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Are People at High Risk for Diabetes Visiting Health Facility for Confirmation of Diagnosis? a Population-Based Study from Rural India

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Are People at High Risk for Diabetes Visiting Health Facility for Confirmation of Diagnosis? a Population-Based Study from Rural India Are people at high risk for diabetes visiting health facility for confirmation of diagnosis? A population-based study from rural India Citation: Srinivasapura Venkateshmurthy, Nikhil, Soundappan, Kathirvel, Gummidi, Balaji, Bhaskara Rao, Malipeddi, Tandon, Nikhil, Reddy, K Srinath, Prabhakaran, Dorairaj and Mohan, Sailesh 2018, Are people at high risk for diabetes visiting health facility for confirmation of diagnosis? A population-based study from rural India, Global health action, vol. 11, no. 1, Article ID: 1416744, pp. 1-8. DOI: http://www.dx.doi.org/10.1080/16549716.2017.1416744 © 2018, The Authors Reproduced by Deakin University under the terms of the Creative Commons Attribution Licence Downloaded from DRO: http://hdl.handle.net/10536/DRO/DU:30109104 DRO Deakin Research Online, Deakin University’s Research Repository Deakin University CRICOS Provider Code: 00113B GLOBAL HEALTH ACTION, 2018 VOL. 11, 1416744 https://doi.org/10.1080/16549716.2017.1416744 ORIGINAL ARTICLE Are people at high risk for diabetes visiting health facility for confirmation of diagnosis? A population-based study from rural India Nikhil Srinivasapura Venkateshmurthy a, Kathirvel Soundappanb, Balaji Gummidia, Malipeddi Bhaskara Raoc, Nikhil Tandond, K. Srinath Reddya, Dorairaj Prabhakarana,e and Sailesh Mohana aPublic Health Foundation of India, Gurgaon, India; bDepartment of Community Medicine, School of Public Health, Post Graduate Institute for Medical Education and Research, Chandigarh, India; cMyCure Hospitals, Visakhapatnam, India; dDepartment of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India; eCentre for Chronic Disease Control, Gurgaon, India ABSTRACT ARTICLE HISTORY Background: India is witnessing a rising burden of type 2 diabetes mellitus. India’s National Received 31 August 2017 Programme for Prevention and Control of Diabetes, Cancer, Cardiovascular diseases and Accepted 9 December 2017 Stroke recommends population-based screening and referral to primary health centre for RESPONSIBLE EDITOR diagnosis confirmation and treatment initiation. However, little is known about uptake of Nawi Ng, Umeå University, confirmatory tests among screen positives. Sweden Objective: To estimate the uptake of confirmatory tests and identify the reasons for not undergoing confirmation by those at high risk for developing diabetes. KEYWORDS Methods: We analysed data collected under project UDAY, a comprehensive diabetes and Confirmatory test; diabetes hypertension prevention and management programme, being implemented in rural Andhra mellitus; screening; SORT IT; UDAY Pradesh, India. Under UDAY, population-based screening for diabetes was carried out by project health workers using a diabetes risk score and capillary blood glucose test. Participants at high risk for diabetes were asked to undergo confirmatory tests. On follow- up visit, health workers assessed if the participant had undergone confirmation and ask for reasons if not so. Results: Of the 35,475 eligible adults screened between April 2015 and August 2016, 10,960 (31%) were determined to be at high risk. Among those at high risk, 9670 (88%) were followed up, and of those, only 616 (6%) underwent confirmation. Of those who underwent confirmation, ‘lack of symptoms of diabetes warranting visit to health facility’ (52%) and ‘being at high risk was not necessary enough to visit’ (41%) were the most commonly reported reasons for non-confirmation. Inconvenient facility time (4.4%), no nearby facility (3.2%), un-affordability (2.2%) and long waiting time (1.6%) were the common health system- related factors that affected the uptake of the confirmatory test. Conclusion: Confirmation of diabetes was abysmally low in the study population. Low uptake of the confirmatory test might be due to low ‘risk perception’. The uptake can be increased by improving the population risk perception through individual and/or community-focused risk communication interventions. Background (oral, breast and cervical) [8]. The Government of India started NPCDCS in 2008. It is currently being Diabetes is an important non-communicable disease implemented in 468 districts. Apart from screening, the (NCD) in India, which is home to the second largest NPCDCS recommends identifying and addressing number of people with diabetes, i.e. 69 million. This modifiable risk factors, diagnosis of diabetes based on number is estimated to increase to 140 million by protocols and follow-up at the community level. 