diabetes intervention in lawa lake, thailand daniel banh, kali … · 2015. 3. 4. · lawa lake,...

RUNNING HEAD: Diabetes Intervention

Diabetes Intervention in Lawa Lake, Thailand

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

Khon Kaen University

Fall 2013

Diabetes Intervention 2

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


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.


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.


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


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


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


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.


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.

Diabetes Intervention

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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?

diabetes intervention in lawa lake, thailand daniel banh, kali … · 2015. 3. 4. · lawa lake,...

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