Introduction
Type 2 diabetes and its complications have become a major health concern in Thailand as a result of rapid economic, lifestyle, and nutritional change in recent decades (Kim et al., Reference Kim, Moon and Popkin2001; Aekplakorn et al., Reference Aekplakorn, Bunnag, Woodward, Sritara, Cheepudomwit, Yamwong, Yipintsoi and Rajatanavin2006). Research evidence indicates that type 2 diabetes can be delayed or prevented with lifestyle modifications (Knowler et al., Reference Knowler, Barrett-Connor, Fowler, Hamman, Lachin, Walker and Nathan2002). Type 2 diabetes and obesity have mainly been treated at the individual level and the success of such interventions has been poor (Glenny et al., Reference Glenny, O'Meara, Melville, Sheldon and Wilson1997). Prevention is more effective than intervention for those who are already obese or have diabetes (Schulz et al., Reference Schulz, Zenk, Odoms-Young, Hollis-Neely, Nwankwo, Lockett, Ridella and Kannan2005; Hossain et al., Reference Hossain, Kawar and Nahas2007). Moreover, the need for preventive action at community, interpersonal, family, organisational, regional, and societal levels has never been greater as countries face the near-epidemic rise of these conditions.
The Thai Ministry of Public Health (MOPH) has developed and implemented a public health policy with the introduction of health promotion programmes nationwide. Although particular health promotion programmes, such as family planning or immunisation services, have been successful, others such as traffic accident prevention, smoking cessation, campaigns against liver cancer, and chronic disease prevention have not been proven to be effective or sustainable (Lyttleton, Reference Lyttleton1996; Wibulpolprasert, Reference Wibulpolprasert2007). In general, health promotion programmes are only effective when health practitioners have to follow policy decisions or when they are financed by both government and non-government organisations (Wibulpolprasert, Reference Wibulpolprasert2000; Reference Wibulpolprasert2007). Some programmes are also short term in practice because responsible health-care personnel have to turn their attention to new policies. There is no research to guide the development of a community-based diabetes prevention programme in Thailand. It may be that such an intensive programme requires resources beyond the reach of most communities. The Thai health-care system and its activities are not focused on diabetes prevention for the at-risk population. Health-care providers are unaware of the need for diabetes prevention and of the positive outcomes of such programmes (Wibulpolprasert, Reference Wibulpolprasert2000).
Community health-care workers (CHCWs) are defined as members of a particular community who work as a bridge between the primary health-care system and the community members (Wibulpolprasert, Reference Wibulpolprasert2000). To help foster the role of CHCWs as change agents and effectively integrate their work into the health system, continuing education that respects the roles, skills, and contributions of the CHCWs are essential (Witmer et al., Reference Witmer, Seifer, Finocchio, Leslie and O'Neil1995; Hill et al., Reference Hill, Bone and Butz1996; Satterfield et al., Reference Satterfield, Burd, Valdez and Eagle2002). One effective approach to health promotion is to use CHCWs as facilitators to bring health information directly to the target populations (Witmer et al., Reference Witmer, Seifer, Finocchio, Leslie and O'Neil1995). Although there is not a lot of research specific to CHCWs, a Cochrane review found that training enhanced effectiveness of CHCWs (Briggs and Garner, Reference Briggs and Garner2006). They cited studies in Tanzania (Armstrong et al., Reference Armstrong, Adam, Mshinda, Masanja, Kabadi, Mukasa, John, Charles, Nathan, Wilczynska, Mgalula, Mbuya, Mswia, Manzi, de Savigny, Schellenberg and Victora2004) and Bangladesh (Arifeen et al., Reference Arifeen, Blum, Hoque, Chowdhury, Khan, Black, Victora and Bryce2004). The World Health Organisation's (WHO, 1996; 1997) health education strategy of providing an extensive 11–14-day training course in the integrated management of childhood illness for health-care workers showed improvements in assessment, treatment, and counselling. It also reduced childhood mortality in Tanzania (Armstrong et al., Reference Armstrong, Adam, Mshinda, Masanja, Kabadi, Mukasa, John, Charles, Nathan, Wilczynska, Mgalula, Mbuya, Mswia, Manzi, de Savigny, Schellenberg and Victora2004).
