diabetes intervention in lawa lake, thailand daniel banh, kali … · 2015. 3. 4. · lawa lake,...
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RUNNING HEAD: Diabetes Intervention
Diabetes Intervention in Lawa Lake, Thailand
Daniel Banh, Kali Deans, Jessica Dubow, and Jhanae Mahoney
Khon Kaen University
Fall 2013
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Introduction
In order to meet our three objectives of confirming the high prevalence of Type 2
diabetes mellitus (T2DM) among women, understanding women’s perceptions of diabetes in
Lawa Lake, and gaining a deeper understanding of available T2DM resources, we decided to
interview villagers door-to-door, conduct a focus group with Village Health Volunteers (VHVs),
and observe a Friday diabetes clinic. From this research, we determined that there is a high
prevalence of diabetes and a need for a diabetes intervention. Given that approximately half of
women surveyed did not know any of the causes of diabetes and the other half of women had a
very vague understanding, we determined that an education and prevention based approach
would be most appropriate.
We decided to conduct a workshop with Village Health Volunteers consisting of a
presentation by a doctor, an inside perspective from diabetes patients, activities on nutrition and
exercise, an aerobics class, and cooking a healthy dinner. This workshop will be supplemented
with a poster that can hang permanently in the Health Promoting Hospital and brochures which
can be distributed to the community. Our focus on village health volunteers will allow them to
gain a more in-depth focus on diabetes and build off their existing knowledge. As the village
health volunteers have had great cohesion within the community, winning the best VHV award
of Khon Kaen Province, we hope that these interventions will support their efforts and
sustainably promote diabetes understanding in the community.
Research Results and Analysis
We set our sample size for the door-to-door interviews at sixty women because we
thought this was feasible given our time constraints while still enough to gain a well-rounded
understanding of diabetes perceptions in Lawa Lake. Our population was randomly selected
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based on which women were home. In order to ensure diversity within our sample, we
interviewed at various times of day and walked down several streets for geographic diversity in
terms of proximity to the Health Promoting Hospital. Because we interviewed women in their
homes, it’s important to note that most of them were available during the day and did not have
physically demanding occupations; thus our data may be skewed towards individuals with
greater risk factors for diabetes. Our population’s ages were evenly distributed, as demonstrated
by the stem and leaf plot below. In total, 16 of the 60 individuals we interviewed were diabetic, a
prevalence of 27% among adult women. This is approximately half as high as the 60%
prevalence we were told by VHVs during our focus group. While very different, both figures
indicate that diabetes is highly prevalent in the Lawa Lake Community and confirm the
importance of a diabetes intervention. Additionally, while conducting interviews in the
community, many women noted that even though they do not know what causes diabetes, they
do know that many community members have it. To ensure that women had Type 2 diabetes
mellitus, we asked them when they were diagnosed to determine if it was at a young age and thus
more likely to be type 1 diabetes. Each diabetic person we spoke to had been diagnosed as an
adult.
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Figure 1. Ages of the 60 individuals surveyed, divided by those with diabetes and those without diabetes.
All of our research methods were qualitative in nature. The semi-structured interviews
asked open-ended questions regarding villagers’ perceptions of diabetes and sources of
knowledge. There were many commonalities between responses, and we were thus able to
organize them and create the following bar graphs. We separated responses from diabetic
participants and non-diabetic participants in order to determine if diabetic participants were more
informed about diabetes.
Figure 2. What non-diabetics perceive as the causes of diabetes.
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Figure 3. Where non-diabetics have received information regarding the causes of diabetes.
Approximately fifty percent of the non-diabetics (21 women) we interviewed did not
have any idea of what causes diabetes. Two of these 21 participants specifically stated that they
did not know what causes diabetes because they do not have the illness. Of the remaining 23
women, 22 had vague ideas about its correlation to diet, exercise habits, and genetics, but their
responses were generally limited. One woman believed diabetes was caused by the chemicals in
agricultural fertilizer.
When questioned where their perceptions came from, twenty-one women did not know
and two women did not answer. Seven individuals got their information from Village Health
Volunteers. It is notable that four of the 44 participants were VHVs themselves and that one of
these four VHVs did not know the cause of diabetes. One woman had gotten her information
from a doctor, three had learned about diabetes from observing diabetics, four participants had
learned about diabetes from their community, two had learned about diabetes from relatives,
three had learned from the internet or TV, and two had learned from self-observation. Self-
observation means that the women had not been informed on the causes of diabetes but that they
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had noticed sticky rice is sweeter than regular rice and they felt unhealthy when eating food high
in fat and sugar.
