Background: Diabetes is 7th largest cause of death worldwide, and prevalence is increasing rapidly in low-and\nmiddle-income countries. There is an urgent need to develop and test interventions to prevent and control diabetes and\ndevelop the theory about how such interventions can be effective. We conducted a participatory learning and action (PLA)\nintervention with community groups in rural Bangladesh which was evaluated through a cluster randomised controlled trial.\nThere was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA\ngroup compared with the control group. We present findings from qualitative process evaluation research to explore how\nthis intervention was effective.\nMethods: We conducted group interviews and focus group discussions using photovoice with purposively sampled group\nattenders and non-attenders, and intervention implementers. Data were collected before the trial analysis. We used inductive\ncontent analysis to generate theory from the data.\nResults: The intervention increased the health literacy of individuals and communities - developing their\nknowledge, capacity and self-confidence to enact healthy behaviours. Community, household and individual\ncapacity increased through social support and social networks, which then created an enabling community\ncontext, further strengthening agency and enabling community action. This increased opportunities for healthy\nbehaviour. Community actions addressed lack of awareness about diabetes, gendered barriers to physical activity and\nlack of access to blood glucose testing. The interaction between the individual, household, and community contexts\namplified change, and yet there was limited engagement with macro level, or â??stateâ??, barriers to healthy behaviour.\nConclusions: The participatory approach enabled groups to analyse how context affected their ability to have healthy\nbehaviours and participants engaged with issues as a community in the ways that they felt comfortable. We suggest\nmeasuring health literacy and social networks in future interventions and recommend specific capacity strengthening\nto develop public accountability mechanisms and health systems strengthening to complement community-based\ninterventions.
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