Various theories and models of behaviour change and social ecology may inform obesity and type 2 diabetes prevention; however, as reviewed by Baranowski et al. (Reference Baranowski, Cullen, Nicklas, Thompson and Baranowski2003), no single model can fully guide prevention efforts. Nevertheless, ‘promising concepts’ derived from these models may be helpful in better understanding behaviours and structuring programmes. Strategies that address determinants of behaviour at a variety of ecological levels should be considered.
Therefore, the objectives of the study were to investigate barriers to and support for implementing a community-based diabetes prevention education programme for CHCWs and to get preliminary input into programme design from the perspectives of health-care professionals and potential programme recipients of Chiang Mai province, Thailand.
Methods
The Office of Research Ethics at the University of Waterloo, Ontario, Canada; Mahidol University, Nakhon Pathom province, Thailand; and the Office of Disease Prevention and Control, Ministry of Public Health, Thailand, granted permission to conduct the study.
Setting
This phase of the study was conducted in San Sai district in Chiang Mai province, Thailand. San Sai district is a semi-urban area that is not far from the city of Chiang Mai. People of the community are mainly labourers at factories or companies. The area has less than 50% agricultural households. This is reflected in the economy and typical socio-economic status of the district and Chiang Mai province (United Nations Development Programme, 2007). The incidence of obesity and new cases of diabetic patients have been increasing over time (Wibulpolprasert, Reference Wibulpolprasert2007). The risk factors for diabetes have been linked to obesity, lifestyle changes, increased dietary fat intake, reduced fibre intake and physical inactivity, and socio-economic status (Aekplakorn et al., Reference Aekplakorn, Bunnag, Woodward, Sritara, Cheepudomwit, Yamwong, Yipintsoi and Rajatanavin2006). Health-care centres are part of the primary health-care systems that are located close to the community where people live. Health-care centres provide basic health care, including health promotion, disease and illness prevention, and treatment of common health problems. They also offer a holistic continuum of care in healthy, high-risk, minor illness, and chronic illness/conditions (Hanucharurnkul, Reference Hanucharurnkul2007). Health-care centres run health programmes according to the standard operational procedures established by the MOPH, under the technical supervision and support of the community hospital (Wibulpolprasert, Reference Wibulpolprasert2002; Reference Wibulpolprasert2007). Roles of Thai CHCWs, health personnel, or general practitioners for health promotion are included in the primary health-care system (Wibulpolprasert, Reference Wibulpolprasert2007). The components of the primary care system are as follows: a community health post is a village-level health service unit established specifically in remote areas, covering a population of 500–1000, and staffed by only one CHCW (a permanent employee of the MOPH). A health-care centre is a sub-district or village-level health service unit, covering a population of about 1000–5000 with health staff, a midwife, a technical nurse, and/or a CHCW.
Study design
The formative phase comprised a 10-day observation at one health-care centre; in-depth interviews with health-care professionals; and in-depth interviews and focus groups with people at risk for diabetes.
Observation
The observation was conducted during regular working hours of the health-care centre from 9am to 4pm for 10 days. The purpose of the observation was to gather health-care information, and to understand the diabetes prevention and health promotion situation at the community level. Information from the observations and informal talks with the health-care staff were noted, such as the role of each health-care professional (three to four staff), routine work, activities, and home visiting. The information was used to develop in-depth interviews and focus group guidelines.
