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Case Management in Mental Health Settings in Bosnia and Herzegovina.

Author(s) Darko Paranos1, Biljana Lakić2, Tatjana Popović3, Dženita Hrelja Hasečić 4.
Affiliation(s) 1Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina, 2Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 3Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 4Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Chronic Diseases
Summary Within scope of the Mental Health Project in Bosnia and Herzegovina (BIH) the Case Management in Mental Health was introduced across the country with the aim of improving the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs. In order to achieve planned objectives an integrated set of activities was conducted compromising of teaching materials development, continuous education activities targeting Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives and (Peer) Support to Mental Health institutions in applying Case Management. Initial findings indicate the significant increase in the number of CMHCs which successfully started with the application of the Case Management in their institutions.
Background Activities were conducted within the scope of the Mental Health Project (MHP) in Bosnia and Herzegovina (BIH). The Mental Health Project in BIH is a result of continuous commitment of the health ministries to continue the mental health reform in BIH. The mental health reform was launched in 1996 focusing on community-based care as a contrast to the traditional model that was mainly oriented towards hospital treatment of persons with mental disorders. The overall goal of the Mental Health Project in BIH, in the period June 2010 - December 2013, was to improve the general mental health of the population and enhance the capacities of policy makers and competent institutions for complying with European standards in mental health care in BIH. Since 2011 the Mental Health Project in Bosnia and Herzegovina was involved in trainings of Community Mental Health Centres staff in the field of Case Management with the aim to improve the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs.
Objectives The objectives of the Mental Health in BiH Project in the period June 2010 to December 2013 were as follows: 1. Improved administrative and legislative frameworks to enable efficient operations and processes in mental health care in both BiH entities, Federation of Bosnia and Herzegovina and Republika Srpska.
2. Persons with mental problems to have access to improved and better quality services of mental health care at the community level.
3. Provision of high-quality mental health services at the community level is supported as a priority of the reform process by the management structures in Community Health Centres.
4. Capacities to fight against stigmatisation and discrimination related to mental disorders are strengthened. Within the objective 2, the specific objectives include: a) Competencies and skills of the multidisciplinary teams of the Community Centres for Mental Health to be enhanced, b) Independence and responsibility of the nurses in provision of the mental health services and direct work with clients to be enhanced.In order to achieve planned objectives the integrated set of activities were conducted:
• Teaching materials development -
o The Case Management continuing education Curriculum and Manual development
• The continuous education -
o A Training of Trainers (ToT) course in Case Management
o The health professionals continuous education of Community Mental Health Centres multidisciplinary teams and
psychiatric hospitals/clinics/departments representatives
• (Peer) Support to Mental Health institutions in applying Case Management -
o Mentoring and support to Community Mental Health Centres and psychiatric
hospitals/clinics/departments in applying Case Management.
Methodology The case management is a collaborative process which connects users with services and available resources aimed at ensuring provision of optimal care. The approach involves the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders, and often reluctant to come into contact with mental health services. It is activated by establishing contact with customers in the community, a comprehensive needs assessment, developing individual "tailored" packages of care and effective coordination of services and treatments in a variety of services which increases the user's potential for recovery. The process of introducing the Case Management principles across Mental Health Settings in Bosnia and Herzegovina is based on a set of integrated activities. The Development of Teaching materials sets the fundamentals for the continuous education of multidisciplinary teams employed by Community Mental Health Centres and psychiatric hospitals/clinics/departments representatives. The core materials are the Case Management in Mental Health Curriculum and Manual which are organised into seven modules: I - Introduction to Case Management - concepts, principles, practices and theories; II – User Involvement and needs assessment; III - Assessment and Risk Management; IV - Planning of care, implementation of treatment and use of resources in the community; V - The Case Management at the first psychotic episode, early intervention and prevention of relapse; VI - Team Approach to Mental Health; VII - Gender and Mental Health. The Mental Health Professional continuous education was organised in two phases. The first step was to identify, recruit and train group of mental health professionals as a part of Case Management Training of Trainers course. The next step was to deploy trainers in training of Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives.Applying the Care Coordination model across the country began after the completion of the trainings. The Peer support to Mental Health Institutions across the country is organised Systematic (peer) support to application principles in Mental Health Settings will be conducted in between September- December 2013 with aim of ensuring increased access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs is secured.
Results The Mental Health Case Management Curriculum and Manual were developed setting the basis for continuous education of Mental Health Professionals in Bosnia and Herzegovina. Training for trainers was completed in 4 training cycles with total duration of 9 days. As an education result, 21 mental health professionals have been certificated and formally appointed as future trainers by entity MoHs. Training of CMHC multidisciplinary teams was organised involving 625 mental health professionals from 67 CMHCs and 15 psychiatric hospitals/clinics/departments. 565 professionals (or 90%) passed the final exam, and successfully completed the training. After completion of the trainings the application of Case Management across the Mental Health care institutions started. Initial findings indicate that the 54% CMHCs (37 out of 69) successfully started the application of the Case Management in their institutions. As such this data indicates the significant increase in number of institutions applying the Case Management compared with 4 CMHCs from the baseline conducted in 2008. (Peer) Support to Mental Health institutions will provide not only support to the institutions in applying Case Management in standardised manner, but will provide insight in terms of effectiveness in changing the practice of those institutions. The key indicators to measure success of the process (in the short term) are the percentage of CMHCs appointing the Case Managers, number of appointed Case managers per CMHC (segregated by profession, particular focus on nurses) and percentage of service users involved in care plan development. A particular focus will be on measuring the service users involved in Case Management satisfaction.
Conclusion CMHCs capacities to involve the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders are improved when compared to the initial survey. The significant increase in the number of CMHCs applying Case Management in their institutions is observed. The Case Management is recognised by the revised service nomenclature, an organised and officially recognised classification/ registry of the health services endorsed by entity/cantonal Health Insurance Funds. As only those services officially recognised in the nomenclature can be performed by health institutions and charged to HIFs, a long term sustainability of Case Management is supported. Initial findings emphasise the issues of a large number of patients covered by the coordinated care, lack of staff and other resources required for adequate Case Management application in their institutions. In addition, another obstacle in the implementation of the Case Management observed is weak cooperation among agencies and institutions involved in the Case Management process.

Nicotine Patch Dispensing Behaviour of Pharmacists in Drugstores: Chiang Mai, Thailand.

