Geneva Health Forum Archive

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Task Shifting for Integrated Management of Hypertension and Diabetes in Rural Cameroon: An Observational Cohort Assessment at Two Years

Author(s): N. D. Labhardt*1, J. Balo2, M. Ndam3, E. Manga3
Affiliation(s): 1Swiss Tropical Institute, University of Basel, Basel, Switzerland, 2District Hospital Mbankomo, 3District Hospital Mfou, Ministry of Public Health of Cameroon, Mfou, Cameroon
Keywords: Non-communicable chronic diseases, Task shifting, Integrated care, Non-physician clinicians, Diabetes, Hypertension
Background:

Sub Saharan Africa (SSA) faces a looming epidemic of arterial hypertension and diabetes for which most countries are not prepared. We tested in eight rural Cameroonian districts a model of integrated care by task shifting of the management of hypertension and diabetes from hospitals to facilities led by non-physician clinicians (NPCs).

Methods:

After a preliminary survey in 75 peripheral health centres, 69 were subsequently trained and equipped for prevention, diagnosis and treatment of hypertension and type 2 diabetes. Two years later the effectiveness of the programme was assessed by the status of equipment and drugs in formerly equipped facilities (1), knowledge among trained NPCs, assessed by a multiple-choice questionnaire (2), number of newly detected and followed patients (3) and trend in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients (4).

Results/Conclusions:

(1): At baseline only 49 (65%) of the 75 health centres were equipped to measure BP and 11 (15%) to measure FPG. Twenty (27%) disposed of an anti-hypertensive and nine (12%) of an anti-diabetic drug. Two years after training and equipment of NPCs, all had still a functional sphygmomanometer and stethoscope, 96% an antihypertensive drug on stock, 70% had a functional glucose meter and 72% an oral anti-diabetic drug on stock. (2): Knowledge about hypertension among nurses was poor before training (on average 41% of correct answers per question), improved dramatically after the course and remained high at two-years (on average 80% of correct answers) (p<0.001). (3): Of the 796 newly detected patients, 2579 visits of 222 patient-years were recorded. Of all patients 562 (70.6%) were lost to follow-up at the time data were collected. Of these, most (75%) were lost during the first three months. (4): Among hypertensive patients with ≥ 2 visits (n=438), systolic BP decreased by 23.5mmHg (CI95%: 20.5-26.6; p<0.0001) and diastolic BP by 12.5mmHg (10.6-14.5; p<0.0001). Among diabetic patients with ≥2 visits (n=79) FPG decreased by 3.4mmol/l (1.8-5.1; p<0.001).
In conclusion, integrated management of hypertension and diabetes by nurses in general NPC facilities in rural settings with limited resources is feasible on a district scale. NPCs were successfully trained and equipped and their patients showed a good treatment response. However, a relatively low case-detection rate per NPC and a very low retention rate in the program at two years severely limit the effectiveness.

How to Improve Retention Rates in NCCD Programmes in Rural Africa: The TAHADIRA Trial

Author(s): N. D. Labhardt*1, J. Balo2, E. Manga3, M. Ndam4, B. Stoll5
Affiliation(s): 1Swiss Tropical Institute, University of Basel, Basel, Switzerland, 2District Hospital Mfou, Ministry of Public Health of Cameroon, Mbankomo, 3Ministry of Public Health, 4District Hospital Mfou, Ministry of Public Health of Cameroon, Mfou, Cameroon, 5Institute of Social and Preventive Medicine, Faculty of Medicine, Geneva, Switzerland
Keywords: Hypertension, diabetes, treatment adherence, treatment retention, non-communicable chronic diseases
Background:

Low retention rates and poor treatment adherence pose major challenges to programs for non-communicable chronic diseases (NCCD) in Africa. Monitoring data of a program that integrated management of arterial hypertension and diabetes into the primary health care of non-physician clinics (NPCs) in eight rural Cameroon districts reveal a one-year retention-rate below 50%. In order to improve the effectiveness of large NCCD-programs, efficient and easily replicable interventions to improve treatment adherence are urgently needed. The aim of this randomized trial is to compare two low-cost interventions on a NPC level in rural Cameroon to lower the attrition in the program.

Methods:

Thirty three rural NPCs from four districts were randomly assigned into three groups: The control group requested a written and oral commitment from the patient to follow the treatment before the treatment start. Facilities of the intervention group A had additionally an active patient-tracing by community representatives. Intervention group B provided as an incentive for adherence one month of treatment for free every four completed months with good adherence.
At one patient-year we assess as the primary outcome the percentage of patients with a regular follow-up. Secondary outcome measures are: percentage of missed follow-up visits (i) trend in blood pressure among hypertensive patients (ii) and trend in fasting plasma glucose in diabetic patients (iii). The study is registered at www.clinicaltrials.gov (NCT00744458)

Results/Conclusions:

During a period of six months, the 33 NPC-clinics recruited 218 new, treatment-naïve patients. The average age was 60 years (inter quartile range: 51-68), 65% were female. Sixty eight percent had arterial hypertension alone, 18% arterial hypertension and impaired fasting glucose, 11% hypertension and diabetes and 9% diabetes alone.
In February 2010 the study will be closed and data collection performed. The primary and secondary outcome measures of this study will be presented at the Geneva Health Forum 2010. This will contribute to the discussion on how to improve the retention rate in NCCD programs in general and give specifically information on the evolution of hypertensive and diabetic patients who are followed by general NPCs in a rural primary health care setting in Cameroon.