Figure 4. What diabetics perceive as the causes of diabetes.
Figure 5. Where diabetics have received information regarding the causes of diabetes.
Four of the sixteen diabetics (25%) interviewed did not know the causes of diabetes, a
smaller percentage than uninformed non-diabetics. Nine interviewees understood diabetes as
being related to sticky rice and sugar, and three women thought it was connected to symptoms of
dry lips and bubbly or sweet urine. Six diabetics did not know where their knowledge, or lack
thereof, came from, five had learned about diabetes from a doctor, one had learned about
diabetes from the community, and four mentioned self-observation as the source of their
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understanding. This means they had observed the sweetness of sticky rice, feeling unhealthy
from certain foods, or ants around their toilet suggesting sweetness in their urine.
Figure 6. What diabetes health programs are available, according to non-diabetics.
Figure 7. What diabetes health programs are available, according to diabetics.
Overwhelmingly, women were not aware of local health programs related to diabetes; the
only program that was mentioned consistently was an aerobics class. However, this exercise
class is held infrequently due to flooding and lack of time during the harvest season; it is
currently on hiatus.
Overall, the responses from both non-diabetics and diabetics are consistent with research
conducted when reviewing the literature on diabetes in Northeast Thailand. In 2008, Dr.
Nakagasien, Dr. Nuntaboot, and Dr. Sangchart of Khon Kaen University’s Faculty of Nursing
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sought to create a cultural definition of diabetes mellitus in the Isan context since they
recognized that villagers’ understanding was based on sociocultural knowledge rather than
biomedical knowledge alone (p. 121). These researchers found that many villagers thought that
diabetes mellitus is caused by sticky rice and diets high in MSG because they observed that
overweight community members who consume many snacks, sweets, and soft drinks are often
diabetic (Nakagasien, Nuntaboot & Sangchart, 2008, p. 124). We found this to be consistent with
responses from our interviews and from our focus group with village health volunteers. In the
focus group, VHVs agreed unanimously that the causes of diabetes are sticky rice, processed
snacks, and fruit, especially consumed in large quantities. In the research, villagers also noticed
that physically active community members were less likely to be diabetic (Nakagasien,
Nuntaboot & Sangchart, 2008, p. 125). In our interviews, two villagers’ observations of sweet
urine attracting ants is consistent with research collected by Napaporn Sowattanangoon,
Naipinich Kotchabhakdi, and Keith Petrie (2009, p. 247). Thus, the data we collected builds
upon several other studies of perceptions and management of diabetes in northeast Thailand.
However, our data was inconsistent with one recent study conducted in 2013 by Supattra
Srivanichakorn, Tassanee Yana, Pattara Sanchalsuriya, Yu Yu Maw, and Frank Schelp, who
found that the Thai population is “astonishingly” well-informed about diabetes (p. 154). These
researchers found despite education levels, the cultural importance of behaviors like consuming
sticky rice may explain the continued high prevalence of diabetes in the northeast region
(Srivanichakorn et al., 2013, p. 154). We found a surprising lack of knowledge in Lawa Lake,
even amongst diabetic individuals, considering the high prevalence of diabetes. However, the
disconnect between knowledge and action discussed in the study was also an issue mentioned by
Dr. Prayoon Kowit from Ban Pi District Hospital who manages the diabetes clinic on Fridays.
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He stated that one of the biggest challenges for diabetes prevention is that patients have a
difficult time avoiding food like sticky rice and fruit. He noted the importance of a nutrition-
based intervention, especially since the work conducted by the Friday clinic is treatment based. It
consists of check-ups for individuals who struggle to control their health status and of dispensing
medications. The VHVs noted in their focus group that this brings about the additional challenge
that patients on medication do not believe they need to control their diet or exercise because they
believe the drugs are enough. There is a lack of prevention-based diabetes campaigns in the
Lawa Lake community.
The lack of prevention-based behavior was apparent in some individuals’ interview
responses. Specifically, several women told us that they do not know the cause of diabetes and
do not visit the Health Promoting Hospital because they are not diabetic. In a study conducted by
Wiporn Senarak, Siriporn Chirawatkul, and Miliica Markovic, researchers found a widespread
belief among middle-aged women that exercise is only necessary for overweight individuals and
thus women free of chronic illnesses do not need to engage in physical activity (2006, p. 5). This
research may indicate a perception that health-promoting behaviors are only necessary for those
who are already sick rather than as preventative measures.