Author(s) Suntheep Batra1
Affiliation(s) 1Department of Pharmaceutical Care, Faculty of Pharmacy, Payap University, Chiang Mai, Thailand.
Country - ies of focus Thailand
Relevant to the conference tracks Chronic Diseases
Summary Community pharmacists in Chiang Mai, Thailand had good knowledge of, but extremely sub-optimal dispensing behaviors of nicotine patches. This is particularly in relation to advising specific usage instructions of the nicotine patch and assessing nicotine dependence and willingness of smokers to quit. This information will be useful to guide and raise the awareness of community pharmacists in dispensing nicotine patches and providing counselling for smoking cessation.
Background Tobacco use is the most important public health problem globally, and a risk factor for many acute or chronic diseases which are the leading preventable cause of death in the world. In Thailand, 14.3 million people (27.2%) are current tobacco users, and 12.5 million people (23.7%) currently smoked tobacco. Smoking killed 42,000 Thai smokers every year or 4.7 deaths in every hour. Pharmacotherapy is one of the success keys to smoking cessation. Community pharmacists can dispense these medicines without prescription in drugstores in Thailand and also have an important role in smoking cessation counselling. Thus, the pharmacists must have good knowledge of the usage instructions of these medicines, especially nicotine gum and patch which require special technique usage instructions, as well as counselling skills in order to improve drug therapy and smoking cessation effectiveness. The pharmacists’ behavior in dispensing nicotine gum has been studied before in Thailand, but the interpretation of the study was limited by small sample size. Furthermore, no data on the nicotine patch dispensing behavior of pharmacists in drugstore are available in Thailand. Therefore, it is important to evaluate nicotine patch dispensing behaviors and knowledge of community pharmacists.
Objectives The objectives of this study were to evaluate nicotine patch dispensing behaviors and knowledge of community pharmacists in Chiang Mai, Thailand.
Methodology In this cross-sectional descriptive study, 54 pharmacists who practiced in drugstores in Muang district, Chiang Mai, were enrolled by purposive random sampling. Pharmacists who practiced in drugstores where nicotine patches were not available, were excluded. The pharmacists’ behaviors in dispensing nicotine patches were observed by the mystery client technique. After a month, pharmacists’ knowledge about nicotine patch was assessed by the self-completion knowledge questionnaire. Data were collected between 1 July 2012 and 30 September 2012, and were analyzed by descriptive statistics, expressed as median (IQR) or n (%), as appropriate.
Results The results found that the median score of pharmacists’ behaviors about dispensing nicotine patches was 7.0 (4.0 – 12.0) from a total of 25. Choosing the appropriate dosage of a nicotine patch for smokers (94.4%) was the most frequently practiced behavior of pharmacists during the dispensing of a nicotine patch. However, advising about usage instructions of nicotine patch, and assessing nicotine dependence and willingness to quit of smokers were practiced by less than 20.0% of pharmacists. In term of knowledge, 48 pharmacists cooperated with the study questionnaire (response rate 88.9%). The median score of pharmacists’ knowledge about nicotine patch was 10.0 (9.0 – 12.0) from a total of 14. Almost every pharmacist (91.7%) knew about adverse drug reactions and prevention of these reactions from the nicotine patch, but most of them (72.9%) didn’t know about usage instructions of the nicotine patch.
Conclusion This study has demonstrated that the community pharmacists in Chiang Mai, Thailand had a good knowledge, but extremely sub-optimal dispensing behaviors of nicotine patches, especially in advising specific usage instructions of nicotine patch and assessing nicotine dependence and willingness to quit of smokers.

Integrating neuro-psychiatric disorders at the level of primary health care centres: Guinea

