Health Promotion Diabetes

Abstract

Title: Diabetes self-Management Education in Community Gathering for Adults with Type-

2 Diabetes in Tiruvallur, Chennai, India.

Introduction: Over the next decade it has been projected that the total number people with diabetes will elevate to 200 million in world .The intended health promotion program will help patients with type 2 diabetes to develop self management skills and becoming empowered to avoid diabetic complications, as there is no cure for it. Research studies have shown that if blood glucose level is not maintained, it will lead to stroke, cataract and other cardio vascular diseases.

Aims: Diabetes self-management education is an interactive, collaborative process that can equip adults with basic knowledge to manage their type 2 diabetes while focusing on their self-identified problems and goals. It emphasizes problem solving and decision making as they relate to core diabetes self-care skills such as healthy eating, physical activity, proper dental care, and monitoring blood glucose level.

Objectives: The intended program will help type 2 diabetes patients, irrespective of their racial or ethnic backgrounds, to develop appropriate diabetes management knowledge and skills. Among the

1

participants, blood sugar level will improve, potentially leading to a decrease in diabetes-related complications and premature death.

Discussion: To tackle the problem of diabetes, there are so many programs running at primordial and primary level in India, but less at tertiary level .So, this community based program will let target population to become empowered, it is especially important for reaching people who have limited access to formal healthcare, do not speak native language, or may not have the option of home-, clinic-, school-, or worksite-based diabetes education.

Conclusion: According to the studies conducted, community based diabetes self-management education program has been proved to be effective in halting diabetes related complication. In addition, program can be bolstered by taking other determinants of health in consideration and making modifications in existing social and government policies .Moreover, it will help in its sustainability.

2

Introduction: Diabetes is a group of disorders sharing the common features of sustained high blood sugar level. Diabetes cannot be cured; it is a common, serious, chronic disease (WHO). It affects health and life expectancy, has major financial and social impacts and its more prevalent form (type2) is 3

preventable diseases. The less prevalent (type 1) is one of the most common chronic diseases of childhood, it is usually genetic. But type 2 results from excess of weight and physical inactivity and in turns can be prevented (Shah et al, 2004).

International scenario: Diabetes prevalence has reached epidemic proportions worldwide as we enter the new millennium. According to the W.H.O, ‘there is an apparent epidemic of diabetes which is strongly related to lifestyle and economic change’. Over the next decade the projected number will exceed 200 million and mostly will have type-2 diabetes. There are approximately 1.3 million people in the U.K who are known to have type 2 diabetes ,this figure will rise to 3 million by 2010 ( Wild et al 2004; WHO, diabetes ).

Indian scenario: There are about 40 million people affected by diabetes (U.N, 2004). Most Indians develop diabetes at an early age and have greater incidence of obesity. The prevalence is escalating at enormous pace. According to WHO (India), there were 46 million people with diabetes in 2007. As economic progression is directly proportional to urbanization, there is a hike in the number of people with diabetes in India (Ramachandra et al, 2000). It’s also estimated that the diabetes prevalence will increase from 6% to 9% in 2025 as a result of increased life expectancy, where the aged population (50 and above) will increase from 16% to 24% between 2007 and 2025 (U.N, 2004).

Sequel of diseases:

4

Type 2 diabetes is also linked with other non-communicable diseases. Various research studies concluded that it is a major risk factor for other associated conditions. Odds and risk ratio associated with diabetes as risk factor for cataract (Pradeep et al., 2002) {OR -8.5, C.I – 3.63 to 20.12}, Neuropathy (Ashok et al. 2002) {OR-1.4, C.I- 1.20 to 6.40}, Stroke (Ramachandra et al ,1999){OR- 1.7 ,C.I 1.1 to 2.6}. In addition, attributable risk of 4% for stroke, 2% for neuropathy and 32% for cataract cases shows that all these post complications can be avoided if individual haven’t acquired diabetes (Ramachandra et al). Diabetes also accounted for 11.57 million year of life lost and for 22.63 million DALY’s during year 2007 (WHO, India).

From the meta-analysis of epidemiological studies conducted in India. It has been observed that prevalence rate in urban is almost thrice as compared to rural areas (Sandeep et al. 2002; Ramachandra et al., 2000).

Chennai as an evidence of rising prevalence: Chennai is perhaps the only city in India, where a series of population based studies have been conducted, which has enabled investigators to compare the prevalence rates. Studies done in the same urban (Tiruvallur) area for past 15 years have shown a rise in prevalence from 8.3% to 14.3% from 1995 to 2005. Thus there was 72.3% rise in the prevalence (Sandeep et al. 2002, Mohan et al, 2003).

