An Intervention to Promote Healthy Behaviors and service utilisation for Hypertension and Diabetes Management in Rural Bangladesh: A pilot randomised controlled trial.

Intervention overview and components: The intervention was a structured, 12-week community–facility programme for adults living with coexisting hypertension and diabetes in Chirirbandar Upazila, Dinajpur District, rural Bangladesh. The intervention comprised four integrated components, including individualised home-based counselling, an interactive group workshop, guided visits to government healthcare facilities, and educational and self-monitoring materials. Individualised counselling addressed knowledge of hypertension and diabetes and their risk factors; healthy diet, including increased fruit and vegetable intake and reduced salt intake; physical activity; smoking cessation and reduced alcohol consumption where applicable; reduction of exposure to household or indoor air pollution; medication adherence; stress and other barriers to self-care; blood pressure and blood glucose monitoring; recognition of complications and warning signs; individual health-goal setting; regular check-ups and follow-up; and appropriate use of qualified healthcare providers. Counselling was tailored to each participant’s baseline circumstances, existing health behaviours, medication use, healthcare-utilisation practices, personal goals, and reported barriers. The interactive workshop reinforced knowledge of hypertension and diabetes, healthy behaviours, medication and treatment adherence, self-care, prevention of complications, and disease-monitoring skills. It included practical demonstrations of blood pressure and blood glucose monitoring and enabled direct communication between participants, government healthcare providers, local administrators, elected local representatives, and community leaders. Participants could ask questions about available services, service costs, medicines, diagnostic tests, follow-up requirements, and procedures for obtaining care. Guided health-service visits introduced participants to formal government primary healthcare services. Participants were shown relevant service points, laboratory and diagnostic facilities, medicine-supply arrangements, the non-communicable disease corner, and the steps required to register, consult a healthcare provider, receive blood pressure or blood glucose measurements and other investigations, obtain treatment or medicines where available, and arrange referral or follow-up care. These visits were intended to reduce uncertainty or hesitation about government facilities, improve health-system literacy, strengthen trust in qualified healthcare providers, and help participants use services independently. Educational and self-monitoring materials included health diaries, posters, leaflets, and practical self-care information presented in accessible language. The materials covered hypertension and diabetes basics, symptoms and risk factors, healthy behaviours, medication adherence, self-monitoring, signs requiring professional medical attention, and the process of accessing government healthcare services. Participants used the diaries to record health-related activities, medication-taking practices, healthcare visits, and blood pressure or blood glucose information where available, and to support discussion during subsequent counselling visits. Intervention providers and relevant expertise: Two Community Health Workers served as the principal frontline intervention facilitators. They were drawn from community health programmes and local field networks supported by the James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. The Community Health Workers had experience in community engagement, health education, basic disease-related support, participant follow-up, referrals, point-of-care activities, and linkage with local healthcare services. They delivered the individualised home-based counselling, motivational and behavioural support, telephone support, follow-up, reinforcement of educational messages, and guidance on accessing healthcare services. Before implementation, the two Community Health Workers completed an intensive five-day training programme. The training covered the clinical basics of hypertension and diabetes; symptoms, risk factors, complications, and management; healthy diet, salt reduction, physical activity, medication adherence, and other behavioural practices; blood pressure and blood glucose monitoring; government hypertension and diabetes services; practical healthcare navigation and referral; communication and counselling skills; motivational support; individual goal setting; problem-solving; and methods of addressing barriers to behaviour change, treatment adherence, self-management, and healthcare utilisation. Government healthcare personnel participated in the facility-based components. The Upazila Health and Family Planning Officer, doctors, nurses, and other personnel at the Upazila Health Complex explained available hypertension and diabetes services, service costs, clinical processes, laboratory facilities, medicine availability, regular check-ups, and follow-up procedures. Mode of delivery: The intervention used an integrated community–facility delivery approach combining individual face-to-face counselling, group education, practical exposure to healthcare facilities, printed educational and self-monitoring resources, and telephone support. Individualised counselling was delivered face to face and one to one in each participant’s home. The Community Health Workers used the 5A’s Motivational Interviewing Approach to assess existing practices, provide personalised education, agree on achievable goals, support healthy behaviours and medication adherence, review progress, identify barriers, and develop practical solutions. The home-based format allowed counselling to be tailored to participants’ living conditions, family circumstances, dietary practices, daily routines, treatment practices, healthcare use, and access barriers. The interactive workshop was delivered face to face as a group activity at the Upazila Health Complex, the main government healthcare facility operating at the subdistrict level. It combined health education, practical