Author(s) Abdoulaye SOW1, Oury SY2, Amatigui DIALLO3, Abdoulaye KOULIBALY4, Mouctar DIALLO5, Binta BAH6.
Affiliation(s) 1Mangment, Medical fraternity Guinea, Conakkry, Guinea, 2Physian, Medical fraternity Guinea, Conakry, Guinea, 3Physian, Medical fraternity Guinea, Conakry, Guinea, 4Physian, Medical fraternity Guinea, Conakry,Guinea, 5Physian, Medical fraternity Guinea, Conakry, Guinea, 6research, Medical fraternity Guinea, Conakry, Guinea.
Country - ies of focus Guinea
Relevant to the conference tracks Chronic Diseases
Summary Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease. According to the World Health Report 2000 neuropsychiatric disorders (a component of mental health) are the second cause of disability-adjusted life years (DALYs), behind the infectious and parasitic diseases. Under the theme “Stop exclusion, Dare to care”, the year 2001 was dedicated by the WHO as the "Year of mental health”. Since ancient times, epilepsy has remained a controversial subject for many world populations. This is because mental illness has been perceived as socio-anthropological for many societies.
What challenges does your project address and why is it of importance? Primary health care strategy aims to make accessible to as many people as possible healthcare according to people’s needs, at an affordable cost and taking into account a country's given resources. Equity and social justice are the basic principles of this strategy.
According to the World Health Report 2002, neuropsychiatric disorders account for 13 % of the global burden of disabilities adjusted life years (DALYs). In Guinea, while significant progress has been made in primary health care programmes, little improvement has been measured in the field of mental health. The psychiatrist ratio per capita is one of the lowest in the world. A similar gap in the number of neurologists prevails throughout the country.
In order to address this gap, the Guinea Medical Fraternity (a Guinean association of doctors) opted for the integration of neuropsychiatric consultation into the daily work of the general practioners working in its health centers.
At the opening of its health centers in the 90's, one missing element was the lack of data about the number of patients who sought consultation for mental health problems. At that time, no information was available due to the lack of qualified human resources and poor access to medicines. To tackle this challenge, Guinea Medical Fraternity initiated the project SaMoa, and used 'action research.'
How have you addressed these challenges? Do you see a solution? The model of care employed is based on the three-dimensional approach used in outpatient mental health management: medical, socio-psychological and the community. These three dimensions are combined for almost all patients in our centers, without following neither a chronological nor a hierarchical order.
For the two groups of diseases described in this abstract, epilepsy and mental health disorders, a care package is offered to the patient. This includes: identification of fixed and advanced strategy for the patient, medical treatment (with antipsychotics and/or anticonvulsants), follow-up and psychosocial support (individual interview, with family members, home visits), family and community reintegration through discussion groups and reintegration workshops (graphical expression, apprenticeships) and finally social support interventions (such as supporting the recovery of a lost job or supporting patients in rebuilding a couple in crisis).
In order to ensure continuity of care, a number of materials have been developed.
These include:
• Personal health record (first visit and follow up)
• Home visit notebook
• Reintegration notebook (describing the patient personal project)
• Group workshops notebook.
• Monthly collection sheet.
• Monthly report
Regular inter-professional encounters have been established in order to promote synergies and complementarity among caregivers and has been used to foster continuous staff training. This framework is supported by:
• A joint consultation between a generalist and a specialist (neuropsychiatrist ) at the beginning of the project
• A daily joint consultation between doctors and social workers
• A weekly team meeting between doctors, social workers and community volunteers, to discuss specific cases
• A monthly coordination meeting, which brings together the heads of unit of each health center and the officials of the NGO.
How do you know whether you have made a difference? From January 2000 to June 2013, 7079 mental health problems were diagnosed among which 47 % were psychoses, 33% were epilepsy cases and the remaining 20% represented by depression, dementia, neurosis, social problems and cerebral motor deficiencies.
Among patients put under treatment, two main molecules were used for psychosis (different forms of Haloperidol and Akineton as corrector) and for epilepsy, four essential generic drugs (carbamazepine, phenobarbital, phenytoin and sodium valproate). We found a positive impact for both patients and their families, health care providers as well as for health centres.
For the patient, the impact is assessed by how much healthcare management has improved by integrating the socio-cultural context of the patient and his/her family, how much the intervention has strengthened patient-provider relationship and contributed to better adherence and how much the intervention has facilitated patients social reintegration and has strengthened their economic capacity.
At the level of health centers and providers: the impact is felt at many levels
 Improved patient-provider relationship (beyond mentally ill patients).
Indeed, GP’s trained to adopt a more holistic bio-psycho-social approach with psychiatric patients and spontaneously applied a similar approach vis-à-vis other patients, spending more time, listening and discussing with them and paying more attention to their psychosomatic problems.
 Improved relationships between health centers and the communities they serve.
Communities started to see healthcare providers and the health centres as partners and contributed to the development of the relationship.
 Improved relationships between primary health centers and referral hospitals.
Given the fact that the care package provided by the programme is not available in district hospitals, the project has reversed the usual pattern of the health pyramid that usually sees PHC centers referring their patients to a hospital. In this case, the opposite took place, hospitals sending their patients to the lower level of care.
 Implementation of several community initiatives around the health centres.
The momentum created by the project has allowed the emergence of community-led initiatives such as economic interest groups among intervention communities, involvement of young people in the village around health promotion activities and the establishment of patient support groups.
 Health centre as a training and internships for medical students in public health and community health workers. Successful health centres are coveted by academics whose students are engaged in the internships and the development of dissertations.
Have you or the project mobilized others and if so, who, why and how? The project involved several actors in different and various socio-medical fields.
In Guinea, networking is not integrated into the system. Each association operates in isolation and tries to protect its field of competencies as a private territory. Initiatives are confined to a limited territory or to a given intervention and do not benefit neither the beneficiaries nor field social workers. To break this single thought mindset, our project has created an inter-professional approach mobilizing a supportive and dynamic network of various health workers, social workers and human rights advocates in order to improve the management of heavy neuropsychiatric disorders.
Among the objectives, this initiative attempted also to demedicalize some health problems, to push healthcare providers to pay more attention to social problems and to involve other social stakeholders in medical work.
As an illustration, health centres provide care (medical consultations, nursing services and drugs) to all populations. Social centres provide services (psycho -social support, legal support, rehabilitation, social and professional reintegration) to the same populations. The interaction of these two levels of intervention can only be beneficial for patients, providers and medical-social structures.
Our methodology involves the organization of platforms for dialogue between actors, field visits, referrals of patients or target groups and the organization of joint actions.
The platforms are organized around a theme: clinical, social, results or best practice.
Field visits take place upon request in order to assess the social and/or medical situation of an identified patient, or to meet with an association that wants to share its experience and best practices or seek advice.
Social workers refer their clients to a healthcare professional for a medical condition and the healthcare professional refers their patients to social workers in order to be more effective not only in medical care but also to delegate certain activities (counseling, search of lost to follow up) in order to deal with other aspects.
Joint actions are put in place to identify, plan and agree upon a synergic mode of implementing activities that improve the quality of services offered.
When your donor funding runs out how will your idea continue to live? The project initially depended on single funding, but since its activities are integrated into health centres, it has become routine and no longer dependent on external funding. Yet, the fact that we are in the process of replicating and scaling up the programme in several other health centres, funding will be needed in order to train staff, provide a starting stock of essential generic drugs, conduct reintegration workshops and provide supportive teaching materials.

Integrating artistic programs in diabetes education and self management in Madagascar.

Author(s) Tojosoa Rajaonarison1, Haja Ramamonjisoa2, Tiziana Assal3, Jean-Philippe Assal4, Georges Ramahandridona5.
Affiliation(s) 1Art-therapy, Madagascar Diabetes Association, Antananarivo, Madagascar, 2Therapeutic Education, Madagascar Diabetes Association, Antananarivo, Madagascar, 3Art-therapy, Foundation for Research and Training in Patient Education, Geneva, Switzerland, 4Therapeutic Education, Foundation for Research and Training in Patient Education, Geneva,Switzerland, 5Medical, Madagascar Diabetes Association, Antananarivo, Madagascar.
Country - ies of focus Madagascar
Relevant to the conference tracks Chronic Diseases
Summary The Malagasy perception of diabetes is negative. Patient with diabetes often do not accept their treatment and their family members reject them. Heath caregivers need to be closer to patients and to promote a good collaboration with them.
Our Diabetic Association has organized up to 12 painting workshops from 2010 to 2013 with 141 patients. They are centered on patients’ problems and needs. Each workshop provides painting exercises associated with specific moments: blood sugar measurements, diet discussion, and hypoglycaemia. Health caregivers provide flashes of therapeutic education during this time. Workshops also provide psychological and social balance enabling patients to be more responsible for their health
What challenges does your project address and why is it of importance? Painting workshops are a tool to promote therapeutic patient education for all types of diabetics. Organized by A.MA.DIA. (Association Malgache contre le Diabète à Antananarivo), they have brought many changes in our participants’ lives: patients are finally able to express themselves more freely, they discover their personal creativity, they are more involved in social activity, they feel less isolated. This process has a strong effect on the coping ability of each patient. Adherence of treatment increases, medical appointments are better respected and the doctor–patient relationship improves. As a consequence, there is a general improvement of patients and care providers’ attitudes. They all feel more empowered in their daily activities. After the workshops patients feel that their family members understand them better.
How have you addressed these challenges? Do you see a solution? The A.MA.DIA has faced many problems over the years including crowded outpatient clinics, lack of enough fully trained personnel, difficulties in continuing education as well as being faced with false copies of medication: diabetic oral agent, antihypertensive drugs, and antibiotics. This situation has forced us to develop specific courses to teach patients to detect the copies of false drugs that patients may have bought cheaply at a local market.
Hypoglymia in children and young adults is another serious problem.
During the workshops with children, the blood sugar is tested and explanations are given about corrective snacks.
Another aspect is the timidity of patients in the presence of the care providers. The consequence is that patients suffer from a lack of psychological support.
Painting workshops reinforce continuing education as well as the self-reliability of patients.
They develop self-confidence and autonomy.
How do you know whether you have made a difference? The various activities we described, linked to therapeutic education, did not exist 4 years ago. Since their creation and development, there is an increasing demand for participation among patients as well as their families.
There is a weekly connection through skype between A.M.A.DIA and the Geneva center, and a monthly video sessions with the participation of experts who are at the disposal of the team of l’AMADIA Hospital. Those meetings allow joint discussions, lectures, supervision, continuing evaluation and support.
The experts have writen some observations about our workshops of Art-Therapy : “The thing that strikes all those who have observed the AMADIA workshops is the extraordinary enthusiasm and commitment of the caregivers and patients. Caregivers experiment continuously new ways of helping patients using art, working with different groups of participants: families, young diabetics, aged people as well as mixed groups."
The example of AMADIA shows that art can be integrated in a global system of care where emotional expression and medical care can be simultaneously present.
Have you or the project mobilized others and if so, who, why and how? Among the various approaches we have developed, we obtained help from the World Diabetes Foundation and the order of St. Jean France and Switzerland. This allowed the improvement of our Hospital AMADIA and the widening of detection campaigns throughout the country. We also have the benefit of monthly Video sessions with Geneva with the help Orange Madagascar and the Foundation for Research and Training for Patient Education in Geneva.
When your donor funding runs out how will your idea continue to live? We think that financial support from donors is of vital importance for the continuity of the painting workshops. Madagascar is a very low income country and so are the majority of our patients. Many people cannot even afford the cost of their daily pills.
However, psychological support is necessary for people living with diabetes. It is fully recognized that painting equipment colors, paper, brushes are expensive. This is why this type of practice should be supported.