5

Fig .1(Source, Sandeep et al. 2002)

With such high prevalence, there will be large number of people suffering from diabetes and its complications. We will target retired people with diabetes and help them to manage the condition by educating them. Targeting retired people will help us to overcome the problem of ‘population paradox’ (Rose 1992).

Strategies: 1. Community based health promotion [Diabetes Self Management Education Program (DSMEP)] 2. Secondary prevention (Rose, 1992)

6

Secondary prevention will help to identify those who have already developed the disease and to halt progress. It will be accompanied by an awareness program, life style changes and supportive environment all through community bases. This will focus on entire population or community as whole. The goal of Diabetes Self Management Support Program (DSMEP) will be to empower people in the community using risk and health oriented approach (Downie et al., 2004) to avoid post-complications of the diseases. This program will provide knowledge, information and support for the development of necessary management skills and will work with the people to let them choose their own agendas with health professionals as facilitators. There is also evidence from meta-analysis of different studies that group-based education programs are significant in reducing blood pressure and body weight, and increase self-empowerment, quality of life, selfmanagement skills and treatment satisfaction (Deakin et al., 2005; Hawthorne K., 2008; Renders, 2000). Moreover, reviews have shown that, for every five patients attending a groupbased education program one patient is expected to reduce diabetes medication and postcomplication (Deakin et al., 2005; Norris et al., 2002).

Model used: Proceed-Precede model (Green & Kreuter, 1991, 1999) will be used to begin the planning process, by assessing the target audience at multiple levels. This model will help to recognize multiple determinants of health (Marmot and Wilkinson, 1999) and the program will be started with an assessment of the quality of life and social problems, as ultimate goals, of which health is a contributory factor.

1. Social, epidemiological, environmental and educational assessment will be done to

understand the perceived needs of the community, prioritized them and setting program goals.

7

2. Administrative and policy assessment – Information gathered from the previous steps

will help us to identify key resources needed, policies and regulation that could affect the program. 3. Evaluation:–  Process evaluation- before implementing the program we will do an evaluation to

gauge the extent to which program is carried out according to action plan  Outcome evaluation- At the end we will look at whether the intervention has

affected health and knowledge of patients in the expected way

Identifying the needs and priorities of community to set goals: The target group (patients already with diabetes) priorities will be assessed prior to implementation of interventions because the structure and scope of program will be developed according to the needs of the intended program participants. Besides, the program for pregnant women will be different from a retired diabetic patient. For gaining people’s support, conduct focus group and semi-structured interviews will be conducted with prospective program participants and their families. This will help to understand the current level of basic diabetes knowledge of prospective participants, assessing their environmental and personal barriers to improved Diabetes Self Management Self Education Program (DSMEP) participation (likeTransport and time limits, child care needs , cultural and community practices , poor access to clinical care , lack of social support , food quality and physical activity opportunity)

Existing partners and key stakeholders will also be identified and will be engaged in the program. Various stake holders could be:  Adult residents with type 2 diabetes  Existing diabetes education and general program in clinical and community settings  Physicians

8

 Other health professionals like diabetes educator  Community health worker  Local and national diabetes organizations  Community leaders  Local media( television, radio , newspapers , internet) Community gathering places for DSMEP The program will be delivered at the locations which will be acceptable and easily accessible for the participants. Community centers, faith-based institutions, libraries, and private facilities (e.g., Diabetes risk reduction centers) will be the potential sites (Reff????). To evade poor outcomes unacceptable and inaccessible places will be avoided and transportation will be provided for the participants to attend DSME classes.

Theory: The program will be based on theory of community building (Minkler 1999) and community organization theory (Rothman 2001), as this program is intended to be user led, facilitated with the help of health professional and empowering people (Wallerstein, 1992) to gain mastery over their lives in context to improving equity and quality of life. The community will become more empowered, will work on specific issue linked with other groups, to take wider action and ultimately will be engaged in collective political and social action. Involvement in self group or action group will provide opportunities for further personal development and individuals can become more critically aware of the wider social forces that are acting on them and their community (Wallerstein, 1992). In contrast, this model of community organization can be too much problem-based (seeking solutions to predefined problems), and may have its roots from approaches that were significantly dependent upon outside technical expertise and professional support. In addition, community building on empowerment is conceptually attractive, but difficult to deliver. It requires high level of trust and commitment between those involved, and a willingness by health promotion workers to relinquish power.It can be challenging, if marginalized and disenfranchised groups in the society are considered (Sidell et al., 2003).

