CVD Project evaluation: Baseline diabetes study … RE CVD Project evaluation: Baseline diabetes...

Ds/ RE

CVD Project evaluation:Baseline diabetes study Davao, Philippines 2010

01

Satellite Document

Research and Studies Collection

Technical Resources Unit

June 2011

1

Author Sophie Pilleron Deputy to technical advisor on diabetes, Lyon, Handicap International With contributions from: Ivy Boyose‐Nolasco New Project manager of CVD project, Davao, the Philippines Jenny Hernandez Former project manager of CVD project, Davao, the Philippines Pauline Guimet Technical advisor on disabling diseases, Lyon, France Kirsten L. Lentz Technical coordinator, Manila, the Philippines Edited by: Michael Guy, Knowledge Management Unit, Handicap International, Technical Resources Unit 14, avenue Berthelot 69361 Lyon Cedex 07 France Graphics: IC&K, Frédérick Dubouchet Maude Cucinotta Cover Picture: © Ivy Boyose‐Nolasco for Handicap International

2

ABSTRACT Objective: To gather baseline data for the CVD Project evaluation and specifically for indicators 5 and 6 of expected result

1. This study also concerned gathering information on the nature of diabetes and common practices in diabetes

management and care, to improve project implementation strategy and data on promoting health care services in the

community.

Method: This study was the first part of a quasi‐experimental before‐after here‐there study conducted in 10 intervention

barangays and 5 control barangays of Davao City. The study population consisted of people with diabetes aged 20 years

and above who had visited the Barangay Health centers and had proof of a doctor’s diagnosis for diabetes mellitus or

proof of a relative‐to‐diabetes medicine prescription. They were all resident of the studied barangays and stated they had

no plans to move away from the research site in the 4 years following the survey. The selection of the respondents was

based upon the masterlist created by Barangay Health Workers of the study zone. The participants were interviewed

using a structured questionnaire in a public facility far away from the health facility, in order to minimize information bias.

In addition, anthropometric measurements (weight, height, and waist circumference), blood pressure, as well as the

percentage of haemoglobin A1c, were also collected in a standardized way by a trained team. All the data collection

process was pretested.

Results: 503 participants in the intervention group and 136 in the control group were analysed. The mean age was 57 for

both groups. The majority of them were female. Participants in the control group were less likely to be a college graduate

or postgraduate than the intervention group and had a significantly lower income and a lower proportion of individuals in

the highest possession category. The control group HbA1c mean (8.5% ±0.17) was statistically higher than in the

intervention group one (7.8% ±0.08 ‐ p=0.003). The proportion of people with controlled blood sugar (HbA1C<6.5%) was

higher in the intervention group (28.2%) than in the control group (17.6% ‐ p=0.013). There is no statistical difference for

other indicators. The table below presents the baseline values for monitoring indicators:

Baseline values for monitoring indicators (%)

Variables Intervention area Control area p

Diabetes control status

HbA1c<6.5% 28.23 17.65 0.013

Anthropometry

<80 cm for women or <90 for men 20.76 25.00 0.29

BMI < 23 kg.m² 34.26 36.76 0.587

Blood pressure

≤130/80 mmHg 24.85 20.59 0.301

Physical activity

at least moderate physical activity 61.94 68.38 0.199

Diabetes knowledge

score≥5 20.68 16.18 0.242

Conclusion: Despite its limitations, this study provides a first insight on the people living with diabetes in Davao City. With

72% of diabetics having uncontrolled glycemia, this study shows the relevance of the CVD project. As a baseline, this

study provides comparison elements for the 2013 survey in order to test effectiveness of the CVD project with the

percentage of diabetics with HbA1c<6.5% as effectiveness criterion.

3

CONTENTS

ABSTRACT.................................................................................................................................................................................2

CONTENTS ................................................................................................................................................................................3

LIST OF FIGURES .......................................................................................................................................................................5

ACKNOWLEDGEMENTS............................................................................................................................................................6

LIST OF ABBREVIATIONS ..........................................................................................................................................................7

I – INTRODUCTION ...................................................................................................................................................................8

II – PROJECT BACKGROUND.....................................................................................................................................................8

III – JUSTIFICATION ................................................................................................................................................................10

IV – OBJECTIVES .....................................................................................................................................................................10

V – METHODS.........................................................................................................................................................................11

5.1 DESIGN OF THE STUDY........................................................................................................................................................11 5.2 PROJECT SITE....................................................................................................................................................................11 5.3 STUDY SITE ......................................................................................................................................................................12

5.3.1‐ Intervention area ................................................................................................................................... 12 5.3.2‐ Control area .......................................................................................................................................... 13

5.4 ‐ TARGET POPULATION .......................................................................................................................................................13 5.5 SAMPLE SELECTION............................................................................................................................................................13 5.6 DATA COLLECTION.............................................................................................................................................................14

5.6.1‐ The questionnaire .................................................................................................................................. 14 5.6.2‐ Data‐collection process ..........................................................................................................................14

VI – DATA MANAGEMENT .....................................................................................................................................................15

6.1 DATA ENTRY AND DATA CHECKS ...........................................................................................................................................15 6.2 CREATION VARIABLES .........................................................................................................................................................15

6.2.1‐ Glycosylated hemoglobin or HbA1c .........................................................................................................15 6.2.2‐ Anthropometric variables .......................................................................................................................16 6.2.3‐ Blood pressure ...................................................................................................................................... 16 6.2.4‐ Possession score.................................................................................................................................... 16 6.2.5‐ Knowledge score ................................................................................................................................... 17 6.2.6‐ Physical activity .................................................................................................................................... 17 6.2.7‐ Disability .............................................................................................................................................. 18

VII –ANALYSIS.........................................................................................................................................................................19

7.1 – ANALYSIS PLAN ..............................................................................................................................................................19 7.2 – ANALYSIS STRATEGY ........................................................................................................................................................19

VIII ‐ ETHICAL ASPECTS ..........................................................................................................................................................19

IX ‐ RESULTS ...........................................................................................................................................................................20

9.1‐ STUDY POPULATION DESCRIPTION .......................................................................................................................................20 9.1.1‐ Socio‐demography ................................................................................................................................ 20 9.1.2‐ Anthropometry, blood pressure and biological measures ........................................................................22 9.1.3‐ Physical activity level.............................................................................................................................23 9.1.4‐ Diabetes and disability ..........................................................................................................................23

9.2‐ MONITORING INDICATORS .................................................................................................................................................24 9.3‐ NATURE OF DIABETES .......................................................................................................................................................25 9.4‐ DIABETES MANAGEMENT AND CARE.....................................................................................................................................26

9.4.1‐ Routine check‐ups and medications........................................................................................................26 9.4.2‐ Nutritionist‐dietetician ..........................................................................................................................27 9.4.3‐ Education session .................................................................................................................................. 28 9.4.4‐ Payment of diabetes care ......................................................................................................................29

9.5‐ KNOWLEDGE ABOUT HEALTH CARE SERVICES PROPOSED BY BARANGAY HEALTH CENTRE..................................................................30

4

9.6‐ MOST EFFECTIVE MEANS OF NOTIFICATION FOR UPCOMING EVENTS IN THE BARANGAY HEALTH CENTRE ............................................30

X‐ DISCUSSION .......................................................................................................................................................................32

X‐ DISCUSSION .......................................................................................................................................................................32

10.1‐ OBJECTIVES AND MAIN RESULTS .......................................................................................................................................32 10.2‐ LIMITATIONS ................................................................................................................................................................33 10.3‐ COMPARISONS WITH LITERATURE.....................................................................................................................................34

XI‐ CONCLUSION ....................................................................................................................................................................36

XII‐ SOME RECOMMENDATIONS FOR THE 2013 SURVEY .....................................................................................................36

XII‐ REFERENCES.....................................................................................................................................................................37

APPENDIX 1: THE QUESTIONNAIRE .......................................................................................................................................40

APPENDIX 2: BLOOD TESTING FOR HEMOGLOBIN A1C ........................................................................................................45

APPENDIX 3: OTHERS SYMPTOMS DECLARED BY PARTICIPANTS ........................................................................................47

APPENDIX 4: OTHER ANTI‐DIABETICS DRUG THAN THOSE PRELISTED ................................................................................49

APPENDIX 5: OTHER REASONS FOR NOT VISITING THE NUTRITIONIST ...............................................................................50

APPENDIX 6 : OTHER BARANGAY HEALTH CENTER SERVICES DECLARED BY RESPONDENTS..............................................50

APPENDIX 7: PHASE 1 LOGICAL FRAMEWORK: FURTHER DETAILS ......................................................................................51