Health-Related Quality of Life in Adults with Metabolic Syndrome: A Systematic Review and Meta-Analysis

Author(s) Asiandi Asiandi1, Miaofen Yen2
Affiliation(s) 1Institute of Allied Health Science, College of Medicine, National Cheng Kung University, Tainan, Taiwan, Tainan City, Taiwan, 2Department of Nursing and Institute of Allied Health Science, College of Medicine, National Cheng Kung University, Tainan City, Taiwan.
Country - ies of focus Indonesia
Relevant to the conference tracks Chronic Diseases
Summary This study found new evidence in the measurement of health related quaity of life in adult with metabolic syndrome (MetS). The main result found that there was a difference in HRQoL results measuring with SF-36 and EQ-5D and EQ-VAS.
Background The interrelationship between metabolic syndrome (MetS) and risk of diseases has consequences in that the impaired health-related quality of life (HRQOL) can become a burden.
Objectives The objective of this review was to estimate the HRQOL in adults with MetS measured with SF-36 and EQ-5D/EQ-VAS.
Methodology This systematic review and meta-analysis was conducted by following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) as a guideline. Articles published from 1983 to 2013 were searched from four databases: PubMed, Medline (Ovid), Scopus, and Web of Science. Two reviewers independently assessed the eligibility of the studies for inclusion in the review on the basis of the strength and quality of articles and extracts of eligible studies.
Results The seven studies which met the criteria of appraisal were included in the systematic review and meta-analysis. All of studies included used a cross-sectional study design with the quality of the evidence A or high quality (n = 3) and B or good quality (n = 4). Based on inverse variance of random effect model test, the results showed that four of SF-36 domains in HRQOL measurements were not significant in heterogeneity (physical functioning, general health, social functioning, and physical components summary), however showed a significant in effect size. Conversely, other SF-36 domains (role emotional, role physical, body pain, vitality, mental health, and mental component summary) showed a significant heterogeneity but did not illustrate a significant effect size. Overall, MetS was associated with significantly reduced HRQOL measured using SF-36 (SMD -0.23; 95% CI -0.29, -0.17; pp <0.00001). Test of heterogeneity was significant (I2 = 72%; p < 0.00001). However, the test for subgroup differences was not significant (I2 = 1.3%; p = 0.43).  MetS was not associated with significantly reduced EQ-5D (SMD -5.65; 95% CI -16.06, 4.43; p = 0.27) with a significant high heterogeneity (I2 = 100%; p <0.00001). Similarly, MetS was not associated with significantly reduced EQ-VAS (SMD -5.63; 95% CI -16.29, 5.02; p = 0.30) with a significant high heterogeneity (I2 = 100%; p <0.00001).
Conclusion The evidence illustrated that MetS was associated with significantly reduced HRQOL measured using SF-36. However, MetS was not associated with significantly reduced HRQOL measured using EQ-5D and EQ-VAS. The greater heterogeneity in this meta-analysis has confirmed the need to avoid the generalizability of study results.

Community exercise based intervention for urinary incontinence in elderly village women in rural Bangladesh.

Author(s) Nasima Yasmin1, Nicola Cherry2.
Affiliation(s) 1Physiotherapy Department, Gonobishwabidalay, Dhaka, Bangladesh, 2Department of Medicine, University of Alberta, Canada, Canada.
Country - ies of focus Bangladesh
Relevant to the conference tracks Chronic Diseases
Summary A feasibility study in 5 GK villages was carried out to assess the effect of exercise on incontinence in this population. Three locally trained female physiotherapists worked with a Canadian physiotherapist experienced in exercise based management of urinary incontinence to develop a culturally appropriate exercise regime and to train 10 community paramedics. The intervention adopted included training in pelvic floor muscle exercises, followed by group exercise classes, lead by physiotherapists, and held in the village for 2 hours twice weekly for 3 months.
Background Urinary incontinence is a common feature of aging adults over 40 years of age. Exercise based interventions to manage incontinence has been practiced effectively in the Western world and Japan, but very little has been published on such interventions in developing countries. Gonoshasthaya Kendra (GK) a national charitable foundation based in Savar, Bangladesh, provides community based comprehensive primary health care among 1.2 million rural residents. In 2009-10 GK health workers interviewed 40,000 men and women over the age of 60 years in 535 villages. Overall, 28% reported troublesome urinary incontinence, with higher prevalence in older women.
Objectives To identify and resolve any problems of implementation of the proposed intervention and measures of outcome through a pilot study in 5 villages (4 intervention and one control).
Methodology This was followed by a three month maintenance period with monitoring and reinforcement by the paramedics. Frequency of micturation and of incontinence was recorded for 3 days each month for 6 months. As almost all participants were illiterate, a body belt with ribbons that were tied upon a urinary episode was used as a bladder diary.
Results More than 80% of women in the intervention villages completed the 3 month exercise program and the urinary monitoring for six months. Urinary frequency and leakage decreased significantly in the intervention group.
Conclusion This presentation will focus on the role of the community physiotherapists in developing and implementing the exercise program and on the reaction of the elderly women to the community exercise program.

