|Year : 2022 | Volume
| Issue : 4 | Page : 466-472
Effect of COVID-19 lockdown on lifestyle habits and self-care practices of diabetic and hypertensive patients in rural Shimla and Udaipur – Findings from the HealthRise India program
Santhosh Kumar Kaza1, Pallavi Gupta2, Ruchi Vaidya2, Shalini Chandrashekar Nooyi3, Nayanjeet Chaudhury4
1 Manager – Data and Analytics, Ramaiah International Centre for Public Health Innovations, Bangalore, Karnataka, India
2 Assistant Professor, Ramaiah International Centre for Public Health Innovations, Bangalore, Karnataka, India
3 Principal and Dean; Professor, Department of Community Medicine Ramaiah Medical College and Technical Advisor, Ramaiah International Centre for Public Health Innovations, Bangalore, Karnataka, India
4 Director, Ramaiah International Centre for Public Health Innovations, Bangalore, Karnataka, India
|Date of Submission||09-Oct-2021|
|Date of Decision||07-Nov-2022|
|Date of Acceptance||25-Nov-2022|
|Date of Web Publication||31-Dec-2022|
Santhosh Kumar Kaza
Manager – Data and Analytics, Ramaiah International Centre for Public Health Innovations, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: COVID-19 pandemic has increased the risk of mortality among patients with noncommunicable diseases. Maintaining a good metabolic control, lifestyle modification along with improved self-care practices are not only associated with less severe COVID-19 infections but also with a high recovery rate. Objectives: This research article explores the changes in lifestyle habits, self-care practices, and metabolic control among patients enrolled in the HealthRise program. The study compares behavioral changes, before COVID-19 pandemic and during COVID-19 pandemic, between intervention and control arms in Shimla and Udaipur. Methods: A quasi-experimental study design was employed for program implementation in select villages of Shimla district, and Udaipur district. A total of 459 patients from Shimla and 309 patients from Udaipur with diabetes mellitus or hypertension or with both were enrolled and followed for 1 year. Results: Metabolic control in Shimla intervention arm was 2.6 times higher than in control arm (P = 0.001) before COVID-19 pandemic. During COVID-19 pandemic, Odds of metabolic control in Shimla intervention was 1.5 times higher when compared with control arm (P = 0.03). In Udaipur, metabolic control before COVID-19 pandemic was comparable between control and intervention arms. During the pandemic, metabolic control in intervention arm of Udaipur was 5 times higher when compared to the control arm ((P = 0.001). Conclusion: Participants exposed to support, appreciate, learn, and transfer-community life competence process (SALT-CLCP) intervention maintained metabolic control during the COVID-19 pandemic with improved behavioral and self-care practices. Community-based interventions such as SALT-CLCP method bring ownership and empower community in achieving the better health outcomes.
Keywords: Appreciate, COVID-19 pandemic, frontline health workers and community-based intervention, learn, Noncommunicable diseases, support, and transfer-community life competence process method
|How to cite this article:|
Kaza SK, Gupta P, Vaidya R, Nooyi SC, Chaudhury N. Effect of COVID-19 lockdown on lifestyle habits and self-care practices of diabetic and hypertensive patients in rural Shimla and Udaipur – Findings from the HealthRise India program. Indian J Public Health 2022;66:466-72
|How to cite this URL:|
Kaza SK, Gupta P, Vaidya R, Nooyi SC, Chaudhury N. Effect of COVID-19 lockdown on lifestyle habits and self-care practices of diabetic and hypertensive patients in rural Shimla and Udaipur – Findings from the HealthRise India program. Indian J Public Health [serial online] 2022 [cited 2023 Feb 4];66:466-72. Available from: https://www.ijph.in/text.asp?2022/66/4/466/366580
| Introduction|| |
The World Health Organization declared COVID-19 as a pandemic in January 2020 and advised various prevention measures, including but not restricted to hand washing, social distancing, and mask use for the population as well as health-care workers. The pandemic has had an unprecedented impact on individuals worldwide. Many studies have reported that co-existing noncommunicable diseases (NCDs) such as diabetes, hypertension, and cardiovascular diseases pose a high risk of mortality following COVID-19 infections., Studies have reported that the severity and complications were high among patients with uncontrolled diabetes when compared with individuals having good glycemic control., Along with mortality and morbidity issues, the COVID-19 pandemic imposed several restrictions which drastically affected the socio-psychological lives of the people. The pandemic has also seen increased physical inactivity among the individuals and thus an increase in the risk for metabolic complications. Maintenance of metabolic control in diabetes and hypertension require modification of lifestyle habits and self-care practices which include diet, physical activity, alcohol and tobacco consumption, medication adherence, and visit to health-care facility (HCF). Interventions promoting the modification of lifestyle habits and self-care practices play an important role in maintaining metabolic control. Community health worker-led primary care models have potential not only to bring behavioral change but also in improving metabolic control in NCD patients at community level.
