Program Impact Pathway of the Positive Deviance/Hearth Interactive Voice Calling Program in a Peri-Urban Context of Cambodia.

BACKGROUND: Positive Deviance/Hearth (PDH) is an internationally recognized nutrition rehabilitation program. However, nutritional improvements are inconsistent across contexts. It is unclear if variations are due to differences in program design, implementation, utilization, or other contextual factors. Furthermore, few PDH programs have addressed the high time and work burdens of caregivers and volunteers. To address this, the study integrated interactive voice calling (IVC) with PDH. OBJECTIVES: A program impact pathway (PIP) analysis was used to evaluate the secondary outcomes of facilitators, barriers, and contextual factors that influenced the design, implementation, and utilization of a Positive Deviance/Hearth-Interactive Voice Calling program to improve the nutritional status of children in Cambodia. METHODS: A PIP analysis was done on data collected through in-depth interviews with caregivers (n = 32), key informant interviews with volunteers (n = 16) and project staff (n = 3), and surveys of project staff (n = 5). RESULTS: In the design phase, facilitators included quality training, technical support and design tools, community mobilization, and linkage to existing health services. Barriers included poor community mobilization. For the implementation phase, facilitators were good volunteer knowledge, follow-up tools and guidance, supervision, and spot checks of volunteers. Barriers were lack of time and overworked older caregivers. For the utilization phase, facilitators included family and volunteer support and access to phones, whereas barriers were lack of support, time, and financial resources; low levels of education and old age of caregivers; and inconsistent phone use. Contextual factors included food insecurity and increased childcare responsibilities of grandmothers due to migration of mothers. CONCLUSIONS: The PIP analysis identified facilitators, barriers, and contextual factors that may affect the design, intervention, and utilization of IVC interventions for health and nutrition behavior change and elements to consider when designing and implementing them. When implementing child nutrition programs in Cambodia, supporting interventions addressing mental health and time and resource constraints of elderly caregivers should also be included.This trial was registered at clinicaltrials.gov as NCT03399058

Utilization of diabetes management health care services and its association with glycemic control among patients participating in a peer educator-based program in Cambodia.

BackgroundSubstantial evidence supports the effectiveness of peer educator programs for diabetes management in low- and middle-income countries. However, little is known about peer educators' impact relative to other treatment components such as medication and physician consultation. In Cambodia, the non-governmental organization MoPoTsyo organizes four services for people with diabetes: self-management training through peer educator visits, lab tests, physician consultations, and low-cost medicines. Our aims were to 1) quantify MoPoTsyo participant utilization of each program service and 2) define the relationship between each program service and glycemic control.MethodsWe conducted a retrospective cohort study among 4,210 MoPoTsyo participants, using data collected by MoPoTsyo from 2006-2016. Independent variables assessed were medication adherence, number of peer educator visits, number of physician consultations, and number of lab tests. A multiple logistic regression model was used to evaluate the association between these disease management services and glycemic control-fasting plasma glucose ≤130 mg/dl or post-prandial glucose ≤180 mg/dl-based on most recent glucose level. The model was adjusted for baseline demographic and disease characteristics.FindingsParticipants with 12 or more peer educator visits per year had a 35% higher odds of glycemic control relative to participants with 4 or fewer visits (odds ratio 1.35, 95% CI: 1.08-1.69; p = 0.009), after adjustment for utilization of other treatment components (medication adherence, number of physician visits, number of lab tests), follow-up time, and demographic and disease characteristics. Better adherence to medications and a greater number of lab tests per year were also associated with a higher odds of glycemic control after adjustment. Number of physician consultations was not associated with glycemic control after adjustment.ConclusionsThis study demonstrates a positive association between peer educator utilization and glycemic control incremental to other elements of diabetes management. These results suggest that peer educators may be a valuable addition to comprehensive diabetes management programs in low- and middle-income countries even when other health care services are accessible. The associations identified in this research warrant further prospective studies to explore the causal impact of peer educators on glycemic control relative to other disease management components