Clinical Audit on Diabetes care in UNRWA Health Centres.

Author(s) Yousef Shahin1, Anil Kapur2, Ali Khader3, Wafaa Zeidan 4, Akihiro Seita 5.
Affiliation(s) 1Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan, 2Diabetes care, World Diabetes Foundation (WDF), Delhi, India, 3Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan, 4Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan, 5Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan.
Country - ies of focus Jordan
Relevant to the conference tracks Chronic Diseases
Summary Diabetes is a major health problem for the Palestine refugees we serve. The number of refugees living with diabetes is already large, more than 110,000 by 2012, and is steadily increasing by 3 to 5% every year. The financial pressure to maintain and expand diabetes care is significant. Insulin alone, for example, accounts for 15% of the entire expenditures on medicines.The audit, conducted in 2012, was the first extensive assessment of diabetes care in UNRWA in recent years. This was the collaboration with the World Diabetes Foundation and international experts on diabetes care. The results of the audit provided us priceless lessons to further improve our diabetes care in UNRWA.
Background UNRWA has delivered comprehensive primary health care services to Palestinian refugees in Gaza, West Bank, Jordan, Lebanon and Syria for over 65 years and has achieved some remarkable health gains particularly in relation to maternal and child health and communicable diseases. There is significant change in the epidemiological transition of disease burden. The main causes of mortality and morbidity among Palestinian refugees are non-communicable diseases (NCDs) such as diabetes mellitus (DM), cardiovascular diseases and cancer. Behavior risk factors like unhealthy diets, physical inactivity and smoking are increasingly prevalent among Palestinian refugees as well.
UNRWA has been providing diabetes and hypertension care at its health centers since 1992. The diabetes care includes screening of high risk groups, diagnosis, and treatment with lifestyle education and medical treatment including insulin therapy. In addition UNRWA invests in primary and secondary prevention activities through health education and the screening of complications. A total of 114,911 diabetic patients were registered at UNRWA health centers in its five fields of operation (Gaza, Jordan, Lebanon, West Bank and Syria) by the end of 2011.
Objectives The objective of this clinical audit was to acquire evidence-based information on the quality of diabetes care in all the five fields served by UNRWA (i.e. Gaza Strip, West Bank, Jordan, Lebanon and Syria). It was not possible, however, to conduct the study in Syria due to the ongoing conflict.
The findings of the clinical audit will be used to define a strategy to improve technical and managerial capacity within UNRWA’s health service and increase diabetes awareness among Palestine Refugees.
Specifically the audit examined the UNRWA health care services provided to diabetic patients under care, collected data on process, outcome and treatment indicators to establish the base-line and current status,  identified areas and means to improve the quality of clinical care provided at health centre level and identified the training needs of health staff in the field of diabetes care.
Methodology A total of 1,600 patients with DM were included in the audit. They were selected from the eight largest health centers in each of the four fields (Gaza, Jordan, Lebanon and West Bank): in total there were 32 health centers. In each health center, the first 50 DM patients attending to the health center for periodic assessment were selected irrespective of their age or sex. Patients with less than 1 year of DM care were not included in the audit.
Patients were not informed of the audit examinations in advance. Patients were asked about the engagement of clinical audit, including HbA1C testing, and only those who were willing to participate and provide written consent were engaged in the audit. Patients were interviewed and examined according to a standardized data collection sheet that was jointly developed by UNRWA and WDF. The sheet included questions on past medical history, current findings, laboratory tests, clinical management and diabetes complications. Comprehensive clinical examination, patient interview and record review were used to complete the questionnaire and these were carried out by the experienced UNRWA experts.. Blood samples were collected and tested for HbA1c at the internationally recognized laboratory at the Augusta Victoria Hospital in East Jerusalem. Data was entered and analyzed with Epi-info 2000. Patients provided informed written consent
The knowledge of UNRWA medical officers working for diabetes patients at NCD clinics was also assessed. To this effect, a questionnaire was developed and distributed to 66 medical officers before the start of the clinical audit in each health centre. The questionnaire analysed the medical officers’ knowledge on the different aspects of diabetes care such as the demographic characteristics of patients, the prevalence of risk factors, and the correct clinical management and follow up of diabetic patients.
Results A total of 1,600 patients were enrolled in the audit. Of them, 68 (4.3%) were affected by type 1 diabetes and 1,532 (95.7%) by type 2 diabetes. A considerably high proportion of them (1,102 or 68.5%) have co-morbidity with hypertension. 1,109 (63.7%) were female: this high proportion of female patients is probably the reflection of general attendance pattern of patients in UNRWA health centers. In regards to risk factors, one significant finding was the very high proportion of obese and overweight patients: 1,024 (64.0%) and 421 (26.3%), respectively. The number of smokers was 313 (19.6%). Clinical management of diabetes is largely in line with the UNRWA’s technical instructions on diabetes care. Of 1,600 patients, 63 (3.9%) receive lifestyle support alone while 1,529 (95.6%) receive diabetes medicines and 8 (0.5%) receive treatment from non-UNRWA health facilities. Of those receiving medicines, the most commonly used was oral hypoglycemic agents (OHA). 1,192 patients (68. 2%) were with OHA alone, followed by combined therapy of OHA and insulin (231, or 14.4%), and Insulin therapy alone (207, or 12.9%). Monitoring examinations for diabetes are also done regularly. Postprandial glucose, cholesterol, creatinine and urine protein tests were regularly done for almost all patients (94.7%, 96.4%, 91.4% and 87.5%, respectively).
The findings from the knowledge, attitude, and practice assessment among 66 medical officers at the health centers involved in the clinical audit also revealed their good knowledge on diabetes care and proper follow up of technical instructions. Almost 80 to 90% of them have correct knowledge on frequency of patients’ follow up visits, laboratory tests on cholesterol and creatinine. More than 70% of medical officers have a correct understanding of the proportion of insulin therapy.
The main shortcomings identified in the clinical audit is that the control rate for diabetes based on the HbA1c tests is much lower than that measured using PPG. While 44.8% of patients have PPG ≤ 180mg/dl, only 452 (28.3%) have HbA1c < 7%. For patients with type 2 diabetes only, 42.6% vs. 25.1%, and for patients with type 2 diabetes and hypertension, 45.7% vs. 30.8%, respectively.
Another shortcoming is the failure of lifestyle support activities. More than 90% of patients are either obese (64.0%) or overweight (26.3%). Among female patients, the proportion is much higher at almost 95% of which 73.4% are obese.
Conclusion The availability of competent health staff and of updated, scientifically documented protocols (named Technical Instructions) is one of the main strengths of the diabetes care programme in UNRWA health centres. The clinical audit confirmed that UNRWA doctors and nurses, working in diabetes care, follow the Technical Instructions rather rigorously. The doctors’ knowledge on diabetes and its care is therefore considered appropriate in principle, as well as their capacity to correctly prescribe lifestyle and drug based treatments. Follow up blood and urine examinations are also conducted regularly as indicated in the UNRWA protocols.
At the same time, the audit demonstrated the poor sensitivity of two-hour PPG testing in measuring diabetes control compared with HbA1c. This could mean that UNRWA has systematically over-estimated control rates of its patients. More than 90% of patients are either obese or overweight. Without addressing such lifestyle issues, UNRWA may not achieve sensible results in diabetes care.
UNRWA’s extensive experience in diabetes care in primary health care settings and the capacity, experience and rigour of UNRWA’s doctors and nurses are a solid foundation on which to improve the performance of diabetes care. A comprehensive and strategic response that goes beyond the activities of the NCD care programme alone is needed to address such fundamental issues and the recently applied person & family centred family health team reform offers an ideal reference framework.

