Title: Diabetes Peer Support in Lilongwe

TITLE: DIABETES PEER SUPPORT IN LILONGWE REF: WDF11-645

SEMI-ANNUAL PROGRESS REPORT

REPORTING PERIOD: 1ST AUGUST, 2013 TO 31ST DECEMBER, 2013 INTRODUCTION

Kamuzu Central Hospital, the second largest in the country, is the only referral hospital in the central region of Malawi. It receives referred patients requiring tertiary services from the surrounding eight government district hospitals and the mission hospitals owned by church organisations within the region. This translates into a hospital catchment population of about 5 million people.

The medical department of the hospital, among the several weekly outpatients clinics, it runs the Diabetes Clinic every Tuesday morning. The clients to the clinic come from the surrounding areas within Lilongwe District and the other districts in the central region. However, over the past few years it has been observed the steady increase in the number of patients being diagnosed with diabetes mellitus and hence an increase in the number of clients attending the Tuesday clinics. For the record, the clinic (within the reporting period of the project- August to December 2013) registered 370 newly diagnosed diabetes mellitus patients. Cumulatively the clinic had a total of 2335 patients at the turn of the year 2013 with an average clinic attendance of about 120 clients (from about 40-60 in the previous years) and with the next review date of at least 3months for the majority of patients.

RATIONALE

The STEPS study of 2009 which WHO jointly carried out with the Malawi Government through the ministry of health showed that 5.3% of adults aged 25-64 met criteria for diabetes (based on fasting blood sugar) or were already on medications for diabetes. An additional 3.7% of adults had impaired fasting glycaemia. These findings were from both rural and urban populations. Meaning there is a large population of people who walk around with high blood glucose levels requiring treatment yet they are not aware of the problem.

The health workers in most of the Malawian hospitals are still not many. As such, for instance in such large clinics of 120 clients against two nurses and four doctors (at most) in one morning, contact time with patients is very minimal. With such limitations patients education and counselling can be compromised, hence poor diabetes control will be the outcome.

Most of these patients are poor, living on less than a dollar a day. Access to a health facility of any sort is a big challenge largely due to distances between their homes and facilities coupled with poor road network and transport systems. This partly explains the late reporting to facilities at first contact. The majority of the patients will have already developed complications by the time they are seen at the hospital for the first time

. The idea of the Diabetes Peer Support is to try to bridge these gaps. The peer supporters will be armed with some basic knowledge of diabetes and how it presents, therefore, helping in diagnosing new patients by referring a suspect to a medical personnel; how to help other patients to control their diabetes; at a local level, how they can develop referral systems to the nearest facility in cases when one of the clients within the catchment area has fallen very ill.

GOAL AND OBJECTIVES:

The goal of the project is to implement a peer support program to improve patient knowledge and self-management of diabetes with the broad objectives to:-

(i) Increase diabetes knowledge and self-management among patients enrolled at the diabetes clinic at Kamuzu Central Hospital.

(ii) Develop peer support groups for patients with diabetes.

(iii) Establish linkages between patients, peer supporters and health care providers.

PLANNED ACTIVITIES TO REACH THE OBJECTIVES

The project has recruited a clinician trainer (also acting as the project coordinator) and a nurse educator who are running the affairs of the project. The laid down activities during this reporting period were:-

- To identify, recruit and train up to 20 motivated individuals to be peer supporters.

- To form 10 peer groups and enrol patients into these groups.

- To develop and distribute educational materials to be used by the peer supporters.

- To conduct monthly supervisory visits by the two officers to the peer groups.

- To conduct weekly education talks during clinic days.

- To procure some equipment for the project (computer for the project coordinator and cell phones for the peer supporters).

- To extend the clinic days from once a week to twice a week. ACHIEVEMENTS

The achievements since the commencement of the project in August, 2013 are as follows:-

- The clinician trainer (project coordinator) and nurse educator have been recruited.

- The 10 peer groups have been formed. These are in Areas 25(25 patients), 36(10 patients), 23(25 patients), 49(Gulliver-17 patients and Kagwa-12 patients), Likuni (9 patients), Ntandire (16 patients), Chinsapo (15 patients), Kawale (10 patients), Biwi (12 patients). A total of 151 patients have been enrolled into these peer groups. Two peer supporters have been identified and trained for each of the 10 peer groups, thus making a total of 20 peer supporters trained.

- Education materials to be used by peer supporters have been developed and distributed. These are in sets of 6 covering the following thematic areas:-

1. Symptoms of diabetes mellitus.

2. Symptoms of hypoglycaemia.

3. Foot care.

4. Planning a diabetes diet.

5. Sites of insulin injection.

6. Complications of diabetes mellitus.

- Weekly diabetes health talks are being conducted during clinic days on Tuesdays by the nurse educator. During this time some trained peer supporters are given a chance to help out to take weight measurements and check blood sugars on fellow patients under supervision of the nurse educator.

- Monthly supervisory visits to the 10 peer groups have been introduced and are being carried out by both the clinician trainer and the nurse educator.

- The lap top computer for the project coordinator (clinician trainer) and the mobile phones for each trained peer supporter have been bought and given out. PROBLEMS ENCOUNTERED DURING THE FIRST 6 MONTHS OF THE PROJECT

The monthly supervisory visits to the peer groups has been the major problem so far. The officers travel by public transport. However, there have been two main problems:-

(a) Because of the current unstable economic situation in the country largely due to price hikes in fuel costs, fares for public transport have gone up as well. Our current budget to this effect is falling short. It will require to be adjusted accordingly.

(b) Other meeting points for peer groups have uncharted routes for public transport system. So the officers resort to walking long distances to get to them or be carried on bicycles at a fee.

The long standing problem observed over the period is the single clinic day a week. Firstly, the clinic is becoming too crowded as such patient care is compromised. There isn’t enough contact time between client and health workers. Secondly, the system within the hospital does not allow the patients to get drug supply for lengthy period of more than a month. Despite being told to get a resupply of medicines whenever they have ran out, most patients prefer to wait for their turn for their clinic day to get the medicines. Which means patients will stay long periods without drugs. Creating another clinic day we believe will help cut down on these problems.

PLANNED ACTIVITIES FOR THE NEXT 6 MONTHS

Among other things, the next 6 months we plan to:-

 Have the teaching materials used by peer supporters be translated into local language. The ones used now are in English.

 Have an internal evaluation of the peer supporters in form of a refresher course.

 Invite external evaluators of the whole project from the Kamuzu College of Nursing.

 Discuss with the rest of the members of the medical department at the hospital the possibility of splitting the diabetes clinic to 2 days a week.

 Try to extend the peer groups supporters to other surrounding areas. Over 6 more areas have already shown interest to form groups.

 Continue monthly supervisory visits to the peer groups.