Focus groups with the CHWs
Experience and knowledge of diabetes and hypertension: The CHWs had heard about hypertension and diabetes, and most knew someone with one of these diseases. They observed that the diseases are more likely to occur if others in the family have the disease. Recently, however, they felt the hereditary basis was not necessary, as more people were getting the disease, even young people. One participant said :
They say that hypertension is a disease for the elderly, but we notice today that there are young people who have hypertension which explains that it is not a disease of the elderly alone.
There was a consensus that salt was linked to hypertension, and sugar to diabetes, and that sports were supposed to help control both. CHWs wanted a better understanding of the diseases and their risks, so that they can really educate and motivate people when talking about the behavior change.
…it is said that if you practice sports or if you deprive yourself of salt in the evenings, you will not have hypertension. We do not understand this because very recently a ten-year-old child was diagnosed at our CSCOM with hypertension. We would like to know how these diseases arise, and what is the difference between those figures that go up and that go down [on blood pressure machines].
Suggestions for behavior change: Participants started with proposals to cut down salt, and then some added sugar, sweets, and sweet drinks.
The change can be to go without salt or sugar, and to take medicine when needed if we receive this recommendation.
We must try to diversify our meals by reducing the consumption of salt. Cooks tend to put lots of salt-concentrated bouillon cubes in the sauce (typically made from dehydrated vegetables or meat stock, a small portion of fat, monosodium glutamate, salt, and seasonings, shaped into a small cube).
Eliminating salty concentrated bouillon cubes was discussed in both groups, but reducing oil was mentioned only once. Cutting down rice consumption (portion size) was only mentioned once, and no one suggested increased consumption of fruits and vegetables.
When asked about the practice of exercise and physical activity, most thought this was for young people and not for elderly.
Young people who have blood pressure can do sport, but old people should have their diabetic sugar apart.
Suggestions for physical activity were mostly to walk at home in the compound or neighborhood, but also bicycling, including stationary bike.
How to motivate change: Involving family and close friends were mentioned several times in both groups. Participants said that making changes in diet for one individual was not easy. Any changes in diet must be for the whole family, necessarily involving the head of the household in the decision to change. Also, all the cooks in the household must agree to the changes. For example, reducing salt-concentrated bouillon cubes will be challenging, since this is a way of cooking on a limited budget.
…it would be very good to involve a close person, it can be the spouse, or a child. The latter can remind you repeatedly while encouraging you…
How to motivate participation in the program: They suggested that referral by a doctor might be necessary to motivate the partner or a support person in the household to attend and participate. However, they agreed that program participants still will need the CHWs to explain what needs to be done and visit them in their homes to provide support.
Findings from the CHW focus groups helped to identify where role plays would be more relevant than words to explain behavior changes, and what aspects of lifestyle change should be considered in the sessions. Table 1 displays a grid showing the original group sessions for DPP-P2P and how they were adapted in this formative research.
Feedback from Participants on the adapted DPP-P2P Sessions
After one month of implementation of the adapted DPP-P2P sessions, the session attendance rates were over 96%, and this attendance rate suggests a high level of interest in the program. In the end of program focus group, participants made helpful suggestions about the format and messages of the proposed adaptation of the DPP-P2P program for use in Bamako. Table 2 summarizes feedback from participants on the sessions. They stressed the importance of involving the family, especially all women preparing food for the household. They felt more confident about increasing their exercise levels than changing their diet but agreed that support from the CHWs was key to these changes. Their suggestions were used to improve the adapted sessions for the subsequent effectiveness study.
Pre-post Changes in Behavior among Participants
After one month of group session implementation, there were significant changes in the proportions of participant self-reported adoption of the recommended dietary and physical activity recommendations (Table 3). There were significant increases in those wanting to eat more healthy and be more active, and they had already begun to limit fat intake and increase their exercise levels.