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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 42-45

The readiness of frontline health workers in enhancing diabetes and hypertension self-management education and practice in the community settings in Delhi, India

Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Submission02-Nov-2020
Date of Decision18-Sep-2021
Date of Acceptance21-Jan-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Dr. Saurav Basu
Room No. 358, Department of Community Medicine, Maulana Azad Medical College, 2 BSZ Marg, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jncd.jncd_83_20

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The present study was conducted among accredited social health activists (ASHAs), female frontline health workers of India, to assess their knowledge of self-care management for diabetes mellitus (DM) and hypertension (HTN) and understand their readiness to promote medical adherence. Only 21 (41.2%) participants (n = 51) were aware of all the four major behavioral risk factors, including physical inactivity, unhealthy diet, tobacco smoking, and harmful alcohol use that increased the risk of development and progression of DM and HTN. The ASHAs were positively inclined toward participation in health education activities through home visits but were disinclined to be involved in the home distribution of medications.

Keywords: Accredited social health activists, community health, diabetes, hypertension, India

How to cite this article:
Basu S, Garg S, Hossain S, Gupta D, Duggal K. The readiness of frontline health workers in enhancing diabetes and hypertension self-management education and practice in the community settings in Delhi, India. Int J Non-Commun Dis 2022;7:42-5

How to cite this URL:
Basu S, Garg S, Hossain S, Gupta D, Duggal K. The readiness of frontline health workers in enhancing diabetes and hypertension self-management education and practice in the community settings in Delhi, India. Int J Non-Commun Dis [serial online] 2022 [cited 2023 Feb 3];7:42-5. Available from: https://www.ijncd.org/text.asp?2022/7/1/43/342084

  Introduction Top

Hypertension (HTN) and diabetes mellitus (DM) are the most important modifiable risk factors for preventing premature mortality from cardiovascular disease.[1] Preventing or delaying the onset of these vascular complications requires maintaining optimal blood pressure and glycemic control through adherence to prescribed medication, diet, and exercise.[2] Poor patient awareness, lack of regular physician consultation, and interrupted access to medication accentuate the risk of nonadherence and the early onset of vascular complications.[2],[3]

The inadequate availability of regular patient-centered care facilities for effective long-term management of chronic diseases at primary health facilities is a major public health challenge in developing countries.[4] Moreover, community-based interventions for health-promoting activities supporting self-care management in DM and HTN patients are urgently warranted as patients spend only a fraction of the time in health facilities compared to that within their homes and communities.[5]

As per the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease, and Stroke in India, accredited social health activists (ASHAs), female frontline health workers of India, have been mandated to be involved in the community-based screening of DM and HTN.[6] A dedicated module for training ASHAs on noncommunicable diseases has also been released by the government under this program.[7] There is also a growing recognition of their potential role in enabling improved health behaviors in patients having DM and HTN through home-based behavior change communication (BCC) and health system linkage.[8],[9]

The objective of the study was to assess the knowledge of DM and HTN self-care management in the ASHAs and their readiness to promote medical adherence (education and practice) in community-dwelling patients.

  Materials and Methods Top

This cross-sectional study was conducted from September to December 2019 among 51 ASHA workers in employment for at least 2 years in two urban resettlement colonies which were selected through convenient sampling. The ASHAs, as part of their routine activities, also identified at least two geriatric individuals at risk of DM and HTN from within their target population and accompanied them to the local urban primary health clinic for screening that was conducted once every week.

A self-administered questionnaire in the local language, Hindi, was used for data collection [Annexure 1]. Participants' perspectives regarding their willingness and concerns in promoting adherence and self-care in their community were also ascertained through face-face open-ended questions among 15 participants selected randomly from within the sample group.

The data were entered and analyzed using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. The results were expressed in frequency and proportions for categorical variables and median and interquartile range for continuous outcomes. P < 0.05 was considered statistically significant.

Written and informed consent was obtained from all the participants.

  Results Top

Sociodemographic characteristics

The median (interquartile ranges) age of the participants was 39 (34.5–42) years. The highest educational attainment of the participants was VIII-X standard in 20 (39.2%), XI-XII in 24 (47%), and graduate in 7 (13.7%) participants. Most (91%) participants reported having elementary reading and writing comprehension of the English language. A total of 40 (78.4%) participants used smartphones and were familiar with installing and running mobile applications.

Knowledge of diabetes mellitus and hypertension self-management

Most participants were unaware of blood pressure, blood sugar, and obesity control targets in DM and HTN patients. Furthermore, only 21 (41.2%) participants were aware of all the four principle behavioral risk factors, including physical inactivity, unhealthy diet (lacking fruits and vegetables), tobacco smoking, and harmful alcohol use that increased the risk of development and progression of DM and HTN [Table 1].
Table 1: Knowledge of diabetes and hypertension.related self.management and control among accredited social health activists (n=51)

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Willingness to promote medical adherence among patients (n = 15)

All the ASHAs informed they had not previously been trained for monitoring the health outcomes and health status for DM and HTN. They also reported a current lack of confidence in accurately measuring blood pressure (53.3%), blood glucose through glucometer (73.3%), and estimation of the body mass index (73.3%). The ASHAs expressed concerns in maintaining continuity of care among the newly diagnosed patients in case of nonavailability of all the prescribed medications at the primary care facilities. They also unwilling to undertake responsibility for enabling home delivery of antidiabetes and antihypertensive medications due to apprehensions over patients blaming them in case of any drug-related side effects or the perceived lack of benefit. A total of 12 (75%) ASHAs instead preferred the distribution of drugs only after verifying the prescription and refill by a physician or a pharmacist at any designated community site. However, all the ASHAs were favorably inclined to participate in community engagement processes and directly provide health education related to DM and HTN self-management to the patients through regular home visits.

