Rural Diabetes Care Model, Maharashtra, India

Objectives

The Himalayan State of Sikkim has a population of 610,577, with three out of four residents living in rural areas.
Sikkim has the highest prevalence of suspected diabetes and hypertensive patients in India. This is due to increased socio-economic prosperity, causing a decrease in physical activity in the population in addition to the intake of a high carbohydrate diet, excess salt and rice. These risk factors predispose individuals to type 2 diabetes.

The northern terrain is furthermore hilly making, outreach difficult. Consequently, follow up of people with diabetes or NCDs is difficult or delayed and the area is therefore considerably underserved. Additionally, following diagnosis, referral for investigations and/or treatment is essential. However, mechanisms for the same are also not in place.



Objectives

To improve prevention and control of diabetes and related NCDs in an underserved rural district of Sikkim state through activities targeting known and newly diagnosed cases of diabetes, hypertension and impaired glucose tolerance (IGT), family members of persons with diabetes and/or hypertension.

Approach

Village based functionaries and primary health care services providers will be trained in diabetes and hypertension epidemiology, clinical features, complications, diagnosis, treatment and rehabilitation. The prime focus of the training is to enhance capacity of community health care functionaries in diabetes and hypertension management to ensure sustainability beyond the lifetime of the project.

1125 awareness activities will be held in the community by trained village-based health functionaries of the public health system with the help of Auxiliary Nurse Midwife (ANMs), multi-purpose workers (MPWs) and other stake holders.

Diabetes care will be converged with primary health centre general outpatient departments (OPDs) for confirmation of diagnosis, treatment and follow-up and planned referrals for difficult cases and complications.

The health management information systems for type 2 diabetes and hypertension in the project area will be updated/modified for monitoring various aspects of the project.

Results at completion

2 diabetes support groups established
11,255 people screened for diabetes
2,553 patients referred for re-confirmation or follow-up
462 detected with diabetes
9,913 people reached through various awareness activities
48 doctors, 24 nurses, 29 ASHA or other HCP trained in diabetes/ NCD care
Project-oriented Health Management Information System (HMIS) developed and functional.