Performance Evaluation of a Communication Plan Implementation for Behaviour Change in People at Risk of Type 2 Diabetes in the Commune of Tchaourou in Benin ()
1. Introduction
To reduce Behavioural Risk Factors and modifiable biological risk factors for Type 2 diabetes (T2D), the setting up of a community programme represents one of the best inexpensive techniques to prevent the occurrence of Type 2 diabetes in at-risk people [1]. According to the International Diabetes Federation (FID), one out of 10 people in the World suffers from diabetes [2]. For the World Health Organization, hyperglycaemias represents high blood pressure and smoking [3] the third risk factor for premature mortality. In Africa, a rapid growth of this disease prevalence is observed [4] and the continent will have the highest proportion of diabetics by 2035 [5]. At the same time, health structures have not undergone a significant development for adequate management of the disease. Moreover, preventive public health measures to contain this growth are slow to be put in place.
In Benin, STEPWISE surveys showed a rapid T2D increase from 2008 to 2015. In the same period, the prevalence of fasting hyperglycaemia increased from 2.6% to 12.4% in subjects aged 18 to 69 years [6] [7]. Borgou, one of the twelve regions of Benin, has the highest prevalence with a prevalence of fasting hyperglycaemia of 4.6% in 2008, while national prevalence was 2.6% [7]. In the same region, the prevalence of diabetes and fasting hyperglycaemia was 12.4% and 24.8% respectively in 2015 [6] [8]. In response to this situation, the Diabetes Prevention Project in Benin (Predibe), in collaboration with the World Diabetes Foundation, has implemented a type 2 diabetes prevention programme based on a communication plan for behaviour change based on the previously identified modifiable behaviours. This study aims to evaluate the performance of the implementation of this communication plan in people at risk of Type 2 diabetes in Tchaourou a Commune of Benin.
2. Framework and Methods
2.1. Study Framework
The study took place in the Tchaourou Commune located in the North East of Benin, West African country with the population is estimated at 11,810,324 inhabitants in 2019 with 51.2% women [9]. The Tchaourou Commune has 268,787 inhabitants [10]. It covers an area of 7256 km2 or 28% of the total area of this Region and about 6.5% of the national territory [11]. The health sector is characterized by a low rate of health coverage at the commune level. This study is part of a “PreDiBe” project initiated by the Ouidah Regional Institute of Public Health (CIHR) and the World Diabetes Foundation (WDF). The political and administrative authorities approved the implementation of the communication plan for a change of behaviour in the Tchaourou Commue, given the increasing evolution of the prevalence of diabetes in the Commune. The municipal council has included a budget line in the municipal development plan to raise awareness among community relays and village committees on risk factors and measures to prevent Type 2 diabetes. The main activities of this Commune are: the cultivation of food products (corn, sorghum, rice, cowberry, soybeans, peanuts, voandzou, yam, cassava) and especially of income products (cotton, cashews, shea nuts) [11]. The epidemiological diagnosis made in 2014 [12] in the populations of the Departments of Alibori and Borgou revealed, high blood pressure in 31.10%, overweight in 60.24%, alcohol consumption of 30.36% and tobacco use of 20.01% and 39.29% of physical inactivity.
2.2. Methods of Study
2.2.1. Type of Study
It was a cross-sectional evaluative study to assess the implementation of the performance of the communication plan developed by the PreDiBe project for behaviour change in people at risk of Type 2 diabetes. This performance was evaluated by combining the elements of two health assessment models. The New public Management model [13] which takes into account the effect, effectiveness, efficiency and satisfaction of all stakeholders of an programme and the Donabedian Model [14] includes the sub variables which are: the structure, process and results, the evolution of the political, economic, cultural and social environment.
2.2.2. Study Populations
· At the structure level
The study focuses on the resources used for the programme implementation:
- Financial resources;
- Human Resources;
- Infrastructure;
- Management material;
- Technical tools was described in Table 1;
- Communication tools;
- Technical equipment.
· At the process level
The study focused on the activities carried out, the beneficiaries of the study and the collaboration between the participants and the beneficiaries:
1)Management activities
They concerned:
- The research team setting up;
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Table 1. Data collection techniques and tools.