HealthRise, a 5-year multi-country project launched in 2014, was aimed at empowering patients, caregivers and building capacity of frontline health workers (FLHWs) for effective management of NCDs at community level. Many community-based activities were implemented under HealthRise project for detection, management, and control of cardiovascular diseases and diabetes among the underserved population., HealthRise India Project was implemented in the Shimla and Udaipur districts of Himachal Pradesh and Rajasthan, respectively. One of the pilot interventions in the project employed support, appreciate, learn, and transfer-community life competence process (SALT-CLCP) method, a unique method that combines an approach called CLCP along with SALT technique. SALP-CLCP methodology showed promising results in select geographies of the HealthRise India program through community ownership and shifting care from FLHWs to the community. The intervention was continued for 1 year (2019–2020) in those villages and was expanded to additional villages to understand the role of SALT-CLCP methodology in the behavior change and metabolic control among patients with diabetes and/or hypertension. Representatives of the local government were consulted in selection of villages and involved in the FLHWs training sessions
SALT-CLCP method is a step-by-step approach that enables the community to take ownership of the challenges that it is facing and to find appropriate solutions to address those challenges at community level using local resources. First, health workers will build rapport with the community and then facilitates the development of a shared community dream. The community undertakes a self-assessment to understand their current status with respect to their dream in the next step and prepare an action plan. Community implements the action plan, reviews the progress, and learns from the actions which will become the basis for the next CLCP cycle. In both Shimla and Udaipur, the SALT-CLCP steps were implemented with active participation of patients, their caregivers and community members over the intervention period by conducting periodic SALT meetings. The program involved an inbuilt monitoring and evaluation plan with a baseline assessment, three quarterly assessments, and an end-line assessment at the end of 1 year. Program activities began in June 2019 and were halted after 9 months due to COVID-19 pandemic after 2nd follow-up assessment which was conducted during February 2020. The third follow-up assessment conducted during July 2020 was considered the end-line assessment.
The present study was undertaken to assess and compare changes in the lifestyle habits, self-care practices, and metabolic control of diabetes and/or hypertension among patients before and during COVID-19 pandemic.
| Materials and Methods|| |
Study design/HealthRise intervention program
A quasi-experimental study design with intervention and control arms was used for program implementation. The project was approved by the Institutional Ethics Committee (IERB Reference number: MERB/May-2019/002).
Intervention and control arms in Shimla included 38 and 36 villages, respectively, and in Udaipur included 10 villages in each arm. Villages in each arm were selected in consultation with state, district health authorities and based on operational feasibility. In Shimla, 22% of the respondents had diabetes, 69% had hypertension, and remaining 9% had both the conditions. In Udaipur, 8% of respondents had diabetes, 80% had hypertension, and 12% had both.