In the literature review, researchers found that individuals’ perceptions are influenced by
the professional medical system, the folk medical system, and the popular system (Nakagasien,
Nuntaboot & Sangchart, 2008, p. 127). We found this to be true as interviewees mentioned not
only doctors and health volunteers but also their community, relatives, diabetic friends, and even
themselves as sources of information.
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Intervention Plan
Our intervention is scheduled for Sunday, December 1st, 2013.
While conducting research in Lawa Lake, five women indicated that they do not go to the
Health Promoting Hospital because they are old or immobile and are unable to travel even short
distances. Many other women said they are too busy to go to the Health Promoting Hospital.
This may help explain why six of the sixteen diabetics we interviewed were diagnosed by chance
when they visited a doctor for another health issue--for example, one woman stepped on a sharp
object and was given a blood test which is how she discovered she had diabetes. For this reason,
we recognize the importance of accessing women in their homes. We decided not to do this
personally as we do not have the language skills nor the translator capacity to reach everyone.
Instead, we decided to equip Village Health Volunteers with the knowledge and materials to
disperse information to the community by conducting a workshop with them and giving them
brochures to distribute. There are 85 VHVs in Lawa Lake, each of whom is responsible for 10
households. The VHVs said that there are enough of them to balance their responsibilities and
that they are aware of all immobile individuals under their jurisdiction.
During our focus group with the VHVs, they suggested three optimal days for an
intervention or workshop: December 1st, 3rd, and 4th. We determined that December 1 would be
the best day for our intervention because it is a Sunday and we hoped more people would be
available to participate on a weekend. The VHVs also expressed a particular interest in the
revitalization of aerobics classes with new music and new choreography. Given exercise
improves both the prevention and care for diabetes, we believe the aerobics class should be an
important component of our intervention. Through exercise individuals can gain lowered insulin
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requirements and improve glucose tolerance; this in turn collectively contributes to reducing the
risk and slowing the progression of diabetes (“Diabetes and Physical Activity,” 2012, p. 129).
Aerobics classes within the Lawa Lake community currently start at 4:30 pm. Since we
did not want our workshop to run late, we decided to conduct it prior to the exercise class at 2
pm on the upper level of the Health Promoting Hospital. The purpose of the workshop will be to
educate VHVs, but all community members will be welcome. VHVs visit patients with diabetes
twice a month with great potential to further educate women and men. Currently, VHVs do not
play a large role in raising awareness of diabetes prevention among at-risk groups. Both diabetics
and non-diabetics, regardless of risk level, have little knowledge on the causes of diabetes; thus
both populations could benefit from our education intervention. One of the goals of our
workshop is to convey the importance of prevention within at risk populations within the
community to the VHVs.
Workshop activities are broken into four categories: presentation, personal stories, poster
presentation, and activities. We will ask Dr. Prayoon Kowit, the doctor at the Friday clinics in
Lawa Lake, to give a presentation on diabetes. If he is unavailable, we will invite a Public Health
Faculty member, preferably a native Thai speaker. The presentation will include an explanation
of what diabetes is, what causes it, and what risk factors are associated with it. Following the
presentation there will be a short question-answer session with the doctor or professor. If
possible, a pre-determined member of the community will provide a personal story on living
with diabetes. We will then present the diabetes poster to be hung in the HPH. Subsequently,
participants will be taught how to read nutrition labels for what contents to optimize and which
to limit. To encourage group participation, everyone will be given a snack to analyze and present.
Next, we will progress into the activity on the Thai nutrition flag. The Thai nutrition flag is a
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pictorial representation of food groups and information on the quantity that should be consumed
of each group. As facilitators, we will describe and explain the Thai nutrition flag in a brief
presentation then lead into an activity. Under each chair a piece of paper will contain one food
item. At the front of the room there will be a large, blank nutrition flag. Each participant will
place their slip of paper in an area of the food pyramid. The correct nutrition pyramid will then
be posted and discussed. Following the nutrition activities, we will facilitate an exercise activity
that can be done at home. We will emphasize exercises that can be done while sitting down in
order to address those who are old or immobile. After a break, we will transition into a 30
minute aerobic dance activity.
The intervention will conclude with the preparation of dinner. We will provide all
ingredients and suggest that all food be steamed, boiled, or grilled. We would like to avoid frying
food and using significant amounts of oil and salt. Ideally, the community will come together to
prepare the food using typical recipes with small modifications on preparation.
Goals of the intervention
Goal 1: Convey the importance of prevention to at-risk populations within the community to the
village health volunteers through a workshop.
Goal 2: Provide a poster for the health promoting hospital to share information about diabetes’
cause, treatment, prevention and risk factors.
Goal 3: Provide brochures to those who are immobile.