demonstrations, discussion, and direct interaction with healthcare providers, local administrators, elected local council representatives, and community leaders. Guided health-service activities were delivered face to face at the Upazila Health Complex and local Community Clinics. Community Clinics are government primary healthcare facilities situated closer to rural communities. The Community Health Workers, lead researcher, and facility personnel physically demonstrated where and how participants could obtain consultations, blood pressure and blood glucose measurements, diagnostic tests, treatment, medicines where available, referral, and follow-up. Participants were also introduced to the non-communicable disease corner, a designated service point for non-communicable disease screening and management within the government health system. Educational materials were supplied for use at home throughout the intervention. Telephone communication supplemented the face-to-face contacts. Community Health Workers provided encouragement, reminders, follow-up, and problem-solving support by telephone throughout the intervention period. Telephone support was used to reinforce healthy behaviours, medication adherence, self-monitoring, attendance at planned intervention activities, use of government healthcare services, and follow-up after participants encountered difficulties accessing care. Frequency and duration: The intervention was delivered over 12 weeks. Each intervention participant received four individual, face-to-face, home-based counselling sessions in Weeks 1, 4, 8, and 12. Each counselling session lasted approximately 30 minutes. The Week 1 session focused on rapport building, assessment of existing practices, disease education, behavioural risk reduction, and individual goal setting. The sessions in Weeks 4 and 8 reviewed progress, reinforced healthy behaviours and medication adherence, addressed barriers, and supported self-monitoring and practical problem-solving using the health diaries and educational materials. The final session in Week 12 focused on maintaining healthy practices, medication adherence, disease monitoring, and continuing engagement with community- and facility-based healthcare services. A three-hour interactive workshop and an approximately two-hour guided visit to the Upazila Health Complex were conducted during Week 2. Guided visits to local Community Clinics occurred during Weeks 6–7. Telephone encouragement, reminders, follow-up, and problem-solving support were provided between scheduled counselling sessions and as needed throughout the 12-week intervention. Educational and self-monitoring materials and telephone access to the Community Health Workers remained available throughout the intervention period. Intervention setting: The intervention was conducted in Chirirbandar Upazila, Dinajpur District, rural Bangladesh. Individual counselling and review of participants’ educational materials and health diaries were undertaken at participants’ homes. The group workshop and principal guided health-service activities were conducted at the Chirirbandar Upazila Health Complex, a government subdistrict-level healthcare facility. Additional guided visits were conducted at government Community Clinics located closer to participants’ residences. Telephone follow-up and support were delivered remotely between scheduled face-to-face contacts. The combination of participants’ homes, community settings, and government healthcare facilities was intended to connect daily healthy behaviours, medication use, disease monitoring, and self-management practices with continuing access to qualified healthcare services. Adherence, reminders, monitoring and fidelity: Participant adherence was supported through four scheduled home-based counselling sessions in Weeks 1, 4, 8, and 12, telephone reminders and follow-up, access to Community Health Worker support during the 12-week intervention, individual goal setting, health diaries, educational materials, and tailored problem-solving. Attendance at counselling sessions, the interactive workshop, and guided healthcare-facility activities was recorded using intervention attendance and follow-up logs. During follow-up contacts, Community Health Workers reviewed participants’ progress in healthy behaviours, including diet, salt intake, physical activity, smoking and alcohol-related practices where applicable, medication adherence, blood pressure and blood glucose monitoring, regular check-ups, and use of qualified healthcare services. Participants’ health diaries were reviewed to reinforce self-monitoring, identify barriers, correct misunderstandings, and revise individual goals where necessary. Intervention fidelity was supported through structured preparation, standardised materials, supervision, and monitoring of the two Community Health Workers. Before implementation, both Community Health Workers completed the five-day training programme described above. Before full intervention delivery, the Community Health Workers conducted moderated counselling with three to four selected cases. This allowed the research team to assess their performance, provide feedback, and standardise the quality and content of counselling. Standardised counselling guidance, healthy-behaviour guidelines, educational materials, intervention schedules, attendance records, and follow-up logs were used throughout the intervention. The lead researcher provided ongoing supervision and implementation monitoring, while the supervisory team provided scientific, clinical, public health, methodological, and local implementation oversight. Implementation fidelity, feasibility, and acceptability were also assessed during and after the intervention through quantitative and qualitative process-evaluation methods informed by the RE-AIM framework. The evaluation examined participant reach and engagement, adherence to intervention activities, perceived changes and useful intervention components, fidelity of delivery, implementation challenges, adaptations made during delivery, additional support requirements, stakeholder adoption, and the potential maintenance and sustainability of healthy behaviours, medication adherence, self-management, and healthcare-service utilisation.