My Child Matters: Fighting against Childhood Cancer in Low and Middle-Income Countries

Author(s): Cary Adams1, Catherine Boniface2, Raul Ribeiro3
Affiliation(s): 1Union for International Cancer Control (UICC),Switzerland, 2Fondation Sanofi Espoir, France, 3St. Jude Children’s Research Hospital, USA
1st countries of focus: Honduras, Morocco, Paraguay, Philippines, Senegal, Thailand
Relevant to the conference theme: Non-communicable chronic diseases
Summary: The My Child Matters initiative was launched in 2005 when the Sanofi Espoir Foundation proposed to create an innovative partnership with the UICC (Union for International Cancer Control) for fighting against childhood cancer in low and mid-income countries where the paediatric oncology is still emerging. It has grown into one of the largest childhood cancer initiatives in terms of the number of countries involved. The programme enables local partners, hospitals and NGOs to benefit from financial support (€20,000 to €50,000 per project per year, following an annual evaluation of each project by the Steering Committee), advice from international paediatric oncology and public health experts, as well as the South/South pooling of project experiences. The Sanofi Espoir Foundation has contributed a total of € 4.400,000 towards the initiative since 2005.
What hallenges does your project address and why is it of importance?: Cancer causes immense suffering and is is the leading cause of death worldwide. While cancer in children represents only a small proportion of all cancers, it is nevertheless testifies to the largest difference in survival rates between industrialized and developing or emerging countries. Childhood cancers are mostly curable, provided they are treated early on. More than 160,000 children face this disease each year, and about 90,000 die from it. In industrialized countries, around 80% of children with cancer can be cured. Yet, this figure falls to 20% or even 10% in the world’s poorest countries, where it is hard to have access to information, early diagnosis, care and treatment.
How have you addressed these challenges? Do you see a solution?: My Child Matters is based on the concept that improvements to healthcare infrastructure, the training of qualified personnel, better public information and the involvement of local governments in more active public health policies are key drivers of improving childhood cancer survival in developing countries.

The programme’s main objectives are to:
  • generate actions on the ground that are as sustainable as possible, directly benefiting the country, including children and their families, and health professional partners
  • raise greater awareness in civil society and among policy makers to help reduce the access-to-healthcare gap between developed countries and developing countries where paediatric oncology is still emerging.
It also creates the opportunity to build momentum by bringing countries together around the same initiative against childhood cancer so that experiences and ideas can be actively shared.
My Child Matters has already provided support to 43 hospitals and NGOs in 26 countries to reduce inequalities between developed and resource-constrained countries through grass-roots projects in these six years. Today, 21 projects across 17 countries continue to benefit from this initiative to improve every link in the health chain: better information, education and prevention, improved training for qualified personnel, helping to ensure earlier diagnoses, fostering better access to care and better pain management, developing palliative care and encouraging better understanding of the social aspects of this disease both for children and their families.
How do you know whether you have made a difference?: Continued monitoring and planned annual reviews by the project’s mentors, experts and the steering committee with all local partners help to measure the programme’s impact on the community - the children, their families and health workers - and assess its leverage on the health policies of the countries concerned.

Extremely promising results have been obtained on the three continents: For example:

Latin America:

In Honduras, in an effort to reduce the number of patients dropping out of treatment, the support provided has made it possible to position satellite clinics much closer to patients. This reduces both time spent travelling to the care centre, and work absenteeism among parents. Following the opening of six satellite clinics, dropout rates fell from 40% to 10% between 2005 and 2010.
In Paraguay, where they face the same problem, a national network of professional support for childhood cancer has been formed (and declared of national interest) and a number of satellite clinics have been opened. Patient treatment dropouts have decreased from 20% to 0% in two years. The programme has expanded to include training projects by twinning with Spain and the United States, and a South/South pooling of expertise with Argentina and Bolivia.

Africa:

In Morocco, an interdisciplinary approach has been set up to fight pain in children, a still largely uncharted area. This integrated approach is based on awareness raising among children and parents, training for caregivers and appropriate treatment. Today, pain management has made significant progress and ‘anti-pain committees’ have been trained in several hospitals. This innovative experience has helped humanize care and will be shared with other countries.
In Senegal, the rehabilitation of the paediatric oncology unit, the prevention of nosocomial infections, the treatment of febrile neutropenia and pain, the introduction of appropriate protocols and better training of health professionals have all led to greater government and civil society commitment to the project. This has led to an overall improvement in the survival rate for cancer, with the survival rate for kidney cancer (the most frequent childrens’ cancer in the unit) rising from 46.7% in 2005 to 71% in 2010.