5

LIST OF TABLES

Table 1 ‐ Socio‐demographic characteristics.................................................................................................................21 Table 2 ‐ Anthropometric and biological measures (%).................................................................................................22 Table 3 ‐ Distribution of type of limitation of activities according to the degree of severity (%) ....................................24 Table 4 ‐ Baseline values for monitoring indicators (%) ................................................................................................24 Table 5 ‐ Diabetes history ............................................................................................................................................25 Table 6 ‐ Hypertension history and its management ....................................................................................................26 Table 7 ‐ Repartition of the participants according to the test performed at least once in the past 12 months (%) ........26 Table 8 ‐ Mean number of test in the previous 12 months (±se) ...................................................................................27 Table 9 ‐ Repartition of participants according to the anti‐diabetes medication declared (%) .......................................27 Table 10 – Health facility where the nutritionist was consulted (%‐n=195) ...................................................................28 Table 11 – Reasons for not having visited a nutritionist (%)..........................................................................................28 Table 13 ‐ Mean found to pay diabetes care (%)...........................................................................................................29 Table 14 ‐ Distribution of sample according to health services declared (%) .................................................................30 Table 15 ‐ Way of notification (%)................................................................................................................................30 Table 16 – Other Ways of notification mentioned by respondents (%)..........................................................................31 Table 17 – Baseline and final expected values of monitoring indicators........................................................................32 Table 18 Other Symptoms (%) .....................................................................................................................................47 Table 19 Others complications (%)...............................................................................................................................47 Table 20 Other antihypertensive drugs (%) ..................................................................................................................48 Table 21 Other anti‐diabetic drugs (%).........................................................................................................................49 Table 22 Other reasons for not visiting the nutritionist (%) ..........................................................................................50 Table 23 Other services available at the Barangay health office (%) .............................................................................50

LIST OF FIGURES

Figure 1 – Map of the Philippines............................................................................................................................... 11

Figure 2 – Location of Davao City ............................................................................................................................... 11

Figure 3 – Flow chart ................................................................................................................................................. 20

Figure 4 – Distribution of HbA1c rate among intervention group and control group (%).............................................. 22

Figure 5 – Distribution of the sample according level of physical activity (%) .............................................................. 23

Figure 6 – Origin of diabetes educators (%) ................................................................................................................ 29

6

ACKNOWLEDGEMENTS We would like to thank all the people who made this survey feasible.

Specifically, many thanks to the Barangay Captains of the following barangays: Lapu‐Lapu, 23‐C, Maa, Toril, 5‐A, Mintal,

Calinan, Pampanga, Matina Aplaya as well as Panacan, Ilang, Tibungco, Bunawan and Lasang.

A special thanks to the Davao City Health Office and the Barangay health workers who listed patients with diabetes in

their own barangay.

This survey would not have been possible without the participants with diabetes who gave us their time to conduct this

survey.

7

LIST OF ABBREVIATIONS

BHW Barangay Health Worker

BMI Body Mass Index

CHO City ealth Office

CVD project Capacity‐building Project for the Prevention of Disabilities Related to Cardiovascular Risks Project

DCCT Diabetes Control and Complications Trial

DJFRD Davao Jubilee Foundation for the Rehabilitation of the Disabled

FBS Fasting blood sugar

HbA1c Glycosylated Hemoglobin A1c

IDF International Diabetes Federation

IPAQ International Physical Activity Questionnaire

MET Metabolic Equivalent of Task (or Metabolic Equivalent)

Php Philippines Peso

PWDM People with diabetes mellitus

RHRDCXI Regional Health Research and Development Consortium XI

Se Standard error

SPMC Southern Philippines Medical Center

T2DM Type‐2 Diabetes Mellitus

WC Waist circumference

WHO World Health Organization

8

I – INTRODUCTION

With an estimated 285 million adults living with diabetes in 2010 and 439 million by 2030, diabetes is increasing

across the world (1). The latest estimations state that 6.8% of all‐cause mortality is attributable to diabetes. Diabetes is

therefore, without doubt, a serious public health problem (2). Diabetes is a chronic disease which, over time, causes

serious damage to many of the body's systems, especially the nerves and blood vessels, often leading to limb amputation,

blindness, kidney failure and other conditions (3). As reported by the International Diabetes Federation (IDF), every 30

seconds a lower limb is lost due to diabetes, whereas 85% of all diabetes‐related amputations are preceded by foot ulcers

and therefore can be prevented (4).

Almost 80% of diabetes deaths occur in low and middle‐income countries. Almost half of diabetes deaths occur

in people under the age of 70 years; 55% of diabetes deaths are in women. The World Health Organization (WHO)

projects that diabetes deaths will increase by more than 50% in the next 10 years without urgent action. Most notably,

diabetes deaths are projected to increase by over 80% in upper‐middle income countries between 2006 and 2015. (3)

Some projections show that by the year 2025, more than three‐quarters of all persons with diabetes will reside in

developing countries. India and China are leading this surge with sub‐Saharan Africa currently following at a much lower

prevalence rate. (5)

According to the estimations of Shaw et al. for 2010, diabetes prevalence in the Philippines is 6.7% and will

increase to 7.8% by 2030. In other words, 3.4 million of people are currently affected by diabetes and this will increase to

6.2 million by 2030. (6)

The 2005 Philippines Health Statistics states that diabetes mellitus is the 8th leading cause of mortality in the

Philippines and accounted for 18,441 deaths. Diabetes mellitus is the 8th cause of mortality among males with 8,912

deaths and a rate of 20.8/100.000 population while this is the 5th cause of mortality among females with 9,529 deaths

and a rate of 22.5/100.000 population. (7). A cross‐sectional population‐based study was conducted in 2002 among 7044

adults aged 20‐65 years old residents of urban and rural areas in Luzon in the Philippines estimated the crude diabetes

prevalence to 5.1% which represented a 54% increase over the figure (3.3%) in 1982. This study reported that diabetes

was unknown by one in three diabetics (8).

A cohort study conducted in 6 of the Philippines’ 13 regions in 2007 by Soria et al. stated that the 9‐year

incidence of type 2 diabetes mellitus (T2DM) was 16.3% among Filipinos and the prevalences of diabetes and pre‐

diabetes were respectively 28% and 31.5%. (9)

In Davao, according to the City Health of Office, over the period 2004‐2008, diabetes was ranked the 7th all‐age leading

cause of mortality with 279 deaths on average annually or 20.6 per 100,000 inhabitants. In 2009, diabetes was the 7th all‐

age leading cause of mortality with 317 deaths or 22.2 per 100,000 inhabitants.

II – PROJECT BACKGROUND The Capacity‐building Project for the Prevention of Disabilities related to Cardiovascular Risks (CVD project) aims

to build local capacities to fight diabetes and resulting disabilities. It began as a three‐year initiative in ten barangays in

Davao City with funding support from the Ministry of Foreign Affairs of Luxembourg and Sanofi Aventis. It is being

implemented with a local inclusive development approach focusing on the autonomy of, and coordination between, local

stakeholders, in order to achieve sustainability. Today, the project has expanded into a city‐wide cardiovascular risk‐

management approach for greater impact.

Handicap International is implementing this project in partnership with the Davao City Health Office (CHO),

Davao Jubilee Foundation for the Rehabilitation of the Disabled (DJFRD), Southern Philippines Medical Center (SPMC),

Diabetes Support Groups and the Barangay Councils of the ten pioneer barangays.

9

The Pilot

From 2007 to 2009 Handicap International assisted in decentralizing diabetes prevention, care and management

by capacity–building of health centers through the City Health Office in the ten pioneer barangays. This project has also

established a local comprehensive approach to diabetic foot care and management. Adapted prosthetic and orthotic

technologies appropriate for persons with diabetes were made available through capacity‐building of Davao Jubilee

Foundation. Finally, advocacy work resulted in improved financial and geographical access to medicines and blood sugar

testing.

The Second Phase

Building on the know‐how gained from the pilot phase, the project will continue the decentralization of diabetes

prevention, care and management to all of the 182 barangays in Davao City. This is made possible through the creation of

a cardiovascular program of the city government. As a result of capacity‐building activities, it is expected that local

stakeholders (health care providers, local government units, and persons at risk of cardiovascular diseases) by the end of

the project are empowered to implement an integrated cardiovascular risk management approach (focusing on diabetes

and hypertension) and to coordinate their actions to improve access to health care services.

Expected results

a. The competence and autonomy of the public primary health care of Davao are improved in the frame of the

cardiovascular risk factor management (focus on diabetes and arterial hypertension)

b. Organizations of persons with diabetes in Davao City are empowered to manage their group and sustain

their activities

c. The rehabilitation services at the public tertiary health care level have improved capacity to take care of

persons disabled by cardiovascular diseases or diabetes

d. Local health and rehabilitation stakeholders implement an effective referral system for persons living with

cardiovascular risk factors

Activities

a. AWARENESS‐RAISING: The project produces educational tools and organizes events to increase public awareness

b. CAPACITY‐BUILDING OF PRIMARY HEALTH CARE PROVIDERS: The project equips health centers with knowledge,

skills and tools to enable them to provide services on diabetes and cardiovascular risk factors for increased

geographic and financial access to health care

c. CAPACITY‐BUILDING OF DIABETES SUPPORT GROUPS: Handicap International trains and facilitates people with

diabetes to form self‐help groups. Through these groups, people with diabetes mellitus (PWDM) are able to share

their experiences with other people and to learn and understand more about their disease. Once organized, the

groups are empowered to manage their organization and sustain their activities

d. SUPPORT TO LOCAL GOVERNMENT UNITS: Access to appropriate health care is a right not a privilege. The project

works with local policy makers to mainstream the issue of diabetes and cardiovascular risk. Policies in support of

diabetes and cardiovascular risk prevention and management can help. The poorest families who must make the

choice between paying for medicines or food

e. SUPPORT FOR INCREASED ACCESS TO DIABETIC FOOT CARE: Through the project, the skills of local prosthetic and

orthotic technicians are upgraded to ensure appropriate technology is used. Handicap International also works with

Davao Medical Center for diabetic foot problems

f. REFERRAL SYSTEM: The project facilitates coordination among major stakeholders to ensure that efforts are

harmonious and not duplicated

10

III – JUSTIFICATION

Six indicators were defined to measure the achievement of the first expected result of the CVD project, among them:

Indicator 5: In the 10 pilot Barangays, increase by 20% of the proportion of people with diabetes who:

a. have an acceptable level of HBA1C (<6.5%)

b. maintain an appropriate Body Mass Index (<23 kg/m²) and waist circumference

c. have an acceptable blood pressure (<130/80)

d. do physical activity at least 30 minutes 3 times a week

Indicator 6: Increase by 50% of the people with diabetes mellitus in the ten pilot barangays whose diabetes knowledge

test score reaches 60%.