Health-care professionals
In-depth interviews were run for health-care professionals (doctors and nurses) and CHCWs who worked at the health-care centres. A purposive selection strategy was used to identify key informant participants for in-depth interviews. The average age of 12 professionals was 45 years, and 83% of them had more than 10 years of work experience in public health (Table 1). The health-care professionals participated in in-depth interviews to explore the attitudes, awareness, and experiences towards diabetes prevention and related risk factors in the community. Interviews were used to gather information on demographics, prominent health concerns, gaps in services, experience with current training, support service needs, and perceived support for an innovative training programme suited for the Thai health-care system.
General information of health professionals and people at risk for diabetes
CHCWs = community health-care workers; BMI = body mass index.
aWHO Expert Consultation (2004).
People at risk for diabetes
The in-depth interviews and focus groups of people at risk for diabetes were conducted to understand their behaviour, beliefs, practices, and knowledge of health promotion and disease prevention. A mix of approaches was used in case people might be more forthcoming in an individual versus group setting. The desire was to select adults, that is, both men and women, who were at risk for diabetes but were not yet diagnosed with diabetes based on Aekplakorn's criteria (Aekplakorn et al., Reference Aekplakorn, Bunnag, Woodward, Sritara, Cheepudomwit, Yamwong, Yipintsoi and Rajatanavin2006). Purposive sampling involved four health-care centres and their at-risk community members. Health-care professionals and researchers worked together for at-risk member selection. The sample of people at risk for diabetes from San Sai district was recruited from the diabetes screening database. Community members were systematically screened by CHCWs and nurses at the community health-care centres for eligibility via the diabetes risk score for Thais. The risk factors for screening were age, sex, body mass index, waist circumference, hypertension, and history of diabetes in a parent or sibling. A cut-off point of the risk score for predicting high five-year risk of diabetes in Thais was six. A score below six indicates low risk of diabetes (Aekplakorn et al., Reference Aekplakorn, Bunnag, Woodward, Sritara, Cheepudomwit, Yamwong, Yipintsoi and Rajatanavin2006). All community members had not yet scored as diabetic patients and hence did not take medications to control their blood sugar. Nurses and CHCWs identified people known to the centre, who they felt would be able and willing to participate and would provide broader perspectives. Initial contact and appointments were made with people at risk for diabetes through the community health-care centres by an invitation letter. The details of the study, objectives of interviewing, and consent letters were sent to the participants before the interview and focus group discussions.
In all, eight people at risk of developing diabetes participated in in-depth interviews and 23 people participated in focus groups (n = 4 groups). The average age was 52 years and 84% of them had graduated from grade 4 level (Table 1). Half of them were labourers in this semi-urban community. Those selected had average diabetes risk scores of 11. More than 80% of them had a family history of type 2 diabetes. The researchers explored the attitudes, beliefs, practices, gaps in health-care service, barriers to and opportunities for health promotion for people at risk for diabetes in the community towards the prevention of type 2 diabetes.
Data collection
Interview and focus group guidelines were developed from the health centre observation to elicit information from participants. Thai interview guidelines were discussed among provincial health-care professionals before implementing them. Minor changes were made to the interview guide to ensure that the questions worked in an open-ended format. The guidelines included an introduction that explained the purpose of the interview and requested permission to audio-tape the interview. A researcher conducted all interviews and focus groups at health-care centres in the communities. Interviews and focus groups averaged 90 min in length (range 60–150 min), and were tape-recorded with the consent of the participants. Then, participants were asked a series of open-ended questions and encouraged to share their perspectives. All interviews and focus groups were conducted face to face in an informal manner. The interviews preceded the focus group in each community. The interviewer probed participants to obtain additional information on interesting topics that emerged, in order to clarify ambiguous comments. The research assistant took notes during the focus groups.
