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Final Days in Bangladesh Pt. II: Chronic Disease Workshop and Modules

April 20, 2012
Global Health, Human Development, Live, Photos, Public Health
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Finally, here we are: The completion of my project at ICDDR, B.

Below you will find a brief article describing the project–its development, aims and goals. The write-up is also to be featured in an upcoming Chronic Disease Newsletter published by the Center for Control of Chronic Diseases in Bangladesh (CCCDB).

Preceding the article is an album containing the powerpoint slides that were used during my final presentation. Click on the image below to view a gallery of the presentation slides, which outline and explain my project, using visuals and text.

CD Community Health Workshop Presentation

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-The Issue-

  More than three in five people will die due to chronic illness this year – a number that is steadily on the rise. According to reports published by the World Health Organization, chronic, non-communicable diseases make up the world’s number-one killer, claiming the majority of lives on the planet annually (7). Of this figure, 80 percent who are affected reside in middle and low-income countries such as Bangladesh, which has proven no exception to these trends. In fact, research has shown that the number of deaths related to chronic diseases in Bangladesh has only grown over the past decades, and will continue to pose a serious threat without proper attention (4, 8, 10).

Chronic diseases are characterized by several key traits, which include (6, 9):

  • Multiple risk factors
  • Require systematic, regulated treatment
  • Lack a cure; in most cases they are life-long diseases

Given their nature, chronic diseases are often quite difficult and expensive to treat, especially at advanced stages. However, due to their prolonged duration and latency period, there are several opportunities for prevention of these illnesses.

This is why it is becoming evermore crucial to address this issue in Bangladesh using preventative measures; especially in rural regions, which experience higher prevalence rates due to a lack of medical resources—doctors, hospitals and medication—and poor levels of health education and awareness (2, 3).

-The Plan- 

  Recent collaboration between ICDDR, B’s Public Health Sciences Department and Chronic Disease Unit has given rise to the creation of the Chronic Disease Community Health Modules as a potential form of intervention for rural communities.

The modules are designed for implementation as a workshop, consisting of a group of villagers (12~15) and one or two appointed facilitators to act as guides. Facilitators provide information and support to the villagers during the workshop, helping them understand the basics of the chronic diseases most prevalent in Bangladesh, namely Diabetes, Hypertension and Cardiovascular Diseases (5).

It has been specified that trial-runs of the project are intended to take place in Chakaria, an Upazila within the Cox’s Bazaar District. The site was chosen based on the location of ICDDR,B’s Chakaria Campus, which maintains close contact with rural villagers in the area via the local Village Health Posts that provide basic health services to the community (4). Additionally, there exist several grassroots Chronic Disease Clubs, where individuals can meet with a village doctor once a month in order to receive minimal assessment services, such as blood pressure monitoring. However, as of yet these clubs do not promote any form of chronic disease education, or further developed prevention-based intervention. This provides for a prime sample population that can be used to assess the potential benefits of the workshop, so that it may one-day be scaled-up and adjusted for use throughout various rural areas in Bangladesh.

-The Modules- 

  The workshop modules focus on the primary modifiable risk factors leading to chronic disease:

  • Unhealthy Diet
  • Physical Inactivity
  • Tobacco Use

The World Health Organization has emphasized that these three items need to be targeted as the first-line means of preventing chronic illness (9). Therefore, by providing information and tactics to navigate these risk factors, the modules may aid in spurring the community to make lifestyle changes necessary for guarding against chronic diseases.

In order to accomplish this goal, the workshop relies on ‘bottom-up’ techniques adapted from Participatory Rural Appraisal (PRA) – a method that facilitates local people to (1):

  • Analyze information,
  • Practice critical self-awareness
  • Share personal knowledge of the community to enact a plan of action

Thus, the majority of the workshop is focused on collaborative problem-solving in the form of group discussion and activities; not only are the participants able to learn about the causes and effects of chronic diseases, but they are also encouraged to examine the underlying systems and barriers in the community that perpetuate risk. Step-by-step instructions, discussion topics, activities, and scientifically verified informational charts and data tables are all provided within the contents of the manual to help guide facilitators to achieve these results.