These two indicators above were measured by conducting a survey among people with diabetes visiting the Barangay

health centers.

IV – OBJECTIVES

The primary objective of this study was to gather baseline data for two indicators of the expected results 1 of the CVD

Project as part of project evaluation. Specifically, this study generated:

1. Data about the population with diabetes, specifically the:

a. Percentage of people with good glycemic control

b. Percentage of overweight people

c. Percentage of people with abdominal obesity

d. Percentage of people with acceptable blood pressure levels

e. Percentage of people with physical activity of at least 30 minutes three times a week

f. Percentage of people whose diabetes knowledge test scores reach 60%

2. Information on the nature of diabetes and common practices in diabetes management and care to

improve project implementation strategy

3. Data on promoting health care services in the community

4. Disability and morbidity data to support advocacy and policy development

11

V – METHODS

5.1 Design of the study

A cross‐sectional survey with control group was conducted between June and August 2010.

5.2 Project site

Davao City is a sprawling metropolis of over one million people, located in the Southeastern part of Mindanao. In

August 2007, the estimated population was 1,363,337. It is one of the largest cities in the world with a land area of

2,443.61 square kilometers. It is a place rich in natural resources. The soil is very fertile and rich in minerals. The city has

an abundant source of potable water. Located in a typhoon‐free zone, its tropical weather is characterized by an even

distribution of climatic elements all year round. The temperature ranges from 15 to 34˚C. On the west, the city’s

boundary line cuts through the highest peak in the country, the inactive Mt. Apo at 3,142 meters above sea level.

Figure 1 ‐ Map of The Philippines Figure 2 – Map of Davao City

Copyright © 2008 Davao Guide

http://davaohotelsonline.com/index.html�

12

As 71 percent of the population resides in urban areas, its urban density is estimated roughly at 2,262 persons

per square kilometer. In 2000, 34.8% of the population was less than 15 years old and 3.1% was aged 65 years old and

above. In 2000, the life expectancy projected for 2000‐2005 was 68.2 years old for males and 72.5 years old for females.

With a predominantly migrant population, the city is very culturally diverse. Major languages and dialects in the city are

Filipino, Chinese, English and Cebuano. The city has one of the highest literacy rates in Asia at 98.3%.

Like the rest of the country, Davao City operates on an economic system that is market‐oriented, although

pricing mechanisms remain regulated in some sectors (particularly for basic commodities) to protect consumers. Davao

City enjoys a diverse economy, featuring a sound mix between agricultural (roughly 45%), industrial (15%) and service (at

around 35%) industries. Poverty reduction has become the main goal of the local government. This is being addressed

through various programs and projects, one of which concerns the encouragement of inward investments to industries

that are labor‐intensive. Fortunately for Davao, private investments have ensured steady growth of Davao City’s economy

over the last two decades. Davao City is divided into 3 districts and 182 barangays. There are about 31 hospitals with a

total of 1,963 beds in Davao City. Medical services are made available to poor residents through the Southern Philippines

Medical Center (previously Davao Medical Center), which has the most number of hospitals beds at 1,200. (10)

5.3 Study site

5.3.1‐ Intervention area1

The intervention area was the ten pilot barangays2 of Davao City selected for the first phase of the project (2007‐

2009). The selection of the pilot barangays was carried out by Handicap International in consultation with other

organizations involved in the project: City Health Office, Davao Medical Center, Davao Jubilee Foundation and Davao

Sugar Club. The selection criteria were as follows:

1. Barangay where each of the four main partners already works

2. Barangay where there are some identified patients with diabetes (by sugar groups)

3. Not too distant from each other

4. At most, one hour away from Davao Medical Center

5. Davao City proper

6. Tenable peace and order

7. Existing health centre within the barangay

8. High number of indigents; random sampling across socio‐economic brackets.

The ten pilot barangays were Toril, 23‐C, Maa, Lapu‐Lapu, 5‐A, Mintal, Calinan, Talomo proper, Pampanga, Matina Aplaya.

However, Talomo Proper was not included in the current study because of the non‐participation of its leaders in the

phase 1 project activities.

1 Intervention refers to the capacity-building of the City Health Office health care teams in these barangays through training and provision of tools and equipment. It is then the health care teams who will apply their know-how in their barangay through provision of cardiovascular risk care services. 2 Barangay is the smallest administrative division in the Philippines and is the native Filipino term for a village, district or ward (source: wikipedia)

13

5.3.2‐ Control area

The phase 2 project plans to be implemented in the entire Davao City from 2010 to 2013. Five barangays in

Davao, where the intervention of the project will begin in 2013, were selected as a control group. It is assumed that the

project will have little or no impact in the control area prior to the after‐study.

In a consultative meeting between Handicap International and the City Health Office on 27th May 2009, the

District Health Officers of Davao City voted for Bunawan as the control District. This was because the District health

officer of Bunawan had not attended any of the trainings provided by Handicap International during the first phase of the

diabetes project. The District Health Officer of Bunawan was asked to choose five out of eight from the barangays in her

District. She chose the biggest barangays along the main road. It was assumed that it would be difficult to reach a good

sample size in the three other Barangays. As a result, Panacan, Ilang, Tibungco, Bunawan and Lasang were the five control

barangays.

5.4 ‐ Target population

The study population consisted of the people with diabetes who visited the Barangay Health centers and who presented

the following criteria:

Inclusion criteria

Aged 20 years and above

Diagnosed by a doctor for diabetes mellitus and presented a proof of diagnosis or relative‐to‐diabetes

medicine prescription

Resident of one of the ten pilot Barangays for the intervention group or one of the five control Barangays for

the control group

Have no plans to move out of the research site during the 4 years following the survey (the duration of the

phase 2 of the CVD project)

Exclusion criteria

Patients who were confined to a bed, on renal dialysis; patients with category 3 diabetic foot and post stroke;

patients who were paraplegic, hemiplegic, and aphasic or with thinking and memory problems were excluded in order to

minimize drop‐out rate. Patients who were confined to a bed were also excluded because it is difficult to measure height,

weight and waist circumference. Pregnant women were also excluded since the anthropometric measures would be

biased due to pregnancy.

5.5 Sample selection

The available funds allowed for an exhaustive recruitment of all people with diabetes listed by Barangay health workers

(BHWs). BHWs listed a total of 1,457 people with diabetes: 1,078 and 379 respectively in the intervention group and the

control group.

During the survey, 50 people were identified as not actually diabetic. Thus, it was decided to include walk‐in participants

who met the inclusion criteria for replacement, but limited to the number of HbA1c tests available.

14

5.6 Data collection

5.6.1‐ The questionnaire

The questionnaire was divided into 5 sections:

Section 1 dealt with history of diabetes and hypertension as complication

Section 2 gathered more information about hypertension and patient health‐seeking behavior. Questions 16

and 17 were used to plan the strategy on health care services promotion

Section 3 consisted of a short set of questions on disability developed by the Washington Group on disability

statistics (11) that were added to develop the beneficiaries with disability database in Handicap International

Section 4 questions were generated based on the IDF Diabetes Education Standards (12) and allowed the

creation of a knowledge score

Section 5 corresponded to the self‐administered short version of the International Physical Activity

Questionnaire (IPAQ) (13), which was used to measure the physical activity level of people with diabetes

Information on birth date, gender, education level, occupation, income level and asset ownership were also

obtained by questionnaire

A specific part was dedicated to the anthropometric (height, weight, waist circumference) and biological

(blood pressure and HbA1c test results) values measured along with the interview on the first page of the

questionnaire

The questionnaire was initially prepared in English and then translated by the research team to enable face‐to‐face

interviews in the Visayan language. The English version of the questionnaire is presented in Appendix 1.

5.6.2‐ Data‐collection process

After updating (intervention area) or creating (control area) diabetes patient registry with BHWs, permission from the

Barangay Captains was requested to conduct the survey, to use an indoor public facility and to contact target participants.

The main criterion for the choice of the venue was that it should be far enough from the Health Center to avoid

information bias. Health centers provide a lot of information on diabetes with posters or leaflets.

The target respondents were contacted through purok3 leaders and BHWs to explain the goal of the survey, encourage

participation, present the schedule, ask for an appointment and give the consent form.

Handicap International CVD Project Team recruited additional field interviewers. All field interviewers received a 1‐day

training which included lecture and practice measurements. The survey was pretested in Barangay Sasa which did not

belong to study area, utilizing the same conditions and methods as the actual survey. The definitive questionnaire was

then finalized and printed.