- The management team setting up;
- The technical team setting up;
- The resource mobilization;
- The drafting of activity reports.
2)Technical activities
Its consist to:
- The training of participants;
- The monitoring of participants;
- The nutritional education for Target groups by nutritionists (the use of educational fact sheets and activity monitoring sheets);
- The culinary demonstrations that were carried out for the target groups by nutritionists (technical diagrams and activity tracker);
- The physical activity practice that was carried out for the target groups by the sports teachers (physical activity program sheet and Activity Monitoring Sheet);
- The coaching of the beneficiaries that was carried out by nutritionists and peer educators (Activity Monitoring Sheet).
3) The beneficiaries of the programme are people at risk of Type 2 diabetes who are sensitized and trained to participate in the programme package (follow-up sheet of participants at the beginning and at the end of each activity session).
4)Collaboration between participants and beneficiaries
The relationship between the project participants and the beneficiaries was also considered.
· Results level
The study focuses on the level of improvement in the knowledge of the participants and the project targets, the motivation of the leaders, the evolution of the number of participants in the sessions, the percentage of targets that participated in all the activity sessions, then the changes achieved in the level of nutrition education and physical activity activities, the effectiveness of the implementation of the communication plan, the efficiency of the implementation of the communication plan, and then the satisfaction of the beneficiaries, participants, political-administrative authorities and taxpayers.
· At the level of the political and socio-cultural environment
The political and administrative actors of the Tchaourou commune were involved in the implementation of the communication plan. These are the communal development committee and the communal Development Council, the Kings and traditional Chiefs.
2.2.3. Sampling
Sampling method
The choice of target populations for the study was based on the probabilistic method.
Sampling Technique
Exhaustive selection was used for the financial resources, technical tools, and communication tools. For Human Resources, the choice of the participants in the programme was reasoned while the convenience choice was used to select the beneficiaries of the programme package. The comprehensive choice was used for all programme activities.
Sample size
*For structure
The process evaluation sample consisted of:
- Three sources of funding (World Diabetes Foundation, Comlan Alfred Quenum Regional Institute of Public Health, Community of Tchaourou);
- The research team of five researchers;
- Three project managers (one project manager, one project coordinator);
- 15 political-administrative and religious authorities (the mayor of the commune, the first Deputy Mayor, the second Deputy Mayor, the General Secretary of the Commune, the coordinator of social promotion, four village chiefs, one King, four religious Chiefs);
- 52 participants in the programme (four nutritionists, two sports teachers, 35 health workers, a social worker, ten peer educators);
- Two infrastructures (an office at the town hall, a housing for nutritionists);
- One project document, 12 activity reports;
- 212 technical tools (4 growth charts, 4 scales, 4 tensiometers, 4 impedance meters, 4 feelers, 6 kitchen utensils - 10 fireplaces, 10 sets of pans, 10 buckets, 10 ladles, 10 skimmers - 4 sports grounds, 9 tape recorders, 90 sports outfits, 9 popular local music keys/USB);
- 20 communication tools (ten picture boxes, six fact sheets of nutritional education sessions, three technical diagrams of culinary demonstration, a physical activity program sheet);
- A follow-up sheet of the beneficiaries for each type of activity (nutritional education, culinary demonstration, physical activity practice).
*For the process:
The process assessment sample consisted of:
- The establishment of three teams (research team, management team and technical team);
- The mobilization of financial resources by the WDF, the IRS and the community of Tchaourou;
- Drafting of reports;
- Training of actors (four nutritionists, two sports teachers, two health workers, one social worker, ten peer educators);
- The formation of political-administrative and religious authorities (the mayor of the commune, the first deputy mayor, the General Secretary of the town hall, four village chiefs, a king, four religious Chiefs);
- Training of the 90 beneficiaries of the programme (subjects at risk of Type 2 diabetes);
- Six quarterly nutrition education sessions and 48 weekly sessions;
- Six quarterly culinary demonstration sessions and 48 weekly sessions;
- 240 sessions of 30 minutes of individual daily physical activity;
- 52 one-hour sessions of physical activity (aerobic and abdominal movements) weekly group;
- 12 one-hour sessions (collective Walk) of monthly physical activity;
- A tracking card of beneficiaries at home;
- Supervision of participants.