Data analysis
A team of Thai research assistants fluent in the local language transcribed in-depth interview and focus group discussions from the audio tape. The data sources for the analysis were transcripts of interview tapes and a synthesis of the interviewers’ debriefing notes made during the interviews/focus groups, including expanded summary notes made immediately following each interview/focus group. A sample of four translations was independently checked for accuracy. Both the transcripts and field notes were organised by hand and using NVivo version 7 (QSR, 2006), and the content was analysed thematically. A blended coding scheme was used, consistent with both the pre-identified interview questions and the categories and themes emerging from the data during an initial process of open coding (Morse and Field, Reference Morse and Field1995; Berg, Reference Berg2006). To increase reliability, the themes were confirmed by a second independent researcher who reviewed transcripts from two interviews (one professional, one community volunteer) and two focus groups. Only minor differences in interpretation were found and a consensus was acquired through discussion. Codes were constructed based on frequency, intensity, clarity, and consistency of participants’ supporting statements. The units of analysis were sentences or phrases. Themes and sub-themes were identified and interrelationships depicted using concept maps. The concept maps helped the researchers to understand barriers, opportunities, and needs regarding diabetes prevention at the community level. The concept maps also helped to frame and inform the diabetes prevention education programme for CHCWs.
Hurricane thinking, as outlined by Kirby and McKenna (Reference Kirby and McKenna1989), was a useful tool in organising the themes from the interviews. Main responses and themes were identified, followed by the delimitation of irrelevant or overlapping data. The data continued to be coded into categories. Concept development was the final stage of the data analysis. This study has generated an emergent diagram of barriers to and support for diabetes prevention education programme for CHCWs from the data gathered from the health-care professionals, CHCWs, and people at risk for diabetes. Analysis of the participant interviews has provided insight into the factors that both limit and facilitate community integration for individuals with people who are at risk for diabetes. The thickness of the arrows depicts the strength of the relationship. The thicker arrows represent stronger relationships, and the thinner arrows weaker relationships. A concept map was developed to depict the relationship of the barriers to and support for a diabetes prevention education programme. In Figure 2, although the themes and categories included in the concept map are similar to the hurricane diagram, the concept map made it possible to visually distinguish themes that showed weaknesses/threats and strengths of diabetes prevention.
Results
Thematic analysis of the transcripts from the combined interviews and focus groups from both the health-care professionals and people at risk for diabetes yielded a range of input that was captured in the hurricane diagram (Figure 1). The findings of health-care professionals and at-risk community members overlapped and were interrelated. The analysis revealed a variety of interrelated themes and sub-themes of primarily contributing factors for a diabetes prevention programme in Chiang Mai province in Thailand. The core issue relating to diabetes for the community was being overweight and obese. Being overweight and obese were associated with other major themes, including lack of exercise, improper food portion, risk factors of overweight/obesity, and lack of information resources. Figure 1 shows the interrelationships between themes and related sub-themes. The concept map (Figure 2) depicts the narrative of findings that identifies major themes and positions them in a modified strengths, weaknesses, opportunities, and threats/barriers analysis for a diabetes prevention education programme for CHCWs in Chiang Mai province, Thailand. A strength for diabetes prevention in communities is the diabetes screening system with at-risk community members. The diabetes screening system is disease surveillance and CHCWs report the prevalence to the MOPH. CHCWs also can educate at-risk people to be aware of diabetes. Available computers and high-speed Internet at health-care centres are one of the opportunities for CHCWs to gain knowledge by themselves. The regular short course training provides another opportunity for CHCWs to learn diabetes prevention. However, the weaknesses/threats of health promotion and diabetes prevention are the health system, lack of interest to implement a diabetes programme for at-risk populations, lack of knowledge support, and lack of computer skills. The Thai health system does not support health professionals and CHCWs to promote good health for people in the community. Health-care professionals focus on treatment more than disease prevention and health promotion. The prevalence of diabetes is increasing over time, but health-care staff and CHCWs do not appear interested in implementing diabetes prevention programmes for at-risk populations in their communities. Indeed, the MOPH provides short course training for CHCWs every year, but they need knowledge resources and opportunities. Use of technology-based resources for delivering knowledge is one effective approach to support to CHCWs. However, the training of computer skills is also necessary for CHCWs. In both Figures 1 and 2, the arrows are not meant to imply causality, only the relationship between categories and the directions of this relationship based on the data analysis.