The data collection schedule was subject to the preference of the Barangay Council or the District Health Center and to

the availability of the facilities. The number of days allocated to each barangay was decided based on the number of

persons with diabetes identified in the master list.

Upon arrival at the survey venue, the respondent presented the invitation letter together with an ID card. The

participant’s name and age was verified, with corrections made to the list of selected participants as required. After giving

their informed consent, the respondent’s name, gender, date of birth, address and contact number were entered in the

registration sheet and one set of questionnaires was given to the respondent. When the participants were not listed in

the master list, evidence of diagnosis was required in the form of medical certificate, doctor referral or laboratory test

results. Then the participant proceeded to the interview. Once the interview was completed, the respondent remained

seated while their blood pressure was measured and recorded in the questionnaire. Anthropometric measurements were

then performed. Finally, the respondent proceeded to the blood testing area to test HbA1c. HbA1c was measured with

capillary blood from a finger prick at the venue by a trained medical technologist. The blood was then analyzed by a

3 Purok is an administrative subdivision of a barangay

15

portative device using a fully automated boronate assay by spectrophotometry. The result was released five minutes

later. The detailed procedure and the machine are described in appendix 2.

The quality control assistant then performed a quality check on the questionnaire. Quality control measures during the

survey involved checking and re‐calibrating equipment, monitoring the performance of the measurers and checking the

completeness and quality of data. If the questionnaire was not complete or if there was a doubt on some data, the

respondent was referred back to the concerned interviewer or measurer. “Passed” was stamped on the questionnaire’s

first page once quality control criteria were satisfied.

The HbA1c result form with interpretation and recommendation was immediately released to the respondent. The

respondent then proceeded to the education area for short nutritional sessions and snacks were provided.

VI – DATA MANAGEMENT

6.1 Data entry and data checks

Version 3.1 Epidata software (14) was used for creating the data structure (including automated data checking controls)

and entering data. Two trained data‐entry agents inputted data from the questionnaires (double data‐entry) at the

Handicap International office. The two databases were then compared (to detect data‐entry mistakes), corrected and

cleaned using logical checks.

6.2 Creation variables

Some variables were categorized into several groups according to international recommendations, or literature, or

variable distribution in the sample. Others were associated to create score.

6.2.1‐ Glycosylated hemoglobin or HbA1c

HbA1c reflects mean glycemia of a person during the three past months and it is recommended for the glycemic control

monitoring among patients with diabetes, to estimate the risk of complications, to judge the effectiveness of control

measures taken and to adjust the treatment.

The CVD project relies on the global guideline for type 2 diabetes of the IDF (15). This guideline recommends an HbA1c

target level of less than 6.5%, “if easily achieved. This is taken as translating to basal self‐monitored plasma glucose level

monitored plasma glucose levels <6.0 mmol/l (<110 mg/dl), with post‐prandial target levels of <8.0 mmol/l (<145 mg/dl).”

This threshold, based on microvascular and macrovascular complications, was thus chosen for this study.

The HbA1c machine could not provide exact measure for HbA1c above 14%. If the participant HbA1c rate was higher than

14%, 14% this was reported with a comment in the questionnaire.

16

6.2.2‐ Anthropometric variables

Body mass index (BMI)

BMI is calculated by dividing weight in kilograms by height in meters squared and rounded to 1 decimal place (kg/m²).

Generally, high BMI is correlated with high all‐causes mortality risk, especially mortality linked to cardiovascular disease,

cancers, diabetes and accidents. (16)

Weight and height were measured at the venue. The weight was measured three times with participants wearing a pre‐

weighed gown. The participant weight was calculated by subtracting the gown weight. If the participants did not accept

to wear a gown, she/he was weighed with her/his clothes and the weight was then reduced by 1.5 kg. The weight

measured in this way was also used in the analysis.

Overweight was defined for Asiatic people as BMI ranged between 23‐25 kg/m² and obesity as BMI value equals to or

above 25kg/m². Normal BMI range is 18.5‐22.9 kg/m², below which is defined underweight. (17)

Waist circumference (WC) is a measurement of central body‐fat, which is associated with insulin resistance, an indicator

that affects blood sugar control. Contrary to BMI, WC takes into account body fat distribution. WC was measured inside a

dressing room with all clothing removed excepted undergarments. The thresholds for Asiatic people were used, meaning

80 cm for females and 90 cm for males. (18)

6.2.3‐ Blood pressure

Blood pressure was measured twice on both arms using a digital blood pressure monitor. A third measurement was taken

in case of a 5‐mmHg difference between the two first measurements. The average was calculated for each arm and the

higher one was used in the analysis. A detachable cuff of the digital blood pressure monitor was used in this study. It

could accommodate up to a 43 cm diameter arm. If a participant’s arm was more than 43 cm in diameter blood pressure

was not taken and the reason noted in the questionnaire.

As recommended by both of WHO (19) and IDF (17), the blood pressure target is 130/80 mmHg for patients with

diabetes. However, we defined two different variables to describe the study population.

Hypertension was defined as diastolic pressure of 140 mmHg or higher or systolic pressure of 90 mmHg or higher or

participants who declared taking anti‐hypertensive medications.

Hypertension uncontrolled was defined as diastolic blood pressure of 130 mmHg or higher and a systolic blood pressure

of 80 mmHg or higher with anti‐hypertensive medications.

6.2.4‐ Possession score

A possession score was computed using 6 variables:

‐ ownership of refrigerator

‐ ownership of computer

‐ ownership of television

‐ ownership of vehicle

‐ ownership of washing machine

‐ ownership of air conditioner

One point was dedicated to a positive answer and the sum was then calculated. Score range is 0‐6, with 0 for the lowest

possession level and 6 for the highest one.

17

The score was then categorized into 3 groups: low, middle and high possession level. Thresholds were decided in the view

of percentiles in the following way:

‐ low: score is below 2;

‐ middle: score is 2 or 3

‐ high: score is above 3.

6.2.5‐ Knowledge score

A knowledge score was calculated from section 4 questions. Only one right answer per question is possible. One point

was allocated at each right answer. The sum of points was calculated. The range score is 0‐7.

It is expected a 50%‐increase of participants with 60% of good answer by the end of the CVD project. As 60% of 7 equals

to 4.2, it was decided to use 5 as threshold.

6.2.6‐ Physical activity

The daily physical activity (PA) is very difficult to measure because of multiple aspects of physical activity. 30‐minute

moderate physical activity is internationally recommended at least five times a week to prevent non‐communicable

diseases,including diabetes.

International physical activity questionnaire (IPAQ) assesses physical activity undertaken across a comprehensive set of

domains, including:

‐ leisure time physical activity

‐ domestic and gardening (yard) activities

‐ work‐related physical activity

‐ transport‐related physical activity

The short form of IPAQ is a 7‐item measure of four domains of activity:

‐ vigorous‐intensity PA (defined as activities that make you breathe much harder than normal)

‐ moderate‐intensity PA (defined as activities that make you breathe somewhat harder than normal)

‐ walking

‐ and sitting

For each activity domain, examples are provided to indicate that activities of work, leisure‐time, house and garden work,

and transportation are to be reported. Frequency (during the last 7 days) and duration (minutes/hours usually spent on

one of those days) of vigorous intensity PA,, moderate‐intensity PA, and walking are to be reported as well. Only sessions

of activity lasting at least 10 minutes are to be reported. The total time that they spend sitting on a week day, during the

last 7 days is also to be reported.

Computation of the total score for the short form requires summation of the duration (in minutes) and frequency (days)

of walking, moderate‐intensity and vigorous‐intensity activities. Domain specific estimates cannot be estimated.

IPAQ proposes to classify population into three levels of physical activity: low, moderate and high.

For more information about IPAQ and score creation please visit the following website: http://www.ipaq.ki.se/ipaq.htm.

Regarding the current survey, the indicator for project monitoring is 30‐minutes physical activity three times a week. We

chose as proxy the moderate category of IPAQ classifications which is considered as equivalent to “half an hour of at least

moderate‐intensity physical activity on most days, leisure‐time based physical activity population health

recommendation.”

The analysis of physical activity was limited to participants who were 69 years old or below since IPAQ is not

recommended above this age group.

http://www.ipaq.ki.se/ipaq.ht�

18

6.2.7‐ Disability

Handicap International requires the provision of statistics on persons with disabilities who are beneficiaries of the project.

Indeed it was interesting to include a disability indicator in this survey. It was important for this indicator to be easily

measured and also conducive to comparisons with other Handicap International projects.

According to the Convention on the Rights of Persons with disabilities, “disability is an evolving concept and that disability

results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders

their full and effective participation in society on an equal basis with others” and “persons with disabilities include those

who have long‐term physical, mental, intellectual or sensory impairments which in interaction with various barriers may

hinder their full and effective participation in society on an equal basis with others.”.

To date, there is not statistical/epidemiological tool developed to measure disability as defined by the Convention.

However the Washington Group on Disability Statistics (WG) developed a set of six questions to measure limitations of

activities in the sense of the International Classification of Functioning, Disability and Health (ICF) promoted by the World

Health Organization (WHO). “The WG was formed as a result of the United Nations International Seminar on

Measurement of Disability that took place in New York in June 2001. An outcome of that meeting was the recognition that

statistical and methodological work was needed at an international level in order to facilitate the comparison of data on

disability cross‐nationally.” The framework utilized for the development of the measure tool is the ICF model.