9

There can be other determinants of health (Marmot and Wilkinson, 1999) for the target group because these can indirectly influence their health. They can be:

 Social stratification factors - Age , sex , hereditary factors  Personal behaviour factor – smoking , physical inactivity , psychological factor(stress)

 Social and community factor- ethnicity, religion , family , peer group  Living conditions – access to health services , source of livelihood ,access to leisure

facilities , regional location  General economic, cultural and environmental conditions – Environment , Advertising ,

Housing tenure.

Type of program An amalgamation of lifestyle change and supportive environment for managing the condition will be used in the program. The program will focus on skills building activities ,where we will contribute to modify life style factors including maintenance of Body Mass Index (25 or less) , eating healthy diet rich in cereal fibres and polyunsaturated fats and low saturated and trans fat and glycemic load, exercising regularly, abstaining from smoking and consuming moderate alcohol. Research shows that ,if above factors are adopted, the chance of developing type-2 diabetes will be alleviated by 90% (Tuomilehto et al., 2001; Wing et al., 2001; Knowler et al., 2002; Frank et al., 2001). The program will also incorporate skills for enhancing self-efficacy (e.g. personal goal setting, collective problem-solving to overcome self-identified barriers to diabetes self-management) and overcoming psychosocial factors that may hinder diabetes self-management, lessons that teach participants skills for advocating environmental changes that support diabetes self-management will also be taken into consideration ( access to quality food).

Risk factors:

10

There are some factors that are associated with an increased risk of type-2 diabetes like obesity, previous gestational diabetes, hypertension, family history of type-2 diabetes and some ethnical groups are more at risk. Persons with "pre-diabetes" are also at high risk: they have abnormal blood glucose levels but not in the range of diabetes. Pre-diabetes often precedes the development of type-2 diabetes (Orozco et al., 2008). Excess body fat is the single most important determinant of type-2 diabetes. Weight control would be the most effective way to reduce the risk of type-2 diabetes (Frank et al., 2001).

Structure and scope of the program This program will incorporate following four diabetes self care behaviour that have been proved effective by systematic reviews conducted (Deakin et al., 2005). These are:  Healthy eating  Physical activities  Monitoring sugar level in blood

 Taking medication

Existing DSMEP curricula and diabetes education material that has been determined to be effective through evidence based research will be searched. Then it

will be modified in

accordance to participant’s background like literacy level, health beliefs, cultural beliefs and other determinants of health. We will also make decisions on items relating to curriculum delivery, including class size, frequency, and length; lesson format; and educational strategies for teaching adults (such as engaging participants through culturally appropriate examples). If the program is less culturally relevant (Sidell et al., 2003) to the participants, it may result in low attendance rates. To increase the program attraction, it will be ensured that its culturally inclusive, sensitive and supportive, that instructor understands participants’ health beliefs, cultural norms, and values (Downie et al., 2004), conveys information in participants’ preferred language (Sidell et al., 2003) and at an appropriate reading level, integrate ethnic food 11

preferences into nutrition education and cooking demonstrations, and feature individuals of the same racial or ethnic group in graphics and videos.

However, just educating regarding the above four self management techniques will not be enough because there can be several other factors (Downie et al., 2004; Sidell et al., 2003) which do not allow the participants to adopt these factors easily even if they will be eager. These can be: Social norms: Inactive lifestyles have become a “social norm”. Surveys have showed that people spend their leisure time as sedentary lifestyle (Brown et al 2003). Personal factors: Older adults may feel out of shape, have physical disabilities, or may not want to walk alone (King, 2001). External factors: Research shows that environmental factors have a remarkable effect on activity levels. People are more likely to engage in physical activities if the sources (such as Parks) are near to them (Casper et al., 1990; King, 2001; Sallis et al., 1990). Social interaction: People are more likely to be active if they are with other persons (Balfour J. and Kaplan., 2002; King, 2001).

TIMETABLE WITH PROJECT MILESTONES: This program work will start on 1 January 2010 and will end on 30 July 2011. The program will consist of multi phases.

I January 2010-----28February2010

Need assessment of key stake holders

1March----------30 July 2010

Providing self management education 12

1August2010---30 April 2011 1 May 2011---- 30 July 2011

Follow up Outcome Evaluation

Resources that will be needed to successfully implementation  Office space for staff, Meeting space, audiovisual equipment, 

Hard-copy educational materials for participants , Instructional materials ( food models, cooking equipment)

 Equipment for on-site assessments of physiological measures (body weight scales, blood

pressure cuffs, glucose meters)  Hard-copy and electronic promotional materials ( flyers, registration forms) 

Items serving as participant incentives ( water bottles)

 Materials for interviews, surveys, and other modes of evaluation And other possible resource would be Program coordinator to direct program planning and manage the program, administrative staff to provide support to the program coordinator and instructional staff, Instructional staff to provide DSME, advisory board composed of committed partners and stakeholders to support the goals of the program.