In total, the manual contains four modules. The first serves as an introduction to chronic disease, and the following three sections are based on each of the primary risk factors. These are outlined in further detail below.

Module 1: Assessing Health and Illness in the Community

This primary objective of the first module is to observe general perceptions of health and illness held by the community. Participants review basic information on chronic diseases, while analyzing how outlying social and physical factors influence health and risk. 

Summary:

• Identify the current physical, social, and health issues faced by the community; examine as a group how these issues overlap

• Discuss the basics of chronic diseases: what are they, who do they affect and how

• Assess risk among participants and within the community

 

Module 2: Diet and Nutrition in Maintaining Chronic Disease

The module assists facilitators to discern general dietary trends in the community, as well as assess the participants’ basic understandings of nutrition. It also provides information and techniques in order to encourage participants to follow a proper balanced diet.

Summary:

• Observe dietary practices and assess dietary knowledge in the community

• Review the basics of nutrition: fruits and vegetables; fats, proteins, and carbohydrates; cholesterol and calcium; salt and sugar

• Assess participants’ learning and reinforce concepts and techniques to maintain a healthy, balanced diet

 

Module 3: Physical Activity and Exercise in Maintaining Chronic Disease

The module reviews the classifications and benefits of physical activity, and its role in guarding against chronic diseases. Not only do participants learn how to better incorporate balanced physical activity into their everyday lives, but they also have the opportunity to participate in a low-impact exercise session as a group for dynamic learning.

Summary:

• Survey seasonal trends that may lead to increased or decreased times of physical activity

• Review the benefits of physical activity and the five keys to incorporating it into everyday life: leisure/sport, house/yard work, occupational activity, self-powered transport, avoiding sedentary activity

• Partake in a group exercise session

Module 4: Tobacco Use and Maintaining Chronic Disease

The final module is designed for in-depth evaluation of the prevalence and effects of tobacco use in the community. An overview of both the health risks of tobacco use and the benefits of quitting give participants the opportunity to discuss ways to mobilize members of the community to quit or reduce smoking and chewing tobacco.

Summary:

• Uncover the root causes and influences leading to tobacco use in the community

• Review the risks, dangers, and health hazards of different types of tobacco use, including: smoking, chewing, and second-hand smoke

• Identify along the “spectrum of quitting” and discuss the personal, economic, and communal benefits to quitting tobacco use

Hopefully, the Chronic Diseases Community Health Modules will prove to be a comprehensive teaching and learning tool, growing in its potency over time. As they are now, the modules serve as a starting point for further development and refinement. As more individuals and specialists access the module—in full or in parts relevant to their work—they may provide their own contributions and feedback, continuing to enhance its effectiveness in addressing chronic disease not only in Chakaria, but eventually, throughout all of Bangladesh.

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WORKS CITED

(1) Bhandari, Bishnu B. “Participatory Rural Appraisal (PRA).” Institute for Global Environmental Strategies (2003). Print.

(2) Center for Control of Chronic Diseases in Bangladesh. “Interaction between Chronic Disease and Poverty in Low- and Middle-income Countries.” Chronic Disease News 2 (Nov. 2010). Print

(3) Center for Control of Chronic Diseases in Bangladesh. “Chronic Disease Prevalence and Risk Factor Situation in ICDDR,B Health and Demographic Surveillance Sites.” Chronic Disease News 2 (May 2010). Print.

(4) ICDDR, B Periodical. “Chakaria Community Health Project Community Mobilization Toward Self-help for Health.” Glimpses 23.3 (September 2001). Print.

(5) International Center for Diarrhoeal Disease Research, Bangladesh. “Diabetes: The Emerging Epidemic in Bangladesh.” ICDDR,B Annual Report (2008): 7-10. Print.

(6) National Public Health Partnership. Preventing Chronic Diseases: A Strategic Framework. Rep. 2001.

(7) World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. 2008

(8) World Health Organization. Impact of Chronic Disease in Bangladesh. Chart. 2002

(9) World Health Organization. Preventing Chronic Diseases: A Vital Assessment. Rep. Geneva, Switzerland: WHO, 2005. Print.

