|Author(s)||Gulzira Karimova1, Barbara Matthys2, Tohirjon Tagoev3, Amridin Abdurahmonov 4, Peter Steinmann 5, Kaspar Wyss 6.
|Affiliation(s)||1 Swiss Centre for International Health, Tajik-Swiss Health Reform and Family Medicine Project (Project Sino) , Dushanbe, Tajikistan, 2 Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Zürich, Switzerland, 3 see below, Republican Clinical Endocrinology Centre, Dushanbe, Tajikistan, 4 see below, Republican Clinical Endocrinology Centre, Dushanbe, Tajikistan, 5 Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 6 Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.|
|Country - ies of focus||Tajikistan|
|Relevant to the conference tracks||Advocacy and Communication|
|Summary||The prevalence of diabetes and associated risk factors was assessed among a population aged ≥45 years in two health districts in southern Tajikistan. Study participants answered a questionnaire on risk factors for diabetes and for general chronic diseases. Blood pressure and anthropometric indicators were taken and the blood glucose level determined. Complete data was obtained from 584 participants. One third suffered from a glucose metabolism impairment and one fifth was diagnosed as diabetic. Two third of the participants were overweight and half had an elevated blood pressure. Based on the study findings, diabetes-related health care was strengthened in rural health centres.|
|Background||About two percent of all deaths in Tajikistan are attributed to diabetes. Representative surveys on diabetes and chronic diseases in general are scarce across Central Asia. A study on the utilization of family medicine services from 2011 described the lack of information regarding the diagnostic and management capacity in rural health centres.
The Tajik-Swiss Health Reform and Family Medicine Project (Project Sino) is developing, validating and supporting the implementation of accessible, affordable and sustainable Primary Health Care (PHC) models and family medicine services in pilot districts. The project was launched in 2003 and has so far covered eight health districts. The project outcomes refer to 1) increased involvement of community groups and strengthened family medicine services; 2) improved access to high-quality PHC services and validated models for family medicine; and 3) transfer of experiences to health policy planning and harmonised activities with health sector partners.
A population-based survey was designed to collect reliable information on the prevalence of impaired glucose tolerance and diabetes and risk factors related to diabetes and chronic diseases among the ≥45 year old population in two pilot districts of Project Sino in southern Tajikistan.
|Objectives||The overall objective was to assess the prevalence of impaired glucose tolerance and diabetes, as well as risk factors associated with diabetes and chronic diseases in general, among rural and urban populations in southern Tajikistan. The quality of care provided to diabetes patients at the level of PHC services was also evaluated.
Specific objectives included:
1) To test a representative population sample for impaired glucose tolerance and diabetes using blood glucose testing and, if indicated, a standard oral glucose tolerance test recommended by WHO, i.e. the 2 hour oral glucose tolerance test (OGTT).
2) To assess risk factors for impaired glucose tolerance and diabetes through an individual questionnaire and measurements of health-related parameters (blood pressure and anthropometric indicators).
3) To assess available services for diabetes patients at the level of PHC services and specialised institutions.
|Methodology||A cross-sectional survey was conducted in April 2012. The survey was carried out in randomly selected rural and urban communities in two pilot districts of the Project Sino in southern Tajikistan. According to the Ministry of Health, the density of medical personnel in both districts is low compared to other districts. The sample size calculation considered an estimated proportion of 18% of the total population aged ≥45 years. The study was hence designed for a screening of 700 subjects. The study area was stratified into rural and urban communities. The survey communities were randomly selected among all eligible communities of the two pilot districts using a probability proportional to size of population approach. A total of 25 households were selected in each community using the EPI survey approach.
The study was carried out by the Project Sino in collaboration with two endocrinologists specialised in diabetes from the Republican Clinical Endocrinology Centre, district head doctors, specialized medical doctors and registered nurses at hospital and PHC level. Potential participants aged ≥45 years and long-term residents of more than 5 years in the community were recruited in their homes. Participants who gave their informed consent for the study were invited to an interview which included questions on the socioeconomic profile of the household, individual nutritional habits and risk factors for diabetes and chronic diseases in general, and previous diabetes diagnosis and treatment history. Health-related parameters (blood pressure and height and weight) were measured, and the blood glucose level determined after overnight fasting. If indicated, the 2 hour oral glucose tolerance test was performed. Semi-structured interviews were conducted with health care workers, family doctors, specialists and PHC managers at different levels of the health system. A range of diabetes-related services offered were explored, and the status of the national health programmes targeting diabetes. Preliminary results of the study were discussed.
Data was entered into a public statistical package used for data entry including double-entry of one third of the data. Data analysis was performed in Stata Statistical Software. Data analysis focused on standard epidemiological outcomes and the identification of risk factors for impaired glucose tolerance and diabetes.
|Results||Out of a total of 672 individuals contacted, complete datasets (questionnaires, test results including 2h follow-up test if required) were available for 584 individuals. Less than one third of the participants were male and less than half were aged 45-54 years. 31% of the study participants were affected by a form of glucose metabolism impairment: 21% were diagnosed or had already been diagnosed as diabetic, 5% had impaired glucose tolerance and 4% had impaired fasting glucose. Half of the participants classified as diabetic were aware of their status.
A range of self-reported signs and symptoms were reported significantly more frequently among individuals with diabetes or impaired glucose metabolism. A multivariate regression model controlling for location, sex and age group identified being thirsty (odds ratio; OR=2.22), numbness of hands or feet (OR=1.96) and itching private parts (OR=3.79) as significant.
|Conclusion||The results indicated high levels of glucose metabolism impairments among the ≥45 year old study population, particularly among men and those aged ≥55 years. A majority was observed to have overweight and high blood pressure, and thus being at risk of chronic diseases. While the population seems to have a certain awareness of diabetes, many of the affected still go without (effective) treatment. The findings of this study were thus made available to key stakeholders such as the family doctors and PHC managers of the project pilot districts, the Republican Clinical Endocrinology Centre and the Ministry of Health, and organizations focusing on chronic disease prevention and care. Recommendations pertaining to strengthen health care and prevention of chronic diseases at the peripheral level were followed-up by the Project Sino in all pilot districts.The awareness for chronic diseases services available in PHC facilities was raised by the following factors:
• Information on chronic diseases is provided by PHC health staff during routine household visits. Blood pressure and anthropometric indicators are measured and identified high-risk patients are invited to the health centre for a blood glucose test.
• Diabetes patients are regularly followed by trained PHC health staff.
Training of PHC health personnel on diabetes and provision of basic diagnostic services has been expanded by the following:
• Training is provided by diabetes specialists of the Republican Clinical Endocrinology Centre to district endocrinologists and to medical doctors of PHC facilities.
• A manual on diabetes including a simple screening form to identify individuals at high risk of diabetes during consultation was developed by the Republican Clinical Endocrinology Centre, and is distributed during trainings.
• Medical kits provided to family medicine practitioners include glucometers.
• Peer-review groups on chronic diseases are regularly held by trained family medicine practitioners. Peer-review groups of trained family medicine nurses recently started.
Awareness on health risks associated with overweight and high blood pressure and prevention is raised by the following:
• Information on chronic diseases and prevention is provided to the population through PHC health staff and community groups. Events such as weddings, parties and meetings in mosques are used as sensitization platforms.
• The health centres are supported by the community groups in identifying high-risk individuals and referring them to the health centre.