All individuals aged between 18 and 70 years from intervention villages were screened for both hypertension diabetes and enrolled in the program after taking informed consent. In control villages, patients were enrolled from the patient registries available with local public health facilities (sub-centers, PHC/CHC) and health workers. A total number of patients enrolled in intervention arm of Shimla and Udaipur were 300 and 146, respectively, whereas the control arm of Shimla and Udaipur consisted of 179 and 168 patients, respectively. All patients were followed for the entire duration of the study and loss to follow-up was <4% (n = 25).
Outreach workers from program implementing agencies, ASHAs, and ANMs were trained in conducting SALT meetings in the community and data collection. Structured questionnaires were developed for periodic assessments which covered socio-demographics, family history, disease details, lifestyle habits, self-care practices, and SALT meeting details. An android application supported by a management information system with automated skips and range checks was developed to minimize data errors, and data were collected using computer-assisted personal interviewing method. HCF visit details, laboratory investigation details (blood sugar levels and blood pressure readings) of previous 3 months at the time of each follow-up were collected from outpatient or discharge records. Patients were tested for blood sugar levels and blood pressure readings using point-of-care devices in case of missing records or no HCF visit in the previous 3 months.
The study tool covered behavioral practices such as consumption of fried food, physical activity levels, alcohol and tobacco consumption, and self-care practices such as HCF visit details and medication adherence. Medication adherence was considered regular if the patient was taking medicines every day without skipping as prescribed by the doctor. Visit HCF was classified as a regular visit if a patient visited HCF at least once in the past 3 months. ICMR guidelines for diabetes management and NPCDCS guideline were used to classify blood glucose and blood pressure readings.,
Data were processed and analyzed using the IBM Corp. SPSS Statistics for Windows, Version 22.0, Armonk, New York. Chi-square test was employed to compare the socio-demographic characteristics of the respondents by study arms. Lifestyle behavior and self-care practices included in the study were coded into dichotomous categories and McNemar test was applied to test the difference in these before and during COVID-19 pandemic. Uni-variate odds were also calculated to compare the lifestyle behavior and self-care practices across the study arms before and during COVID-19 pandemic. Forward logistic regression was used to identify the factors associated with the metabolic control of disease among patients after adjusting for all variables. The level of significance was reported at 0.05.
| Results|| |
Socio-demographic profile of the respondents from intervention and control arms of Shimla and Udaipur is presented in [Table 1]. Majority of the respondents in both Shimla and Udaipur were females and had studied up to 10th standard or below. Around 40% of the respondents in both locations have age >60 years. In Shimla, more than 60% of the respondents were currently retired or not working and were living in joint families, while in Udaipur, a little <50% of respondents were retired or not working and were living in joint family. About 80% and 50% of the respondents in Shimla and Udaipur, respectively, possessed “below poverty line (BPL)” cards issued by local government.
|Table 1: Sociodemographic characteristics of the participants by intervention and control, Shimla and Udaipur|
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The socio-demographic characteristics of the participants were comparable among the study arms of Shimla, except for the gender distribution. Intervention arm of Shimla had significantly higher proportion of female participants compared with the control arm (P = 0.001). Age distribution, education levels, and occupation of the participants in the intervention and control arms of Udaipur were also comparable. The proportion of female participants was significantly high in both study arms of Udaipur (P = 0.03). Nuclear families and above poverty line card holders were high in number in Udaipur control arm whereas joint families and BPL card holders were high in Udaipur intervention arm (P = 0.01).