Asia:

In the Philippines, the support provided has helped improve early diagnosis of acute leukaemia and retinoblastoma by boosting the training of primary care physicians and paediatricians. In 2010, the first and only centre for the diagnosis and treatment of childhood cancer was opened, and is now deemed a reference centre by the health authorities. In 2011, the first computerised database of childhood cancer will be compiled with the support of My Child Matters.
In Thailand, advances have resulted in the recognition of the importance of palliative care and psychosocial support. The country will host a World Congress on palliative care for the first time in 2012.
Have you or the project mobilized others and if so, who, why and how?: Nearly five years after the initiative ‘ My child matters’ was launched, it continues to show that we can all work together to create new types of partnerships to meet health challenges that do not receive sufficient attention, such as childhood cancers in developing countries.

Estimating the size of the problem in the chosen countries, assessing the needs and resources, enhancing political commitment, initiating public education and advocacy activities, providing professional education including development of training materials, encouraging stakeholder participation, providing continued monitoring and evaluation, forming collaborative partnerships – by engaging multiple actors, interest groups and organizations made the success for many countries where grassroots foundations, other stakeholders, and ministry of health have been involved. Some projects have been considered as reference centers (the Phillipines, Paraguay, Senegal..)
The partners of the project are: St Jude Children's Research Hospital, USA; the International Confederation of Childhood Cancer Parent Organizations – ICCCPO; SIOP International Pediatric Oncology Society, The Netherlands; National Cancer Institute, USA; Childhood Cancer Foundation, USA; Groupe Franco-Africain d’Oncologie Pédiatrique, France; International Network for Cancer Treatment and Research, Belgium; Centre International de Recherche sur le Cancer, France.
When your donor funding runs out how will your idea continue to live?: Focusing on the most impactful projects , determining gaps among the projects, evaluating barriers for success, project evaluation have been introduced as well as reinforcing healthcare capacity building and networking among the projects by sharing best practices and lessons learned in low- and mid-income countries. Leveraging MCM projects and more widely the cause of quality childhood cancer care in the participating countries for gaining sustainability has begun. In specific cases, support to scaling up the initiatives from local projects to regional or national plans will be provided, in particular if achievable goals by country can be agreed upon in order to get a better access to care for poor families and make quality childhood cancer care become a national health priority. An important role will be played by the UICC and its member organizations through strong advocacy actions.

The Mauritanian Model: An Effective Way to Improve Access to Mental Healthcare in Developing Countries

Author(s): Ahmed Ould Hamady1, Daniel A Gérard2, Osman Sall, Youssouf Ould Limame1
Affiliation(s): 1Ministry of Health, Mauritania, 2Chronic Diseases, Sanofi, France
1st country of focus: Mauritania
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Mauritania is a wide country of 1 million square kilometers mainly covered by desert, with 3 million inhabitants and only 3 psychiatrists. A pilot project designed to improve access to mental healthcare in the country was implemented in Nouadhibou city at the North West country border. In May 2009, 7 mental health clinics were opened in the city and surrounding areas. Thanks to the commitment of the medical staff and local NGOs, the treatment gap in schizophrenia was reduced by 38% in 2.5 years (from 93% to 58%) by running a strong awareness program and providing adapted, available, affordable medicines.
Background (max 200 words): Four mental disorders are in the top ten leading causes of disability (depression, bipolar disorders, schizophrenia, alcohol abuse) and the prevalence of main mental disorders is similar in developed and developing countries. Mental disorders are one of the leading contributors to the Global Burden of Diseases in Low- and Lower-Middle-Income countries yet only scarce resources are devoted to them.

A survey conducted in the general population of Nouakchott in 2003 indicated that 35% of the sample population had at least one mental disorder: anxiety: 20%, mood disorders: 19% and psychotic disorders: 2.4%.  Available mental health care systems are not aligned with needs in Mauritania.
Resources are mainly concentrated in the capital, Nouakchott: 3 outpatient psychiatric clinics, 1 Neuropsychiatric center and 1 psychiatric department in the Military Hospital and very few resources are accessible in the rest of the country.
In addition the survey highlighted the overlap between madness and mental disorders in the perception of the population who mainly believes that psychiatric symptoms are from magic or religious origin.
These data underline that improving mental health care in Mauritania requires a comprehensive process that combines: conducting awareness campaign; setting up services; getting funding; training healthcare professionals and making medicines accessible.
Objectives (max 100 words): The aim of this pilot project was :

(1) to test the feasibility of implementing one mental health clinic in each of the 13 Mauritanian provinces, working in a close network with the specialists from the Nouakchott neuropsychiatric center;
(2) to assess the impact of the project on the access to mental health care
(3) to learn from this experience for preparing an extension of the project to the rest of the country.
Methodology (max 400 words): This project is an action research project focused on access to healthcare for psychotic patients.