*For results
For the evaluation of the results, the sample consisted of:
- 90 subjects at risk, beneficiaries of the program;
- Four nutritionists;
- Two sports teachers;
- 35 health workers;
- A social worker;
-10 pairs-educators;
-12 political-administrative and religious authorities.
The Variables study
The main variable in this study was the performance of the communication plan implementation for the behaviour change based on the identified modifiable behaviours. It consisted of the following sub-variables:
- The structure performance;
- The process performance;
- The Results performance.
The sub-variable “the structure performance” is made up of the following components: financial support, human resources (the participants of the programme), infrastructures, management materials, technical tools, communication tools and their elements and the monitoring sheets of the different activities (Table 2).
The sub-variable “the process performance” components are: the management process quality, the technical process quality and the quality of collaboration between the project participants and beneficiaries and the elements resulting from it (Table 3).
The sub-variable “Results Performance” includes the following components and it derived elements: the competence level of: nutritionists sports teachers, peer educators, health workers, beneficiaries, the evolution of the participants number in the different activities, the obtained changes (new culinary demonstration practices,
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Table 2. Score used for the “structure performance” sub-variable.
reduction of high-calorie meals in favour of vegetables, the practice of at least 150 minutes of physical activity, per week, reduction of tobacco use and alcohol consumption) the effectiveness and efficiency of the communication plan implementation and the satisfaction of all stakeholders (Table 5). Tables 2-4 present the criteria for assessing the performance components of the communication plan implementation for behaviour change based on the identified changeable behaviours.
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Table 3. Score of the sub-variable “process performance”.
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Table 4. Score for the “results performance” sub-variable.
2.2.4. Performance Measurement and Assessment
The process performance sub-variables of the implementation of the behaviour change communication plan (Figure 1) were operationalized through the scores assignment. Two score scales were used. A score of “1” is assigned when the criterion is present and “0” when the criterion is absent. The sum of the scores of the each component elements determines the total of each sub-variable. The assessment of the sub-variables was made according to the Varkevisser rating scale: “good” (if the score is above 80% of the highest score); “acceptable” (if the score is between 80% and 60% of the highest score) and “poor” (if the score is below 60% of the maximum score) [15]. The implementation performance of the behaviour change communication plan was obtained by summing the scores of the three sub-variables. Thus, the total score for the “structure performance” sub-variable is 0 to 26 (Table 2); 0 to 34 for the “process performance” sub-variable (Table 3) and 0 to 20 for the “outcome performance” sub-variable (Table 4).
2.2.5. Ethical Advice and Approvals
The guideline was approved by the ethics committee of the Benin Ministry of Health, the authorization of the coordinator of the Tchaourou Regional hospital and the communal administrative authorities.
2.2.6. Data Analysis
The observation of the analysis document, transcription of semi-structured interviews and group discussions helped for the development of a detailed programme account. The implementation performance of the communication plan was assessed by summing the scores of the three sub-variables of the main variable. The activities achievement level was assessed by Varkevisser standards.
Commentary on the Conceptual Framework
The implementation performance of the communication plan for behaviour change communication in subjects at risk of type 2 diabetes was achieved through structure performance, process performance and outcome performance while taking into account the political, economic, social and cultural environment.
3. Results
3.1. Description of the Sample
This study included project managers (project manager, project coordinator, RPHI research team), one PhD student, three nutritionists, two sports teachers,
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Figure 1. Conceptual framework of the study.
two health workers, one social worker, four sports fields, four tape recorders, four keys/USBs of popular local music, six nutrition education sessions, six culinary demonstration sessions, 240 individual daily physical activity sessions, 52 weekly group physical activity sessions (aerobic and abdominal movements), 12 monthly group physical activity sessions and 90 beneficiaries of the programme (people at risk of type 2 diabetes), political-administrative authorities and taxpayers.
3.2. Characteristics of the Programme Beneficiaries
The programme involved a sample of 90 people, 70% of whom were women. The participants were on average 40 ± 9 years old with low (76.7%), medium (14.4%) and high (8.9%) levels of education. The study sample consisted of shopkeepers (43.3%), farmers (17.8%), housewives (8.9%), craftsmen (6.7%), civil servants (5.6%), pensioners (4.4%) and other socio-professional categories (13.3%). The socio-economic level of this target population was high for 37.0%, medium for 37.2% and low for 25.6%; 78.9% were married or living with a spouse, 11.1% were widowed or divorced and 10% were single or engaged living alone.
