exercise in a rural Bangladesh setting before and after the first wave of COVID-19.
in PLOS global public health
Pires M
(2022)
Equity impact of participatory learning and action community mobilisation and mHealth interventions to prevent and control type 2 diabetes and intermediate hyperglycaemia in rural Bangladesh: analysis of a cluster randomised controlled trial.
in Journal of epidemiology and community health
Fottrell E
(2023)
Intermediate hyperglycaemia, diabetes and blood pressure in rural Bangladesh: five-year post-randomisation follow-up of the DMagic cluster-randomised controlled trial.
in The Lancet regional health. Southeast Asia
Morrison J
(2023)
Community engagement in population-level research in the context of Covid-19 in rural Bangladesh
in Research for All
Description | COVID-19 Grant Extension Allocation |
Amount | £40,000 (GBP) |
Organisation | United Kingdom Research and Innovation |
Sector | Public |
Country | United Kingdom |
Start | 01/2021 |
End | 09/2021 |
Description | Contextual Awareness, Response and Evaluation: Diabetes in Ghana |
Amount | £2,041,746 (GBP) |
Funding ID | MR/T029919/1 |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 08/2020 |
End | 07/2024 |
Description | Developing an integrated community mobilisation package to prevent childhood injuries in rural Bangladesh |
Amount | £151,612 (GBP) |
Funding ID | MR/T027185/1 |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 04/2020 |
End | 09/2022 |
Description | GCRF Health and Context |
Amount | £2,294,017 (GBP) |
Funding ID | MR/T029919/1 |
Organisation | United Kingdom Research and Innovation |
Sector | Public |
Country | United Kingdom |
Start | 08/2020 |
End | 07/2023 |
Description | Self-management approaches for individuals with multiple chronic health conditions in rural South Africa |
Amount | £194,245 (GBP) |
Funding ID | MC_PC_MR/T038241/1 |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 05/2020 |
End | 10/2021 |
Description | UCL Social Science Plus - Syndemic Urbanism |
Amount | £9,516 (GBP) |
Organisation | University College London |
Sector | Academic/University |
Country | United Kingdom |
Start | 01/2022 |
End | 07/2022 |
Title | Community survey data from the DClare Project, Faridpur District, Bangladesh |
Description | Data from two cross-sectional surveys conducted in Faridpur district, Bangladesh, from February to March 2020 (survey 1), and January to March 2021 (survey 2). Conducted as part of the DClare Trial (ISRCTN 42219712). |
Type Of Material | Database/Collection of data |
Year Produced | 2022 |
Provided To Others? | Yes |
URL | https://figshare.com/articles/dataset/Community_survey_data_from_the_DClare_Project_Faridpur_Distric... |
Description | GACD Working Groups |
Organisation | Global Alliance for Chronic Diseases |
Country | United Kingdom |
Sector | Charity/Non Profit |
PI Contribution | The D-Magic team have participated in new collaborations and working groups established by the Global Alliance for Chronic Diseases (GACD). These include working groups on data standardisation, context and mHealth intervention development. Collaborations has involved participation in meetings, completion of surveys, and contributions to draft manuscripts. |
Collaborator Contribution | The working groups have been facilitated by the GACD secretariat and led by GACD-funded researchers across the network. |
Impact | Draft manuscripts have been developed and work is ongoing. The collaboration is multi-disciplinary, representing social science, health systems research and epidemiology. |
Start Year | 2016 |
Description | Karolinska Institutet |
Organisation | Karolinska Institute |
Country | Sweden |
Sector | Academic/University |
PI Contribution | DClare project co-investigator Dr Carina King and PHIND Injuries co-investigator Prof. Marie Hasselberg are based at the Department of Global Public Health at Karolinska Institute. |
Collaborator Contribution | Dr King leads DClare activities in survey design and data processing. Dr Hasselberg contributes to protocol design in the injury intervention development project. |
Impact | Trial registration; co-authored publications. |
Start Year | 2019 |
Description | NCD Risk Factor Collaboration (NCD-RisC) |
Organisation | Imperial College London |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | We have joined the NCD-RisC collaboration (https://www.ncdrisc.org/) and shared survey data with this global consortium seeking to better describe and characterise NCD (and specifically diabetes) risk globally. |
Collaborator Contribution | As above. |
Impact | Manuscript in development as of March 2023. |
Start Year | 2022 |
Title | DClare PLA Intervention |
Description | Building on work from the DMagic trial, and in response to contextual changes related to the COVID-19 pandemic, we have adapted the participatory learning and action community mobilisation intervention to reduce diabetes risk and occurrence. The nature of the intervention remains the same, i.e. monthly facilitated group meetings for community members to identify, discuss and respond to local threats to their health. Adaptations relate to the duration of intervention and delivery to adhere with COVID-safe guidelines. A cluster randomised trial is underway. |
Type | Preventative Intervention - Behavioural risk modification |
Current Stage Of Development | Early clinical assessment |
Year Development Stage Completed | 2021 |
Development Status | Under active development/distribution |
Clinical Trial? | Yes |
Impact | Due to necessary adaptations in response to COVID-19, we are developing important understandings of implementation and sustainability of the intervention. |
