India has the second highest number of people (73 million) with Diabetes, just after China and unless intensive measures are instituted, the number would rise to 134 million by 2045. The problem in India is intensified due to its huge rural population, which face issues such as poor access and availability of healthcare. This is complemented by issues such as illiteracy, poverty and lack of awareness about non-communicable diseases (NCDs) such as Diabetes. Accredited Social Health Activists (ASHAs) are the first point of contact with the health system for villagers residing in rural settings. ASHAs have also been traditionally involved in activities related to vertical programmes such as the reproductive, maternal, new-born, child and adolescent health programme. The Government of India launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) in 2010 but there were no specific guidelines for engagement of ASHAs in the NPCDCS. Only recently, new guidelines have been developed under the NPCDCS for ASHAs, Multipurpose Workers (MPWs) and medical officers. Some interventions in India involving ASHAs and community health workers such as Auxiliary Nurse Midwife (ANM) and MPW have been shown to be effective in prevention and management of Diabetes.
Project DWD was a pilot, community-based quasi-experimental trial, conducted in two Primary Health Centre (PHC) areas (Intervention area – Pandare PHC; Control area – Shirshuphal PHC) of Baramati block in Pune district. The project was implemented in five villages each under each PHC. Intensive training sessions were conducted with ASHA for screening of high-risk subjects (adult 30-70 year old) with diabetes in both the intervention and control areas. ASHAs conducted initial screenings using the Indian Diabetes Risk Score (IDRS) tool and glucometers and referred the at-risk participants and known cases of diabetes to sub-centres for further evaluation. Baseline evaluation was conducted with 431 diabetic participants which included clinical assessments including anthropometry, blood pressure (BP) recording, biochemical evaluation including HbA1c and lipid profile, urine microalbumin, ankle brachial index (by a hand-held Doppler), vibratory perception threshold (by Biothesiometer) and retinal images (by fundus camera). The non-clinical assessment involved assessment of knowledge, attitudes and practices of participants related to diabetes and healthy lifestyle and indicators of quality of life (QoL) through interviewer-administered surveys. The baseline evaluations were followed by a six month community-based and ASHA-led DWD intervention only in the intervention area, involving monthly home visits and patient/caregiver as well as community-based awareness raising. The community-based institutions such as the Village, Health, Sanitation and Nutrition Committee (VHSNC), Gram Sabha and Diabetes Self-help Groups (SHGs) and community-leaders such as village Sarpanch were also involved in awareness raising activities. The six month intervention was followed by endline evaluation with 416 diabetic participants using similar methods as used for baseline evaluation. No intervention except educational leaflets were given to participants in the control area