Lifestyle behavior and self-care practices before and during COVID-19 pandemic in intervention and control arms of Shimla and Udaipur are shown in [Table 2]. A significant reduction in consumption of fried, spicy, and oily food and visits to health-care facility was observed among the participants during COVID-19 lockdown in intervention arm of Shimla. On the other hand, improved physical activity levels and medication adherence was reported by Shimla intervention arm during the pandemic as compared to before. Metabolic control among the patients in the Shimla intervention arm during the pandemic remained the same as compared to metabolic control before pandemic (79.0% during vs. 78.2% before). Similar changes in lifestyle and self-care practices were observed in the control arm of Shimla; however, the changes were comparatively higher in intervention arm, except for metabolic control. About 58% of participants in the control arm had metabolic control of disease before pandemic, and it increased significantly to 70% during the pandemic (P = 0.01).
|Table 2: Lifestyle behavior and self-care practices in intervention and control arm before and during COVID-19 Pandemic in Shimla and Udaipur|
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There were no significant changes in the lifestyle behavior, self-care practices, and metabolic control in Udaipur intervention arm before and during COVID-19 pandemic. Metabolic control among respondents significantly reduced during the lockdown in the control arm of Udaipur (P = 0.001) with increased tobacco consumption (P = 0.03) and reduced visits to HCF (P = 0.001) despite improvement in physical activity levels (P = 0.001).
Univariate odd ratios were calculated to compare the lifestyle behavior and self-care practices of participants by study arms before and during the lockdown in Shimla and Udaipur [Table 3]. The odds of no or reduced consumption of fried, spicy, and oily food in the intervention arm were found to be 3.4 times higher compared to that in control arm in Shimla (P = 0.001) before the COVID-19 pandemic, and it remained the same during the pandemic. Whereas in intervention arm of Udaipur, odds of no or reduced consumption of fried, oily, and spicy food were 1.73 times higher before lockdown (P = 0.001), and there was no significant difference in consumption during lockdown when compared to control arm of Udaipur (P = 0.06).
|Table 3: Comparison of life style and self-care practices of intervention arm with control arm before and during COVID-19 pandemic|
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The odds of physical activity levels in the intervention arm of Shimla and Udaipur were 2.4 and 2.2 times higher compared to control arm before lockdown (P = 0.001), respectively, however, these odds increased significantly during the lockdown period (P = 0.001). Further, as compared to the control arm in Shimla, the odds of no alcohol consumption before the pandemic in the intervention arm of Shimla was 2.1 times higher (P = 0.03) and it increased to 2.9 times during the pandemic (P = 0.001). Odds of not consuming tobacco in the Udaipur intervention arm before pandemic were 13.3 times higher when compared to control arm (P = 0.001), and it further increased to 43.7 during pandemic in Udaipur (P = 0.001).
When compared with the control arm, visit health-care facilities reduced in intervention arm of Shimla during the lockdown period (odds ratio [OR]: 0.61; P = 0.01). The odds of HCF visits in Udaipur intervention arm were low before lockdown (OR: 0.11; P = 0.001), however, visits of HCF increased significantly by 7.7 times during the lockdown (P = 0.001) when compared with control arm. The odds of medication adherence were 5.4 times higher (P = 0.001) in the intervention arm of Udaipur before COVID-19 lockdown, which significantly increased up to 8 times during the pandemic (P = 0.001) when compared with control arm. There were no significant differences in medication adherence before and during COVID-19 lockdown in the intervention arm when compared to control arm in Shimla.
Overall, both the intervention arms of Shimla and Udaipur have had better metabolic control, compared to control arms during COVID-19 pandemic. Before COVID-19 lockdown, Metabolic control in Shimla intervention arm was 2.6 times higher (P = 0.001) and there were no significant differences in the metabolic control of Udaipur intervention arm when compared with respective control arms. Although the odds of metabolic control have reduced in the Shimla intervention arm during lockdown it was 59% higher in comparison to control arm (P = 0.03). Odds of metabolic control have increased by 5.2 times during the pandemic in Udaipur intervention arm (P = 0.001).