Intervention: inclusive approach bringing together:
  1. Advocacy towards decision makers (national, regional and local) so as to get their support for the implementation of the project;
  2. Training of health care professionals selected by the Head of the Regional Health Services;
  3. Regular supervision from specialists from the Nouakchott Neuropsychiatric center;
  4. Sustainable supply of quality affordable antipsychotics;
  5. Patients and families psycho-education sessions;
  6. Communities awareness initiatives on mental health issues;
Collected data: Number of patients included in the program, sex, age and diagnosis according to CIM 10. In addition, specifically for psychotic patients: estimation of the number of people with schizophrenia in the area; number of patients treated at baseline; conformity of the diagnosis made by the “investigator” and the diagnosis made by the specialist; Clinical Global Improvement, number of hospitalizations, questionnaire of integration in family and community; Drug Attitude Inventory-10 questionnaire; Involvement Evaluation Questionnaire
Results (max 400 words): An agreement was concluded between the Mauritania Ministry of Health represented by the Nouakchott Neuropsychiatric Center and Sanofi Access to Medicines in July 2008.

Nouadhibou (100,000 population), at the north border of the country, in front of the Canary islands, was selected as pilot site because of its population exposure to many risk factors for mental disorders: life style changes (from nomad life to settlement), transit place for illegal migration and drug trafficking…
The pilot program commenced in October 2008 with a meeting in the National Assembly and the endorsement of the national and local political and administrative decision makers. Between October 2008 and December 2010:
  • 37 health professionals from both public and private sectors were trained;
  • Outpatient mental health clinics were opened (since May 2009) in seven centers in the city (regional hospital, city hall dispensary, mine polyclinic, military infirmary, Moughataa dispensary) and in the surrounding areas (Boulenouar dispensary, Nouamghar dispensary).
  • Information tools were specifically designed for awareness campaigns and are used by several NGOs: posters, flipcharts and booklets.
  • More than 1000 people (patients, patient families, teachers, woman associations…) attended the different information meetings.
  • About 1200 patients are followed up in the mental health clinics (mainly for psychosis, depressive disorders, anxiety disorders and epilepsy)
  • In schizophrenia, with 342 new patients in 30 months, the treatment gap has decreased by 38% from 93% (May 2009) to 58.8% (December 2010).
The detailed results of the impact assessment will be presented.
Conclusion (max 400 words): This pilot program has a positive impact on the Nouadhibou population mental health. It indicates that access to care for patients with mental disorders can greatly be improved by a simple, assessable, replicable and scalable program. An agreement for the program extension to the whole country over 5 years through a partnership between the Mauritania Ministry of Health, the World Association for Social Psychiatry and Sanofi Access to Medicines was signed in June 2011. In addition to psychosis, the expanded program will also include other major mental disorders and epilepsy

Assessing the Impact of Medical Nutrition Therapy in Pregnancy Complicated by Diabetes in a Maternity Centre: Ibadan, Nigeria

Author(s): Hamidu Oluyedun1
Affiliation(s): 1Oyo State Hospital Management Board Secretariat, Ibadan, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): The WHO regards diabetes as avicious silent killer diseases with its overall prevalence on the increase. This study aimed to reduce pregnancy mortality and faciliate better pregnancy outcomes. Two Hundred pregnant volunteers were chosen for the study which included the participation of various categories of Health Workers.  The study revealed a correlation between Health, Social and Educational levels of participants and the awareness of the dangers posed by diabetics to pregnancy. Training and the provision of specific information to volunteers resulted in better pregnancy outcomes.
Background (max 200 words): The WHO regards diabetes as one of the most vicious silent killer diseases with overall prevalence on the increase.   It is forecasted to afflict at least 200million people by 2012. In 1998 1.05million diabetics were reported in Nigeria, and  5% - 10% of Nigerians were believed to be diabetic in 2010. Type 2 diabetes is more widespread than type 1 diabetes and the prevalence of type 2 prevalence is increasing rapidly. Diabetes leads not only to immediate health symptoms but also long term complications such as cardiovascular and kidney disease. The  target levels for plasma glucose is >or = 6 but <7 mmol/l FPG and < 7.8mmol/l for PPG
Objectives (max 100 words): To help pregnant women with diabetes learn how to make lifestyle choices which enable them to achieve optimum metabolic control and prevent diabetic complications. To achieve and sustain acceptable body weight and prevent, delay or treat, complications. In addition to integrate diet, activity and pharmacological therapy were also the objectives.
Methodology (max 400 words): St. Peters Maternity Hospital, Aremo, Ibadan, a community based maternity centre, was chosen for this study. Volunteer pregnant women were selected for the study after consent forms were completed and the study was explained to the volunteers in languages they understood. In all, 200 pregnant women were involved in the study that spanned a 6 months period. Social History and Social Economic parameters were obtained from the pregnant women. The following diagnostics parameters were obtained from the recruits with the assistants of the Laboratory Scientists:- 1)Random blood glucose (RBG) – sample of blood taken at any time 2)Fasting blood glucose (FBG) – sample of blood obtained after a period of not eating or drinking for at least 8 hrs 3)Oral glucose tolerance test (OGTT) – a fasting blood glucose sample was initially taken, then a sweet drink is consumed and blood samples were then taken every 30mins for next 2hrs. The sample taken at 2hrs is the most important as it is linked to poor glycaemic control. Educational Intervention on nutrition were organised for the volunteers.
Results (max 400 words): Type 2 Diabetics was common in 25% of the volunters. The perception of the pregnant women was related to their educational bacground. Thereofore training on nutritional modificatios and exposure to the benefits of adequate diets from indigenous foods is important. The results showed that 50% of the diabetes in the pregnant women was controlled while the remaining 50% needed additional anti diabetics drugs for management. The pregnancy outcomes were better when compared to the pregnancy outcomes of the precedding 3years when the training and interventions were not in place.
Conclusion (max 400 words): The Millenium Development Goal 5 on Maternal Mortaltiy can be achieved with collaborative effort from all health workers. The result showed that good pregnancy outcomes are reliant on the collective efforts of all the health workers. The training should be increased and replicated in other health care facilities in the community.