Integrating non-medical needs for Chronic Diseases: the example of Type 1 diabetes

Author(s) David Beran1.
Affiliation(s) 1Division of International and Humanitarian Medicine, University of Geneva, Geneva, Switzerland.
Country - ies of focus Tanzania,Thailand,United Kingdom,United States,Vietnam
Relevant to the conference tracks Chronic Diseases
Summary Onset of Type 1 diabetes leads to a “biographical disruption” where the individual’s life completely changes. International standards for clinical management of diabetes exist, but fail to adequately consider the needs of individuals beyond those provided by the health system.
Background Type 1 diabetes is the most common paediatric endocrine disorder and the second most common Chronic Non Communicable Disease to affect children after asthma. Type 1 diabetes is characterised with the need for life-long care including daily insulin injections, management of diet and lifestyle as well as regular check-ups. Diabetes highlights the problems of managing Non Communicable Diseases in many health systems as these are not currently organised for long-term care of individuals, but rather acute care. As these Chronic Non Communicable Diseases are now the leading causes of death in the world, health systems need a “paradigm shift” from an acute to a chronic care model. However, this shift focuses primarily on the organisation of the health system and not individual’s needs.
Objectives The objective of this research is to identify non-medical needs for people with Type 1 diabetes and highlight that there is more to diabetes management than what is included in international guidance.
Methodology It was decided to use a qualitative approach in this research using Grounded Theory as this provides a systematic framework for collecting and analysing qualitative data that is flexible and assists in the creation of theories “grounded in the data collected”. Small samples can be used in GT as the aim is to develop concepts and the relationships between different concepts. A qualitative design was used as this is a new area of study and has as its aim the development of a new theory. This meant that the interviews needed to be carried out in a flexible way allowing the interviewee to freely speak about their experience. Also, as the topics were unclear, as they were to emerge from the research itself, different questions or areas of investigation needed to be researched as the project advanced. Therefore any form of structured data collection tool would have made it impossible to investigate the depth and breadth of the issues. Interviews were carried out in 13 countries with a total of 100 individuals with Type 1 diabetes interviewed. The interviews were transcribed verbatim and analysed using NVivo software. This enabled needs to be identified and defined as "tangible" (being able to be provided by the health system), "process" (the way this element is delivered is important) and "intangible" (falling outisde the normal role of the health system).
Results Needs can be viewed as tangible in that they can be provided by the health system, e.g. insulin, access to specialists, etc. Others are processes that entail a series of needs or actions to fall into place, e.g. proper diagnosis. Finally a third category that will be labelled intangible is when a variety of factors will contribute to these, e.g. routine, personality, etc.The tangible needs identified were: Access to specialists; Awareness of population; Community support; Control e.g. blood or urine glucose; Delivery of insulin; Family support; Financial aspects; Healthcare worker knowledge; Healthcare workers; Information and education; Insulin; Peers and Policies.Processes described by the interviewees were: Clear path of care - Organisation of care; Follow-up (Clinical); Management of diagnosis and Proper diagnosis.

Finally intangible aspects were: Acceptance; Active involvement; Adapting; Being Open; Being special - special treatment; Confidence; Cure; Discipline; Experience; Explanation; Hope; Independence; Knowledge; Motivation; Personality; Positive aspects; Psychological factors; Putting it into practice; Reassurance; Relationship with healthcare worker; Routine; Second nature; Stigma and Theory versus practice.

Conclusion Current diabetes management is far from perfect and it is argued that this is due to a disjuncture between what health professionals feel is the best way to manage Type 1 diabetes and the capacity of people with Type 1 diabetes and their families to manage this condition. It could be argued that this is due to more needs being "intangible" for people with diabetes than "tangible". Health systems, in their transition to the proper management of NCDs, need to include these "intangible" needs as they may impact diabetes management as much as the absence of tangible or process needs. Health systems will need to find effective ways of doing so. As Type 1 diabetes can be considered a tracer condition this work has an impact for other chronic conditions.

Chronic disease risk factor and physical activity patterns: Findings from Sri Lanka