Hurricane diagram generated from input from health-care professionals, community health-care workers, and people at risk for diabetes.
A concept map of barriers to and support for a diabetes prevention education programme for community health-care workers in Chiang Mai province, Thailand.
The health-care system
The concept of diabetes prevention and health promotion had not yet been a concern in the health-care system even though the diabetes prevalence in Chiang Mai province has been increasing over time. Health professionals have had many responsibilities, such as focusing on treatment and their routine screening reports. They agreed that their workload did not allow them much time to focus on people with diabetes risk factors even though they have annual screening for risk factors. All health professionals agreed that they do not take any actions when they know who at-risk people with diabetes are. They focus on newly diagnosed diabetic patients and treatment by medications that are free of charge. Screening for diabetes and other risk factors of chronic diseases are routine work for CHCWs and staff at the health-care centres. They normally monitor once a year. Nurses and CHCWs screened for factors affecting diabetes according to a standard format from the MOPH. The minimum rate of screening was 60% of the total population aged more than 35 years reported to the MOPH annually. This activity has been included in the national health promotion policy of Thailand for the last five years (Wibulpolprasert, Reference Wibulpolprasert2007). Unfortunately, the ministry has only service support for patients with diabetes and chronic diseases. People at risk for diabetes have no activities to help them to prevent diabetes. CHCWs mentioned that they did not understand the screening results, including the meaning of some of the risk factors. Nurses and CHCWs mentioned that:
I think it is hard to educate people to take care of themselves and prevent diabetes because the MOPH provides free of charge medicine. (In-depth interview doctor no. 5)
Yes, we have screening for diabetes with all people, aged 35 years old, but diabetic patients are increasing over time, I don't know how to prevent this problem. (In-depth interview nurse no. 3)
Knowledge support
Lack of learning opportunities and health information resources for nurses, CHCWs, and people in the community came out clearly under the ‘knowledge support’ theme. Although the MOPH and provincial hospitals provided annual training courses, some of the health-care staff have no opportunity to attend the training. When we asked about training on diabetes prevention, respondents said that the provincial hospital provided some lectures to health-care staff, for example, a one-day symposium made up of traditional lectures. A recurring theme was that CHCWs at the health-care centres had received limited education and support on health promotion and type 2 diabetes prevention. They felt that not only did their information/knowledge provide them with an inadequate understanding and skill base, but also that it failed to prepare them for working with at-risk people in the community, who had chronic diseases including diabetes. One participant made this statement:
…the hospitals set training for us at least one time a year…I don't like the training… Nothing is new. (In-depth interview CHCW no. 12)
CHCWs and nurses were asked how they found/accessed information when they needed more knowledge about health, disease prevention, nutrition, or diet-related diseases. They received some support materials from the centre/district hospitals. Some pamphlets, books, guidelines, and posters were delivered by or requested from the health offices in the province. However, some materials took a long time to arrive. A participant commented:
Well, we got materials supported from the health office in Chiang Mai, but they came when we didn't need it and some information were not fit for us. (In-depth interview CHCW no. 6)
Health-care professionals and CHCWs appeared to have a general knowledge that obesity, diet, and exercise are all related to developing diabetes, and that some changes in lifestyle behaviour could help prevent diabetes. They often identified categories of healthy factors, but they required prompting to describe specific factors within these categories, such as avoiding sweet, salty, and oily foods. They spoke generally about nutrition, physical activities, and even spirituality as influencing health. Some of them had searched for nutrition information about diet-related diseases on the Internet. They, however, were not sure of the reliability of the information sources. None of them liked to search and read information in English.