Type 2 Diabetes and Migrants: A Twelve Country Study

Author(s): Manuel Carballo1, Klea Faniko2, Alexandre Lefebvre1
Affilation(s): 1International Centre for Migration, Health and Development, Geneva, Switzerland, 2University of Geneva, Switzerland,
1st country of focus: Greece
Additional countries of focus: Austria, Canada, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This twelve country study (Austria, Canada, Greece, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK) addressed the prevalence of type 2 diabetes (T2DM) in migrant and non-migrant populations and responses to its diagnosis and management.  Respondents were recruited from health care facilities and they were interviewed using a standardized questionnaire in their language of choice.  Statistically significant differences emerged between migrants and non-migrants with respect to a number of health care indicators, and the study highlights the importance of reaching out to migrants with T2DM diagnostic and therapeutic services designed around their particular needs and sociocultural situation.
Background (max 200 words): Over the last two decades the number of people with diabetes mellitus (T2DM) has increased by almost 50 percent. While better diagnosis and reporting may in part account for this increase, there is growing evidence that the problem is in fact becoming more common in developing as well as developed countries, and that migrants and ethnic groups tend to have a higher risk of developing T2DM than other groups do.  Chronic psychological stress, poor nutritional acculturation, radical changes in lifestyle and difficulties with health care in general may be important factors in the development of T2DM in migrants and ethnic minorities. There is also evidence that migrants and ethnic minorities are not always able to benefit from diabetes-related programs as they are currently structured.  There is a growing understanding that the complex relationship of T2DM and migration must be better characterized and that more should be done to ensure that migrants and ethnic minorities are reached with timely prevention, diagnosis and care programs that take into account their risk factors and special needs.
Objectives (max 100 words): The overall aim of the project was to provide a body of socio-epidemiological data that could form the basis for national policies and programs, including training of healthcare personnel and development of guidelines that can be used in the day-to-day prevention, diagnosis, care and treatment of T2DM in migrants and ethnic minorities.  The specific objectives of the project were to: • define what is currently known about the link between migration and T2DM and its treatment/management in migrants;• determine the incidence/prevalence of T2DM among people meeting the study definition of “migrant”, and identify contributing factors;• describe how people meeting the study definition of “migrant” perceive T2DM and its care and treatment/management;• assess how healthcare personnel working with people who meet the study’s definition of “migrant” and are diagnosed with T2DM perceive their interaction with them;• assess how a control group of non-migrants with T2DM perceive the disease and its care and self-management;• develop a program to sensitize stakeholders, including migrants, their families, health care personnel and others, on the needs of migrants with respect to T2DM;• develop guidelines on the prevention, diagnosis, care and treatment of diabetes in migrants and ethnic minorities;• develop public information materials for migrants (and ethnic minorities) on T2DM prevention, diagnosis, care and treatment;• develop training materials and training programs for healthcare personnel on the theme of multi-cultural health care with special reference to diabetes;• evaluate the impact of these interventions by measuring changes of attitudes and knowledge among healthcare personnel and migrants (and ethnic minorities).
Methodology (max 400 words): The study focused on four groups of interest: migrants and non-migrants diagnosed with T2DM; healthcare staff working with migrants and others with T2DM.  Respondents were recruited from pre-selected public health care facilities in locations with a known high presence of migrants.  Respondents were recruited with the agreement of healthcare authorities and patients.  Contact with respondents was made by letter from the PIs in the countries concerned.  Healthcare personnel working with migrants with T2DM were also contacted directly by the PIs.  All migrants and non-migrants were aged between 35-59 years, and PIs were also asked to ideally involve healthcare providers within the same age-range as the patient/respondent group in order to minimize possible “time-cultural” differences.  Participating centers were asked to select and interview the following; between 50 and 100 migrants with T2DM; between 50 and 100 non-migrants with T2DM; at least 20 healthcare staff providing diabetes care to migrants and others.  Information about the study and its aim was disseminated through local healthcare facilities in each city and through associations, clubs and other facilities known to be frequented by migrants and non-migrants.  Potential participants in the study were given details on the purpose of the study, namely to improve the quality of care available to migrants and others with respect to diabetes, and were given an opportunity to ask questions about the study.  