final paper: lawa diabetes - wordpress.com...form of diabetes is type 2 (t2dm), which affects 90-95%...

Type 2 Diabetes Mellitus in Lawa Lake, Thailand:

Research and Intervention Final Report

Daniel Banh, Kali Deans, Jessica Dubow, and Jhanae Mahoney

Khon Kaen University; CIEE Thailand

Fall 2013

DIABETES MELITUS IN LAWA LAKE 2

Abstract

Our research sought to understand the informal knowledge that exists in the Lawa Lake

community surrounding type 2 diabetes mellitus (T2DM). In order to further explore perceptions

of diabetes in the Isan context, we collected qualitative data by conducting 60 individual

interviews, leading a focus group with Village Health Volunteers, and observing a local clinic. It

was found that approximately fifty percent of the non-diabetics we interviewed did not have any

idea of what causes diabetes. Of the remaining 23 women, 22 had vague ideas about its

correlation to diet, exercise habits, and genetics, but their responses were generally limited. In

addition, our research found that women did not know the resources available to them within

their community. This information guided an education-based intervention within the Lawa Lake

community targeting T2DM among adult women. The intervention consisted of a poster

presentation on diabetes, at home stretching exercises, food label and nutrition activities, an

aerobic dance session, and cooking a healthy lunch with the community. During the workshop,

Village Health Volunteers counted sixty individuals in attendance with as many as 43 individuals

at one time. The success of our intervention was analyzed qualitatively by the audience’s active

participation and excitement throughout the workshop.


Type 2 Diabetes Mellitus in Lawa Lake, Thailand:

Research and Intervention Final Report

1. Introduction

According to the World Health Organization, 347 million people worldwide are affected

by diabetes (World Health Organization). With the increasing trends in obesity and sedentary

lifestyles, the International Diabetes Foundation has predicted the prevalence of diabetes to

become 439 million by 2030 (Sicree, Shaw, Zimmet, & Heart, 2010, pg 2). The most common

form of diabetes is type 2 (T2DM), which affects 90-95% of those who have this disease

worldwide (American Diabetes Association, 2010). Diabetes is a major public health issue not

only worldwide, but specifically in the northeast Isan region of Thailand. Thailand's transition to

a more urbanized nation has resulted in increased rates of obesity, which causes insulin

dysfunction and is thus closely tied to diabetes (American Diabetes Association, 2010).

Consequently, in 2009 approximately 3.2 million Thai people above age 20 were living with

diabetes, an estimated one third of whom were undiagnosed (Aekplakorn, 2011). The

northeastern Isan region of Thailand has a higher female population than any other region as well

as the highest incidence of type 2 diabetes (Srivanichakorn, 2013).

For these reasons, our research team decided to conduct further research about diabetes in

Lawa Lake, a community of several villages located in the Isan region of Thailand. This

community is located approximately one hour from Khon Kaen city. In Lawa Lake, there is a

Health Promoting Hospital, which is supported by over 80 Village Health Volunteers who play

active roles in their communities. Similar to the rest of Thailand, Lawa Lake has a large aging


population. This contributes to a growing number of non-communicable diseases, of which

diabetes is one of the most prevalent.

A review of the literature confirmed that while Thai people are aware of diabetes, they

have more of a sociocultural understanding of the disease rather than a biomedical one. Our

research team further investigated understandings of diabetes within the Lawa Lake community

by conducting 60 semi-structured interviews with women in the community and a focus group

with Village Health Volunteers to understand local diabetes resources. We also observed a

diabetes clinic and interviewed Dr. Prayoon Kowit from Baan Pai District Hospital who manages

the clinic on Fridays.

From this research, we determined that a significant population of our sample size had

diabetes and we saw 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

best. From an interview with Dr. Prayoon Kowit, who runs the Friday diabetes clinic, we found

that nutrition in this community is an issue and were encouraged to incorporate this into our

project. From all of this information, we developed an intervention plan which consisted of a

workshop with 60 elderly community members including of a brief presentation on diabetes,

activities on nutrition and exercise, an aerobics class, and cooking a healthy dinner. Our intention

with this intervention plan was to allow community members to gain a more in-depth focus on

diabetes and build off their existing knowledge in order to sustainably promote diabetes

understanding in the community.


2. Literature Review

Evidence has shown that proper diet and physical exercise have many physiological as

well as psychological benefits, resulting in the improvement of glycemic control (“Diabetes and

Physical Activity,” 2012, p. 129). Through regular physical exercise, individuals can develop

lower insulin requirements and improve glucose tolerance; this in turn contributes to reducing

the risk and slowing the progression of diabetes (“Diabetes and Physical Activity,” 2012, p. 129).

The U.S. Surgeon General’s report recommends that most people exercise at a moderate

intensity for more than 30 minutes a day every day (Sigal, Kenny, Wasserman, & Castaneda-

Sceppa, 2004, p. 2528). As the effect of insulin sensitivity from physical activity usually does

not last more than 72 hours, it has been recommended to exercise at least every other day (Sigal,

Kenny, Wasserman, & Castaneda-Sceppa, 2004, p. 2528).

Diet also plays an integral part in diabetes prevention and management. In order to

develop the most accurate nutritional guide for diabetes patients, individual circumstances,

preferences, and cultural and ethnic preferences must all be taken into account (“Evidence-Based

Nutrition,” 2002, p. 202). The goal is to improve diabetes care by increasing patients’ awareness

while still implementing supportive lifestyle changes. In order to do this, patients are

recommended to change eating habits that reduce insulin resistance and improve metabolic status

(“Evidence-Based Nutrition,” 2002, p. 202). Excessive intake of simple sugars, complex

carbohydrates, and fast-acting carbohydrates should be avoided (“Evidence-Based Nutrition,”

2002, p. 203). Instead, patients with T2DM are encouraged to consume food high in fiber like

whole grains, fruit, and vegetables (“Evidence-Based Nutrition,” 2002, p. 203).

Thus, a review of the literatures surrounding diabetes research firmly establishes a

relationship between behaviors regarding diet and exercise and diabetes. Extensive research has


also been conducted on diabetes mellitus in Thailand, as it is responsible for a leading burden of

disease. However, little research exists regarding social determinants of health specific to the

northeastern Isan region. The research that covers this topic overwhelmingly agrees that both

Western biomedicine and Thai culture influence the way that patients perceive the causes of their

illness and how they live with their diabetes (Sowattanangoon, Kotchabhakdi, & Petrie, 2009, p.

245).

Dr. Piyatida Nakagasien of Siam University’s Faculty of Nursing is one of the primary

scholars who emphasizes the importance of culture on individuals’ understanding of diabetes.