I tell people got risk factors for diabetes avoiding salt, sweet, and fat food…especially sticky rice (a stable food for the north people), it will increase their blood sugar. I don't know why sticky rice can cause. (In-depth interview nurse no. 4)
I think to make my own posters about diet and diabetes prevention, so I use the Google for searching. If these information look good, I copy them. (In-depth interview CHCW no. 1)
Feasibility of a diabetes prevention education programme for CHCWs
Computer skills of CHCWs emerged as a potential problem, although computers are not a new technology in Thailand. All health-care centres at the sub-district level have computers, hi-speed Internet access, and/or wireless. Health-care professionals have only basic computer skills. Some of them have no individual e-mail addresses, and they do not understand technology or any key words related to the computer, such as, MSN, upload/download, Chat room, SKYPE, or conference call. Most of the health-care professionals, who were over 40 years of age, felt that computers were difficult to use. If they needed to start to learn, they would need more time and to learn it step by step. However, they not only wanted to know how the computer works, but also practice. Hence, health professionals, including CHCWs, wanted to learn to use new technology and were open to the use of learning technology in a training programme to support their work and to prevent diabetes for at-risk people.
I seldom used computer to send e-mail. I have an assistant…can help me any things about computer. She is a technology girl. (In-depth interview CHCW no. 6)
No, I don't know how to chat. I just saw the chat icon, but I don't know how to use it. I have no time to chat. (In-depth interview nurse no. 3)
Diabetes prevention programme implementation
A barrier to prevent chronic disease in people at risk for diabetes in the community was lack of interest, motivation, and understanding of disease prevention. One main reason is the Thai health policy and health-care system because the government provides, free of charge, any medicine for all, even though they set health promotion as one of the policies. People at risk for diabetes did not feel concerned about food, nutrition, and exercise. They mentioned that knowledge of nutrition, diet-related diseases, and diabetes was generally provided by a relative's experience, friends, health-care professionals at the hospitals, or the media. Most participants recognised that personal lifestyle choices including diet (especially sugar, salt, and fat), excess bodyweight, and physical inactivity contributed to the development of diabetes. They saw that the condition was at least partially preventable through lifestyle change. Doctors, nurses, CHCWs, and people believed that sticky rice, a high glycemic index staple food of the northern Thai people, could cause diabetes. They did not understand an appropriate portion size of foods and food exchange lists in each food group as recommended by Thai Flag Food Based Dietary Guidelines (Sirichakwal and Sranacharoenpong, Reference Sirichakwal and Sranacharoenpong2008). People at risk for diabetes explained that:
When I go to the hospital, nurses tell me how many portions of rice that I should eat, but I do not understand. When I want to ask more information, nurses cannot tell me and they have no time to chat. (Focus group with people at risk for diabetes, group no. 1)
I do not understand how many portion sizes of rice that I should eat per day, no one tell me. (In-depth interview people at risk for diabetes no. 4)
Yes, I know that I should avoid sweet, salty, and fatty foods, but they are yummy. (In-depth interview people at risk for diabetes no. 5)
Health-care professionals and people at risk for diabetes suggested suitable types of implementation programmes for them, which can integrate with their ways of life in the community. Their statements included, ‘We do need an exercise programme or other methods that we can know we are fit and healthy,’ ‘We want a health care staff that can tell there are foods we should eat and foods we shouldn't eat,’ and ‘Set this programme from a small group of people interested.’
Health-care professionals mentioned that a variety of health training programmes, such as HIV/AIDS, tuberculosis, and accident prevention, were available, but ineffective. Training programmes on diabetes are offered on a service basis to reinforce knowledge of health-care staff every year by the MOPH and provincial hospitals. Health-care professionals and some CHCWs attend the intensive training programme at least once a year. The format of this training was similar to previous training. For example, a one-day meeting was held at a hotel with speakers and their presentations or a small-group workshop; neither offer on-going support nor any contact between speakers and participants. After health-care staff were trained by the provincial hospitals each year, they were expected to deliver knowledge to people in their communities through ‘diabetes education camps’ consisting of lectures and demonstrations. However, they did not do this as part of their regular work because of time constraints, budgets, knowledge supports, and lack of interest of target people.