They were assured of confidentiality.  No incentives were offered, but in cases where the participant requested assistance with counseling or referral, this was provided.  Face-to-face interviews were conducted using structured questionnaires specially developed for the purpose of the study by interviewers who were capable of speaking the language of the respondents. If respondents chose not to participate in the project, this was recorded as a refusal.  If respondents started and then decided to discontinue the interview, it was recorded as a discontinued interview and the reason was recorded.  The interviews lasted approximately 40 minutes.  Focus groups were also organized to generate information from health care personnel using guidelines developed specially for the purpose of this study.  Data entry was done locally on an on-going basis using data entry sheets provided by ICMHD and sent to ICMHD and analyzed centrally.
Results (max 400 words): Statistically significant differences emerged between migrants and non-migrants in a number of areas, such as knowledge about T2DM, factors influencing its occurrence, its short and long-term implications, the ways in which it can and should be managed, and where help can be had if and when complications arise.  Attitudes to T2DM also differed; migrants were far more inclined to take a more fatalistic view of the disease than non-migrants were.  There were also significant differences with respect to the circumstances in which T2DM was diagnosed; data from all the countries suggested that migrants tend to be diagnosed with T2DM as a result of other health problems/complaints and not as a result of regular checkups; almost 60% of migrants with T2DM had been diagnosed during medical examinations for other problems including occupational injuries.  On the whole, migrants diagnosed with T2DM were much more likely to say that the diagnosis had been poorly explained to them, or that they had not understood what had been said. There was also a fairly widespread feeling that the people treating them were not interested in them as migrants or in their needs, even though the diagnostic setting was typically described as friendly. Migrants frequently expressed concern at not feeling sufficiently “in control” of their lives to manage their diabetes, and they had much more difficulty keeping appointments with healthcare providers.  They were also more likely to use emergency call numbers (hotlines) for diabetes related problems than non-migrants.  One of the background characteristics we believe may be important in the development of T2DM is the relatively large proportion of migrants who had been separated from their significant others by migration and who said they were chronically stressed.  There was a clear tendency for migrants to also have less economic/occupational security than their host population equivalents; contractual employment was less common among migrants and was also seen by them as a source of stress. There was also a tendency for migrants to work longer hours than non-migrants and have little time for personal activities including cooking, a fact that they said contributed to their use of pre-prepared foods. In accordance with what has been observed elsewhere, migrants were also more likely to be living in overcrowded dwellings and sharing accommodation with a number of people to whom they were not related.
Conclusion (max 400 words): The prevalence of T2DM is significantly higher among migrants than non-migrants in Europe and Canada. A number of factors may be linked to this, including chronic stress, rapid and often difficult changes in lifestyle, high dependence on ready-made foods and fast foods outlets, poor awareness of the factors contributing to T2DM and the importance of T2DM as a disease. It is also clear from the study that the diagnosis of T2DM in migrants often occurs incidentally to other complaints and not as part of any targeted regular checkups. Migrants also appear to have more difficulty coping with T2DM than non-migrants and in many cases do not have the level of personal control needed to make self-treatment easy or successful. On the whole communication between healthcare providers and migrants with respect to explaining the nature of the disease, the contributing factors and ways of dealing with it is also lacking, and many migrants tend to interpret this as a lack of interest on the part of healthcare providers in them as migrants and, in particular, as people with different medical and socio-cultural histories. In view of the growing problem of T2DM and the growing magnitude of migration it is clear that much more will have to be done to tailor national diabetes strategies in ways that address the specific needs of this new population. There is a need for more and better outreach to migrants, and there are grounds for promoting regular screening for T2DM in migrants.  Certainly more needs to be done to convey to migrants what the risks of developing T2DM are and what the main factors contributing to those risks are.  It is also clear that providing psychosocial support to migrants could well help them to manage their diabetes better and be less reliant on health care providers and emergency care in particular.  Although this type of intervention might at first seem costly, it is probably one of the more cost-effective investments that can be made once migrants have been diagnosed with T2DM.

