Community Health
From community diabetes risk screening to a knowledge library for self-care at every age — community public health work that connects data, services and knowledge.
Translated from Thai · reviewed by the CF team
From reactive to proactive care
Our community health work aims to shift the goal of chronic disease care from “controlling symptoms” to “disease remission” (Remission). We classify people at risk according to the stage of their disease, then plan proactive care before symptoms develop, rather than waiting for patients to seek services once problems arise.
A platform connecting services at multiple levels
The digital system connects local health service providers with the public. This includes self-screening for health risks, accessible health information for the general public, and building two-way communication skills between providers from different professions and service users with varying levels of health literacy (Health/Diabetes Literacy).
People living with diabetes and at-risk groups in urban communities, primary healthcare service providers, and members of the general public seeking knowledge about self-care. Work is carried out with Sathaban Wichai lae Phatthana Nayobai Foundation (PRI) and Folk Doctor Foundation.
- 01 Enable people to screen themselves for diabetes risk and classify service users by disease stage to plan individualised care.
- 02 Connect comprehensive chronic disease management services and build multidisciplinary collaboration skills.
- 03 Share an accessible knowledge library on self-care for the general public at every age.
- 04 Design effectiveness indicators and test new approaches in pilot areas before scaling up.
2 projects
A project is how we act on an Issue. Every progress update from the field is on the project’s own page.
Health Promotion Platform for People Living with Diabetes
A community-based diabetes risk screening system that aims to shift the care goal from "symptom control" to "diabetes remission"
Empower Living
A self-care health knowledge website tailored to specific population groups, by the Folk Doctor Foundation in partnership with ThaiHealth.
How can we
help you?
Choose the question that fits your role. Answers are summarised from our own records of the work, and you can talk to the CF team from any card.
What change does this work create, and how do you know it is effective?
Work to develop proactive diabetes care approaches and digital health tools, with reported operations in 5 provinces and 1,406 service users, but no published health outcomes
Community health work connects screening, care tailored to each stage of the disease, and health knowledge to shift from waiting for treatment to proactive care, but evidence of health outcomes remains limited. This Issue
- Health Promotion Platform for People Living with Diabetes has reported operations in 5 provinces and 1,406 service users. The system collects health indicators and has a Dashboard that compares data from users’ first and most recent records, including the proportion of service users who reach the Prevention or Remission level for diabetes, as configured by the Local admin. ProjectHealth Promotion Platform for People Living with Diabetes However, we have not yet made public data on the number of users, service areas, or health outcomes, so it is not yet possible to conclude how much the approach has changed health outcomes. ProjectHealth Promotion Platform for People Living with Diabetes
- Empower Living is a self-care health information website for 5 population groups, using questions and real cases as its content. However, we have not yet recorded results showing changes in visitors’ health or use of the information. ProjectEmpower Living
How was this work carried out, and what lessons can be applied going forward?
We screen and classify service users by disease stage, plan individual care, and develop tools through discussions with local areas. The lesson is that tools should fit existing workflows and real-world constraints.
We use the platform to connect risk assessment, individual care, and communication between the public and service units, then adapt the tools based on how they are used and the needs identified locally. ProjectHealth Promotion Platform for People Living with Diabetes The key lesson is that we should not start by introducing a new system to replace existing mechanisms without first considering the context. UpdateLampang: Mae Tha primary care unit’s field data collection system works well; identifies demand for 3 new Micro-apps
- Health Promotion Platform for People Living with Diabetes classifies service users by disease stage to plan individual care and allows them to assess their own risk through an online screening form without having to register as members. ProjectHealth Promotion Platform for People Living with Diabetes In further development, we adapted the service-user and Local admin sections and created a public Micro-app for assessing diabetes status and interpreting blood test results, without requiring a user account. UpdateProgress on the diabetes care platform, periods 2–3: adding personalised health plans, Local Admin tools and 2 public Micro-apps Discussions in Lampang found that the system for collecting data through village health volunteers and Google Form suited the way people worked in that area, showing that it is best to build on systems that are already working well. UpdateLampang: Mae Tha primary care unit’s field data collection system works well; identifies demand for 3 new Micro-apps
- Empower Living uses questions and answers based on real cases, categorises them by population group, and provides a website-wide search system. This is another approach to making knowledge relevant to different user groups. ProjectEmpower Living
What types of areas is this approach suitable for, and what is needed to get started in our area?