(10) Zunaid Karar et. al 2009 – Epidemiological Transition in Bangladesh 1986-2006, Global Health Action

Final Days in Bangladesh Pt. I: Chakaria

February 3, 2012
Culture, Global Health, Human Development, Live, Photos, Writings
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It certainly has been some time since the last post on Bangladesh. However, after leaving Southeast Asia and returning to United States at the beginning of November, it has taken a couple of months to re-adjust to the modern chaos of New York City. Although I am typing piece in retrospect to my research trip, I believe it to be necessary contribution in order to wrap up and explain the closing of this past trip to Bangladesh—hopefully to be the first of many in the future.

During my time at ICDDR, B, I had been working on a solo project to develop community health modules and a workshop, which would be used to inform rural areas of chronic diseases and how social behavioral modifications could be used in order to prevent the onset of illness.

Within the last 60 days of being in the country it was decided that I was going to be temporarily transferred to one of these rural regions. Once there, I would have the opportunity to meet with local villagers and fieldworkers in order make some ground-level assessments and gain feedback on the project, so that adjustments could be made to help it run more efficiently. Of course, I was more than thrilled at the prospect of meeting with those residing with in the rural outskirts. After all, it was for their sake that the project had even commenced in the first place, and it was important to receive their input and observe the situation locally.

Leaving Dhaka City circa 8:00 in the morning, I boarded a train that would take me on a 7-hour journey southward to the second largest city of Bangladesh, Chittagong. From there, I would immediately continue towards the neighboring district, traveling by car for an additional 4 hours on treacherous unpaved roads, until finally reaching my destination: ICDDR,B’s Chakaria Field Site. By this time, the town was well cloaked by the darkness of night, and my exhaustion from the voyage left me with little interest in anything besides my bed.

 

 

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Interview with Dr. Masuma Khanam – The Burden of Chronic Disease in Bangladesh

September 7, 2011
Global Health, Human Development, Interview, Listen, Public Health
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  “The Bangladesh you see now is no where near the same as it was ten years ago,” declared Dr. Masuma Khanam MBBS, a research investigator at the Center for Control of Chronic Diseases in Bangladesh (CCCDB). “The environment has changed drastically, and it is reflected in the people’s health.”

Previously—in similar accordance with other third-world, developing nations—the people of Bangladesh primarily suffered from a long-waged battle against infectious diseases, such as Cholera, Tuberculosis and Malaria. However, a combination of health strategies, globalization and modernization, has coupled with shifts in lifestyle to unveil new health concerns among the population. While successful health interventions have led to receding cases of infectious disease in Bangladesh, increasing trends of chronic non-communicable illnesses have been consistently observed. As of 2002, chronic diseases have accounted for nearly 50% of deaths in Bangladesh, a figure that is steadily escalating, and has generated a great deal of concern among Dr. Khanam and her colleagues at CCCDB for the growing population’s health. “If the situation persists as is, in the next five years, it will be really alarming for our country,” she ensures.

It was in response to this rising epidemic that CCCDB was first instituted in 2009 by several partner organizations, including: BRAC, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), Institute of Developmental Studies (IDS), and Johns Hopkins Bloomberg School of Public Health (JHSPH). Dr. Khanam has worked at the center alongside fellow physicians and researchers since its founding, conducting a series of studies focusing on hypertension and diabetes, two of the most prevalent chronic diseases currently plaguing the population of Bangladesh. Based on her findings, Dr. Khanam believes that the key to combating chronic non-communicable disease lies in using preventative measures. She points out that unlike infectious diseases, for which a majority of the time there exists a definite form of treatment or procedural remedy, chronic afflictions do not have a “cure” per se; rather, they rely on regulated therapies and/or lifestyle changes, which are costly and burdensome if left unattended. In the audio below, Dr. Khanam further discusses her thoughts on this issue:




By utilizing diagnostic techniques to identify patients or those who are high-risk, and following up with “lifestyle interventions”, such as awareness campaigns, information sessions and community learning programs, Dr. Khanam believes that we will be able to prevent such diseases from ever coming into full form—or at the very least, delay their progression.