Dr. Nakagasien notes that “Knowledge is constructed on the basis of social and cultural values,

in relation to eating, taking care of health, and doing exercises” (Nakagasien, p. 24). She finds

that diabetes mellitus patients view and manage their illness based on past experience, resulting

in a perspective of their health status that may differ from a biomedical analysis (Nakagasien, p.

20). For example, diabetes patients want to live their lives normally without thinking about their

blood sugar levels whereas the aim of professional treatment is to control those blood sugar

levels (Nakagasien, Nuntaboot & Sangchart, 2008, p. 128). By studying a rural unspecified

community in northeast Thailand, Dr. Nakagasien concludes that “diabetes knowledge

management within the community socio-cultural context [consists] of three process: the process

of constructing knowledge, the process of communicating knowledge, and the process of using

knowledge” (Nakagasien, p. 19). This places importance on local beliefs and also considers the

family and community’s role in creating understanding, whereas past studies of diabetes had

focused on the patient separate from the wider population (Nakagasien, p. 21).

Such ethnographic studies of diabetes, which consider the role of culture, have existed for

decades. In 1994, scholars from the University of Southern California’s Department of Nursing


conducted research regarding diabetes patients’ compliance to their prescribed treatment

regimens (Cohen et al., 1994). In examining how patients understand disease, these researchers

considered factors related to care, thought processes, and decision making; in doing so they

found a significant difference between patients’ and health professionals’ understanding of

etiology, pathophysiology, and scope (Cohen et al., 1994). Khanitta Nuntaboot, associate

professor at Khon Kaen University’s Faculty of Nursing conducted similar research specific to

Thailand in 2003 that accounted for Isan culture as a potential explanation for the disconnect

between patients’ and professionals’ understandings (Nakagasien, p. 21). The difference between

patients’ and professionals’ perceptions was further explored in Thailand 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). This

high education level surrounding the disease is surprising because the illness continues to be so

prevalent, but again culture was determined to potentially account for the incongruity between

knowledge and behavior (Srivanichakorn et al., 2013, p. 154). For example, despite education

efforts the importance of sticky rice prevails and may explain why the highest prevalence of

diabetes is found in the northeast region (Srivanichakorn et al., 2013, p. 154). Wiporn Senarak,

Siriporn Chirawatkul, and Miliica Markovic have also found that perceptions of cultural norms

and stigmas affect health behaviors in a community. For example, in reviewing health promotion

for middle-aged Isan women not specific to diabetes mellitus, the researchers found that many

women perceived exercise as necessary only for the obese and thus women free of chronic

illnesses did not engage in physical exercise (Senarak, Chirawatkul, & Markovic, 2006, p. 57).

Other barriers included lack of time, injuries which prevented them from performing certain

levels of activity, and stigmas that exercise was not appropriate to middle-aged women in the


context of gender expectations in Isan culture (Senarak, Chirawatkul, & Markovic, 2006, p. 57).

This again builds on past research by concluding local perceptions must be considered in

addition to the biomedical model in order for individuals to participate in their health care and

thus increase the chances of treatment and prevention success (Senarak, Chirawatkul, &

Markovic, 2006, p. 57).

In 2008, Dr. Nakagasien, Dr. Nuntaboot and their colleague Dr. Bumphenchit Sangchart

worked together to confirm that Thai individuals understand their health status based on their

perceptions, beliefs, and first hand experiences. The researchers then sought to create a cultural

definition of diabetes mellitus in the Isan context (Nakagasien, Nuntaboot & Sangchart, 2008, p.

121). This definition comprises many components, as villagers understand diabetes as an

incurable and chronic illness of excessive appetite, laziness, pancreatic malfunction, and genetics

(Nakagasien, Nuntaboot & Sangchart, 2008, p. 123-124). Villagers’ understandings of

consequences like kidney diseases and high blood pressure came from witnessing these

complications among other individuals in their community rather than from their doctors

(Nakagasien, Nuntaboot & Sangchart, 2008, p. 126). Many villagers believe that diabetes

mellitus is caused by sticky rice and diets high in MSG (Nakagasien, Nuntaboot & Sangchart,

2008, p. 124). These villagers noticed that overweight community members who consumed

many snacks, sweets, and soft drinks as well as those who consumed large quantities of coconut

milk often had diabetes mellitus (Nakagasien, Nuntaboot & Sangchart, 2008, p. 124). Villagers

also determined that community members who were active in their jobs or who engaged in

physical exercise were less likely to have diabetes mellitus than those who were inactive

(Nakagasien, Nuntaboot & Sangchart, 2008, p. 125). From this knowledge, villagers based their

self-care on a practice called Ka Lum Naew Kin, which involves avoiding fattening and sweet


food like durian, mango, tamarinds, papayas, coconut based curry, and fatty meat, and replacing

it with healthier substitutes, for example eating regular rice rather than sticky rice (Nakagasien,

Nuntaboot & Sangchart, 2008, p. 125). Their self-care also included exercise ranging from daily

activities like playing with children and working in the field to specific activities like aerobics

classes (Nakagasien, Nuntaboot & Sangchart, 2008, p. 126). Some understandings of diabetes

had to do with karma; individuals believed they had done something wrong in a past life and

were punished for their bad karma by being diagnosed with diabetes mellitus (Nakagasien,

Nuntaboot & Sangchart, 2008, p. 125) which in Thai is called rohk waehn karm

(Sowattanangoon, Kotchabhakdi, & Petrie, 2009, p. 247). What patients perceive to be the cause

and meaning of their illness affects how they care for it; those who believe diabetes is not

curable are less motivated to control their diet and exercise because they do not think it will

make much difference and those who believe diabetes is the result of karma fatalistically accept

their illness (Nakagasien, Nuntaboot & Sangchart, 2008, p. 127). In Bangkok, Napaporn

Sowattanangoon, Naipinich Kotchabhakdi, and Kieth J. Petrie further study the importance of

Buddhism on diabetes understanding and care (2009, p. 245). This includes karma, meditation as

a positive form of stress reduction, and the perception of aging as an enjoyable end to life’s

journey thus resulting in an unwillingness to restrict diet (Sowattanangoon, Kotchabhakdi, &

Petrie, 2009, p. 249).

Dr. Nakagasien, Dr Nuntaboot, and Dr. Sangchart found that community members’

perceptions are influenced by information they gather from the professional medical system, the

folk medical system, and the popular system (Nakagasien, Nuntaboot & Sangchart, 2008, p.