“The ICF is WHO's framework for measuring health and disability at both individual and population levels.” It is a

classification of health and health‐related domains. These domains are classified from body, individual and societal

perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and

participation. Since an individual’s functioning and disability occurs in a context, the ICF also includes a list of

environmental factors.

These questions are the ones in section 3 of the questionnaire in appendix 1.

For the full text of the Convention on the Rights of Persons with disabilities, please visit

http://www.un.org/disabilities/convention/conventionfull.shtml.

For more information about the Washington Group on Disability Statistics, please visit the following website: http://www.cdc.gov/nchs/citygroup.htm.

For more information about the ICF, please visit http://www.who.int/classifications/icf/en/.

From these 6 questions, a disability score can be computed by adding the value of each item. The score range is 0‐18. An

individual was considered as having functional limitation if the score was ≥2, meaning the individual answered at least

one of the 6 questions with ‘with a lot of difficulty’ or at least two questions with “some difficulties”. (20)

http://www.un.org/disabilities/convention/conventionfull.shtml�

http://www.cdc.gov/nchs/citygroup.htm�

http://www.who.int/classifications/icf/en/�

19

VII –ANALYSIS

7.1 – Analysis plan

The main objective of the current study is to obtain baseline values for indicators 5 and 6 of expected result 1 of the CVD

project. A control group, from an area where the project was not implemented, was created to be able to measure the

effectiveness of the CVD project. This study will be repeated at the end of the project in 2013. If a change of proportion of

persons with diabetes with HbA1c <6.5% is observed at the end of the project in 2013 and not in the control group, it will

provide evidence to confirm the effectiveness of the CVD project. Otherwise, if there is a similar change in both groups,

we cannot conclude to the effectiveness of the project. Thus, the data analysis is mainly descriptive, comparing the

intervention group with the control group.

7.2 – Analysis strategy

The analysis strategy comprised a description of each variable, then, comparisons between control and intervention

groups. The mean of continue quantitative variables are presented with its standard error (se). Percentages were not

presented with their 95% confidence interval since the sample is not representative of the population with diabetes of

the study area. Regarding comparisons, chi‐square test and Fisher exact test were used for categorized quantitative

variables when appropriate. Logistic regressions were performed if appropriate. T‐test was used for continue quantitative

variables after checking of the equality of variances. A level significance of 5% was used for each statistical test.

VIII ‐ ETHICAL ASPECTS The study protocol was approved by the Regional Health Research and Development Consortium XI (RHRDC XI) for ethical

review before conducting the survey.

The CVD project team requested permission from the Barangay Captains to conduct the survey, to use their public

facilities, and to contact the target respondents through purok leaders and Barangay Health Workers.

Each participant signed an informed consent form in the local language.

Blood pressure and HbA1c value were released to the participants for their records. The medical doctor present at the

survey venue oriented participants toward a medical doctor if needed.

Invited participants who did not meet inclusion criteria were measured for hypertension and invited to take a snack.

20

IX ‐ RESULTS

Figure 3 presents the flow chart detailing the process to reach the sample size.

1,457 patients with diabetes were registered on the master list by the BHWs: 1,078 in the intervention area and 379 in

the control area. 549 people listed came to the venue. Among them, 50 were not actual diabetics. 142 people with

diabetes who came to the venue without invitation were included.

A total of 641 people with diabetes were interviewed, measured and tested for HbA1c. Among them, 504 came from the

intervention area while 137 came from the control area. Out of 641 respondents, two participants were excluded since

they were less than 20 years old.

Figure 3 ‐ Flow chart

The analysis was thus carried out on 639 participants: 503 in the intervention group and 136 in the control group.

9.1‐ Study population description

9.1.1‐ Socio‐demography

Table 1 presents the detailed socio‐demographic characteristics of the intervention group and the control group.

In the intervention group the mean age was 56.9 years old and the large majority of participants were women. The

majority of respondents were homemakers (41.2%), of which 83.7% were women. 38.4% of participants declared that

they worked, with around half was working part‐time.

76.7% participants attained at least high school level and 21.7% was graduated from College or even postgraduated.

The mean income was 8.756 Php4.

4 1 dollar ≈ 43.7 Philippines Peso (PhP) and 1 euro = 57.70 PhP.

1 457 listed - 1 078 in intervention area (IA)

- 379 in control area (CA)

549 came to the

survey venue

624 did not come

2 excluded (<20 y.o)

639 analysed 503 in IA 136 in CA

142 not listed but were included

499 diabetics

50 were not actual diabetics

21

The control group was different from the intervention group in education, income and possession score. The control

group attained a significantly lower level of education than the intervention group (p=0.009). More specifically, the

control group were less likely to be a college graduate or postgraduate even after adjustment for age and gender

(p=0.009). Another important difference concerns income. Mostly, the control group was poorer than the intervention

group. The control group had a significantly lower income and a lower proportion of individuals in the highest possession

category. The income difference was still significant after adjustment for age and gender (p<0.001). Table 1 ‐ Socio‐demographic characteristics


Demography

Mean Age (±se) 56.94 (± 0.46) 57.09 (±0.86) 0.88

Age (%)

20‐49 23.46 19.85

50‐59 34.79 38.24

60‐69 30.02 27.94

70 and above 11.73 13.97

0.667

Women (%) 69.18 70.59 0.75

Employment status (%)

Working full‐time 18.89 16.18

Working part‐time 19.48 26.47

Homemaker 41.15 41.18

Retired/pensioner 16.90 13.97

Others1,* 3.58 2.21

0.438*

Educational attainment (%)

Elementary level 9.15 13.24

Elementary graduate 14.12 16.91

High School level 14.12 21.32 0.009

High school graduate 21.07 21.32

College level/vocational 19.88 18.38

College graduate/postgraduate 21.67 8.82

Economy

Income (±se) 8,576.34 (±390.64) 5,891.91 (±666.88) 0.0006

Possession score (%)

Low 21.07 26.47

Middle 42.54 55.88 <0.001

High 36.38 17.65 * Fisher exact test 1 “Others” category includes Unemployed or laid off and looking for a job; Unemployed or laid off and not looking for a job; and other category

22

9.1.2‐ Anthropometry, blood pressure and biological measures

Table 2 gives results with regard to anthropometry, blood pressure and HbA1c level.

In the intervention group, mean BMI was 24.6(±3.6) kg/m². One person out of five (22.3%) was overweight while two

people out of five (43.4%) were obese.

Mean waist circumference was 91.9 (± 9.2) cm among males and 89.7 (± 9.4) cm among females.

57% of participants were hypertensive and for 29.4% of those under medication the hypertension was not controlled.

There was not a statistical difference either for the mean BMI between the intervention and the control groups or for

hypertension proportion.

Table 2 ‐ Anthropometric and biological measures (%)


BMI

Underweight (<18.5 kg.m²) 2.99 8.09

Normal (≥18.5 and < 23 kg.m²) 31.27 28.68

Overweight (≥23 and < 25 kg.m²) 22.31 27.21

Obese(≥25 kg.m²) 43.43 36.03

0.023

Blood pressure

Hypertensive 57.06 61.03 0.405

Hypertensive not controlled 29.42 27.94 0.736

The figure 4 presents the distribution of HbA1c in the intervention group and the control group.

In the intervention group, the mode was 7.4%. The HbA1c median (value separating the higher half of a sample from the

lower half) was 7.4% and 50% of the sample had HbA1c value comprised between 6.3% and 8.9%. The HbA1c mean was

7.8% with a standard error of 0.08.

In the control group the mode was 8.4%, the median was 8.4% and 50% of the sample was comprised between 6.8% and

10.1%. The HbA1c mean was 8.5% with a standard error of 0.17.

The control group HbA1c mean is statistically higher than in the intervention group one (p=0.003).

Figure 4 ‐ Distribution of HbA1c rate (%)

among the intervention group among the control group

05

10

15

20

Pe

rcen

t of p

artic

ipa

nts

4.0 6.0 8.0 10.0 12.0 14.0HbA1c rate (%)

02

46

81

0P

erc

ent o

f par

ticip

ant

s

4.0 6.0 8.0 10.0 12.0 14.0hba1c

23

9.1.3‐ Physical activity level

Figure 5 shows the repartition of our sample according to levels of physical activity as defined by IPAQ. The majority of

survey participants were categorized into the moderate‐level class, regardless of the group. Globally there was no

significant difference between the intervention group and the control ones (p=0.078).

Figure 5 – Distribution of the sample according to levels of physical activity (%)

Regardless of control or intervention group, the median sitting time per week day was 120 minutes, or 2 hours. 25% of

the sample declared to sit less than 60 minutes a week day in average during the 7 previous day and 25% more than 240

minutes a week day.

9.1.4‐ Diabetes and disability

In the intervention group, 86.4% of participants were identified as having limitations of activities, most commonly

regarding eyesight (84.3%), memory (75.4%) and walking (61.0%).

Table 3 presents the repartition of participants according to the limitation of activities and its level for each group.