  Discussion Top

Previous studies in India have reported low awareness of aspects of DM and HTN prevention and control in the general population.[10],[11] The present study shows that in the absence of training, the knowledge of ASHAs on key preventive and self-management aspects of DM and HTN was only comparable to the general population. However, previous studies have validated the efficacy of appropriate training in bridging the knowledge deficits among ASHAs despite their limited educational attainments. A study in rural South India demonstrated the feasibility of training ASHAs to independently lead community-based health education and support programs for hypertension management.[9] Another study in Eastern India reported the successful implementation of an integrated approach for improving HTN and DM control through the involvement of ASHAs for enabling BCC and promoting physician seeking behavior.[9]

Treatment interruption due to running out of drug stocks among socioeconomically vulnerable patients with DM and HTN is a concern that could be potentially alleviated through home delivery of these medications by frontline or community health workers. However, in this study, ASHAs, the frontline health workers expressed reservations on facilitating drug distribution due to concerns over unanticipated adverse drug reactions in the patients.

There were several study limitations. The small sample size reduces the generalizability of the findings. The feasibility of implementing ASHA driven community health programs for promoting adherence and self-management among patients with DM and HTN could not be assessed due to the lack of follow-up in the study. Consequently, future studies should ascertain if ASHAs could be adequately trained to assess medical adherence, identify reasons for nonadherence, and implement measures for promoting adherence in their target communities.

In conclusion, a high prevalence of suboptimal awareness of common behavioral risk factors of noncommunicable diseases and lack of confidence in promoting patient medical adherence with associated lack of training despite a programmatic mandate was observed among the frontline health workers (ASHAs).

Ethical approval statement

The study was approved with exemption from full review by the Institutional Ethics Committee, Maulana Azad Medical College & Associated Hospitals (F.1/IEC/MAMC/(68/03/2019/No151).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Long AN, Dagogo-Jack S. Comorbidities of diabetes and hypertension: Mechanisms and approach to target organ protection. J Clin Hypertens (Greenwich) 2011;13:244-51.  Back to cited text no. 1
World Health Organization. In: Sabaté E, editor. Adherence to Long-term Therapies: Evidence for Action. Geneva: World Health Organization; 2003.  Back to cited text no. 2
Rhee MK, Slocum W, Ziemer DC, Culler SD, Cook CB, El-Kebbi IM, et al. Patient adherence improves glycemic control. Diabetes Educ 2005;31:240-50.  Back to cited text no. 3
Basu S, Sharma N. Diabetes self-care in primary health facilities in India – Challenges and the way forward. World J Diabetes 2019;10:341-9.  Back to cited text no. 4
Correia JC, Lachat S, Lagger G, Chappuis F, Golay A, Beran D, et al. Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries: A scoping review. BMC Public Health 2019;19:1542.  Back to cited text no. 5
Ministry of Health & Family Welfare: Directorate General of Health Services. Government of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS): Operational Guidelines; 2017. Available from: https://main.mohfw.gov.in/sites/default/files/Operational%20Guidelines%20of%20NPCDCS%20%28Revised%20-%202013-17%29_1.pdf. [Last accessed on 2021 Sep 15].  Back to cited text no. 6
National Centre for Disease Control. Module for ASHA on Non-Communicable Diseases. New Delhi: Ministry of Health and Family Welfare (IN); 2017. Available from: https://main.mohfw.gov.in/sites/default/files/Module%20for%20ASHA%20on%20Non-communicable%20Diseases_1.pdf. [Last accessed on 2021 Sep 15].  Back to cited text no. 7
Abdel-All M, Thrift AG, Riddell M, Thankappan KR, Mini GK, Chow CK, et al. Evaluation of a training program of hypertension for accredited social health activists (ASHA) in rural India. BMC Health Serv Res 2018;18:320.  Back to cited text no. 8
Khetan A, Zullo M, Rani A, Gupta R, Purushothaman R, Bajaj NS, et al. Effect of a community health worker-based approach to integrated cardiovascular risk factor control in India: A cluster randomized controlled trial. Glob Heart 2019;14:355-65.  Back to cited text no. 9
Mukherjee PS, Ghosh S, Mukhopadhyay P, Das K, Das DK, Sarkar P, et al. A diabetes perception study among rural and urban individuals of West Bengal, India: Are we ready for the pandemic? Int J Diabetes Dev Ctries 2020;40:612-8.  Back to cited text no. 10
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens 2014;32:1170-7.  Back to cited text no. 11


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