Description | Academic presentations |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | Co-investigator Dr Abdul Kuddus shared successes and challenges of community-based interventions to address non-communicable diseases, including a discussion on using of local resources and community participation at a meeting organised by Bangladesh Adhayan Kendra-Centre for Bangladesh Studies (19th July 2022) and the Public Health Department of the Independent University, Bangladesh (July 2022). In addition, Dr Kuddus presented a poster entitled "Community engagement in population-level research in the context of COVID-19 in rural Bangladesh' at the 9th Regional Public Health Conference 2022 organized by Bangladesh University of Health Sciences (BUHS) on 25th & 26th February, 2022. |
Year(s) Of Engagement Activity | 2022 |
Description | Adapting PLA |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Dr Joanna Morrison, UCL Institute for Global Health co-investigator on DMagic and DClare moderated a webinar discussion about adaptations to the participatory learning and action intervention approach. Professor Kishwar Azad, Co-I of DMagic and DClare presented experiences of successfully adapting PLA to prevent Type-2 diabetes in rural Bangladesh. Annemijn Sondaal, collaborator on the PHIND injuries project Women and Children First, provided a case study on adapting PLA to improve family planning uptake among rural communities in Ethiopia. Engagement and dissemination objectives were achieved and the webinar was part of a wider initiative to develop a community of practice for community mobilisation interventions. |
Year(s) Of Engagement Activity | 2021 |
Description | August 2020 Community & Stakeholder Engagement: Faridpur |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | DClare Project staff traveled to Faridpur district in August 2020 to engage with local health service and community leaders to explore feasibility of conducting project activities during the ongoing COVID-19 pandemic. Face to face discussions were held with the District Civil Surgeon,Upazila (sub-district) Health and Family Planning Officer, Union (community) Chairmen, and members of Community Advisory Groups. Discussion focused on concerns and precautions needed to safely resume field activities in a way that was acceptable to community members. These engagement activities shaped revisions to study protocols. |
Year(s) Of Engagement Activity | 2020 |
Description | Community Clinics |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | Co-investigator Dr Abdul Kuddus met with Deputy Project Manager (DPM), Community Clinic Project on December 29, 2022 and discussed about the DClare project, community groups using PLA approach and ways to integrate group meetings into community clinic activities using multi-purpose health volunteers (MHV). Following the discussions, flip charts, publications, project brief were shared with the DPM. The next steps would be to visit community clinic, see the works done by the MHV and find any possibilities to take up our activities within their existing activities. |
Year(s) Of Engagement Activity | 2022 |
Description | Community engagement and discussion |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Public/other audiences |
Results and Impact | Project District Manager and Intervention Manager engaged with district authorities to share preliminary project findings and agree future activities. This included community orientation meetings in three unions (sib-districts) of Alfadanga Upazila where community leaders including elected representatives, government health authorities, NGO workers, religious leaders, and teachers were present. |
Year(s) Of Engagement Activity | 2022 |
Description | Engagement with district-level policy/care providers |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Policymakers/politicians |
Results and Impact | Project intervention manager, Tasmin Nahar, met with Civil Surgeon of Faridpur, Upazila Health and Family Planning Officer (UH&FPO) and Upazila Nirbahi (Administrative) Officer (UNO)of Boalmari and Saltha Upazila and local elected representatives about planned project work to prevent and control diabetes using NCD mobilisers including health screening along with the participatory groups and received their approval and recognition about this intervention in December, 2022. |
Year(s) Of Engagement Activity | 2022 |
Description | Faridpur stakeholder engagement 2021 |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Policymakers/politicians |
Results and Impact | The project team in Bangladesh discussed current activities of DCLARE with the Civil Surgeon, Faridpur and Upazila Health and Family Palnning Officer (UH&FPO), Alfadanga. We also briefed our activities to District Commissioner's office, Faridpur and, as part of our research activities, have interviewed a number of key stakeholders at national and district level to seek their opinion and suggestions how our participatory community mobilisation intervention could be scaled up. We have also met with local elected representatives, elites and other stakeholders about the ongoing activities including interruption of our work due to COVID-19 lock downs. |
Year(s) Of Engagement Activity | 2021 |
Description | GACD AGM 2021 |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Malini Pires (DClare project research assistant) presented updates of the DClare project to an audience of 50-100 participants at the GACD Scale Up Research Programme Workshop. |
Year(s) Of Engagement Activity | 2021 |
Description | GACD AGM 2022 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Project researcher, Dr Naveed Ahmed, attended the GACD Annual Scientific Meeting held in London on December 5-8, 2022 and spoke as a panel member in the session titled 'Sustainability and impact beyond the project timeline' where he gave an overview of the DMagic and DClare trials and highlighted the lessons learned from the DMagic Trial and discussed planning and strategies to ensure sustainability and impact for the DClare Trial. |