Author(s) Shreenika DE Silva Weliange1, Dulitha Fernando2, Jagath Gunathilake3.
Affiliation(s) Community Medicine, University of Colombo, Colombo, Sri Lanka, Department of Community Medicine- retired, University of Colombo, Colombo, Sri Lanka, 3Department of Geology, University of Peradeniya, Kandy, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Chronic Diseases
Summary There is a tremendous increase in chronic diseases worldwide. A similar pattern is observed in Sri Lanka. Physical inactivity contributes to 6% of deaths globally and is identified as the fourth leading risk factor for mortality due to chronic diseases. There is sparse knowledge of the profile of the risk factors of chronic diseases as well as inadequate knowledge of the pattern of physical activity in Sri Lanka. The objective of this study was to assess the risk factors of chronic disease and the association with physical activity for adults in the Colombo Municipal Council (CMC) area.
Background 'The Global Strategy on Diet, Physical Activity and Health' endorsed at the 57th World Health Assembly states that a “profound shift in the balance of the major causes of morbidity and mortality has already occurred in the developed countries and is underway in many developing countries”. The World Health Report 2002, 'Reducing Risks, Promoting Healthy Life', shows that few risks are responsible for a large number of premature deaths and account for a big share of the global burden of disease. The immediate risk factors for chronic diseases are raised blood glucose, high blood pressure, high concentrations of cholesterol in the blood and overweight or obesity. Physical inactivity and tobacco use, along with poor diet, are the common modifiable risk factors. In Sri Lanka a changing trend in the pattern of disease burden is observed. Trend analysis using Registrar General’s data shows that chronic disease mortality rates are increasing rapidly during the past decades. In 2001, 71% of all deaths in Sri Lanka were due to chronic diseases. Chronic disease mortality is reported to be 20-30% higher in Sri Lanka than in many developed countries. According to the Annual Health statistics, coronary heart disease was the leading cause of hospital deaths in Sri Lanka since 1997.
Objectives Urbanisation and other socio economic changes have led to changes in individuals’ lifestyle thereby causing an increase in the intermediate risk factors of chronic diseases, such as raised blood pressure, raised blood glucose, abnormal blood lipids and overweight/obesity. However, to further understand the problem it is necessary to study these intermediate risk factors and the common modifiable risk factors in the most urbanized part of Sri Lanka namely the CMC area. This study aims to assess these risk factors and the association of physical activity for adults in the CMC area.
Methodology Study design and area: This was a cross sectional study of a representative sample of adults aged 20-59 (both inclusive) years living in the CMC area in which has the highest population density, and covers most of the metropolitan and the economic area in Sri Lanka. Study population: All adults living in the area for a continued period of not less than six months were the study population. The exclusion criteria were: institutionalised adults, adult visitors to the study area, pregnant females up to postpartum period of 3 months, adults with severe psychiatric illness and those not providing consent. Sampling: Four hundred adults were selected using a probability proportionate to size cluster sampling method. The Primary Sampling Unit was a ward in the CMC area which is similar to a village structure. The Grama Niladhari (village headman) in each ward helped the data collectors to locate the selected houses. Within the household an adult was selected using a random procedure. Only one eligible individual was selected from a household so as to minimize cluster effect, as members of the same household share similar life styles. Recruitment was done irrespective of the availability of the study participants in the house at the time of the first visit to the households. The cluster was considered as complete when 40 consenting eligible people were identified and interviewed.Measurements: An interviewer administered questionnaire consisting of socio-demographic, economic characteristics was used to collect data. Medically trained officers interviewed individuals and assessed the disease status by questioning and going through medical records. Physical activity was assessed using the validated long version of the international physical activity questionnaire and individuals were classified into ‘sufficient activity’ and ‘insufficient activity. Trained personnel took anthropometric measures of height and weight from all participants.Ethics: All participants received an information sheet about the study and signed a consent form if they agreed to participate. Ethical clearance was obtained from the Ethics Review Board of the Faculty of Medicine, University of Colombo. The provincial and the district government authorities gave permission to carry out the study in their area.

Statistical analysis: Descriptive analysis was done using chi square tests. All analysis were conducted using SPSS software version 17.

Results Out of the 400 participants 43% (n=172) were males and 57% (n=228) were females. Only 46% (n=184) had a G.C.E. ordinary level education or more and 86.3% (n=345) had an income of less than Rupees 30,000. Fifty four percent were between 40-59 years of age while the rest (46%) were between 20-49 years of age.
The self-reported prevalence of type 2 diabetes mellitus was 12.3% (n=49) while the prevalence of raised blood pressure and abnormal lipds were 13.3% (n=53) and 5.5% (n=22) respectively. The majority (60.5%, n=242) were overweight while another 7% (n=28) were underweight. More than half (64.5%, n=258) of the participants had at least one immediate risk factor for NCD, and out of them 110 (27.5%) were 40 years or less. Of the sample 11.8% were current smokers and 14.5% were previous smokers.
Seventy two precent (n=288) of the participants were in the ‘sufficiently active’ category, with activity accumulated mainly through household, travel and job related behaviours. However, 85.8% (n=343) reported no leisure-time PA, and 21.3% (n=85) reported that they did not walk either for travel or leisure for more than 10 minutes a week. No active transport (walking/cycling) methods were used by 23.5 % (n=94). Of those who were had at least one immediate risk factor 85.6% (n=221) had no leisure activity while 21.3% (n=55) and 93.4% (n=240) reported no walking or cycling during the previous week.
Having an immediate risk factor for chronic disease was not statistically significantly associated with socioeconomic or demographic characteristics of the individuals. This study also did not find a strong evidence of association between the presence of at least one immediate risk factor and physical activity.
Conclusion An alarming percentage of immediate risk factors were observed in the CMC area although no particular socioeconomic and demographic group was more affected than the others. The major contributors to energy expenditure in the local setting according to this study were housework, transportation and job related activities. This is different to the pattern seen in the developed countries. Being active while attending to day to day chores should be encouraged and promoted in the developing countries since it is already their habitual practice. Special concern is necessary due to the counteracting forces of rapid urbanisation taking place in Sri Lanka which makes it more convenient and fashionable for people to use mechanical equipment for housework, to seek sedentary jobs and use motorised vehicles for transport. Since it is seen that most of the participants in the present study enacted their activity from transportation it is necessary to promote active transportation. Thus the importance of an activity friendly physical environment with good street structure to facilitate walking and cycling, traffic and general safety, access and connectivity needs to be highlighted.
Strength and limitations: This study explored the burden of risk factors in the most urban part of Sri Lanka and its association with physical activity. Physical activity measurement, although validated for Sri Lanka, was carried out through self-reports. Thus there was a possibility for recall bias and for over-reporting or under-reporting the number of occasions and time spent on physical activity in different domains. This is due to various reasons such as social norms determining socially acceptable answers. A cross sectional study design had to be used. Therefore causal interferences cannot be made because of the inability to determine the temporal sequence.

An Integrated Approach to Management of Diabetes and Hypertension in Western Kenya