2040 [1]. The prevalence of diabetes in India is 7.3% Under NPCDCS, the Accredited Social Health [2], and the burden of undiagnosed diabetes is also Activists (ASHA) are entrusted with the responsibility high. Estimates suggest that almost 50% of those with of risk assessment of all adults aged ≥30 years in their the disease are undiagnosed [1]. service area using a risk score [8]. The risk is assessed Diabetes satisfies most of the criteria for screening based on age, use of tobacco and alcohol, waist circum- [3]. A number of institutions recommend screening for ference, physical activity and family history of diabetes, diabetes [4–7]. The National Programme for hypertension and heart disease. A person scoring more Prevention and Control of Cancer, Diabetes, than four on the risk score is determined to be at high Cardiovascular diseases and Stroke (NPCDCS) also risk and is encouraged to participate in the screening recommends screening for diabetes together with camp to be organized at the village/sub-centre. The other NCDs like hypertension and common cancers CONTACT Nikhil Srinivasapura Venkateshmurthy [email protected]; [email protected] Public Health Foundation of India, Plot no. 47, Sector 44, Institutional Area Gurgaon – 122002, India © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 N. SRINIVASAPURA VENKATESHMURTHY ET AL. auxiliary nurse midwife (ANM) assisted by ASHA will Project UDAY screen for diabetes. Those with a random blood sugar of Since 2013, Public Health Foundation of India (along 140 mg/dl and above are to be referred to a medical with partners Population Services International and officer, at the nearest facility, for confirmation of diag- Project Hope) has been implementing project UDAY nosis and initiation of treatment. in these two mandals. The components of project It is crucial that those who are at high risk and UDAY are summarized in the framework below undiagnosed are identified through screening. The (Figure 1). UDAY is a comprehensive diabetes and screen positives are required to visit the health facility hypertension prevention and management pro- for confirmation of diagnosis. If the confirmation of gramme. Among many other components, screening diagnosis does not happen, the programme will fail to of adults aged ≥30 years for diabetes is an important effectively address the growing burden of diabetes. component of UDAY. A total of 22 trained health Only a limited number of studies on confirmation of workers of UDAY are engaged in screening. The diabetes among screen positives have been published health workers visit the households and screen all from India [9–11]. We analysed data from an ongoing eligible adults. They collect information on socio- community-based study to determine the socio-demo- demographic factors, use of tobacco and alcohol in graphic, behavioural and clinical factors of population the past 30 days, family history of any cardio-meta- screened for diabetes, uptake of the confirmatory test bolic diseases (diabetes, hypertension, cardiovascular for diabetes and the reasons for non-uptake. disease or stroke) and date and time of last meal. They measure blood pressure, height, weight and Methods waist circumference using standard procedures. Using a glucometer, they measure capillary blood Study setting glucose. Based on the difference between the time of Andhra Pradesh is situated in the southern part of the capillary blood glucose test and the time of the India. The prevalence of diabetes in Andhra Pradesh last meal, the blood glucose value was either deter- is 8.4% [4]. Visakhapatnam is the fourth largest dis- mined as fasting (difference of ≥8 hours) or random trict of Andhra Pradesh. Makavarapalem and (difference <8 hours). Nathavaram are two mandals (administrative units An android-based application has been specially under a district) in Visakhapatnam district. The com- designed for screening. Each participant is assigned bined population of these two mandals is 118,659 a unique participant ID (PID) by the application. with 59,540 adults aged ≥30 years. Four primary The application incorporates a validated diabetes health centres and 22 health sub-centres deliver the risk score [12]toidentifythoseathighrisk.After health services under the public health system in the health worker enters the information, the appli- these mandals. cation calculates risk score based on four Figure 1. Implementation framework and components of UDAY. GLOBAL HEALTH ACTION 3 parameters – age, family history of diabetes, blood up data were merged using the unique PID. Variables pressure and waist circumference. Those scoring were summarized using means (standard deviation) more than 16 are determined to be at high risk. or frequencies (percentages).
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