127). The professional medical system is comprised of doctors and hospitals, the folk system

includes folk herbalists who sell remedies to relieve symptoms and reduce blood sugar levels,


and the popular system exchanges information between family and relatives (Nakagasien,

Nuntaboot & Sangchart, 2008, p. 127). Patients base their behaviors not only on the advice of

health professionals, but also on that of family and neighbors, which is rooted in cultural beliefs

(Nakagasien, Nuntaboot & Sangchart, 2008, p. 127).

While all these studies and particularly that of Dr. Nakagasien, Dr Nuntaboot, and Dr.

Sangchart begin to develop an understanding of diabetes mellitus perceptions and behavior

through a cultural lens, they are limited in their scope. Moreover, they only slightly touch upon

where these perceptions and knowledge bases come from. More research must be conducted on

these subject areas to determine if these findings are consistent in other communities and, if so,

to understand how to successfully control diabetes in the Isan context.

2.1 Research Objectives

Using this prior research as a guide, we developed three research objectives. We wanted

to validate the findings of the literature review in the Lawa Lake community. Since we wanted to

use our research to guide an intervention, we sought to determine if there was a lack of

knowledge on diabetes and if therefore an education-based intervention would be appropriate.

We also wanted to look for gaps in diabetes resources that we might be able to fill, or

alternatively to find available health resources we could use to support our intervention. Thus,

our three objectives were to: 1.) confirming a percentage of T2DM among adult women in Lawa

Lake higher than our baseline of 10.8%, 2.) understand what perceptions women have of T2DM

in Lawa Lake, and 3.) understand local T2DM-related resources.

2.2 Intervention Objectives

We used our literature review and our research results, which will be covered later on in

this paper, to guide the development of our intervention. Because our results showed us that


many community members were diabetic and because Dr. Prayoon Kowit of Baan Pi District

Hospital and the Lawa Lake Village Health Volunteers indicated there is a general lack of

diabetes prevention in the community, we decided to lead a prevention-based workshop. One of

our goals was to increase diabetes knowledge in the community with an emphasis on small but

powerful preventative behaviors within villagers’ means. We also wanted to revitalize the

exercise classes, something present but irregular at the Health Promoting Hospital, with new

moves and new music. To do this, we decided to conduct a workshop with several different

nutrition and exercise activities. In doing this, we hoped to encourage preventative behavior and

health promotion in Lawa Lake and further empower the Village Health Volunteers.

3. Methods

3.1 Sample Population

3.1.1 Pre-intervention Research. For our research study we targeted adult women,

defined as women above the age of 18, to participate in our semi-structured interviews. We

decided to target women because research has shown that northeast Thailand has a higher female

population than any other region and that northeast Thailand also has the highest incidence of

type 2 diabetes (Srivanichakorn, 2013). According to the American Diabetes Association,

women are at greater risk of complications from diabetes; diabetes is the third leading cause of

death for Thai women (Senarak, 2006). A 2006 study surveyed 80 middle-aged Isan women and

found a diabetes prevalence of 15% (Senarak), a rate higher than the overall age-adjusted

incidence of 8.3% in women (Aekplakorn, 2011). In past community visits we had also found

women to be more available survey participants than men. Our sample size was sixty women

between the ages of 22 and 84.


When observing the Friday diabetes and hypertension clinic, we interviewed the director,

Dr. Prayoon Kowit, with a set of pre-prepared questions. We also conducted a focus group to

target Village Health Volunteers (VHVs) in the community. Of the 85 Village Health Volunteers

in Lawa Lake, nine attended the focus group. Of these nine VHVs, eight were female and one

was male.

3.1.2 Intervention. The audience of our intervention workshop was predominantly older

women, but there were also some older men present. The workshop began with 30 women and 6

men. As the workshop progressed, as many as 43 villagers were present at once. Our final count

confirmed an overall attendance of 60 villagers. A total of six identifiable VHVs were present

and two helped facilitate the workshop.

3.2 Measurements

Our methodological approach for investigating our research questions was qualitative.

Research tools included semi-structured interviews, a clinic observation, and a focus group. The

objective of the semi-structured interviews was to develop an understanding of diabetes

perceptions among women in Lawa Lake. We asked women what they believe causes diabetes

and from where they got this impression (see Appendix A). These interviews also served the

purpose of measuring the extent of diabetes as a health issue in Lawa Lake. We asked each

survey participant if she had any illnesses and if she had diabetes. Even though we did not have a

sample size large enough to calculate the prevalence of diabetes among women in the Lawa Lake

community, we used the prevalence of diabetes among women globally, 10.8%, as a benchmark

(American Diabetes Association, 2011). A percentage of women with diabetes greater than this

benchmark would indicate that diabetes is a significant health issue among women in Lawa

Lake. Sources of information play a major role in how perceptions are developed. In order to


understand available health resources, we observed and interviewed Dr. Kowit and conducted a

focus group with Village Health Volunteers (for notes, see Appendix B and Appendix C).

3.3 Data collection

3.3.1 Composition of the semi-structured interviews. We began by asking basic

demographic questions regarding age and health status of our participants (Appendix A). If a

participant indicated she was diabetic, we inquired when she was diagnosed to rule out type 1

diabetes: if she said that she was born with diabetes then we assumed she did not have type 2

diabetes. Next, we proceeded with open-ended questions such as: “What do you think causes

diabetes?”, “What gave you this impression?”, and “What has changed since you've been

diagnosed (if anything)?” (Appendix A).

3.3.2 Semi-structured interviews conducted at the clinic. Before conducting interviews

door-to-door, we spoke with seven women at the Health Promoting Hospital for the Friday

clinic. Women at the clinic were given the same semi-structured interview as all other women

surveyed. Once Dr. Prayoon Kowit, the director of the clinic, had seen all the patients, we

interviewed him about the clinic’s structure and services, his patients, and diabetes prevention

methods in the community. For this interview, we prepared open-ended questions in advance and

then asked follow-up questions based on his answers. Information gathered in this interview

provided significant background information on diabetes related resources within the

community. Dr. Kowit also gave suggestions on beneficial interventions. One translator

interpreted each interview while two of us researchers acted as interviewers and two acted as

note-takers.

3.3.3 Semi-structured interviews conducted outside of the clinic. Following the

interview with Dr. Kowit, data collection continued with door-to-door interviews. We selected


homes at random that were both near and far from the Health Promoting Hospital. We only

approached homes if someone was outside. We interviewed fifty-three women between 2 pm and

6 pm on Friday and 9:30 am to 10:30 am on Saturday. One translator assisted in conducting each

interview, and we rotated two note takers and two interviewers within our group of four

researchers.