3.3. Description of the Level of Knowledge of the Programme Participants and Beneficiaries and Their Degree of Collaboration
The level of knowledge about diabetes (symptoms, complications and prevention) of the programme beneficiaries was assessed through a questionnaire has increased from 32% to 92%. Participants also benefited from training and the post-test revealed a high level of competence of: nutritionists, sports teachers and peer educators. Furthermore, the appropriation of the approach by the beneficiaries and local communal authorities testifies to the quality of friendly collaboration and mutual respect between the programme participants and beneficiaries.
3.4. Description of the Components of the Implementation Performance of the Communication Plan for Behavior Change
Description of the “structure” component
Table 5 presents the elements of the “structure” component. All the technical management tools, communication tools, target monitoring tools, infrastructure and financial support existed at the start of the programme.
Description of the “process” component
Table 5 also shows the elements of the process component. The setting up of the research team, the setting up of the management team, the setting up of the technical team, the availability of financial resources at the right time, the follow-up of nutritionists, sports teachers and peer educators, the implementation of the programme package and the home coaching of targets were effective in at least 95% of the expected score.
Description of the “results” component
Table 5 presents the elements of the results component. These were the first results obtained one year after implementation of the programme.
3.5. Determination of the Overall Performance of the Implementation of the Behaviour Change Communication Plan
Table 6 shows the overall performance of the process of implementing the
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Table 5. Sub-variable score for the evaluation of implementation of a communication plan the behaviour change.
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Table 6. Performance score for the implementation of a communication plan for behaviour change.
behaviour change communication plan. The overall performance is good for all (90%) of the villages with a record of 96.5% for the village of Tchaourou.
3.6. Testimonies of Project Stakeholders
3.6.1. Beneficiaries
· Improving health well-being: “Ms. Kochoni Marthe is a support group leader called Iwossan (which means Healing in ‘Nago’ a local language) from the Tchalla district of the village of Tchaourou centre. Before the project started in May 2015, she was overweight and unwell, and was taking medication to help her recover. During the activity sessions, explanations and advice were given on the disease and its management. So she committed herself to mobilizing the group members for the effective implementation of the lessons learned during the educational and physical activity sessions. Since then, she has been organizing herself and the others to play sports on the basketball court of the Tchaourou stadium every day. She feels lighter every time she comes back from sport. I have stopped taking my medication since then and my weight has gone down; I’m very happy.” she says!
· Changing cooking habits: “Mrs. CODO Prisca is a member of the group called Fifamè (which means in Peace) from Sinankpassor district of the village Tchatchou centre. She says: before the project arrived, she used to prepare the sauce with a lot of oil. Moreover, she supported the idea that it is the oil that makes a good vegetable sauce. She also used enough salt. ‘I noticed that a spoonful of oil was added to the sauce at the end of cooking. Also the onion was used to precook the leaves. The cube (sodium glutamate) was replaced by mustard, shrimp and small fish as well as garlic. I repeated the same way of cooking at home and to a group of teachers. The teachers liked it and it saves me money. I’ll adopt this way of cooking forever because my whole family will be healthy.’”
3.6.2. The Politico-Administrative Authorities
The commitment of the mayor of the commune and his council to work for social mobilization for the diabetes prevention activities: “I commit,” said the Mayor of Tchaourou during the advocacy workshop, “to make funds available from the communal budget to organize an awareness session for the commune’s 2000relays and village nutrition committees on the signs, risk factors of diabetes and means of prevention, in order to support mobilization; I support this project 100%”.
“I’m General Secretary of the Commune. I didn’t know the risk factors for diabetes. Following the screening organised by Dr AZANDJEME at the beginning of the project, I was classified as a high-risk subject for diabetes. I was also hypertensive. I had been prescribed bundles of medication. But I started to review my diet and balance it by eating vegetables and fruits. I started dancing early in the morning from midnight to two o’clock or sometimes from two to four o’clock in the morning. My big belly started to shrink. I haven’t taken any medication since then. I have been saved by the coming of this project.”
