Okatiranti, Okatiranti
(2024)
Development of a footcare education intervention delivered by community health workers to Type 2 diabetes patients.
PhD thesis, University of Nottingham.
Abstract
Background: Diabetes-related complications can be severe and costly, particularly diabetic foot problems, which can arise or be exacerbated by patients’ lack of awareness of proper footcare. Indonesia has the fifth highest diabetes incidence globally and is expected to have a diabetic population of 28.6 million by 2045. It is predicted there will be an inevitable rise in the occurrence of diabetic foot ulcers (DFUs) that can be anticipated and forestalled with proactive measures. One potential approach is to involve community health workers (CHWs) who can increase community awareness about diabetes prevention and promotion. Although there is evidence demonstrating the effectiveness of CHWs delivering footcare interventions (FCIs) as part of Diabetes Self-Management Education (DSME) programmes in high-resource countries, there is limited evidence on delivering such interventions in low-resource countries. Furthermore, there is a lack of detailed information on the core components of FCI delivered by CHWs from previous review.
Aims and objectives: This study aims to develop an FCI for diabetes patients delivered by CHWs, referred to as FIne-CHWs (“Footcare Intervention Delivered by CHWs”).
Method: An exploratory sequential mixed-methods approach was employed to develop the FIne-CHWs following the new Medical Research Council (MRC) framework for developing and evaluating complex interventions. An initial scoping review to identify the core components of foot care intervention within the context of a DSME programme delivered by CHWs did not provide detailed information about FCI. A mapping review was then conducted to gather more evidence on FCI delivered by healthcare professionals (HCPs) for patients with low-risk DFUs (LR-DFUs), to address the paucity of data. Following the scoping and mapping review, semi-structured interviews were conducted to gather the opinions of key stakeholders' patients, their family members, CHWs, and HCPs regarding the acceptability and practicality of FIne-CHWs in the Indonesian context.
Data from previous steps were integrated and triangulated to develop the core components of the FIne-CHW. These core components of FIne-CHWs were then subjected to a three-round Delphi consensus. This consensus process involved gathering agreement or disagreement among a panel of diabetes experts across Indonesia to refine the intervention. All these steps in data collection sought to establish and justify the core component of the intervention, aligning with the initial phase of the new MRC Framework, before deciding to proceed with a feasibility study of the FIne-CHWs.
Findings: This study identified the core components of FIne-CHWs from the scoping and mapping review. Thematic analysis of interview data generated several key themes: community experience of foot prevention, enhanced healthcare uptake by extending CHW’s role, community embeddedness, CHW resources (recruitment and selecting CHWs), and community training approach.
All participants in the interviews supported the acceptability of the FIne-CHWs, but they raised concerns about its practicality within the community. Using the triangulation approach to synthesise the data collected in previous steps, 42 statements were identified representing the core components of the FIne-CHWs. After two rounds of the Delphi exercise, a consensus agreement was reached on 41 out of 42 statements of the core components of FIne-CHWs, with a consensus disagreement regarding the specific types of patients who can be referred to the FIne-CHWs programme. Free-text responses of the Delphi survey were analysed using thematic analysis. One overarching theme emerged: CHWs are only “volunteers” (reflecting a lack of policy for connectivity and integration of CHW programme into healthcare service delivery); this then was discussed in three themes, namely CHWs deliver footcare education for all people with diabetes (role CHW clarity); flexibility of community FCI (community-based intervention); and remuneration and incentives. This study also identified that the position of CHWs within the Indonesian healthcare system could impact the implementation of the FIne-CHWs programme alongside remuneration and CHW resources and recruitment.
Implications: This study determined the core components of FIne-CHWs. Even though all the key stakeholders interviewed affirmed the acceptability and practicality of FIne-CHWs, as reflected in the expert panel consensus agreement on most statements on the core components of the intervention, there are certain barriers related to healthcare policies concerning the role of CHWs within the Indonesian healthcare system that need to be resolved prior to expanding the FIne-CHWs programme. These challenges must be addressed to effectively implement CHWs in the community for promoting and preventing DFUs. Nevertheless, this study serves as a fundamental building block for future investigations into foot care intervention delivered by CHWs.
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