3.3.4 Focus group with Village Health Volunteers. In order to gain a deeper

understanding of available diabetes-related health resources–an objective of our research–we

conducted a focus group that was held in the evening after dinner at the Health Promoting

Hospital. Because we were only supported by one translator, we divided ourselves into two

facilitators and two note-takers. Before asking any diabetes related questions, we confirmed that

everyone present was a Village Health Volunteer to avoid having to eliminate data. We then

discussed the severity of diabetes in the community and learned more information on what

resources are available to those affected by this disease (for notes, see Appendix C). The two

mediators of the focus group sat next to each other and alternated proposing questions to the

group. The two note takers sat adjacent to the mediators and attempted to take note of everything

said within the focus group. The translator sat next to one of the mediators.

3.4 Data Analysis

3.4.1 Pre-Intervention. All three research tools were qualitatively analyzed because we

asked open-ended questions with varying follow-up questions that depended on participants’

responses. We organized responses from the semi-structured interviews into charts to see if there

was a difference in understanding between diabetics and non-diabetics. These tables and charts

can be seen in the results section of this paper. Information gathered from speaking to Dr. Kowit

and the Village Health Volunteers provided us with a general idea of what resources were


available to the community related to diabetes prevention and care. Qualitative assessment of this

information with relation to responses gathered in semi-structured interviews gave context to the

perceptions of diabetes among adult women.

3.4.2 During and Post Intervention. We planned to ask questions throughout the

workshop in order to judge our participants’ knowledge prior to conducting each activity

(Appendix D). These questions were intended to serve as a pre-test to be compared with

responses at the end of the workshop. Though these questions were asked, the audience’s

responses were not always conclusive. It was not possible to conduct the post-evaluation for

reasons explained in the discussion section. Therefore, quantitative data analysis for the

intervention was not possible. Instead we analyzed our intervention through qualitative

observation of participation level, mood, and small behavioral changes.

3.5 Outcome Measure

Qualitative analysis of the audience’s participation, their excitement throughout the

workshop, their complete participation throughout the entire 30 minute aerobics class, and the

increase in attendance from start to finish noted the success of our intervention. The main goal

of our nutrition session was to encourage healthier eating habits. The success of this was evident

while cooking lunch a Village Health Volunteer. While she was cooking the vegetable stir fry,

she asked before adding sugar. She seemed to understand the importance of cooking with less

sugar. During the meal, several of the workshop participants really enjoyed eating the brown

rice. While this was a small success for healthy cooking habits, it was a start.

3.6 Ethics

As students researching in the Lawa Lake community, we wanted to ensure that our

recruitment procedures and data collection methods were ethical. Before beginning each


interview and conducting the focus group, we introduced ourselves and explained the purpose of

our study. This ensured that the participants could give informed consent to participate in our

data collection process. The same occurred during the intervention. Before beginning with the

poster presentation we introduced ourselves, explained where we were from, and briefly

presented our research to convey the purpose of the workshop. We never forced anyone to

participate, and we remained flexible adapting to the audience whenever necessary.

3.7 Budget

Item Predicted Cost Actual Cost

Supply Transportation 500 140

Groceries for Dinner 4450 2509.75

Gifts: Fruit Baskets 1200 1200

Printing 610 680

Translation of Materials -- 2000

Translator 1000 500

Misc. Materials -- 30

Transportation to/from Lawa 2100 1450

Total 9860 8509.75

Table 1. The table above outlines the approved budget prior to the purchase of materials in the

second column, and the third column outlines the actual cost of the intervention expenses.

3.8 Timeline

3.8.1 Pre-Intervention.

Date Activities

November 22nd

, 2013 Data collection in the Lawa Lake community: Semi-

structured interviews, Focus group, interview with Dr.

Prayoon Kowit

November 23rd

, 2013 Conducted the final five semi-structured interviews, and

began synthesizing the data

November 25th

, 2013 Consulted with Ajaan Pattara and began writing the

intervention proposal

November 26th

, 2013 Determined intervention logistics and began creating a

budget. Also consulted with Ajaan Jen and program

facilitator Sarah.

November 28th

, 2013 Intervention Proposal submission and presentation

November 29th

- December 2nd

, 2013 Individual and group planning of intervention activities


December 3rd

, 2013 Group meeting to continue planning intervention

December 5th

, 2013 Group meeting to write script and run through

intervention with program facilitator Rachel

December 6th

, 2013 Group trip to Tesco Lotus to collect materials, and

meeting to print brochures, handouts, and finalize

preparations for intervention day as well as a final run

through.

Table 2. The table above outlines the preparations leading up to the intervention day on

December 7th

, 2013. The time period of preparation begins with the date of research collection

and ends with the final run-through and group meeting the evening before the intervention.

3.8.2 Intervention.

Time Event

09:30 AM Arrive at Lawa Lake

09:45 AM Set up for Intervention

09:55 AM Present Previous Research

10:00 AM Poster Presentation

10:20 AM At Home Exercise Activity

10:40 AM Nutrition Label Activity

11:00 AM Nutrition Flag Activity

11:25 AM Break: Thai Dance

11:35 AM Aerobics Class

11:40 AM Begin Cooking Lunch

12:05 PM Aerobics Class Ends

01:30 PM Lunch Ends

Table 3. The above figure is illustrates the proceedings of our diabetes intervention on the 7th

of

December, 2013 at the health promoting hospital in the Lawa Lake community.

4. Results

4.1 Pre-intervention Results

4.1.1 Objective 1. We accomplished our first objective by confirming a percentage of

type 2 diabetes among adult women in Lawa Lake higher than our baseline of 10.8%. Our results

demonstrated similar age distributions for both diabetic and non-diabetic women, with the


majority of women surveyed in both groups between the ages of 40 and 70 (Figure 1). From on

our sample size of 60 women, 16 were diabetic. That is 27 % of our sample, representing a

percentage of women well above our benchmark of 10.8%. When we conducted the focus group

with VHVs, they told us that the prevalence of diabetes is 60% among adult women, more than

twice as high as what we found.

Figure 1. Ages of 44 non-diabetic and 16 diabetic interviewees.

4.1.2 Objective 2. To address our second objective of understanding the perceptions of

type 2 diabetes in Lawa Lake, we divided our responses by the 16 diabetics and 44 non-diabetics

that participated in our research. It was found that approximately 50% of the non-diabetics (21

women) we interviewed did not have any idea of what causes diabetes. Of the remaining 23 non-

diabetic women, 22 had vague ideas about diabetes’ relation to diet, exercise habits, and

genetics, but their responses were generally limited. One woman believed diabetes was caused

by the chemicals in agricultural fertilizer.

