The unique aspect of this project is the use of mobile technology to develop a cost-effective, scalable rural PPP model for case finding, linkage to care and treatment compliance for diabetes and other NCDs within existing rural healthcare infrastructure. In this mHealth intervention (software application with mobile and cloud infrastructure) that builds on our current CHW-led program will facilitate sustained linkage to care at PHCs (appointment reminders), support intervention by CHWs (multimedia content delivery and data collection), reinforce self-care behaviours and lifestyle changes (by personalised mobile messages to patients) and help monitor clinical outcomes and process measures, and lead to cost-effective, scalable and sustainable diabetes intervention in low-resource setting.
With the help of trained CHWs we have completed door-to-door demographic and clinical survey of over 50,000 persons in the target area; based on our survey of the population, 51% were women, with 50% of the population having less than primary school or no formal education; the prevalence of hypertension, overweight/obesity (BMI> 23) and abnormal waist circumference were 21%, 40% and 48%, respectively. The overall prevalence of diabetes was 16%. with 85% of them previously undiagnosed; thus nearly 3000 newly diagnosed persons with diabetes and/or hypertension have been identified; Long-term, accessible adult population above age 30 – around 8,000 persons will get screened at their homes for blood sugar and blood pressure once in two years, and get some education on NCD prevention.
3000 identified diabetic/hypertensive persons got to know of their condition for the first time, got counselled to take treatment, got educated on needed diet and lifestyle changes, of which 500 get followed up every 1 month with help of mobile technology on compliance with needed treatment and complementary actions, which will be expanded to all 3000 participants; gain from family education on needed actions; and become competent to self-manage their health condition effectively and keep away from complications of this illness as much as possible.
Seven CHWs trained and remain fully capable of handling all responsibilities entrusted to them – from screening to counseling to data handling; additional seven CHWs to be trained; In addition to CHWs from the local community, other community based strategies being implemented have the potential to strengthen the sustainability of the this PPP model; These strategies include recruitment and training of 230 village volunteers to support some of the efforts by CHWs and establishing support groups among persons with diabetes in each of the 115 habitats; The CHWs will actively facilitate these support groups to build sustainable peer and community partnerships that help promote and support positive behaviour change towards diabetes self-management.
Leaflets, posters, events in schools and colleges and yearly mega events in the target villages and district level that reach at least 500, 000 persons per year, will result in increase awareness of the real threat of NCDs and lead to reduction in the spread of NCDs in the medium to long-term.
Using the mobile technology, we monitor overall program process/efficacy and clinical outcome.
The program manager remotely monitors CHWs performance– number of visits per day, duration of each visit and completeness of data entry- using the online tools. In addition, the program manager meets with the CHWs on a weekly basis.
Utilizing data collected using the mobile phones the follow up clinical data points (BMI, waist circumference, blood pressure, blood sugar and lab data that is available) are analyzed online in real-time, such as, number of individuals with blood sugar and blood pressure under control and percent weight loss. Based on the clinical parameters, further intervention or changes to clinical protocol are looked into.