In late every September, the ending of annual budget report, we have a lot of training programmes that want us to participate. Well, it is good if the training organisers can prepare effective training programmes. I feel waste time and budget compared with the quality of knowledge I get from the training. (In-depth interview CHCW no. 12)
A tailored diabetes prevention programme
Other important themes revealed from the formative research were used to inform overall diabetes education programme development. Some health-care professionals and CHCWs appeared to lack basic knowledge regarding health and healthy eating, and understanding of risk factors related to diabetes. When the researcher interviewed health-care professionals about the format of training that can support CHCWs’ work, they recommended small-group workshops, hands-on learning activities, case studies, and video presentations that bring knowledge to practice within their cultural contexts. They also informed the researcher that Thai translation of the training materials was important. In the same way, people at risk for diabetes lacked knowledge of nutrition, diabetes risk factors, and resources to access health information. When they visited the hospitals or health-care centres, they desired two-way communication with CHCWs or nurses. When the researcher asked what needed to be in place for the programme to be successful, some health-care professionals suggested that the researchers might pay for CHCWs’ time and contributions. However, others suggested that CHCWs should receive a credit for continuing study.
Discussion
This research study brought together information from community health-care professionals, people at risk for diabetes, and university researchers to investigate the potential barriers to and support for implementing a training programme for CHCWs in the semi-urban areas in Chiang Mai province, Thailand. Through interviews and focus groups, this study explored the perspectives of the participants. The findings were important and, based on data saturation, reflect the dominant concerns of participants about diabetes prevention programmes and the need for education. The interviews and focus group discussions generated a picture of the diabetes prevention situation in Thailand and the potential for programmes to support the continuing education of CHCWs and, in turn, the public. The study revealed four main barriers and three supports for a diabetes prevention education programme for CHCWs (Figure 2). The Thai MPOH has established a public health policy that mandates public health programmes across Thailand in areas such as family planning, AIDS, tuberculosis, and immunisation. Although these programmes have been successful, other programmes such as smoking cessation, campaigns against alcohol, and chronic disease prevention have not been effective and sustainable (Lyttleton, Reference Lyttleton1996; Wibulpolprasert and Pengpaibon, Reference Wibulpolprasert and Pengpaibon2003).
It seems that health promotion programmes are only instituted in Thailand when health practitioners are mandated to implement them by government policy or when the programmes are financed by the government (Wibulpolprasert, Reference Wibulpolprasert2000). In the same way, some programmes have not been sustained because they were run by CHCWs who have many responsibilities and have had to turn their attention to new government policies and mandated programmes. Therefore, as there are currently no government policies or mandated programmes aimed clearly at diabetes prevention, the concept of health promotion is not currently a focus for CHCWs and other health professionals. Their work is confined to routine treatment of existing disease and, since 2004, screening for chronic disease risk factors (Wibulpolprasert and Pengpaibon, Reference Wibulpolprasert and Pengpaibon2003; Aekplakorn et al., Reference Aekplakorn, Bunnag, Woodward, Sritara, Cheepudomwit, Yamwong, Yipintsoi and Rajatanavin2006; Wibulpolprasert, Reference Wibulpolprasert2007).
On the other hand, the formative results also indicate some points of strength to support a diabetes prevention education programme for CHCWs. Some health professionals, including CHCWs, expressed concern that the incidence and prevalence of diabetic patients in their community has increased over time. Unfortunately, they have had no specific mandate to educate people about prevention or risk management. Moreover, CHCWs expressed a lack of knowledge and confidence in their ability to provide relevant advice on lifestyle. Hence, they recognised a need not only for diabetes prevention action, but also for their own education, so as to enable them to address diabetes prevention. Other supportive points that emerged from this formative study were the existence of a comprehensive, government-supported diabetes screening system, short course training at local hospitals, and the feasibility of using computers and the Internet to support CHCW education at the health centre level.