No diabetes:

1

2 2,3,

3 3, 4, 6, 6, 9,

4 0, 0, 0, 1, 2, 1, 2, 4, 5, 5, 6, 7, 7, 9

5 0, 0, 1, 2, 5, 6, 7, 7, 7, 7,

6 1, 1, 1, 3, 4, 5, 8

7 0, 2, 5, 5, 8,

8 1, 3, 4,

Diabetes

1

2

3 5,

4 3, 9,

5 0, 0, 3, 3, 3, 6, 8,

6 1, 4, 5, 6,

7 5, 6,

8


Figure 2. This graph represents the perceived causes of diabetes by non-diabetic women.

Of the diabetics, four of the 16 women (25%) interviewed did not know the causes of

diabetes, a smaller percentage than uninformed non-diabetics. Nine diabetic interviewees

understood diabetes as being related to sticky rice and sugar and the remaining three women

related symptoms of dry lips and bubbly or sweet urine to their development of diabetes.

Figure 3. This graph represents what diabetic women perceive as the causes of diabetes.

0 5 10 15 20 25

Sticky rice

Sticky rice and sugar

Diet and no exercise

Genetics

Don't know

Number of Women

Cau

ses

of

Dia

be

tes

What Nondiabetic Women Perceive as the Cause of Diabetes

0 1 2 3 4 5 6 7 8

Sticky rice

Rice and sugar

Urine

Dry lips

Don't know

Number of Women

Pre

ceiv

ed

Cau

se

What Diabetic Women Perceive as the Causes of Diabetes


When questioned on the source of their perceptions, there were mixed responses within

both groups. Of the non-diabetics, 21 women did not know and one woman did not answer.

Seven individuals got their information from Village Health Volunteers. One woman had gotten

her information from a doctor. Three women had learned about diabetes from observing

diabetics. Four participants had learned about diabetes from their community. An additional two

women had learned about diabetes from relatives, and three had learned from the internet or TV.

Two women expressed self-observation as their final source of perception. Self-observation

means the women had not been informed on the causes of diabetes but that they had noticed

sticky rice is sweeter than regular rice and they felt unhealthy when eating food high in fat and

sugar. It is notable that by chance, 4 of the 44 non-diabetic participants were VHVs and that one

of these four VHVs did not know the cause of diabetes.

Figure 4. This graph represents the sources that attributed to the perceptions of non-diabetic

women.

0 10 20 30

Village Health Volunteers Relatives

Doctor Community members

Diabetics Internet/TV

Self-observation Don't know about diabetes

Number of Women

Sou

rce

s o

f In

form

atio

n

Nondiabetic Women's Souces of Diabetes Information


On the other hand, six diabetics either did not know the source of their perception or did

not have a perception. Five diabetics had learned about diabetes from a doctor, one had learned

about diabetes from the community, and four also mentioned self-observation as the source of

their understanding.

Figure 5. This graph represents the sources attributed to the perceptions of diabetes among

diabetic women.

4.1.3 Objective 3. To meet our third research objective, we asked women about the

health resources available to them. Overwhelmingly, women were not aware and the only

program mentioned consistently was an aerobics class. However, this exercise class occurs

infrequently due to flooding and lack of time during the harvest season. The general lack of

prevention resources was confirmed by Dr. Kowit and by the VHVs during the focus group.

4.1.4 Intervention Suggestions. Overall, the responses from both non-diabetics and

diabetics were consistent with research conducted when reviewing the literature on diabetes in

Northeast Thailand. From talking to Dr. Prayoon Kowit and conducting the focus group with

Village Health Volunteers, our group decided implementing a nutrition-based intervention as

0 2 4 6 8

Doctor

Community

Self-observation

Don't know

Number of Women

Sou

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of

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Sources by which Diabetics Receive Information on Diabetes


well as an aerobics session could help increase prevention-based diabetes campaigns in the Lawa

Lake community.

4.2 Post-intervention Results

During the workshop, Village Health Volunteers counted a total 60 individuals in

attendance, with as many as 43 individuals at one time. The majority of the community members

were women; only six men were in attendance. Of the 60 individuals at the workshop, six were

Village Health Volunteers. Although we did not survey participants for their ages, we noted that

the majority of the attendees were elderly.

A presentation of a poster on diabetes was held in the absence of both the nurse from

Baan Pai Hospital and the personal speaker living with diabetes. The poster explained the risk

factors for developing diabetes, foods to avoid when preventing or caring for diabetes,

preventive measures that reduce the risk of developing diabetes as well as a few guidelines on

exercise. Brochures were also handed to attendees prior to the start of the workshop, reiterating

general information related to diabetes and nutrition. The poster was left at the Health Promoting

Hospital as a sustainable source of information on diabetes for any patients who come to the

hospital.

In terms of exercise, community members were taught five stretches that they could do at

home to help increase their mobility and blood flow. These included abdominal, oblique, and

lower back reaches as well as arm punches and leg lifts. By demonstrating exercises done while

seated, majority of community members were targeted. The feasibility of these exercises for

people of all ages was validated by the participation of the elderly women in the audience.

Throughout the workshop, there was consistent dialog between the presenter and the

audience. Posing questions to community members created a more interactive environment and


raised participation within the group. We asked questions both before and after providing

educational information.

Before the start of the first nutrition activity, the participants were asked to express two

things learned from the poster presentation. The participants responded with good nutrition and

exercise. The community members were then asked whether they had ever read a nutrition label

or understood what the contents meant. It was found that 18 of 43 present community members

had looked at the nutrition label but none could explain the purpose of a nutrition label.

Community members rated Oreos and Bugles on a scale of 1 to 5, with 1 being unhealthy and 5

being healthy. A few participants responded with a rating of two, a boost up from one simply

because the snack tasted delicious. Following the nutrition label session, the majority of the

members raised their hands when asked if they felt comfortable reading a nutrition label the next

time they purchased a snack. The nutrition label activity ended with a comparison between fruit

and packaged snacks. Our intervention group then explained the different nutrients of each fruit,

concluding that it is better to consume these fruits instead of packaged snacks. Participants

understood that fruit should be consumed more than package snacks but questioned whether

mangos or apples were healthier. They believed that mangos were more unhealthy because they

had more sugar. In response, we encouraged participants to focus on eating more fruits in

general.

Following the nutrition session was the Thai nutrition flag activity. Attendees were given

a food and asked to place it on the flag with the top being the foods that were to be eaten most

frequently. Figure 6 shows the ending result of where the community members thought their

foods should go. Comparing the 30 pictures shown to the Thai nutrition flag, 14 were placed

incorrectly in the wrong area. Of those misplaced, two were rice-starchy foods, seven were meat


or dairy products, three were vegetables and fruits, and two were from the oil, sugar and salt

category. Many of the incorrect meat or dairy products were placed higher in the nutrition flag.