The only significant difference observed between intervention and control group concerned difficulty with memory. A

greater number of patients with diabetes in the control group declared they had “a lot of difficulties” with remembering

or “cannot at all” as compared to the intervention group, even though they were less likely to declare having this

difficulty (66.9% versus 75.3%). Even though the control group seemed to be more affected by more severe visual

difficulties than the intervention group, the difference was not statistically significant.

38,97

45,73

15,31

23,53

35,29

41,18

0

5

10

15

20

25

30

35

40

45

50

Low Moderate High

Intervention area Control area

24

Table 3 ‐ Distribution of type of limitation of activities according to the degree of severity (%)

Intervention area Control area

0 1 2 or 3 0 1 2 or 3 P

Difficulty seeing 15.71 74.16 10.14 13.97 69.12 17.91 0.090

Difficulty hearing 59.56 37.85 2.59 58.82 38.24 2.94 0.928*

Difficulty walking or climbing 38.97 47.71 13.32 33.82 52.21 13.97 0.542

Difficulty remembering or

concentrating 24.65 59.64 15.71 33.09 47.06 19.85 0.031

Difficulty with self‐care 86.68 11.93 1.39 80.15 17.65 2.21 0.131*

Difficulty communicating 82.50 16.90 0.60 83.09 16.91 0.00 1.00*

0: No difficulty; 1: Some difficulties; 2: lot of difficulties; 3: Cannot at all * Fisher exact test

The proportion of people with low limb amputation was very low in both of the two groups. Eight (1.6%) and four

participants (2.9%) respectively from intervention area and control area were amputated. The difference was not

statistically significant (p=0.2955).

9.2‐ Monitoring indicators

The table 4 reports the baseline values for CVD project monitoring indicators in the intervention and the control group.

The results illustrate the statistical significant difference in proportion of participants achieving HbA1c<6.5% between the

two groups. The proportion of people with controlled blood sugar was higher in the intervention group than in the

control group (p=0.013). This difference was maintained when age, gender, BMI, education attainment and income were

taken into account (p=0.009).

There was no significant difference for other indicators according to the group. Table 4 ‐ Baseline values for monitoring indicators (%)


Diabetes control status

HbA1c<6.5% 28.23 17.65 0.013

Anthropometry

<80 cm for women or <90 for men 20.76 25.00 0.29

BMI < 23 kg.m² 34.26 36.76 0.587

Blood pressure

≤130/80 mmHg 24.85 20.59 0.301

Physical activity

at least moderate physical activity 61.94 68.38 0.199

Diabetes knowledge

score≥5 20.68 16.18 0.242

5 Fisher exact test

25

9.3‐ Nature of diabetes

Table 5 gives some information about the diabetes history of participants. There was no statistical difference between

intervention group and control group for all variables presented, except for “I do not remember”.

Participants were mostly diagnosed with diabetes at 50 years old and on average 6 years had been elapsed since

diagnosis. The three most frequently declared symptoms were (1) frequent urination, (2) fatigue and (3) extreme thirst. A

high percentage of participants in both groups gave other symptoms than the ones prelisted. The most cited in both

groups was dizziness since it was declared by more than 20%. Then we found limb numbness, itchiness, weakness, fever

or sweating, etc. The detailed answers for both groups are available in appendix 3.

Hypertension was the most common complication declared by participants in both groups, around 50%. Retinopathy

follows with 22% of participants declared this in both of the groups. Some participants declared complications other than

those prelisted. The most cited was problem linked to lungs (1.6% in intervention group and 2.2% in control group). Refer

to appendix 3 for additional information. Table 5 ‐ Diabetes history


Diabetes

Mean duration since diagnosis (±se) 5.79 (±0.26) 6.42 (±0.50) 0.2628

Mean age at diagnosis (±se) 50.65 (±0.49) 50.17 (±0.86) 0.6451

Symptoms Ŧ (%)

Frequent urination 34.79 37.50 0.558

Extreme thirst 32.80 32.35 0.921

Extreme hunger 14.51 13.24 0.705

Sudden lost of weight 13.32 7.35 0.058

Fatigue 34.00 38.97 0.281

On and off blurring of vision 28.03 33.09 0.249

Vaginal itches1 (n=444) 30.75 27.08 0.488

Others symptoms 48.51 57.35 0.067

I do not remember 3.78 0.00 0.019*

Complications Ŧ (%)

Neuropathy 6.40 6.62 0.927

Retinopathy 22.20 22.06 0.972

Nephropathy 8.60 6.62 0.454

Hypertension 51.59 47.06 0.348

Heart disease 11.60 12.50 0.773

Erectile dysfunction2 (n=194) 3.90 0.00 0.349*

Vaginal itchiness1 (n=442) 10.98 11.46 0.896

Others complications 6.60 5.15 0.536

None 32.00 34.56 0.572

I do not know 2.80 2.21 1.000* 1 % computed only for women;

2 % computed only for men;

3 several answers were possible that is why sum of percentage by group is more

than 100%. Ŧ This answers were given by respondents themselves without medical proof.

* Fisher exact test

Table 6 presents some variables linked to hypertension history and its management.

On average, hypertension was diagnosed at 50 years old, regardless of the group. The large majority of participants were

on anti‐hypertensive medication. Among those, one third were under Metoprolol and around 9% under Captopril. More

than 60% in both groups cited other antihypertensive drugs than those prelisted. The three most drugs cited were

26

Amlodipine (9.5% in intervention group and 5.2 in control group), Losartan (around 8% in both of two groups) and

Nifedipine (3.4% in intervention group and 5.9% in control group). Other drugs cited are showed in appendix 3.

Table 6 ‐ Hypertension history and its management

Variable Intervention area Control area p

Hypertension

Mean age at diagnosis (±se) 50.82 (±0.79) 49.55 (±1.77) 0.484

Anti‐hypertensive medication (%) 91.89 89.06 0.471

Anti‐hypertensive medication (%)

Metoprolol 33.75 33.33 0.952

Captopril 8.40 8.77 0.928

Others 62.14 61.02 0.873

I don’t know 7.05 11.86 0.222

9.4‐ Diabetes management and care

9.4.1‐ Routine check‐ups and medications

Table 7 below describes diabetes management and care.

In the intervention group, 9.3% of participants declared having no check‐up in the previous 12 months. However the

majority declared at least 4 check‐ups. There was no statistical difference with the control group.

For each listed examination, the proportion of participants who performed at least one examination was always higher in

the intervention group than in the control group. However the difference was only statistically significant for HbA1c,

cholesterol tests and fasting blood sugar done in lab. All these differences were still significant after adjustment for

gender, age, income and glycemia control status. Table 7 ‐ Repartition of the participants according to the test performed at least once in the past 12 months (%)


Fasting Blood Sugar (FBS) using Glucometer 83.06 77.94 0.169

FBS done in lab 67.13 57.35 0.034

HbA1c test 20.20 3.70 <0.001

Blood pressure measure 94.01 90.44 0.141

Cholesterol or lipid profile done 44.22 30.15 0.003

Foot exam using monofilament 13.35 8.82 0.155

Foot exams using Doppler machine 7.78 4.41 0.173

Among those who performed at least one test (table 8), results showed a statistically significant difference between the

two groups for the number of fasting blood sugar tests using glucometer. The intervention group declared an average of

having been tested with glucometer which was more than twice that of the control group (p<0.0001). There was also a

significant difference between the two groups as regards the mean number of HbA1c performed in the previous 12

months against the control group.

Even though participants from the control area seemed to have had more foot exams than participants from intervention

area, the difference was not statistically significant.

27

Table 8 ‐ Mean number of test in the previous 12 months (±se)

Variables1 Intervention area Control area p

FBS using Glucometer 8.85(±0.53) 4.49(±0.55) <0.0001*

FBS done in lab 2.52(±0.12) 2.77(±0.38) 0.5311*

HbA1c test 0.26(±0.03) 0.065(±0.03) <0.0001*

Blood pressure measure 8.11(±0.39) 7.12(±0.86) 0.2637

Cholesterol or lipid profile done 1.65(±0.11) 1.78(±0.30) 0.6658

Foot exams using monofilament 1.55(±0.19) 4.83(±3.04) 0.3057*

Foot exams using Doppler machine 1.82(±0.41) 2.83(±1.83) 0.6109* 1 computed among participants who answer more than 0

Regarding medications (table 9), Metformin was the most cited anti‐diabetic drugs in both groups. However this was

more frequently declared by the intervention group (p=0.034). Glibenclamide was more frequently cited by the control

group than the intervention group (p<0.001).

A big proportion of participants in the two groups gave others drugs than those prelisted. Among those, the three most

declared were glicazide (29.6% in the intervention group and 19.9% in the control group), glimeperid (7.9% in the

intervention group and 2.9% in the control group) and insulin (3.0% in the intervention group and 0.7% in the control

group). Other drugs were cited and are presented in appendix 4.

Table 9 ‐ Repartition of participants according to the anti‐diabetes medication declared (%)


Metformin 62.23 52.21 0.034

Glibenclamide 29.22 49.26 <0.001

Others 41.75 33.82 0.094

None 3.98 2.21 0.441*

I don’t know 0.80 0.00 0.583*

* Fisher exact test

11.3% and 9.6% of participants respectively from the intervention and control groups declared themselves as a smoker,

without significant difference (p=0.557).