Goal 4: Promote physical exercise through a 30-minute aerobics session.
Timeline
Friday November 22, 2013- Saturday November 23, 2013
- Research on perception of diabetes among women in Lawa Lake conducted in community
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- Analysis of data and formation of intervention proposal
Tuesday, November 26, 2013
10:00am- 12:00am: Group Meeting to edit proposal
1:00pm - 1:30pm: Consultation with Ajaan Jen on intervention project details
Thursday, November 28, 2013
10:00am-12:00am: Group Meeting
1:00pm- 5:00pm : Presenting Intervention proposal for approval
Saturday, December 7, 2013
9 am- Arrive at Lawa Lake to set up workshop and invite Village Health Volunteers to
participate
2:00pm - Diabetes workshop at Health Promoting Hospital
2:00pm- 2:30pm : Presentation from Dr./Ajaan on diabetes followed by question and
answer session
2:30pm - 4:00pm: Interactive Exercises
- Personal story from community member
- Presentation of poster
- Nutrition label activity
- Nutrition flag activity
- At home exercises
4:30pm- 5:00pm: Aerobics Class
5:00-5:30- Break
5:30 pm- 6:00pm: Cooking with Village Health Volunteers
6:00pm- 7:00pm: Dinner
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Budget
Budget and Materials
The materials needed for this intervention project include transportation, compensation
for the translator, pamphlets, one large poster, fruit baskets, and food for the dinner that we are
going to prepare and eat with the community members. The pamphlets are for distribution to the
village health volunteers and any community members and will be distributed throughout the
diabetes workshop. Fruit baskets will be given to the Dr. Payoon, the community member who
tells their personal story, and to the hospital for hosting us. The baskets will be purchased from
the local fruit stand, and will be given out after each person presents for the speakers, and at the
conclusion of the workshop for the hospital. For the healthy dinner that we are cooking and
eating with the community members, the food will be purchased from the market closest to Lawa
Lake and picked up on the way to the village.
Budget
Transportation (gas, vehicle, tip for driver): 2,100 Baht
Transportation to buy food: 500 Baht
Translator: 1,000 Baht
Poster Printing: 300 baht
Printing of brochures (100): 300 baht
Printing of labels for Thai food pyramid activity : 10 Baht
Food for dinner with community (for about 30 people)
- Steamed Vegetables: 1,000 Baht
-Grilled Chicken: 1,500 Baht
- Scrambled Eggs: 300 Baht
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- White Rice: 300 Baht
- Apples (30): 600 Baht
- Water and Tea: 300 Baht
- Spices (Salt, Pepper, Garlic, Hot Peppers): 150 Baht
Fruit Baskets for Speakers (3): 1200 Baht
Snacks for workshop: 300 Baht
Total: 9,560 Baht
Anticipated Outcomes
Through implementing our interventions, we seek to work with the village health
volunteers to promote healthy behaviors related to T2DM. From our workshop, we hope to give
the village health volunteers a broader perspective on healthy food preparation and also
recommendations for helping at-risk groups. We plan to have a presentation from Dr. Payoon
Kowit where questions can be directly asked in Thai and common misconceptions can be
clarified. We also plan to gain inside perspectives of diabetes patients from personal stories of
coping with the disease and how it has affected their lives. By leading an aerobics class, we hope
to give new life to the exercise sessions through new movements and also give a wider variety of
music. The community will then be left with a poster and brochures as a sustainable reference for
information on T2DM. These interventions all work together to increase awareness about
diabetes and provide a framework for progression in healthy behaviors.
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References
Diabetes and Physical Activity. (2012). The Diabetes Educator, 38(1), 129–132.
doi:10.1177/0145721711426094
Nakagasien, P., Nuntaboot, K., & Sangchart, B. (2008). Cultural care for persons with diabetes
in the community: an ethnographic study in Thailand [PDF]. Thai J Nurs Res, 12(2), 121-
130.
Sowattanangoon, N., Kotchabhakdi, N., & Petrie, K. J. (2009). The influence of Thai culture on
diabetes perceptions and management. Diabetes Research and Clinical Practices, 84,
245-251.
Srivanichakorn, S., Yana, T., Sanchaisuriya, P., Maw, Y., & Schelp, F.P. (2013). Importance of
regional differences in the features of type 2 diabetes mellitus in one and the same
country-- The example of Thailand [PDF]. Journal Diabetes Mellitus, 3(3), 150-155.
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Appendix
1. Lawa Lake Focus Group – Village Health Volunteers
Introduction
Hello! We would like to thank you for taking time out of your day to participate in our focus
group. We are a group of American students studying Public Health at Khon Kaen University.