Figure 6. The nutrition flag that participants completed at the beginning of the nutrition flag

activity.

For the aerobics session, upbeat movements were implemented along with modern k-pop

music. Movements were rotated every eight seconds and the session lasted for 23 minutes.

Although the numbers of participants were not counted, it was noted that some community

members chose to sit and clap instead of follow the movements, possibly from being an older

age. Most participation was seen in Village Health Volunteers and middle-aged women.

Lastly, we cooked lunch, with a few Village Health Volunteers, using ingredients bought

by our intervention group. We asked those who helped cook to use less oils and salt, substituting

those ingredients with garlic, pepper and chili peppers. Because of the large need of help in the


kitchen, rescheduling of the workshop, and time restraints, the planned post-test could not be

conducted (see Appendix D for proposed post-test questions).

5. Discussion

Our original research question changed numerous times throughout our planning process

as a result of feedback we received from Ajaan Pattara. Guided by our literature review, which

emphasized the importance of socio-cultural understanding, we shifted our focus towards

understanding perceptions of diabetes in the Lawa Lake community. We created three objectives

for ourselves: to confirm that diabetes is an important issue in Lawa Lake, to understand local

perceptions of the disease, and to determine available local health resources. One of the methods

we used to achieve these objectives was conducting interviews. We wanted a well-rounded idea

of the community’s perceptions and thus needed to conduct many surveys, but we also needed to

consider we had limited time. In previous community visits, each group had successfully

conducted 15 interviews. To be efficient and successfully complete our ambitious target of sixty

surveys, we made our semi-structured interviews concise and prepared our translator in advance.

Because Lawa Lake is the furthest community that CIEE students worked in, we had to

consider both time and van costs when conducting our research and implementing our

intervention. A visit required at least two hours of travel time, which meant that unlike other

groups, we could not go to the community to simply drop off a poster or have dinner. We also

had to budget significantly more than other group for transportation. This budget expenditure

was reduced because we coordinated with the other student research group, but even so we did

not feel as if we were as able to return to the community often throughout the research and

intervention process.


During the planning of our intervention, we made a crucial mistake in forgetting to

budget for the translation of materials. Though we had budgeted for a translator, we failed to

budget for having our poster, brochure, and worksheets translated. We also failed to budget for

the printing of our poster. Fortunately, we had allotted twice as much money for food as

necessary and additionally over-budgeted in other categories, and thus were able to afford

translation and printing regardless of our error.

Throughout the planning process we discussed different scenarios that could happen on

our workshop day. We knew that in order to be prepared, we would have to be flexible. We

created back-up plans for if our guest speaker did not show up, if our participants were

unengaged, if our participants talked with each other while we presented, and more. We also

scheduled optional breaks that we would implement depending on our participants’ level of

engagement.

Though we thought we had prepared for all situations, when we arrived in Lawa Lake the

morning of our intervention day, we realized we had not. We had planned to conduct our

workshop at 2 pm and use the morning to set-up and invite Village Health Volunteers, our target

demographic group. We had decided to work with Village Health Volunteers because we didn’t

think we could effectively access the whole community, but through their work door-to-door and

at the Health Promoting Hospital we would be more able to make a difference in the community.

Because we had worked with the Village Health Volunteers before, we knew they were

animated, middle-aged, understood health terms, and had a very basic knowledge of diabetes.

Since we do not speak Thai, we prepared a PowerPoint presentation with many visuals as an

integral part of our presentation. We planned to use the morning to set up our PowerPoint on the


second floor of the Health Promoting Hospital and to arrange the room as was necessary for our

workshop.

Few of these plans went as intended, however. When we arrived in the community at 9

am, a group of elderly women was assembled behind the Health Promoting Hospital. We were

told that a festival was happening that day and no one was available, but these women were

ready for our workshop. While we were excited about the large turnout, we had no time to

prepare ourselves for the many changes. Since our workshop began five hours earlier than

planned, we were unable to get in touch with and reschedule our speaker from Baan Pai District

Hospital; instead, we presented our prior research in Lawa Lake and our poster on diabetes.

Because the women were old, they were not able to climb the stairs to the second story of the

Health Promoting Hospital where we would have been able to set up PowerPoint. Instead, we put

our presentation on a small television screen behind us, but most of the audience was unable to

see it. Because our audience was older than we had anticipated, we did not expect that they

would not be able to read the small nutrition labels on the packaged snacks or that they would be

unable to participate in the aerobics session. Additionally, we had purchased the snacks in bulk

so we had not been able to see how small the nutrition labels were nor that on one of the snacks

the labels were in English rather than Thai.

Due to some miscommunication, our translators were not with us. Thankfully Ajaan

Toon stepped in and was an excellent translator, but we hadn’t worked with her before and didn’t

have a chance to brief her before our workshop. However, because she was our Ajaan, she knew

our project. She had heard our research proposal and intervention proposal presentations and had

helped translate materials for us. As always, using a translator poses some limitations as nuances

of language and implied meaning can be lost. It also made it more difficult for us to personally


engage with community members. Ajaan Toon was more qualified to discuss health topics

especially from a Thai perspective, and we noticed that she often added additional information.

We appreciated this because we think she has a better grasp of relevant health information, but

since we were unable understand the Thai, we weren’t always sure what had been already

covered and what we should add.

We had decided to conduct our pre- and post-test verbally rather than by doing a written

exam, because CIEE had told us that handing out surveys has been unsuccessful in the past. This

is why during research we administered our semi-structured interviews one by one. We thought a

focus-group style might help, and that way we could also address incorrect perceptions of

diabetes and discuss topics for the review benefit of all. From past community visits we knew

that the Village Health Volunteers were energetic and engaged, so we made our workshop very

interactive to encourage their participation. We expected them to be very responsive to

incorporating questions into our workshop, but our new audience was less engaged. We received

few responses, even when we asked them to simply raise their hands, and so we cannot be

certain that everyone who would have answered affirmatively actually raised their hand each

time a question was posed.

We decided to do our post-test during the meal rather than before because we wanted to

ask questions about cooking and about the taste of the food. We also thought it might help make

our post-test more like a conversation if we were all eating and speaking together. We didn’t

realize how long it would take to cut the ingredients or that we would only have two burners to

cook the food. We had been planning on looking at the kitchen and adjusting our plan and

preparing materials between 9 am and 2 pm, but since our intervention was earlier than expected

we were not able to. We thought that we would eat together with the community, but instead we


continued to cook while many of the women at our workshop ate. When we were done, most of

them had left and we were unable to ask our prepared questions. Even if the villagers had not left

we may not have been able to conduct our post-test as the other Lawa Lake intervention group

needed Ajaan Toon to translate their stakeholder meeting.