9.4.2‐ Nutritionist‐dietetician

Around one third of people from the intervention group (32.8%) declared to have met with a nutritionist or dietetician

about a meal plan or diet. This proportion was statistically higher than the 22.1% observed in the control group (p=0.016) even after adjustment for age, gender and income, as well as glycemia control status (p=0.023). Table 10 shows the place where participants saw a nutritionist. Regardless of the group, participants answered more

frequently that this was at a public hospital rather than the other places listed. This item was statistically more often cited

by the control group than by the intervention group (p=0.005). On other hand, the participants from the intervention

group were statistically more likely to have answered ‘district health center’ than in the control group (p=0.018).

Nine participants in the intervention group gave a provider other than the ones prelisted. Among those, six cited

Handicap International.

28

Table 10 – Health facility where a nutritionist was consulted (%‐n=195)


Private clinic 10.91 10.00 1.0*

Public hospital 56.36 83.33 0.005

District health center 26.67 6.67 0.018*

Others 5.45 0.00 0.359*

I don’t know 1.21 0.00 1.0*

* Fisher exact test

Table 11 below shows the given reasons why participants did not visit a nutritionist (from those who answered not to

have visited a nutritionist).

In the intervention group, the main reason for not visiting a nutritionist was that participants did not know they were

supposed to do so (28.1%), followed by the fact they did not feel the need (25.7%). It was not recommended by doctor

for 12.1% of participants.

The only significant difference between the two groups concerned the statement “do not need”. The participants from

control group were more likely to cite this item than the ones from the intervention group (p=0.006).

Other answers than those prelisted were proposed. Among those, the main reason cited was that participants were busy

or did not have time to consult a nutritionist (3.8% in the intervention group and 2.9% in the control group). The others

answers are presented in appendix 5. Table 11 – Reasons for not having visited a nutritionist (%)


Too expensive 4.14 2.83 0.773*

Not recommended by doctor 12.13 17.92 0.128

Do not feel it was important 13.31 8.49 0.185

Did not know I was supposed to 28.11 25.47 0.596

Do not need 25.74 39.62 0.006

Others 22.19 13.21 0.044

* Fisher exact test

9.4.3‐ Education session

The proportion of participants who have never attended an education session was statistically higher in the control group

than in the intervention group with 67.2% and 43.1% respectively (p<0.001). This difference remains significant even after

adjustment for age, gender and income as well as glycemia control status and BMI (p<0.001).

Among those who declared to have attended an education session at least once, the mean number of sessions was 2.82

(± 0.16) in the intervention group, which was not statistically different than 2.22 (± 0.35) in the control group (p=0.1658).

Figure 4 presents the repartition of answers about origin of diabetes educators.

The control group mostly declared the hospitals as education providers (p<0.001) while the intervention group cited more

often the district health centers.

Table 12 presents the other answers cited that those prelisted. Note that Handicap International was cited as provider of

educators in 15.5% of case in the intervention group. BHWs played also this role for 2.8% of participants of the

intervention group.

29

Figure 4‐ Origin of diabetes educators (%)

Table 12 “other” category (%)

9.4.4‐ Payment of diabetes care

More than two thirds of participants from both of the study zones have already had a problem paying for diabetes care

(68.8% in the intervention group and 72.1% in the control group – p=0.462). Among them (table 13), more than two

thirds stated that they took out a loan or have borrowed or asked for money at least once to pay for diabetes care. Table 13 ‐ Mean found to pay diabetes care (%)

Variable Intervention area Control area P

Loan or borrow money from anybody 65.03 73.47 0.117

Pawn any property 20.81 21.43 0.894

Sell any property 6.36 11.22 0.105

Ask for money from anybody 69.65 69.39 0.960

Other government 25.72 21.43 0.385

Other 3.47 2.04 0.370*

* Fisher exact test

Intervention group Control group

HI 15,51 0

BHW 2,78 0

Others 0,99 1,47

Organized by the government 0,8 0

Brokenshire nurse 0,2 0

5,59

27,97

44,06

34,27

0

11,36

68,18

11,36

4,55 4,55

0

10

20

30

40

50

60

70

80

Private clinic Hospital District healthcenter

Other I don’t know

Intervention Control

30

9.5‐ Knowledge about health care services proposed by barangay health centre

Table 14 presents the proportions of participants distributed according declared health care services which may be found

in barangay health centers.

In the intervention group, the two most cited services were immunization/well‐baby service and general medical

consultations, followed very closely by pre‐natal care. This result is coherent with the high percentage of female

participants.

Only one service presents a significant difference between the two study areas. General medical consultations were more

frequently declared by the intervention group (31.8%) than the control group (17.7% ‐ p=0.001).

In the “other” category, the most frequent answers were linked to diabetes and regrouped into the term “diabetes

consultation”. This concerned 38.8% of the participants from the intervention group and only 8% in the control group.

This difference is statistically significant (p<0.001). The others answers are presented in appendix 6.

Table 14 ‐ Distribution of sample according to health services declared (%)


TB consultation and medications 14.71 13.97 0.828

Pre‐natal care/mother’s disease 28.43 29.41 0.822

Immunization/Well‐baby 31.81 31.62 0.966

General medical consultations 31.81 17.65 0.001

Dental services 5.77 5.15 0.781

Others 45.33 13.97 <0.001

9.6‐ Most effective means of notification for upcoming events in the barangay health centre

In light of the results below, the most relevant means of notification , according to the interviewees, is through house‐to‐

house visits. Table 15 ‐ Way of notification (%)


House‐to‐house visit 71.17 69.85 0.764

Poster 3.58 1.47 0.210

Leaflets 3.78 3.68 0.956

Meeting 7.16 8.82 0.513

Recorrida6 3.98 2.94 0.800*

Other 8.55 9.56 0.712

* Fisher exact test

Respondents gave some responses other than the ones prelisted. Table 16 presents the percentages of each of these

responses among the total sample.

6 Recorrida is a way of public announcement using a megaphone while riding a vehicle..

31

Table 16 – Other Ways of notification mentioned by respondents (%)

Variable Intervention group Control group

Invitation letter 3.78 5.88

Text message 1.59 0.74

Senior citizen organisation/Barangay council/Purok chairman 0.99 0.74

Health center/BHWs 0.80 1.47

Telephone call 0.60 0.00

Meeting 0.20 0.74

Monthly information 0.20 0.00

32

X‐ DISCUSSION

10.1‐ Objectives and main results

This study provides baseline values for CVD project monitoring indicators. Table 17 summarizes the values obtained and

those expected at the end of the project.

Table 17 – Baseline and final expected values of monitoring indicators

Indicators in the logical framework Indicators used

Baseline

values

(2010)

Final

Expected

values

(2013)

Indicator 5: 20% Increase of persons with

diabetes

‐ with HbA1c<6.5% HbA1c<6.5% 28.23% 33.88%

‐ with BMI< 23 kg.m² BMI<23 kg.m² 34.26% 41.11%

‐ with acceptable waist circumference Waist circumference <80 cm among

females OR <90 cm among males 20.76% 24.91%

‐ achieving 130/80 mmHg as blood

pressure Blood pressure <130/80 mmHg 24.85% 29.82%

‐ doing 30‐minute physical activity at least

3 times a week

Moderate category of IPAQ = at least

30‐minutes moderate level physical

activity 5 times a week

61.94% 74.33%

Indicator 6:

50%‐increase of persons with diabetes

with diabetes knowledge score > 60% Knowledge score ≥5 20.68% 31.02%

The indicators, as written in the logical framework, were defined without information about the actual values. Due to this

survey, a value close to the reality was computed for each of the indicators listed in the table. Reaching 75% of persons

with diabetes with adequate physical activity or more than 40% with adequate BMI seems ambitious.

In addition to providing baseline data for indicators, this study also gave a description of people with diabetes living in the

study area in terms of socio‐demography, anthropometry and glycemic control.

The mean level of HbA1c and the proportion of patients with poor glycemic control of levels of HbA1c (≥6.5%) all

indicated that glycemic control was unsatisfactory in the two groups. This fact may be explained by poor diabetes

management: in the intervention group, around one participant out of 10 declared not to have had a check‐up the

previous year and 56.7% had less than 4 checks‐up the previous year. The high level of uncontrolled diabetes may explain

the high rate of people who declared at least one complication (67.1%). Additionally, 51.6% of participants declared to be

affected by hypertension, 22.2% by retinopathy, 11.6% by heart disease, 8.6% by nephropathy and 6.4% by neuropathy.

The rate of female respondents was high (69.2%). Regarding the entire sample, 63.0% of women were homemakers or

retired, against 44.6% of men. Men who generally work outside from their home may have less opportunity to participate

in the research. This may explain the high rate of female respondents. Generally speaking, women participate more in

surveys about health than men.

However, a cross‐sectional study conducted in Luzon in 2003 to estimate the prevalence of diabetes mellitus and

impaired glucose tolerance showed that the prevalence of diabetes was higher among females than males. (8). Therefore

the high rate of participation of females in our study may partly be related to high prevalence of diabetes among this

specific population. A further prevalence study is necessary to test this assumption.

33

10.2‐ Limitations

Representativeness or external validity

Initially the survey was designed to be representative of diabetics visiting study zone health centers using a sampling

method. However, the project had sufficient funds to recruit all the diabetics registered in the master list by BHWs.