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia

Abstract Non-communicable diseases are increasing in developing countries and control of diabetes and hypertension is needed to reduce rates of the leading causes of morbidity and mortality, stroke and ischaemic heart disease. We evaluated a programme in Cambodia, financed by a revolving drug fund, which utilizes Peer Educators to manage diabetes and hypertension in the community. We assessed clinical outcomes and retention in the programme. For all people enrolled in the programme between 2007 and 2016, the average change in blood pressure (BP) and percentage with controlled hypertension (BP &amp;lt; 140/&amp;lt;90 mmHg) or diabetes (fasting blood glucose (BG) &amp;lt; 7mg/dl, post-prandial BG &amp;lt; 130 mg/dl, or HBA1C &amp;lt; 7%) was calculated every 6 months from enrolment.  Attrition rate in the nth year of enrolment was calculated; associations with loss to follow-up were explored using cox regression. A total of 9139 patients enrolled between January 2007 and March 2016. For all people with hypertension, mean change in systolic and diastolic BP within the first year was −15.1 mmHg (SD 23.6, P &amp;lt; 0.0001) and −8.6 mmHg (SD 14.0, P &amp;lt; 0.0001), respectively. BP control was 50.5% at year 1, peaking at 70.6% at 5.5 years. 41.3% of people with diabetes achieved blood sugar control at 6 months and 44.4% at 6.5 years.  An average of 2.3 years [SD 1.9] was spent in programme. Attrition rate within year 1 of enrolment ranged from 29.8% to 61.5% with average of 44.1% [SD 10.3] across 2008–15. Patients with hypertension were more likely to leave the program compared to those with diabetes and males more likely than females. The programme shows a substantial and sustained rate of diabetes and hypertension control for those who remain in the program and could be a model for implementation in other low middle-income settings, however, further work is needed to improve patient retention.</jats:p

Facilitators and Barriers to Chronic Disease Self-Management and Mobile Health Interventions for People Living With Diabetes and Hypertension in Cambodia: Qualitative Study

Background In many low- and middle-income countries (LMICs), heart disease and stroke are the leading causes of death as cardiovascular risk factors such as diabetes and hypertension rapidly increase. The Cambodian nongovernmental organization, MoPoTsyo, trains local residents with diabetes to be peer educators (PEs) to deliver chronic disease self-management training and medications to 14,000 people with hypertension and/or diabetes in Cambodia. We collaborated with MoPoTsyo to develop a mobile-based messaging intervention (mobile health; mHealth) to link MoPoTsyo’s database, PEs, pharmacies, clinics, and people living with diabetes and/or hypertension to improve adherence to evidence-based treatment guidelines. Objective This study aimed to understand the facilitators and barriers to chronic disease management and the acceptability, appropriateness, and feasibility of mHealth to support chronic disease management and strengthen community-clinical linkages to existing services. Methods We conducted an exploratory qualitative study using semistructured interviews and focus groups with PEs and people living with diabetes and/or hypertension. Interviews were recorded and conducted in Khmer script, transcribed and translated into the English language, and uploaded into Atlas.ti for analysis. We used a thematic analysis to identify key facilitators and barriers to disease management and opportunities for mHealth content and format. The information-motivation-behavioral model was used to guide data collection, analysis, and message development. Results We conducted six focus groups (N=59) and 11 interviews in one urban municipality and five rural operating districts from three provinces in October 2016. PE network participants desired mHealth to address barriers to chronic disease management through reminders about medications, laboratory tests and doctor’s consultations, education on how to incorporate self-management into their daily lives, and support for obstacles to disease management. Participants preferred mobile-based voice messages to arrive at dinnertime for improved phone access and family support. They desired voice messages over texts to communicate trust and increase accessibility for persons with limited literacy, vision, and smartphone access. PEs shared similar views and perceived mHealth as acceptable and feasible for supporting their work. We developed 34 educational, supportive, and reminder mHealth messages based on these findings. Conclusions These mHealth messages are currently being tested in a cluster randomized controlled trial (#1R21TW010160) to improve diabetes and hypertension control in Cambodia. This study has implications for practice and policies in Cambodia and other LMICs and low-resource US settings that are working to engage PEs and build community-clinical linkages to facilitate chronic disease management. </jats:sec

Factors associated with medication adherence among people with diabetes mellitus in poor urban areas of Cambodia: A cross-sectional study

10.1371/journal.pone.0225000PLoS ONE1411e022500