The Asthma Drug Facility: A Practical Solution for one of the Major Non-Communicable Diseases

Author(s): Cecile Mace1, Nils Billo1, Christophe Perrin1
Affiliation(s): 1The International Union Against Tuberculosis and Lung Diseases, Pantin, France
1st country of focus: Not applicable
Additional countries of focus: Low- and Middle-Income Countries
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): The Asthma Drug Facility, a project of the International Union Against Tuberculosis and Lung Disease (The Union) is one of the practical solutions to support low- and middle-income countries to offer standardised asthma management to patients using essential medicines. However, the ADF services have only been used by a very limited number of countries. Having a procurement system in place for asthma medicines at global level is only part of the solution to improve asthma management in low- and middle-income countries. To change the situation, countries also need the political will to invest in asthma management and funds to support all important activities.
Background (max 200 words): The Union established the Asthma Drug Facility (ADF) to provide affordable access to quality-assured, essential asthma medicines for low- and middle-income countries and to promote a quality improvement package for the diagnosis, treatment and management of asthma.
Objectives (max 100 words): This presentation will help participants to understand the ADF procurement system and services and how it will help to overcome one of the major barriers to asthma management in low- and middle-income countries: the lack of access to inhaled corticosteroids. It will also look at the additional barriers for countries to improve asthma management.
Methodology (max 400 words): The ADF is now fully operational since 2009 and has performed two rounds of qualification followed by restricted tenders to establish contracts with manufacturers. Countries, organisations and programmes can now use the ADF services to implement asthma programmes or integrated approaches to respiratory health.
Results (max 400 words): The ADF has already supplied essential asthma medicines to Benin, El Salvador, Kenya, Sudan, Burundi and Vietnam. New orders are also in progress for Guinea Conakry and Burkina Faso and new contacts have also started with other countries. Through the ADF, these countries have seen the cost of inhalers fall by as much as 50%, making one year of treatment with Beclometasone and Salbutamol for a patient with severe asthma cost less than 40 USD. However, the ADF services have only been used by a very limited number of countries. Millions of people with asthma in low- and middle-income countries currently have no treatment, or inappropriate treatment.
Conclusion (max 400 words): Having a procurement system in place for asthma medicines at global level is only part of the solution to improve asthma management in low- and middle-income countries. To change the situation countries need also political will to invest in asthma management and funds to support their activities. The financing options used by the first ADF clients can be an incentive for other countries to move forward to implement asthma management. It is also hoped that further actions following the High-Level Meeting on Non-Communicable Diseases in September 2011 will recognise and promote practical solutions such as the ADF.

Prevalence and Re-Infection Rates of Soil Transmitted Helminths among School Children in Ardokola, Nigeria

Author(s) Innocent Vakkai1, C.L. Ejembi2, P. Aboa3
Affiliation(s): 1Ministry of Health Taraba State Nigeria, Jalingo, Nigeria, 2Ahmadu Bello University, Zaria, Nigeria, 3University of Port Harcourt, Choba, Rivers State, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): The Prevalence and re-infection rates of soil transmitted helminths was high among school children, therefore regular deworming of school children every six months in endemic communities is required.
Background (max 200 words): Soil transmitted heminths has been a major cause of morbidity and mortality among school children in many developing countries including Nigeria. It affects the develoment of school age children and developing countries carry a greater share of the global burden of this disease than developed countries. This situation requires public health attention.
Objectives (max 100 words): The objectives of the study are 1) To determine the baseline prevalence of soil transmitted helminths among school children in Ardokola Local Government Area of Taraba State. 2) To determine the rate of re-infection with soil transmitted helminths among the studied school pupils at one, three and six months intervals. 3) To recommend periodic deworming of school children for the control of soil transmitted helminths among pupils.
Methodology (max 400 words): The study was a field interventional study. A total of 365 primary school pupils were selected using a multistage sampling method. Stool specimens were collected and the prevalence of soil transmitted helminths was diagnoised and determined. Albendozole 400mg was given as an intervention, the number of pupils cured were established with those cured followed up at one ,three and six momths interval to determine rate of re-infection.
Results (max 400 words): The prevalence of soil transmitted helminths was 64.4% at base line among school pupils with a cure rate of 88%. The re-infection rates  were 11.1%, 31.7% and 58.3% at one, three and six months interval.
Conclusion (max 400 words): The prevalence of soil transmitted helinths was high amomg school children in Ardokola Local Government Area of Taraba State and the rate of re-infection was highest after six months(58.3%) hence the need for periodic deworming every six months within endemic communities.

Community Based Intervention through 1 Stop Centre for Health: A Community Empowerment Approach in Malaysia