[Table 4] shows the covariates of metabolic control during COVID-19 lockdown after adjusting for socio-demographic characteristics, lifestyle behavior, and self-care practices before COVID-19 lockdown. In Shimla, the significant covariates of metabolic control during the COVID-19 lockdown were education levels (≥10th class) (OR: 1.96, P = 0.03), not consuming fried/spicy/oily food during the lockdown period (OR: 2.27, P = 0.001) and those with metabolic control before lockdown (OR: 3.47, P = 0.001). Similarly, in Udaipur, the covariates such as not consuming fried/oily/spicy food during lockdown (OR: 2.65, P = 0.001), visiting HCF during the lockdown (OR: 2.9, P = 0.001), and maintaining physical activity levels (OR: 4.18, P = 0.001) during lockdown were found significant for metabolic control.
|Table 4: Predictors for metabolic control of diseases during COVID-19 lockdown among intervention arms in Shimla and Udaipur - Multivariate logistic regression analysis|
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| Discussion|| |
Overall, intervention arms of Shimla and Udaipur had better metabolic control compared to the control arms. Given the restrictions due to the lockdown, it is interesting to note the improvement in physical activity levels and HCF visits in intervention arms of both locations. The intervention has two components where SALT process brings a shared ownership of the problem among the community and the CLCP process guides them in achieving the common vision. SALT-CLCP method has been applied to improve community mobilization in Ebola outbreak, HIV program and to improve immunization coverage. Social mobilization and community engagement were identified as key strategies to contain Ebola outbreak in West Africa. Furthermore, SALT-CLCP methodology was employed to build trust and confidence on quality of health-care services provided by the public health system among the community during Ebola outbreak in West Africa. SALT-CLCP intervention has improved Ante Natal Care visits and utilization of public health service by local community in West Africa. Communities Acting Together to Control HIV program, a national program of Botswana, has adapted SALT-CLCP method for community-engaged planning and action by involving tribal leaders. SALT-CLCP method in Ebola outbreak and HIV program, though employed on small scale, has shown promising results in behavior change through community ownership.
Thus, there are examples of successful utilization of SALT-CLCP approach in the social development sector, although there are also reported experiments where it has not shown much difference, for instance in immunization coverage. Improvement in lifestyle habits and self-care practices among intervention patients is encouraging given the magnitude of COVID-19 pandemic and measures taken to contain it. A pulse survey conducted during the pandemic reported that the essential health services such as routine immunizations, NCD diagnosis, and treatment services were frequently disrupted during the COVID-19 pandemic. The major reasons identified for the disruption of health services were the cancellation of services by health-care facilities, redeployment of health-care personnel, and limited availability of personal protective equipment kits as reported., HCF visits by patients across study arms of both Udaipur and Shimla have reduced over the time due to lockdown measures and disruption of healthcare services.
A study conducted on type 1 diabetes mellitus (T1DM) patients in south India reported that the mean HBA1C levels increased significantly during COVID-19 lockdown. Level of compliance with medication and healthy lifestyle practices have reduced in T2DM patients after lockdown, whereas in the current study, medication adherence has improved significantly in Udaipur intervention arm during lockdown but not in Shimla arm. A pan India study conducted on 1510 DM patients reported that during COVID-19 pandemic, physical activity levels have reduced and food intake has increased. Physical activity levels in intervention arms of Shimla and Udaipur have improved during the pandemic whereas patients of Shimla intervention arm have reduced the consumption of fried, spicy, and oily food. It is worth noting that these patients have made significant improvement in lifestyle habits and self-care practices and metabolic control even before completing one round of CLCP cycle.
