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

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

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

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

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

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

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

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

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

BACKGROUND: In Cambodia, the age-standardized prevalence of diabetes mellitus has increased in both men and women. The main objective of this study was to identify factors associated with diabetes medication adherence among people with diabetes mellitus in poor urban areas of Phnom Penh, Cambodia. METHODS: A cross-sectional study was conducted in 2017 using a structured questionnaire for face-to-face interviews by trained interviewers. The participants were people with diabetes mellitus who were the active members of a peer educator network, lived in poor urban areas of Phnom Penh, and attended weekly educational sessions during the survey period. Diabetes medication adherence was measured using four items of modified Morisky Medication Adherence Scale. Participants were classified into two groups based on their adherence score: 0 (high adherence) and from 1 to 4 (medium or low adherence). Sociodemographic characteristics; medical history; accessibility to health services; and knowledge, attitude, and practices related to diabetes mellitus were examined. A multiple logistic regression analysis was conducted adjusting for sex, age, marital status, and education levels. RESULTS: Data from 773 people with diabetes were included in the analyses. Of the total, 49.3% had a high level of diabetes medication adherence. A high level of adherence was associated with higher family income (≥50 USD per month) (adjusted odds ratio [AOR] = 5.00, 95% confidence interval [CI] = 2.25-11.08), absence of diabetes mellitus-related complications (AOR = 1.66, 95% CI = 1.19-2.32), use of health services more than once per month (AOR = 2.87, 95% CI = 1.64-5.04), following special diet for diabetes mellitus (AOR = 1.81, 95% CI = 1.17-2.81), and absence of alcohol consumption (AOR = 13.67, 95% CI = 2.86-65.34). CONCLUSIONS: High diabetes medication adherence was associated with better family economic conditions, absence of diabetes mellitus-related complications, and healthy behaviors. It would be crucial to improve affordable access to regular follow-ups including promotion of healthy behaviors through health education and control of diabetes mellitus-related complications.

Using Targeted mHealth Messages to Address Hypertension and Diabetes Self-Management in Cambodia: Protocol for a Clustered Randomized Controlled Trial.

BACKGROUND: Hypertension and diabetes represent the first and third highest contributors to global disability. While mobile health (mHealth) messaging programs have rapidly increased in low- and middle-income countries (LMIC), adaptations for specific patient health needs is a new approach to manage chronic conditions. OBJECTIVE: The primary aim of this study is to develop and test an mHealth communication intervention using electronic data capture (by tablet) and voice messaging to improve hypertension and diabetes self-management in Cambodia. The secondary aim is to share results with the Cambodian Ministry of Health and development partners to inform health policy and develop strategies for hypertension and diabetes control. METHODS: The study design is a cluster randomized controlled clinical trial randomizing each of 75 Community peer educators (PEs), trained and coordinated by MoPoTsyo Patient Information Center in Phnom Penh, into one of 3 groups of 25 (approximately 60 patients each) to receive either tablet+messages, tablet only, or no intervention (control). The total sample within each group includes 25 clusters and approximately 1500 patients located in 7 Operational Districts in rural regions or urban slums in Cambodia. The interventions (groups 1 and 2) were compared with usual PE monitoring without the tablet or mHealth messaging interventions. Focus groups and informant interviews were conducted to develop messages according to specific themes-medications adherence, laboratory testing, physician visits, obesity, smoking, and general lifestyle issues. Using the data received at monthly PE monitoring meetings, patients will receive specific messages based on their individual health challenges. Following the intervention completion, clinical and process outcomes will be compared with baseline metrics between groups. RESULTS: PEs were randomized in July 2017, and the intervention was implemented in September 2017 through June 2018. Analyses are underway. CONCLUSIONS: This project is unique in its combination of electronic data transfer, which can be accessed immediately, with voice messages most relevant to individual patients' needs. Positive results will indicate the value of using targeted messaging in patient-specific, self-management issues to improve hypertension and diabetes control. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11614.

Process evaluation of a mobile health intervention for people with diabetes in low income countries - the implementation of the TEXT4DSM study.

Introduction Evidence about mobile health (mHealth) approaches to manage diabetes shows modest effects on outcomes, but little is known about implementation variability. This is a process evaluation of an mHealth intervention to improve diabetes self-management through Short Message Service (SMS) provision in three diabetes care programmes in the Democratic Republic of Congo (DRC), Cambodia and the Philippines. Methods The intervention involved Diabetes Self-Management Support via text messages. The content and process of the intervention is based upon the core principles of diabetes self-management and behaviour theory. In each country, messages were sent by project managers to 240 participants in each country, who were randomly assigned to the intervention group. Contracts were negotiated with national phone providers and open access software was used to send the messages. Participants received a mobile phone and SIM card. We analysed data about the implementation process over a one year period. Results The mean monthly number of messages delivered to recipients' phones was 67.7% of the planned number in DRC, 92.3% in Cambodia and 83.9% in the Philippines. A telephone check revealed problems with one-third of the phones, including breakage, loss and cancelled subscriptions. The number of people reached at least once was 177 (70.0%) in DRC; 147 (60.7%) in Cambodia; five in the Philippines (2.0%). Those reached each time was 144 in DRC (56.9%), 28 (9.9%) in Cambodia, none in the Philippines. People used their phone more frequently than before the intervention. Discussion Implementation of the intervention meets constraints at every step in the process. Barriers relate to the technology, the context and the participants.

Content, participants and outcomes of three diabetes care programmes in three low and middle income countries.

AIMS: To improve access and quality of diabetes care for people in low-income countries, it is important to understand which elements of diabetes care are effective. This paper analyses three diabetes care programmes in the DR Congo, Cambodia and the Philippines. METHODS: Three programmes offering diabetes care and self-management were selected. Programme information was collected through document review and interviews. Data about participants' characteristics, health outcomes, care utilisation, expenditures, care perception and self-management were extracted from a study database. Comparative univariate analyses were performed. RESULTS: Kin-réseau (DR Congo) is an urban primary care network with 8000 patients. MoPoTsyo (Cambodia) is a community-based peer educator network, covering 7000 patients. FiLDCare (Philippines) is a programme in which 1000 patients receive care in a health facility and self-management support from a community health worker. Content of care of the programmes is comparable, the focus on self-management largest in MoPoTsyo. On average, Kin-réseau patients have a higher age, longer diabetes history and more overweight. MoPoTsyo includes most female, most illiterate and most lean patients. Health outcomes (HbA1C level, systolic blood pressure, diabetes foot lesions) were most favourable for MoPoTsyo patients. Diabetes-related health care expenditure was highest for FiLDCare patients. CONCLUSIONS: This study shows it possible to maintain a diabetes programme with minimal external resources, offering care and self-management support. It also illustrates that health outcomes of persons with diabetes are determined by their bio-psycho-social characteristics and behaviour, which are each subject to the content of care and the approach to chronic illness and self-management of the programme, in turn influenced by the larger context.