The project seeks to develop a continuum of care model for diabetes through a nurse-led pilot model approach targeting two districts
• Develop a culturally tailored and locally contextual diabetes training programme for nurses
• Improve diabetes awareness in the community through nurse-led diabetes awareness campaigns
• Detect diabetics early and link patients to quality health care provided through a nurse-led diabetes management programme
First the project will develop a diabetes nurse curriculum. The curriculum will be based on IDF and ADA guidelines and will be developed by the project advisory board and steering committee with members from all stakeholder groups during a national level workshop. Once the curriculum has been developed it will be accredited.
Subsequently, nurses will be recruited from the partner base hospital, outreach and primary clinics and trained in smaller groups during a two-week training programme. The trainings will be conducted by endocrinologists and other specialists. The trained nurses will be certified as ‘diabetes-nurses’. Community health workers (CHWs) will also be recruited and trained during a five-day diabetes training programme. The trained CHWs will serve as a link between the communities and the health care level and they will also support the roll out of various project activities.
Once the training is completed the implementation of the nurse-led diabetes prevention and care model across two selected districts will be rolled out. Screening sessions will be arranged by the trained nurses at outreach/primary clinics and the CHWs will mobilise the communities to participate. A referral mechanism will be established and diabetes cases diagnosed at screening camps will be referred to the partner hospital for treatment and care. The diabetes nurses will provide counselling of patients at group meetings at community level, and ‘patients clubs’ will be established.
Electronic patient registry will be developed and implemented at the base hospital and at outreach/primary clinics.
A community awareness programme on diabetes will also be rolled out by the trained nurses and CHWs incl. through radio and written media, awareness camps and community events.
Advocacy efforts will be undertaken to promote scale-up by continuously coordinating with health authorities. At the end of the project the results will be presented at a national conference
• 11 clinics strengthened with improved diabetes care capacity, incl. electronic registry
• 25 nurses certified as diabetes nurses
• 130 community health workers trained and mobilised.
• 25,000 people screened for diabetes
• An estimated 1,875 people diagnosed with diabetes and provided with care
• An estimated 175,000 people given access to improved diabetes care and to sensitised about diabetes
• Baseline/mid-line/end-line evaluations conducted