The approach is intended for urban communities and primary care units, and should be adapted to local work systems and internet access. We have not formally recorded any requirements or initial conditions.
This approach is designed to connect people with local health services, particularly care for people living with diabetes and at-risk groups in urban communities. This Issue Findings from the areas indicate that it should begin with an understanding of existing work systems and how easily people can access tools, rather than applying the same model everywhere. UpdateLampang: Mae Tha primary care unit’s field data collection system works well; identifies demand for 3 new Micro-apps
- Health Promotion Platform for People Living with Diabetes uses self-screening, classification by disease stage and links to multidisciplinary services. ProjectHealth Promotion Platform for People Living with Diabetes In Lampang, nearby primary care units and Mae Tha Hospital have a system for collecting field data through village health volunteers, using paper and Google Forms, which is suitable for the local context. At the same time, there is a need for easy-to-understand educational materials that work with limited or slow internet access. UpdateLampang: Mae Tha primary care unit’s field data collection system works well; identifies demand for 3 new Micro-apps Discussions in Nakhon Phanom also found interest in food menus and diabetes information, as well as the possibility of hosting service-user data on the university's cloud server. UpdateNakhon Phanom: Nakhon Phanom University indicates readiness to host project service-user data
We have not yet recorded any specific requirements or conditions that areas must have to begin using this approach.
What methods or tools can we start using right away?
There is an online diabetes screening tool and public Micro-apps for assessing diabetes status and interpreting blood test results, which can be used without a user account, as well as a website with information on self-care.
There are tools designed for the public to use on their own, as well as information channels with content organised by user group. ProjectHealth Promotion Platform for People Living with Diabetes The recorded tools are as follows:
- Health Promotion Platform for People Living with Diabetes has an online screening tool for people to assess their own risk of diabetes, which can be used without registering as a member. ProjectHealth Promotion Platform for People Living with Diabetes In addition, 2 public Micro-apps have been developed: one for assessing diabetes status and another for interpreting blood test results and health information. Both can be used without a user account. UpdateProgress on the diabetes care platform, periods 2–3: adding personalised health plans, Local Admin tools and 2 public Micro-apps If users want to save their assessment results for follow-up, the diabetes status assessment system recommends signing in to the members’ section. UpdateProgress on the diabetes care platform, periods 2–3: adding personalised health plans, Local Admin tools and 2 public Micro-apps
- Empower Living is a website with question-and-answer content based on real cases, organised into categories for new parents, single parents, freelancers, people of diverse sexual orientations and gender identities, and older adults. It also has a search function across the entire website. ProjectEmpower Living
These tools cover screening, understanding health information, and finding information to support self-care.
How does this work connect to systemic issues, and what kind of collaboration is needed?
Work connecting public care with service providers and health knowledge, with collaboration recorded with PRI and the Folk Doctor Foundation. We have not yet recorded any specific requests for collaboration from new partners.
Community health work addresses the need to connect information, services and knowledge so that people and service providers can work together on proactive healthcare. This Issue The recorded collaborations relate to operating the platform and sharing knowledge, but no specific form of support sought from new partners has been identified.
- Health Promotion Platform for People Living with Diabetes connects screening and individual care with local health service providers, while emphasising multidisciplinary collaboration. ProjectHealth Promotion Platform for People Living with Diabetes The project is run by the Policy Research and Development Institute Foundation (PRI), with support from the Thai Health Promotion Foundation (ThaiHealth). ProjectHealth Promotion Platform for People Living with Diabetes Discussions with local organisations have also helped identify needs for meal menus, education and tools suitable for areas with limited internet access. UpdateLampang: Mae Tha primary care unit’s field data collection system works well; identifies demand for 3 new Micro-apps UpdateNakhon Phanom: Nakhon Phanom University indicates readiness to host project service-user data
- Empower Living works on health knowledge for specific groups. The Folk Doctor Foundation owns and publishes it, and the Thai Health Promotion Foundation (ThaiHealth) supported its joint launch. ProjectEmpower Living
We have not yet recorded what form further collaboration is sought in, or which types of partners are specifically being sought.