Today we are conducting a focus group in order to learn more about available diabetes related
health resources in Lawa Lake. These responses will help inform our future intervention project
with your community. All responses will be used for educational purposes only.
This focus group should take no longer than 1 hour. Your participation is voluntary and you may
choose to leave the focus group at any time. To be eligible to participate, our only request is that
you are a current Village Health Volunteer in Lawa Lake.
Questions and Answers
Names: Luan, Eat, Pung, Khai, Dolly, Meaw, Inn, Mommy, Nana
How long has everyone been VHV?
-14, 10, 3, 5, 5, 9, 8, 3, & 6 years
How many have received training? What kind of services have you learned about?
-They were trained for Dengue Fever, hypertension, flu, diabetes.
What do they teach specifically about diabetes?
-They teach how to prevent and about it
What services do they provide for diabetes?
-First they filter the villagers of who has or who doesn’t have diabetes by knocking door-
to-door and drawing blood of everyone who is more than 15 years of age. Does this twice
a year in January and June.
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What have been some of your successes as a volunteer?
-This village won the best VHV of Khon Kaen Province and on the 27th
of this
month(November), they will send people to compete in best VHV award in terms of liver
fluke
Do they just take blood or provide information too?
-When they draw blood, if the sugar level is above 126, they will educate them, if not
then they don’t. Also inform if they are eating, sugar levels in blood can be up to 176, but
if they arrive at time when they aren’t eating, the level should be at 126. If it is above 176,
they will tell those villagers to stop eating for 6 hours and to re-check again. Note
mentioned: They don’t give information on diabetes.
Last time people expressed concern about diabetes, is there still a problem?
-Still a big concern for them. She add that some patients think they are on medication so
they can eat whatever they want, which is wrong.
-Sticky rice is eaten a lot. Also snacks and sweet fruits year-round.
-“They struggle because it is a chronic disease that can cause stroke and organ failure,
and cause wounds that they cannot treat. “
-Another concern is a genetic disease.
-Also talks about how easy villagers can get to unhealthy food
-“Women above 40 years old are most prevalent especially if they are fat”
Percentage of women having diabetes?
-60 percent of women above age of 40 have diabetes ~Not exact number but reliable
Do they offer services to those who cannot walk?
-Yes. There are three groups of patients
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1 those who can walk easily
2 those who can walk for 50 percent
3 those who cannot walk anymore – this group they will visit them. Twice a week.
Massage trained?
-They do but for diabetic patients with bad health, they don’t touch them.
-They teach them how to massage themselves at the VHC
Common roles?
-Each VHV is responsible for 10 households which is enough for the community with 85
VHVs
-Promoting what to eat, what not to eat to radio in the village. VHV are responsible for it
and they must send in reports .
Is there a reason why the aerobic exercise stopped?
-It is harvesting time. They will come back after the first of January.
Do children receive education on Diabetes?
-They haven’t noticed, only English, mathematics
Intervention options recommended by VHV:
-They want to invent something that can prevent Diabetic patients from having their legs
hurt.
-Dancing songs for aerobics
-Draw blood tests for diabetic patients
-Aerobic suits
-Find a way to decrease the sugar in patient’s blood
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-Leading dancer for aerobics. Okay 1st 3
rd and 4
th of December! 4 in afternoon but usually
5:30
-Filtering diabetic patients, nov 29 and 6th
of December drawing blood tests at 9:30 in the
morning
-Provide them some knowledge about diabetes- small workshop
2. Lawa Lake Diabetes Survey
Introduction
Hello! We would like to thank you for taking time out of your day to participate in our survey.
We are a group of American students studying Public Health at Khon Kaen University. Today
we are conducting a survey in order to learn more about diabetes in Lawa Lake. These responses
will help inform our future intervention project with your community. All responses will be used
for educational purposes only.
This interview should take around 10 minutes. Your participation is voluntary and you may
choose to stop the survey at any time. To be eligible to participate, our only request is that you
are a middle-aged woman above 40 years of age.
Questions
1. How old are you? ___________
2. Do you have diabetes? ?Yes ?No
-If so, when were you diagnosed? _________
3. What do you think causes diabetes?
_____________________________________________________________________
______________________________________________________________________
4. What gave you this impression?
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___________________________________________________________________
_____________________________________________________________________
5. How do the VHVs help you manage diabetes? .
___________________________________________________________________
______________________________________________________________________
6. What health programs are available to you? Please list:
a.________________________________
b.________________________________
c.________________________________
d.________________________________
e.________________________________
7. Have you gone to the Friday clinic?