Thus, we have to judge the success and impact of our intervention qualitatively. The

stretching and aerobics classes were well received. Almost everyone participated in the

stretching and seemed to laugh and talk to each other a lot. While only a few women participated

in the aerobics activities, they seemed to find it very fun and many others watched and clapped.

We were able to maintain a large attendance throughout the workshop. We had 43 steady

participants, and approximately 17 others stopped by for a brief time. While we did not receive

much participation during the nutrition activities as we would have like, we do believe some of

that information was absorbed. While cooking with the women, they used the same amount of oil

when frying the eggs, but they asked if they could add sugar to the vegetables and greatly

reduced the amount from when we had observed them cooking in the past. Many of the women

eating seemed really excited about the brown rice and to enjoy the taste of the food, so we can

realistically hope they will incorporate new healthy nutrition behaviors in their lifestyles.

We believe our intervention was in large part successful because of the help of a few

Village Health Volunteers who were present. One in particular stood with us at the front of the

group and repeated information or encouraged villagers to participate. In total, we recognized six

Village Health Volunteers at our workshop. We hope that they will be able to share the

information we discussed with other VHVs and with their communities especially because we

left them with the materials to do so—the poster, brochures, and CD. Finally, although our

intervention population was different than we had expected, many of the women at the workshop


were women we had interviewed, and this consistency allowed us to better form relationships

with a certain demographic group and tie our research directly to our intervention.

6. Conclusion

In conclusion the data we collected from our 60 door-to-door semi-structured interviews,

Village Health Volunteer focus group, clinic observation, and interview with the clinic’s director

highlighted a lack of diabetes prevention resources in Lawa Lake. The little emphasis on health

promotion for those with and without diabetes explains data which showed that more than half of

our sample population had a limited knowledge of diabetes as a biomedical disease. In order to

address this, our research team designed and implemented an intervention consisting of a brief

presentation on diabetes, at home exercises, nutrition label and nutrition flag reading activities,

aerobic dance, and the preparation of a healthy lunch with community members. As part of these

activities, we presented a poster on diabetes to the community and distributed 100 brochures

with the same content as the poster. Our objectives were to increase education and encourage

feasible and sustainable behavioral changes. Due to logistical problems on intervention day, we

were unable to conduct a pre- and post-test in the way that we'd initially planned. However, our

intervention was still extremely successful, with many participants who were enthusiastic about

the activities that we planned.

6.1 Strengths

One of the main strengths of our intervention project was the ability of our research team

to be flexible and adapt to last minute changes. As previously mentioned, many facets of our

workshop did not go as planned. We were still able to be successful thanks to our positive group

dynamic, an important strength of our project. Our research team worked well as a unit and at

supporting one another, and we also contributed our individual strengths to benefit the project.


Despite the things that went wrong, we had an incredibly enthusiastic and receptive

audience, particularly for the at-home exercises and aerobics. Even though it wasn't the audience

we had planned for, we observed community members enjoying themselves and learning

throughout. The high turnout of participants at our intervention was another indication of its

success. In addition, the Village Health Volunteers played an important role in ensuring that

everything ran smoothly by urging people to attend our workshop, assisting with translation, and

helping lead various activities.

6.2 Limitations

One main limitation of our workshop was that our audience was different from our

expected audience for our intervention. Because we worked with older women rather than

Village Health Volunteers, some were unable to do the aerobics activities because the activities

were too vigorous. In addition, the nutrition food label activity wasn't as effective as it could

have been because the print on the food labels was too small for many of the participants to read.

Due to miscommunication, we also did not have a translator. Fortunately, Ajaan Toon

volunteered to translate for us.

In our original timeline, we planned to arrive in Lawa Lake around 9am to have 5 hours

to set up and invite community members to our event. However, when we arrived, we were told

that we needed to start immediately. This served as a limitation for our group because the nurse

from Baan Pai hospital was unable to present and answer questions at the earlier time. Also due

to the change of location, we did not have a projector for our sideshow. Most of our elderly

audience was unable to read off the little computer screen we used instead for our powerpoint

presentation. In addition, we were unable to ask post questions in order to evaluate our


intervention. By the time we were done cooking, most of the community members had eaten and

left, making it difficult to do a discussion-based post-test.

6.3 Recommendations

Moving forward, our research team has a series of recommendations for future groups

conducting research and planning an intervention on diabetes in Lawa Lake. The first is to over-

prepare and be ready for anything. It was extremely beneficial for our team to have backup plans

when things did not go as planned. Working with different communities is often unpredictable,

and it is important to be flexible and ready for last minute changes. Similarly, it is helpful not to

rely on technology and have paper printouts of everything if possible. Due to a last minute

location changing on the day of our intervention, we did not have a projector for our powerpoint

so we were very happy we had printed our poster and the brochures.

As previously discussed our group dynamic was a huge strength, aiding in the success of

both our research and intervention project. It was helpful for our group to work in the same space

as often as possible even if we were working on separate tasks. This way we were able to consult

each other and support each other. Lastly, we would recommend being especially careful when

budgeting to avoid mistakes. As far as future interventions in the Lawa Lake community,

diabetes is still a problem that is worthy of being addressed. Nutrition still seems to be something

that community members in this community struggle with, as observed when community

members continued to use large amounts of sugar and oil while cooking lunch. Future

interventions should work on specifically educating VHV's on diabetes, in order to sustainably

promote prevention in this area.


References

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P., & Taneepanichskul, S. (2011). Prevelence and Management of Diabetes and

Metabolic Risk Factors in Thai Adults [PDF]. Diabetes Care, 34, 1980-1985.

American Diabetes Association. (2010). Diagnosis and Classification of Diabetes Mellitus

[PDF]. Diabetes Care, 33(1), 562-569.

American Diabetes Association. (2002). Diabetes Fact Sheet [PDF]. Diabetes Basics

Diabetes and Physical Activity. (2012). The Diabetes Educator, 38(1), 129–132.

doi:10.1177/0145721711426094

Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of

Diabetes and Related Complications. (2002). Diabetes Care, 25(1), 202–212.

doi:10.2337/diacare.25.1.202

Nakagasien, P. (n.d.). Diabetes mellitus knowledge management in the rural community: an

ethnographic study in Thailand.

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.