Author(s): Noraryana Hassan1
Affiliation(s): 1Ministry of Health, Melaka, Malaysia
1st country of focus: Malaysia
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This paper presents the outcome results of a 6 months structured intervention program  among 107 subjects in a  community in Pantai Peringgit, Melaka, Malaysia which aimed to reduce  Non Communicable diseases (NCD) risk factors and improve walking stamina.
Background (max 200 words): Obesity is an epidemic in Malaysia and Melaka has one of the highest prevalence of people with obesity in the country. Experts propose that the possible reasons are sedentary lifestyles and over eating which contribute to the fast growth of obesity and is responsible for deaths caused by Non Communicable diseases (for example  ischemic heart diseases, diabetes, and hypertension).  A structured intervention program through community empowerment was found to be effective in making changes in sedentary lifestyle and unhealthy eating.
Objectives (max 100 words): The objective of this study was to reduce the NCD risk factors among the community in Pantai Peringgit Melaka through a structured 6 months community based intervention program.
Methodology (max 400 words): This is a cross sectional study with structured community based intervention.  A total of 107 people in the Pantai Peringgit Community were recruited in the study.  Study subjects were chosen from those who conducted self screening of NCD risk factors and agreed to the intervention. All screening and intervention programs were conducted in the community centre called 1 Stop Centre For Health. Screening and intervention activities were conducted by 10 volunteers in this community lead by the Pantai Peringgit community leaders. Community leader and the volunteers were trained by the Melaka State Health Department in the two main parts components of the intervention screening and intervention. The intervention began in March 2011.  The 107 participants were divided into 8 groups. The intervention programs were easily monitored by the volunteers and community leader in these smaller groups. In order to reduce dropout rate, competitions were held among the groups. Examples of physical activities include aerobic, brisk walking and football games which were carried out twice a week. The diet intervention was carried out by 4 series of health education talks, 4 cooking demonstrations and cooking competitions. Screenings of pre and post intervention included individual BMI, random blood sugar and blood pressure. All data were monitored by the individual through a web system which was then monitored by the Melaka State Health Department. To see the improvement of walking stamina of the intervention groups, every individual in each group had to walk for 5 km and the mean time for each group was recorded.
Results (max 400 words): A total of  number 34 (31.8 % ) men and 73  (68.2 %) women agreed to participate in the intervention program. The mean age was 46.8±17.1. In the pre assessment screening 20.6%  were in the group of normal weight , 35.5 % overweight and 43.0 % obese. After the 6 months intervention the percentage of overweight increased to 38.3%,  however the obesity group reduced to 41.1%.  Percentage of normal BMI remains the same. The mean sugar level was 7.4±7.1 in the pre assessment screening reduced to 5.3 ±1.2 after 6 months intervention (p<0.001). The mean for systolic blood pressure reduced from 134.3±25.1 to 120.2±20.3 (p<0.001) and mean for diastolic reduced from 82.8 ±18.2 to 72.4 ±9.2 (p<0.001). For random blood sugar level the mean reduced from 7.4 ±7.1 to 5.3 ± 1.2. 2 (p<0.001). The mean time to complete 5 km walk between the groups improved from 65 minutes before the intervention to 43.9 after 3 months and to 40 minutes after 6 months.
Conclusion (max 400 words): Structured Community based intervention with the concept of community empowerment has reduced the NCD risk factors of Pantai Peringgit community. The percentage of people in the obese group reduced after the 6 month intervention. Mean systolic blood pressure, mean diastolic blood pressure and mean fasting sugar level showed significant reduction.  Walking stamina among the group has also improved.

Estimation of Salt Intake Using 24-Hour Urine Collection: Switzerland

Author(s): Aline Chappuis1, Fred Paccaud1, Murielle Bochud1, Michel Burnier2
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland, 2 Division of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): We submit this abstract on behalf of the Swiss Survey on Salt Group. Within the framework of a nationwide strategy on dietary salt reduction launched by the Swiss Federal Office of Public Health, we conducted a national population-based survey aiming at estimating dietary salt intake in the population aged 15 years and over, using 24-hour urine collection. Mean urinary salt excretion was 10.6 g/24h in men and 7.8 g/24h in women; a large proportion of participants had a urinary salt excretion above the recommended thresholds, which is similar to what is found in other Western countries.
Background (max 200 words): The Swiss Federal Office of Public Health has launched a nationwide strategy on dietary salt reduction for 2008-2012. The aim of this strategy is to reduce salt intake to less than 8g/day in the population. The long term goal is to stabilize salt intake to the WHO-recommendation of less than 5g/day. Data on dietary salt intake are lacking at a national level in Switzerland.
Objectives (max 100 words): We conducted a national survey in 2010-2011 to estimate dietary salt intake in the population living in Switzerland aged 15 years and over.
Methodology (max 400 words): The population-based survey included eleven study centers, covering nine cantons and the three main linguistic regions of Switzerland (German, French and Italian). Participants aged 15 years and over were recruited within eight predefined sex- and age-strata, using a 2-level sampling strategy similar to the one used in the Swiss Health Interview Surveys. Participants collected 24-hour urine; collections <300ml were excluded from the following analysis (n=3). Urinary sodium was measured centrally in the Laboratoire de Chimie Clinique, CHUV, Lausanne, Switzerland using indirect potentiometry.
Results (max 400 words): Data from 704 men and 740 women were available for the analysis. The mean (SD) urinary salt excretion was 10.6 (4.2) g NaCl/24h in men and 7.8 (3.3) g NaCl/24h in women (p<0.001). In the 15-29, 30-44, 45-59 and ≥60 year-old groups, salt excretion was 9.8, 11.1, 11.3 and 10.2 g NaCl/24h in men and 7.8, 8.2, 8.2 and 7.0 g NaCl/24h in women. The age-, sex- and body mass index-adjusted mean urinary salt excretion in the German-speaking region (9.3 g/24h) was higher than in the French- (8.7 g/24h) but similar to the Italian- (9.2 g/24h) speaking region. Cantons of Luzern and St.Gallen had significantly higher salt excretion (9.8 g/24h) than Zürich and Basel (mean 9.0 g/24h), which highlights heterogeneity within the German-speaking region. A large proportion of men and women had a urinary salt excretion above the WHO recommendation of 5 g/day (94.2% and 78.7% respectively, p<0.001); furthermore, 71.2% of men and 41.5% of women (p<0.001) were also above the national short-term objective of 8 g/day.
Conclusion (max 400 words): Similar to what is found in other Western countries, 24-hour urinary salt excretion, which reflects dietary salt intake, is above the recommended thresholds in a large part of the population of Switzerland, especially in men and middle-aged people. The observed small regional differences do not justify different strategies to reduce salt intake in the Swiss population.