However, before this is possible, she emphasizes that immediate action must take place in order to raise awareness, among lay peoples and healthcare professionals alike, of the threat of chronic diseases. By taking into account certain “risk factors”, researchers, health professionals and individuals themselves will be able assess where on the spectrum of susceptibility they lie, and what preemptive measures should be taken in response. Such risks include uncontrollable factors—age, environment and genetics—as well as modifiable factors—nutrition, physical fitness and tobacco use. While there is little that can be done to change the effects produced by the first category of risks, those of the latter group are very much within the realm of control for professionals and individuals. In fact, the World Health Organization (WHO) has named these last three categories—nutrition, physical fitness and tobacco use—as the primary points of intercepting chronic non-communicable diseases, leading Dr. Khanam to believe that these are where we should be focusing our efforts in Bangladesh, not only to prevent diabetes and hypertension, but all chronic illnesses: cardiovascular disease, cancer, chronic respiratory diseases, and others.

But as previously mentioned, raising awareness and providing knowledge constitute only a piece of the puzzle. Building up the necessary health infrastructures in Bangladesh will be no easy feat, and it will take several paradigm shifts in order to properly address these looming health threats. Most importantly, there must be a transition in the national mindset from one that is almost solely geared towards eradicating infectious disease, to one that is prepared to successfully handle chronic diseases. Furthermore, it will be necessary to create a systemized manner in order register current and potential patients, so that long-term assessments can be made. What Dr. Khanam is calling for is nothing short of a health revolution in Bangladesh.

Posted below are a series of interview questions and answers with Dr. Khanam as she further outlines a battle plan to tackle chronic disease in Bangladesh. First, she expands on the current status of chronic diseases in the country, discussing why it is imperative that these issues be addressed with the utmost haste. She then focuses on the primary barriers currently in place, which are inhibiting the realization of a healthcare structure that she would define as sufficiently equipped for the next generation of health concerns. Lastly, Dr. Khanam shares her thoughts on potential intervention strategies, speaking directly towards the Chronic Disease Community Health Modules currently being developed by the Public Health Sciences Division at ICDDR, B to be implemented in health clinics around Bangladesh.


Based on your observations and research, what is the current situation in Bangladesh regarding chronic diseases; why is it important that we address these issues?

Chronic Disease in Bangladesh Today Why It’s Important to Address Such Issues
-Demographic Transition has led to increased birthrates and lifestyle changes due to industrialization and modernization in Bangladesh.-Epidemiological Transition has led to successful maintenance of infectious diseases and decreased rates of child mortality Bangladesh.

-With a growing population and increased life expectancy, a higher percentage of the nation are now being affected by—or at risk for developing—Chronic Diseases, which have increased prevalence with age.

 -Healthcare Providers in Bangladesh have for a long time now been focused on infectious disease. Hospitals, researchers and physicians are ill-prepared—lacking supplies and infrastructure—for the imminent “wave” of chronic disease patients.

-While infectious disease may be remedied by a procedure or course of treatment, chronic diseases have no cure; they must be maintained and controlled, which is much more burdensome and expensive.





What do you feel are some the greatest challenges to chronic disease treatment, and in general, creating sustainable healthcare systems, in Bangladesh?

Primary Challenges to Addressing Chronic Disease in Bangladesh

Health Consumers

Health Providers
-Raising awareness on basic models for “healthy lifestyles”— especially in rural areas with little access to information of health campaigns-Changing deeply rooted cultural and behavioral practices that have adverse effects on health (dietary habits, etc.) -Refocusing the attention of healthcare professionals on chronic disease topics, so that they are able to follow guidelines, promoting accurate and relevant information to their patients.-Creating (centralized) registries and follow-up systems that ensure long-term care and evaluation of chronic disease patients.





What can we be doing in order to meet these challenges to healthcare and reduce the burden of chronic diseases in Bangladesh?

Next Steps

Short-Term

Long-Term
-Creating community health modules that are culturally relevant and tap into local resources and health structures (e.g. community health clinics in Chakaria, Bangladesh). -Look towards health models that have been successfully implemented in the developed world to lower chronic disease rates, and “twisting” them in a way that can flourish in the cultural context of Bangladesh.