Together, these suggest an opportunity to build on strengths and overcome weaknesses. It seems critical that CHCWs’ education about disease prevention and health promotion must be addressed. CHCWs expressed a lack of knowledge and confidence in their ability to provide relevant advice on lifestyle. Moreover, the results can serve as a guide for the learning approach, materials, and course curriculum, which will support successful implementation. Diabetes prevention education programmes delivered in community-gathering places may reach CHCWs who have not normally received health information/education. The use of appropriate learning approaches that serve CHCWs’ needs may increase the relevance and acceptance of the programme (Sranacharoenpong et al., Reference Sranacharoenpong, Hanning, Sirichakwal and Chittchang2009).
Clearly, at this point in time in Thailand, the health policy and infrastructure support for CHCW health promotion education is not in place. It is the hope that the strong formative research conducted through this study can be used to demonstrate the feasibility and effectiveness of a diabetes prevention education programme for CHCWs. It may then be possible to better support the CHCWs, for example, through credit from the academic university for the course and for support of CHCWs’ health promotion education by MOPH policy and paid training. Consulting and engaging people within their unique context are important factors for the successful implementation of programmes (Kreuter et al., Reference Kreuter, Oswald, Bull and Clark2000; Potvin et al., Reference Potvin, Gendron, Bilodeau and Chabot2005). Broad consultation was used in the development of the programme, based on the recognition that stakeholders are more likely to accept a programme if they, or colleagues they respect, have been a part of the development phase. Successful community-based approaches to public health concerns have been addressed through coalitions of community members, academicians, and practitioners (Baker and Brownson, Reference Baker and Brownson1998). Moreover, local relevance is a key component of any programme. Our process was built on the experience of Baker et al. (Reference Baker, Kreuter, Homan, Starkloff-Morgan, Schonhoff and Francioni2002) in which members of community-based programmes – including health professionals, and programme participants – helped in defining the areas of interest, the specific content, and the process of dissemination.
The formative research demonstrated that there was general support for a diabetes prevention education programme on the part of the many stakeholders who were consulted within Chiang Mai province. This was critical because input from these individuals would be necessary to further develop and, ultimately, help sustain such a programme (Buranatrevedh and Sweatsriskul, Reference Buranatrevedh and Sweatsriskul2005; Mosavel et al., Reference Mosavel, Simon, van Stade and Buchbinder2005). The increasing incidence and prevalence of diabetes and obesity and the importance of effectively addressing lifestyle-related diseases were undoubtedly a concern for community stakeholders at all levels. Health education to support CHCWs to work with their communities to develop and deliver culturally appropriate lifestyle interventions was seen as a priority that the study research went on to address. An innovative, tailored diabetes prevention education programme for Thai CHCWs was developed based on the results of formative community evaluation. The diabetes prevention education programme was designed to facilitate the learning and skill development of CHCWs about community-based prevention of type 2 diabetes. The course curriculum was designed to prepare CHCWs with a strong background to support activities aimed at prevention of diabetes for at-risk people, for example, those who are overweight or obese. In addition, it supported the role of CHCWs as communicators at the community level through skill development and resource templates. The diabetes prevention education programme was effective in improving CHCWs’ health knowledge relevant to diabetes prevention (Sranacharoenpong et al., 2009). The innovative learning model has potential to expand chronic disease prevention training of CHCWs to other parts of Thailand. Ultimately, prevention of chronic diseases and associated risk factors should be enhanced.
Acknowledgements
This research was supported by a grant from the Nestlé Foundation, Switzerland.
The authors acknowledge the team staff of the health-care offices at San Sai district in Chiang Mai province, Thailand. The authors particularly thank Dr Saowanee Wiboolsanti, Ms Nittaya Rawangpan, and team staff of The Office of Disease Prevention and Control 10 Chiang Mai province, Ministry of Public Health for their facilities and hospitality. The authors would like to thank Ms Julia Verhaeghe for editing the English language.
Competing interests: The authors declare that they have no competing interests.