Evaluation methods: (Scott and Welson, 1998; MacDonal et al., 2006 ; Issel, 2004; Mulcahy et al., 2003) Evaluation will be conducted before and after study. To assess whether program was implemented as intended, we will collect data on quality and effectiveness of our activities and following question will help us to assess it. Process evaluation: assesses actions taken in pursuit of program outcomes  Is the advisory board representative of appropriate community stakeholders? 13

 To what extent are program participants representative of the target audience?  Has the level of participation decreased over time?  What are the program costs, from a participant and from a delivery perspective?

Outcome Evaluation: refers to the assessment of program goals to determine if discernable changes to behaviour, attitudes, or knowledge have been attained as a result of the intervention (Mulchay et al., 2003).  To what extent have participants achieved their self-identified behavioral goals (e.g.,

quitting tobacco use, eliminating candy consumption, taking a 10-minute walk every day, specified taking steps to reduce stress, practicing proper oral health)?  To what extent have participants improved targeted physiologic measures such as

weight, blood pressure, cholesterol, blood glucose level?  How do participants rate the improvement in their overall quality of life as a result of program participation?

Evaluation challenges (Sidell et al., 2003) The Cost Challenge: Program evaluation can be expensive The Time Challenge: Evaluation efforts may be time consuming The Expertise Challenge: As experts may be involved to analysis of the data collected

14

Potential sources of collecting data for above evaluations can be: Participant registration and attendance records, participant satisfaction surveys, Interviews, questionnaires, and focus groups with participant (Qualitative methods).Results from physiologic measures—such as weight, blood pressure, and blood glucose level—taken onsite at DSME classes (Quantitative methods)

Dissemination of the DSME program The information obtained from the community assessment and input from the advisory board will be used to develop promotional messages about the DSME program. Marketing materials will be developed that describe the program and the benefits to participants; using the audience’s native language and incorporating culturally appropriate symbols and key messages. Post flyers in stores and community gathering places (e.g. faith-based institutions, schools, community centres, ethnic centres, senior centres, supermarkets, libraries, healthcare centres, fitness centres, pharmacies). Also, local faith-based leaders, tribal leaders, community health workers and other respected community figures, will be engaged for promotion of DSME program among members of the community. The program will also offer an “open house” or informational class about the DSME before it begins, which will address questions that potential participants may have, provide them with an overview of the program and introducing them to staff.

Sustaining DSME program Following steps will be taken for sustaining the program  Encourage participants to share their experiences in order to reduce feelings of isolation and learn from each other. 15

 Help participants set goals that meet their individual needs.  Give incentives (e.g. food samples, useful handouts, free glucose test strips, door prizes)

at each class.  Incorporate the target population’s culture into program components.  Foster social support by encouraging participants to bring a “buddy” to classes.

Conclusion: It’s clear from the range of literature that Group based training for self-management strategies in people with type-2 diabetes mellitus are effective in halting post complications. But, sustaining the program can be a daunting task; there can be several institutional, socioeconomic or political structural, cultural, personal factors that may hamper it. The program can be more successful if integrated with modification on macro economic and political structure.

16

References Ashok S et al., 2002; Prevalence of Neuropathy in Type-2 Diabetes patients attending Diabetic Centre in Southern India; Journal of physician association of India; 50:546-550. Association for Community Health Improvement, Planning, Assessment, Outcomes, and Evaluation Resources. Available at: http://www.communityhlth.org/communityhlth/resources/planning.html (accessed on 05-05-09). Balfour J., Kaplan G., 2002; Neighborhood Environment and Loss of Physical Function in Older Adults: Evidence from the Alameda County Study; American Journal of Epidemiology; 155: 507-515. Brownson et al., 2001; Environmental and Policy Determinants of Physical Activity in the United States; American journal of Public Health; 91:1995-2003. Deakin T. et al., 2005; Group Based Training for Self-management Strategies in People with Type-2 Diabetes Mellitus; Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003417. DOI:10.1002/14651858.CD003417.pub2. Diabetes:

Health

topic,

World

Health

Organization

[online]

available

from

http://www.who.int/topics/diabetes_mellitus/en/ (accessed on 01-05-09). Downie et al., 2004; Health promotion: Models and Values; 2 nd edition; Oxford University Press; London. Frank.B et al., 2001; Diet, Life style and Risk of Type-2 Diabetes in Women; New England 17

Journal of Medicine; Volume 345:790-797. Green L.W., Kreuter M.W., 1999; Health Promotion Planning: An Educational and Ecological Approach; 2nd/3rd Edition; California, Mayfield. Issel L.M., 2004; Health Program Planning and Evaluation: A Practical, Systematic Approach for Community Health; MA: Jones and Bartlett Publishers; Sudbury King A., 2001; Interventions to Promote Physical Activity by Older Adults; Journals of Gerontology: Series A; 56A: 36-46 Knowler W. et al., 2002; Reduction in the Incidence of Type-2 Diabetes with Lifestyle intervention or Metformin; New England Journal of Medicine; 346: 393-403. Marmot M., Wilkinson G., 1999; Social Determinants of Health; Oxford University Press, London. Minlers M., 1999; Community Organization and Community Building for Health; Rutgers University press; Cited in Nutbeam D., Harris E.; Theory in nutshell : A practical guide to health promotion theories 2nd Edition; McGraw-Hill Publication Ltd. Mohan V. et al., 2003; Glucose Intolerance in Selected South Indian Population with Special Reference to Family History, Obesity, Lifestyle factors; Journal of Association of Physicians of India; 51: 771-777. Mulcahy K., Maryniuk M., Peeples M. et al, 2003; Diabetes Self-management Education Core Outcomes Measures; Diabetes Educ; 29 (5):768–803. In MacDonald G et al., 2002; Steps Program: Foundational elements for Program Evaluation planning, implementation, and use of findings; American Journal of Preventive Med.; 22 (4 Suppl):99-101. Norris S.L., Nichols P.J., Caspersen C.J., et al., 2002; Increasing Diabetes Self-management education in community settings: A systematic review; American Journal of Preventive Med.; 22 (4 Suppl): 39–66. 18

Orozco L. et al., 2008; Exercise or Exercise and Diet for Preventing Type-2 Diabetes Mellitus; Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD003054.

Pradeep R. et al., 2002; Prevalence and Risk Factors for Diabetic Retinopathy in Urban-rural South Indian Population; Journal of Physician Association of India; 55: 225-230. Ramachandra et al., 1999; Prevalence of Vascular Complication and Their Risk Factors in Type2 Diabetes; Journal of physician association of India; 47: 1152-1156. Ramachandra et al., 2000; Impact of Urbanization on Life Style and Prevalence of Diabetes in Native Asian Indian population; Diabetes Research council practice; 44(3): 208-214. Ramachandra A. et al., 2002; Impact of Poverty as Prevalence of Diabetes and its Complication in Urban Southern India; Diabetic Medicine Journal; 19:130-139. Renders C. et al., 2000; Interventions to improve the management of diabetes mellitus in community settings; Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD001481. DOI: 10.1002/14651858.CD001481. Rothman J., 2001; Approaches to community intervention; Peacock publishers, cited in Nutbeam D., Harris.E.; Theory in nutshell: A practical guide to health promotion theories, 2nd edition, McGraw-Hill Publication Ltd. Sallis J. et al., 1990; Distance between homes and exercise facilities related to frequency of exercise among San Diego residents; Public Health Reports; 105: 179-185. Sandeep S. et al., 2002; Development and updating of the Diabetes Atlas of India; Madras diabetic research foundation, Chennai, India. Scott D., Weston R., 1998; Evaluating Health Promotion, Stanley Thornes Ltd.

19

Shah B. et al., 2004; Non-Communicable Diseases: A supported project by WHO India office, Indian Medical Council Research Sidell M. et al., 2003; Debates and Dilemmas in Promoting Health; Open university Press. Tuomilehto J. et al., 2001; Prevention of Type-2 Diabetes Mellitus by changes in lifestyle among subjects with impaired glucose tolerance; New England Journal Medicine; 344: 1343-50.

United Nation Population Division (UNPD), 2004: World Population Prospects; United Nations, Geneva. Wallerstein N., 1992; Powerlessness, empowerment and health: implications for health promotion programs; American Journal of Health Promotion, 6(3): 197–205. Wild S. et al., 2004; Global prevalence of Diabetes: estimate for the years 2000 and projection of 2030. Diabetes care journal; 1047-53. Wing R. et al., 2001; Behavioural Science Research in Diabetes: Lifestyle changes related to Obesity, Eating behaviour and Physical activity; Diabetes Care; 24: 117-23.

20