Year(s) Of Engagement Activity | 2022 |
Description | GACD Implementation Science School 2020 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Malini Pires, Research Assistant for DClare and PhD student at UCL attended the GACD Implementation Science School was a 2 week intensive course aimed at early career global health researchers. Through plenary sessions, individual study, group work and discussion, participants learnt about methods of implementation science and how to influence policy and practice. |
Year(s) Of Engagement Activity | 2020 |
URL | https://www.gacd.org/research/implementation-science-capacity-building/2020-gacd-implementation-scie... |
Description | Global Alliance for Chronic Diseases Annual Scientific Meeting |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | DClare Research Assistant, Malini Pires participated in the 2020 Global Alliance for Chronic Diseases Annual Scientific Meeting conducted online, where the aims and objectives of the project were presented in the format of an online pre-recorded ppt video to an audience of other grant holders. The presentation was followed by a Q&A session where specific aspects of the project was clarified and discussed with the other researchers. |
Year(s) Of Engagement Activity | 2020 |
URL | https://www.gacd.org/research/research-network/gacd-annual-scientific-meeting-2020 |
Description | Government of Bangladesh engagement |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Co-investigator Dr Abdul Kuddus shared the DMagic findings and DClare scale up activities in a round-table meeting organized by Non-communicable Disease Control, Directorate General of Health Services, Government of Bangladesh, on December 12th, 2022. |
Year(s) Of Engagement Activity | 2022 |
Description | Health Inequalities in Diabetes Research Workshop |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | Project PI, Edward Fottrell, was an invited participant at a Health Inequalities in Diabetes Research Workshop organised by Diabetes UK. This workshop brought together people with lived experience of diabetes, researchers and healthcare professionals to identify key research recommendations around health inequalities in diabetes. The two-day workshop sought to better understand how research can be used to reduce diabetes-related health inequalities, including for socially deprived and minority ethnic groups. A summary of the event and recommendations for future activity were published in Diabetic Medicine (https://onlinelibrary.wiley.com/doi/full/10.1111/dme.15024). As a direct consequence of this workshop, UCL and Diabetes UK have organized a further workshop and round-table discussion to be held in March 2023 to explore cross-learning and knowledge exchange between global health diabetes research and UK-based diabetes research, with a focus on mixed-methods implementation science approaches. |
Year(s) Of Engagement Activity | 2022 |
URL | https://onlinelibrary.wiley.com/doi/full/10.1111/dme.15024 |
Description | Karolinska Institute Lifestyle4Health Network |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Dr Carina King presnted work on DMagic and DClare to an academic audience as part of a network at Karolinska Institute, Sweden, to promote mutual learning around behaviour change and non-communicable diseases. Approximately 20 people attended, with the aim to share learning and promote collaboration. |
Year(s) Of Engagement Activity | 2021 |
Description | Realising community engagement webinar |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Prof. Ed Fottrell and Prof. Kishwar Azad participated in a webinar hosted by Women & Children First UK on the theme of 'Realising Community Engagement in Global Health'. Prof. Azad discussed lessons learned from adapting PLA for diabetes in Bangladesh, and Prof. Fottrell discussed key future research priorities for PLA and related community mobilisation approaches. The purpose of sharing experiences and disseminating activities and findings to a wide international community of participants who may be engaged in health promotion and community mobilisation activities was achieved. This activity contributed to the establishment of a community of practice for participatory community mobilisation activties. |
Year(s) Of Engagement Activity | 2021 |
Description | Regional Public Health Conference 2021 |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Professional Practitioners |
Results and Impact | Dr Abdul Kuddus attended the 9th Regional Public Health Conference held on 25 & 26 February, 2002 organized by Faculty of Public Health, Bangladesh University of Health Sciences, Dhaka and shared poster presentation on "Learning from a diabetes mHealth intervention in rural Bangladesh: what worked, what did not and what next?" During the poster presentation various queries were responded regarding D-Magic trial and DClare scale up of the PLA intervention in Alfadanga Upazila. |
Year(s) Of Engagement Activity | 2021 |
Description | UCL South Asia Regional Network Meeting |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | Prof. Fottrell presented an overview of research activities undertaken in Bangladesh, with a particular focus on the DMagic, DClare and PHIND Injuries projects. The audiience represented academics and researchers from a range of disciplines across UCL with an interest in South Asia. |
Year(s) Of Engagement Activity | 2021 |
Description | Uppsala Diabetes Centre lecture |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | Prof. Fottrell gave an invited key-note lecture at the opening symposium for the Uppsala Diabetes Centre in Sweden, November 30th 2021. |
Year(s) Of Engagement Activity | 2021 |
URL | https://www.kalendarium.uu.se/event?eventId=65808 |