Author(s) Simon Manyara1, Jemima Kamano2, Diama Menya3, Jeremiah Laktabai4, Benjamin Andama5, Evans Tenge6, FlorenceSituma7, SonakPastakia8
Affiliation(s) 1Pharmacy, Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya, 2Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya, 3Epidemiology and Nutrition, School of Public Health, Moi University, Eldoret, Kenya, 4Family Medicine, Moi University, Webuye,Kenya, 5Family Preservation Initiative, Academic Model Providing Access to Medicines, Eldoret, Kenya, 6Family Preservation Initiative, Academic Model Providing Access To Healthcare, Eldoret, Kenya, 7Home Glucose Monitoring, Webuye District Hospital, Webuye, Kenya, 8Purdue University College of Pharmacy, Purdue University, Eldoret, Kenya
Country - ies of focus Kenya
Relevant to the conference tracks Chronic Diseases
Summary This pilot project seeks to establish whether the provision of intensive, self and peer management trainings to patients combined with the integration of income generating incentives leads to enhanced diabetes and hypertension control for resource-constrained patients in rural western Kenya. Patients are placed into peer support groups where they receive group care and are trained on various aspects of diabetes and hypertension self-care. These groups also double as microfinance groups that offer capital to patients to start up income generating activities. The groups are further incentivised to compete against each other based on both clinical and non clinical parameters.
What challenges does your project address and why is it of importance? Developing countries are facing an increasing burden of non communicable diseases (NCDs). While there has been increased emphasis in addressing communicable diseases by the international community, the vast majority of NCDs have been neglected, leaving patients with very poor outcomes and limited prospects for a healthy life. Due to their chronic nature, NCDs strain the already scarce resources of healthcare systems and families in resource constrained settings. Furthermore, NCDs are no longer associated with the wealthy or elderly, for they also affect poorer rural dwellers and younger members of the society who are expected to be economically productive. This adversely affects economic development in these populations, further propagating the vicious cycle of poverty. The prevalence of diabetes in Kenya is 4.7%, while that of hypertension has been reported to be as high as 23.7% in some urban settings. Patients with chronic diseases in Kenya face several barriers to care, including lack of access to essential services and inadequate information. This project uses a holistic approach which directly addresses barriers related to the socioeconomic status of patients with diabetes and hypertension, while encouraging positive health seeking behaviors.
How have you addressed these challenges? Do you see a solution? Bridging Income Generation with Provision of Incentives for Care (BIGPIC) uses an integrated approach that capitalizes and builds on the AMPATH’s (Academic Model Providing Access To Healthcare) existing infrastructure and years of experience in managing patients with HIV/AIDS throughout western Kenya. We focus on the following points of intervention:
1) Peer Groups.
Following community-based screening, positively diagnosed patients are placed into peer groups where they receive intensive training on self-management strategies for diabetes and/ or hypertension. They are given targets for their management which will be evaluated upon completion of the pilot. Targets will comprise of both process metrics such as clinic attendance, medication refills, fulfillment of ordered tests and clinical outcome metrics including blood pressure and sugar control. Patients receive group care and are provided with essential services like clinical consultations, selected portable laboratory tests and medication at affordable prices. They are expected to pay for each service and all the money collected is used to restock supplies.
2) Incentivization.
Patients are instructed on the incentives that can be earned through participation in this program. Their care is evaluated after 6 months to document the progression of their glucose and/or blood pressure control using standardized laboratory assessments. They receive points based on the set targets and these points can be used to earn various predetermined rewards. Incentives are awarded at two levels of participation – the group level where the top three groups with the most improved outcomes will receive rewards, and at the individual level where each participant attaining pre-set goals receives a reward.
3) Economic empowerment
The economic component of the project is facilitated by the Family Preservation Initiative (FPI), which is AMPATH’S income generation program. This will be achieved by the incorporation of a micro finance component which provides interest-bearing loans to members while offering a limited form of financial insurance. Participants mobilize and manage their own savings. They can therefore access affordable loans and get advice from FPI agribusiness officers on sustainable income generating activities. BIGPIC combines the socioeconomic benefits of FPI activities with the care strategy utilized by our diabetes program to synergistically enhance the outcomes and retention in both programs.
How do you know whether you have made a difference? While AMPATH has enjoyed immense success in the management of patients with both communicable and non communicable diseases, a lot of effort still needs to be put into retention of new patients to care. Data from the chronic disease management team shows that only 30% of patients who screened positive for diabetes and hypertension ever returned to a health facility for care. Preliminary data from this project shows that out of the 902 patients that were screened, 157 patients screened positive for either diabetes or hypertension. Of those that screened positive, 67.5% (n=106) came back to the health centre for confirmatory screening. Currently, 70.3% (n=71) of all those who confirmed positive for diabetes or hypertension are enrolled into the peer groups and are receiving care. The pilot will be completed in December and the final results will be presented at the conference
Have you or the project mobilized others and if so, who, why and how? This project draws expertise from a multidisciplinary team and intricately incorporates several aspects of patient care. The chronic disease management team provides the necessary platform for the management of diabetes and hypertension, from facilitation of screening activities to capacity building through staff training at health facilities. The Primary Healthcare team at AMPATH provides valuable insights into community strategies and engagement both at the macro and micro levels. One of the key approaches has been the use of community health workers (CHWs) for the purposes of finding patients, linking them to health facilities and raising awareness on chronic diseases within the community. The peer groups are also led by the CHWs who we train intensively on diabetes and hypertension self-care and on the operations of the GISE groups. The project taps into AMPATH’s Family Preservation Initiative’s GISE project. Through the microfinance groups, we strive to empower our patients economically through access to capital and giving them advice on viable business ventures. These microfinance groups have been shown to have high retention rates of its members, an outcome that we hope to achieve by incorporating the microfinance element into healthcare. This project is further strengthened by AMPATH’s pharmacy team which has a revolving fund pharmacy project that provides quality medicines to its patients at affordable prices. The revolving fund pharmacy works by procuring quality controlled medication in bulk and availing it to patients at a price that is almost at cost. Through this project, we have been able to provide quality, low cost essential antidiabetic and antihypertensive medicines to our patients. The biggest piece of the puzzle is the government health management team which is responsible for the implementation of all health initiatives within a district. This team facilitates all our activities on the ground. Part of the activities that we engage in include capacity building of the existing infrastructure by carrying out refresher courses on good practices in the management of diabetes and hypertension and mentoring the staff in the lower level facilities like dispensaries and health centres.
When your donor funding runs out how will your idea continue to live? BIGPIC offers a sustainable means of ensuring access to healthcare while at the same time promoting economic empowerment, leading to a healthier, more productive labor force. The project is modeled around the existing healthcare system and infrastructure in Kenya. Care for diabetes and hypertension at the facility level is enhanced through capacity building by training of the existing government healthcare workers. This is followed by close mentorship by the chronic disease management team at AMPATH, ensuring that patients can access quality care even in our absence. The microfinance groups have been shown to have a high retention rate of its members, and we believe that this model will maintain the members of the peer groups long after completion of the initial six months of our involvement. This will promote self-care within the members hence leading to improved patient outcomes. Patients are also empowered economically through these groups where they can access capital from their own savings. The groups create their own constitutions that guide their operations, and we only facilitate income generation through our agribusiness advisors. This ensures that they own the project and that the groups can continue independent of our support. Provision of drugs through the revolving fund pharmacy ensures continuity of drug supply since patients pay for the drugs and the money collected is solely used to purchase more drugs. Furthermore, antihypertensive and antidiabetic medicines are not supplied to dispensaries and health centres and the provision of these drugs at this level ensures accessibility while promoting the use of lower level facilities, with only complicated cases being referred to higher level facilities. Patients are expected to pay for every service that is provided through group care. The money collected from this model of care makes its continuity sustainable. The information provided to the community through the CHWs and the patients participating in the project will also go a long way in preventing NCDs by averting common risk factors such as poor diets, physical inactivity, unhealthy use of alcohol and cigarette smoking. This project therefore draws its strengths from a multidisciplinary team and integrates proven, sustainable interventions to achieve a holistic care model for diabetes and hypertension within a resource-constrained setting.