Senarak, W., Chirawatkul, S., & Markovic, M. (2006). Health promotion for middle-aged Isan

women, Thailand: a participatory approach. Asian Pacific Jouranl of Cancer Prevention,

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Sicree, R., Shaw, J., Zimmet, P., & Heart, B. I. (2010). The global burden. Diabetes and

impaired glucose tolerance. Baker IDI Heart and Diabetes Institute.


Sigal, R. J., Kenny, G. P., Wasserman, D. H., & Castaneda-Sceppa, C. (2004). Physical

Activity/Exercise and Type 2 Diabetes. Diabetes Care, 27(10), 2518–2539.

doi:10.2337/diacare.27.10.2518

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).

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country-- The example of Thailand [PDF]. Journal Diabetes Mellitus, 3(3), 150-155.

What Can I Eat. (n.d.). Retrieved December 12, 2013, from American Diabetes

Association website: http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/

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http://www.who.int/mediacentre/factsheets/fs312/en/index.html

http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/


Appendix A

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?

(Or, why do you think you have diabetes?)

_____________________________________________________________________

______________________________________________________________________

4. What gave you this impression?

___________________________________________________________________

_____________________________________________________________________

5. How do the VHVs help you manage diabetes?

อสม .

___________________________________________________________________

______________________________________________________________________

6. What health programs are available to you? Please list:

a.________________________________

b.________________________________

c.________________________________

d.________________________________

e.________________________________

7. Have you gone to the Friday clinic?


Appendix B

Interview with Dr. Prayoon Kowit

An interview was conducted with Dr. Prayoon Kowit in order to discuss the information sources

offered at the diabetes and hypertension clinic as well as any concerns regarding diabetes

knowledge among patients. The proceedings of this interview are as follows:

Q: How many doctors work at the clinic?

A: Only one doctor comes to the clinic. Send the diabetes/hypertension patients to district

hospitals to give patients convenience.

Q: How many patients do you see each Friday?

A: Depends. 5-10. Patients that come to the clinic are the ones that cannot control/manage their

diabetes.

Q: Does the same doctor come to the clinic each Friday?

A: Yes, Dr. Prayoon Kowit . Sometimes nutritionists, physicians, and pharmacists come to

provide information to the patients. If he cannot come, Village Health Volunteers (VHV) can

consult him and he will tell them what to do. He goes to every Health Promoting Hospital (HPH)

in Khon Kaen to improve access to care for patients with unmanaged diabetes.

Q: Have you seen a reduction in type 2 diabetes?

A: He has seen lots of improvement because the Health Promoting Hospital is easier to get to

than the big hospital and records keep track. The HPH helps those who have trouble managing

their diabetes.

Q: What do you think the prevalence is of diabetes?

A: Type 1: 10%; Type 2: A lot.

Q: What services are available at the clinic?

A: Upon first diagnosis, tell the patient to change lifestyle for 1-2 months then to come back.

Lifestyle changes include limiting eating, no rice, no dessert, no fruit, and exercise. If there is no

improvement, medication is prescribed.

Q: Are any education materials offered on diabetes?

A: Thai massage can help with numbness in the feet. So patients are trained to do it themselves.

Q: Do you have any ideas for a possible intervention on diabetes?

A: Big problem: patients cannot control how they eat in Thailand. Fruit contains a lot of sugar

and it is hard to avoid. Help villagers change how they eat. No idea how. He would be happy to

take part in the intervention.

Additional Comments:

- numbness always appears in the feet of patients with diabetes for more than 4 years

- HPH can only test blood sugar, nothing more


Appendix C

Lawa Lake Focus Group with 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

Q: How long has everyone been VHV?

A: 14, 10, 3, 5, 5, 9, 8, 3, & 6 years

Q: How many have received training? What kind of services have you learned about?

A: They were trained for Dengue Fever, hypertension, flu, diabetes.

Q: What do they teach specifically about diabetes?

A: They teach how to prevent and about it

Q: What services do they provide for diabetes?

A: 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.

Q: What have been some of your successes as a volunteer?

A: 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

Q: Do they just take blood or provide information too?

A: 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.

Q: Last time people expressed concern about diabetes, is there still a problem?

A: 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.

A: Sticky rice is eaten a lot. Also snacks and sweet fruits year-round.


A: “They struggle because it is a chronic disease that can cause stroke and organ failure, and

cause wounds that they cannot treat. “

A: Another concern is a genetic disease.

A: Also talks about how easy villagers can get to unhealthy food

A: “Women above 40 years old are most prevalent especially if they are fat”

Q: Percentage of women having diabetes?

A: 60 percent of women above age of 40 have diabetes ~Not exact number but reliable

Q: Do they offer services to those who cannot walk?

A: Yes. There are three groups of patients

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.

Q: Massage trained?

A: They do but for diabetic patients with bad health, they don’t touch them.

A: They teach them how to massage themselves at the VHC

Q: Common roles?

A: Each VHV is responsible for 10 households which is enough for the community with 85

VHVs

A: Promoting what to eat, what not to eat to radio in the village. VHV are responsible for it and

they must send in reports .

Q: Is there a reason why the aerobic exercise stopped?

A: It is harvesting time. They will come back after the first of January.

Q: Do children receive education on Diabetes?

A: 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

-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


Appendix D

Intended Pre and Post Test Questions

Our intended plan to measure the outcome of the intervention was to conduct a pre-test and post-

test. The pre-test was woven into the workshop, but a post-test was not conducted for reasons

discussed previously. Listed below are the pre-questions asked during the workshop and the

proposed post-test--debrief during lunch.

Pre-test Questions:

1. Raise your hand if you have ever read a nutrition label.

2. Raise your hand if you understood what it meant.

3. Does everyone agree? Do you think that these (point to top) are foods you should eat the most

and these (point to bottom) are foods you should eat the least in order to be healthy?

4. Would you change anything?

5. Do you prepare meals like this, using lots of these foods at the top (point) and only a little of

these foods at the bottom (point)?

6. Raise your hand if you have seen this nutrition flag before.

Lunch Debrief (Post test):

Food:

1. How does the food taste? Better or worse than it usually tastes?

2. Would you want to change anything about the food?

General Info:

1. Do you have a better idea of what causes diabetes? What have you learned today?

2. Do you think you will be able to teach others in the community more about diabetes?

3. Will you be able to teach others in the community how to read a nutrition label?

4. Do you think reading a nutrition label is helpful for eating healthier?

Aerobics:

1. Were the exercises you learned today useful?

2. Was the exercises in the aerobics class as intense as others?

3. Would you want to change anything about the aerobics class taught today or other aerobics

classes taught in the past?

final paper: lawa diabetes - wordpress.com...form of diabetes is type 2 (t2dm), which affects 90-95%...

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