Similar to other community-based NCD programs, SALT-CLCP method involves community health workers in screening, diagnosis, and referral activities. SALT-CLCP method mobilizes community to take action against health problems, reviews the progress made and decides on the future course of action, which differentiates from other community-based health interventions. Community adheres to behavior changes in the long term, as they evolve with the process, and change comes from within the community. It is important to note the improvement in behavior and metabolic control in the community even though one round of the CLCP cycle was not completed. FLHWs like ASHA, ANMs were working with control villages as well and this may possibly lead to contamination, thereby causing improvements in lifestyle and self-care practices in control villages. This is one of the limitations of the study as patients were not randomized into intervention and control arms. Bias in self-reported practices such as medication adherence, HCF visits were minimized by verifying available records, however, bias in the other self-reported behaviors cannot be ruled out.
| Conclusion|| |
In both the geographical regions, participants SALT-CLCP intervention have maintained metabolic control during the COVID-19 pandemic lockdown with improved behavioral and self-care practices. Given the magnitude of the pandemic, the community-based interventions such as SALT-CLCP method showed communities can become resilient by bringing ownership and empowering community in achieving the positive health outcomes.
We would like to thank Medtronic Foundation for funding the transition grant; program implementation partners MAMTA- Health Institute for Mother and Child, Catholic Health Association of India, and the constellation for supporting evaluation activities. We acknowledge Dr Ananth Ram MD, for supporting the monitoring and evaluation of the HealthRise India project. We also acknowledge the support received from the government health officials, India for their support throughout the intervention.
Financial support and sponsorship
Ramaiah International Centre for Public Health Innovations (RICPHI) has conducted independent evaluation of the HealthRise program which was funded by Medtronic Foundation and implemented by a consortium led by MAMTA - Health Institute for Mother and Child.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chen R, Liang W, Jiang M, Guan W, Zhan C, Wang T, et al
. Risk factors of fatal outcome in hospitalized subjects with coronavirus disease 2019 from a nationwide analysis in China. Chest 2020;158:97-105.
Mehraeen E, Karimi A, Barzegary A, Vahedi F, Afsahi AM, Dadras O, et al
. Predictors of mortality in patients with COVID-19-a systematic review. Eur J Integr Med 2020;40:101226.
Zhu L, She ZG, Cheng X, Qin JJ, Zhang XJ, Cai J, et al
. Association of blood glucose control and outcomes in patients with COVID-19 and pre-existing Type 2 diabetes. Cell Metab 2020;31:1068-77.e3.
Kumar A, Arora A, Sharma P, Anikhindi SA, Bansal N, Singla V, et al.
Is diabetes mellitus associated with mortality and severity of COVID-19? A meta-analysis. Diabetes Metab Syndr 2020;14:535-45.
Chopra S, Ranjan P, Singh V, Kumar S, Arora M, Hasan MS, et al
. Impact of COVID-19 on lifestyle-related behaviours- a cross-sectional audit of responses from nine hundred and ninety-five participants from India. Diabetes Metab Syndr 2020;14:2021-30.
Jeet G, Thakur JS, Prinja S, Singh M. Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications. PLoS One 2017;12:e0180640.
Flor LS, Wilson S, Bhatt P, Bryant M, Burnett A, Camarda JN, et al
. Community-based interventions for detection and management of diabetes and hypertension in underserved communities: A mixed-methods evaluation in Brazil, India, South Africa and the USA. BMJ Glob Health 2020;5:e001959.
Gillespie AM, Obregon R, El Asawi R, Richey C, Manoncourt E, Joshi K, et al
. Social mobilization and community engagement central to the ebola response in West Africa: Lessons for future public health emergencies. Glob Health Sci Pract 2016;4:626-46.
Verma A, Rajput R, Verma S, Balania VK, Jangra B. Impact of lockdown in COVID 19 on glycemic control in patients with type 1 Diabetes Mellitus. Diabetes Metab Syndr 2020;14:1213-6.
Alshareef R, Al Zahrani A, Alzahrani A, Ghandoura L. Impact of the COVID-19 lockdown on diabetes patients in Jeddah, Saudi Arabia. Diabetes Metab Syndr 2020;14:1583-7.
Khader MA, Jabeen T, Namoju R. A cross sectional study reveals severe disruption in glycemic control in people with diabetes during and after lockdown in India. Diabetes Metab Syndr 2020;14:1579-84.
[Table 1], [Table 2], [Table 3], [Table 4]