3.6.3. The Contributors or Donors
I am Mrs. Suzanne OLEJAS, Project Coordinator of the World Diabetes Foundation for West Africa.
In 2016 when I visited the four programme villages after the project was set up in the department of Borgou in the commune of Tchaourou “I was very satisfied with the implementation of all the elements planned by the PreDiBe project. I did not expect such a good implementation of the project, the involvement of the local authorities and such a great commitment of the beneficiaries. I am convinced that the project will bear satisfactory fruit.”
4. Discussion
This study assessed the performance of the implementation of the behaviour change communication plan through the three components of Donabédian’s conceptual framework combined with the New Public Management model: “structure”, “process” and “outcomes”. The level of performance in the implementation of the behaviour change communication plan in subjects at risk of type 2 diabetes appeared to be satisfactory.
Three sampling techniques were used for target selection. The exhaustive choice was used for financial resources, human resources, technical tools, communication tools and activities carried out; the choice for convenience was used for the beneficiaries of the programme package and the reasoned choice for the political-administrative authorities and contributors. The data collection techniques used were in line with the sampling techniques selected.
The enthusiasm and commitment of the beneficiaries are real and palpable. As proof, local activity management committees have been spontaneously set up in each village. This committee plays a decisive role in mobilizing the beneficiaries, monitoring activities, ensuring group cohesion, and making sure that materials are used wisely.
In this study, we noted the existence of all the technical management tools, communication tools, target monitoring tools, infrastructure and financial support that existed at the programme beginning. One of the determining elements of this completeness is the availability of all listed resources in the project document. Our results are consistent with those published by Aziz & al., and which, after an evaluation study of a type 2 diabetes prevention programme implementation in Australia in 2018, have concluded that our implementation was carried out as planned in the project document [16].
The setting up of: the research team, the management team and the technical team was the main advantage in the implementation of the communication plan for behaviour change. In addition, the involvement of all stakeholders in the implementation, especially the motivation of peer educators, nutritionists and sports teachers, was an important factor that boosted the activities so that the programme package could be carried out. The involvement of peer educators (from the community itself) at all stages of the programme increased the confidence of the study participants in the practice of the programme activities. This justifies the 80% participation rate in all programme activities. Moreover, this participation rate reflects the participants’ willingness to respect the new approaches proposed. At the end of our investigations, the performance of the implementation of the communication plan for behavioural change has a good appreciation. This can be explained by the involvement of the entire research team, the commitment of the local authorities and the motivation of the targets, according to the high prevalence of type 2 diabetes in the locality. The disease is already known by the subjects at risk who sometimes have cases of diabetes with whom they live. It should also be noted that the training of nutritionists, sports teachers and peer educators on nutrition education topics, support for subjects at risk of type 2 diabetes in physical exercise, motivation and follow-up of subjects at home, have also made it possible to achieve these results.
By analysing the obtained results during this work, we have identified favourable and unfavourable factors for the learning retention of PreDiBe’s. Among the favourable factors, we noted the existence and functionality of a support committee made up of peer educators and a few volunteers motivated to continue the activities of the programme, which guarantees the sustainability of the activities. Another main advantage of this study is the low drop-out rate of the beneficiaries of the programme. Aziz & al., reported in an evaluation study of the implementation of a programme to promote healthy lifestyle habits in subjects with type 2 diabetes, a programme in which peers were involved, gave a 92.7% retention rate in Australia in 2018 [16]. Another lifestyle programme study conducted in subjects at risk for type 2 diabetes showed a participation rate of more than half of the subjects after 18 months of programme [17]. A shortfall was noted in the availability of vegetables, but this was addressed by another component of the project that provided training in home gardening practices. The testimonies confirming the good implementation of the communication plan for behaviour change show the involvement at all levels of the different stakeholders of the project.
5. Conclusion
The results of this study suggest that community-based programmes for people at risk for type 2 diabetes based on changing unhealthy behaviours are feasible and acceptable, it can help to get a positive impact on the people at risk for type 2 diabetes lifestyle. The satisfactory evaluation results will bring to better understanding the programmes implementation in people at risk for replication of future programmes in other similar situations.