Unfortunately some diabetics registered did not actually have diabetes. However, walk‐in people who met the inclusion

criteria were included for replacement. The master list was therefore (1) not reliable and (2) not exhaustive. The source

population is thus unclear and this prevents extrapolating data to all diabetics visiting the health centers. The figures

presented in this report should be read as concerning only the sample and not be used to speak about all diabetics.

Nevertheless, this survey was designed to evaluate the CVD project and provide baseline value to indicators of the CVD

project. This will be repeated at the end of the project in 2013. If the 2013 sample is the same, or at least comparable

with 2010 sample, this can allow for some conclusions to be drawn on the effectiveness of the project.

Sample size

The non‐statistical differences between the intervention and the control groups need to be taken with caution. Indeed

the sample size of the control group was small, which means that the statistical power of comparisons is low. In other

words, the ability of statistical tests to detect a significant difference is reduced. Thus, some proportions seem different

between the two groups (intervention and control) but the statistical tests did not result to a significant difference. If the

sample had been bigger, perhaps the difference could have been significant. In the current study only a raw difference of

15 points or above between two percentages (P2‐P1≥15) can be detected as statistically significant.

Difference between intervention group and control group

The main criterion of the study is the rate of HbA1c. The CVD project has as goal to increase the percentage of diabetics

with HbA1c<6.5% by the end of the project. To assure that the possible increase observed at the end of the project is

linked to the project, it is necessary to have a control group in all respects similar to the intervention group, except for the

project. This design permits to control confounding factors (other factors explaining the difference observed i.e. age,

gender, education level, economic level etc.). The only difference between the two groups is thus the presence or the

absence of the project.

In our study, the intervention group and the control group did not have the same characteristics. The control group was

poorer than the intervention group, had a lower level of education and had a higher mean of HbA1c. Thus the

intervention and control groups are not strictly comparable. This is a limitation when evaluating the project. The after‐

study analysis will need to use multivariate analysis to adjust on confounding factors and make artificially groups

comparable.

Limitation due to the start of the project in 2007

The high mean of HbA1c and the high percentage of uncontrolled glycemia in the control group may be explained by

poorer diabetes management than those of the intervention group. The results show that the control group performed

less frequent routine tests than the intervention group. This difference was particularly significant for HbA1c test and

fasting blood sugar test using glucometer. The survey participants from the control area were less likely to have had at

least one education session or to have ever seen a nutritionist. These differences may be partly explained by the project

implemented in the intervention area since 2007. The impact of the project is also clear when we notice that the

participants from the intervention group are more likely to declare that the District Health Center provides

nutritionist/dietetician and education sessions while the ones from the control area declared more often the hospital as

provider of these sessions. The first phase of the project aimed at building local skills in terms of diabetes care

management, targeting the three levels of diabetes prevention. For more details on the phase 1 of the project, please

refer to appendix 7.

It would have been wise not to have chosen the pilot Barangays as the intervention area to test the effectiveness of the

CVD project. An area free from any influence of the first phase of the project would have been more relevant to assess

the effectiveness of the CVD project.

34

10.3‐ Comparisons with literature

Although the proportion of participants with uncontrolled glycemia is still very important, the proportion observed in our

sample is lower than what it is usually found in existing literature, and also lower than the measures taken by Handicap

International in 2007 and 2009.

For South‐East Asian countries, rates of diabetics with poor glycemic control (HbA1c≥7%) vary from one to another. In

current literature, the range of diabetics with poor glycemic control (HbA1c≥7%) is 59% to 81% (21‐26). Using this

threshold, 57.7% of our participants in the intervention area would be considered as having poor control glycemic but this

is a lower percentage than for South‐East Asia generally.

The study of Ng et al. showed that ethnic difference exists with regard to diabetic control as reflected by HbA1c levels

among people with diabetes living in same country (27). We can assume this ethnic difference exists between countries of

South‐east Asian, explaining in part the range observed above.

The DiabCare‐Asia 1998 study collected data from 230 diabetes centers distributed in 12 Asia countries. This study stated

that the mean central HbA1c was 8.6(±2.0)% for the entire sample and 65% had HbA1c>7.5% compared to 64.7% in our

study.(28) In the DiabCare‐Asia study, the mean of onset age was 48.7 ± 12.2 and the mean of BMI was 24.4± 4.0 kg.m².

Theses values are similar to those obtained in our study. In addition the DiabCare‐Asia showed that 27% had systolic

blood pressure >140 mmHg and 10% had diastolic blood pressure > 90 mmHg, while our values are respectively 54.7%

and 21.7% for intervention group and 58.8% and 24.3% for the control group. Specifically regarding the Philippines, this

same study stated that the mean of HbA1c was of 8.9% in the Philippines and 84.0% of Filipino sample had HbA1c above

7% (in our study. respectively 7.8% and 57.7%). The articles do not explain the differences observed in our study.

The study of Lantion‐Ang carried out in the Philippines in 2000 provides information about diabetes control using HbA1c

level. The mean HbA1c level in Lantion‐Ang’s 2000 study was 8.9% and 73% of diabetics had HbA1c value above 7.4% (29). With this threshold, our study shows a lower proportion (53.1% in the intervention group and 65.4% in the control

group). The sample used in Lantion‐Ang’s 2000 study was older than ours (59 years old versus 57 years old. respectively) and more corpulent (60% had BMI≥25 kg/m² versus 44.4% in the intervention group and 36.3% in the control group). The

main difference is the selection method. In Lantion‐Ang’s 2000 study the diabetics were included in a randomly selected

hospital. In our study, people with diabetes were selected using a list created from the patients known by the barangay

health workers. We can suppose that those who consult at hospitals are more affected by diabetes complications and so

their HbA1c value is higher. Moreover the survey was conducted in a specific venue, meaning that people with diabetes

had to travel to the survey venue to participate. Thus we can easily assume that people with a diabetic foot or blindness

or other disabling conditions were less able to attend. In addition, persons with diabetes most affected by complications

were voluntarily excluded from the survey for logistic reasons. The proportion of people with diabetes with good glycemic

control is certainly lower in the entire population of patients with diabetes.

On other hand, Handicap International has previously measured HbA1c in 2007 and 2009 among 268 and 289 persons

with diabetes respectively from the intervention area used in this survey. The proportion of persons with HbA1c below

6.5% was respectively 26.5% and 26.6% and the mean of HbA1c values was 8.7% (±2.8%) in 2007 (this data was not

available). These two first values are to be compared with 28.3% of our study. If the project explains the difference

observed between 2007 and 2010, it cannot explain the difference observed between 2009 and 2010, since only 7

months had elapsed between the two measures, which do not seem sufficient to observe such a difference. The variation

may be explained by the difference of methodology used to obtain these two values. In 2007 and 2009, the tests were

done in a lab at San Pedro Hospital in Davao while in 2010 a portative device using boronate assay by spectrophotometry

was used. At San Pedro Hospital, the assay measures both HbA1c and hemoglobin. The HbA1c measurement is based on a

turbidimetric inhibition immunoassay principle, and the measurement of total hemoglobin is based on a modification of

the alkaline hematin reaction. Using the values obtained for each of these two analytes (in g/dL), the percentage of the

total hemoglobin that is glycated is calculated and reported as %HbA1c. The final HbA1c result has been standardized to

the results obtained in the Diabetes Control and Complications Trial (DCCT). The Clover A1c System (appendix 2) used in

the present study is a fully automated boronate affinity assay certified by the National Glycohemoglobin Standardization

Program due to its traceability to the Diabetes Control and Complications Trial Reference Method. Nevertheless, HbA1c

35

results from the two analytical techniques are standardized on the DCCT. The results are then comparable. The difference

observed is not linked to the measure method.

Concerning the difference observed with the 2007 data, it may be linked to the impact of the first phase of the project.

However it may be also due to a difference of sample profile. The 2007 respondents were more likely to present

abdominal obesity (70.0% in 2007 versus 57.1% in 2010), there were less females (61% in 2007 versus 70% in 2010) and

they were poorer: 70% declared to earn less than 5.465 Php in 2007 versus 54% in 2010. Moreover, one quarter of

respondents declared not to be employed in 2007 against 4% in 2010.

The proportion of respondents with moderate physical activity level seems important in our sample. In Indonesia, only

4.7% of survey participants had physical activity considered as sufficient, namely above 600 MET, which corresponds to

the moderate category of IPAQ (30). In the Philippines, Baltazar et al. stated a high percentage of persons with diabetes

with physical inactivity: 78.2% among males and 69.8% among females (8), which is contrary to this study’s data. The

precise methods used to measure the physical activity level were not described in these two articles. Moreover there is

not sufficient available data that allow sample comparisons. It is thus difficult to identify the underlying reasons for this

difference. The short version of IPAQ was chosen for several reasons: (1) it tends to capture physical activity done during

leisure, domestic and gardening, the work‐related activity and transport‐related activities; (2) it was the most feasible

approach to evaluate physical activity level with the funds available; (3) to avoid having a too long questionnaire. The

IPAQ short form was designed for population surveillance of physical activity among adults and the IPAQ committee does

not recommend using this tool as an outcome measure in small scale intervention studies. In our survey, the idea was not

to measure precise individual changes in physical activity but to have a general idea of the proportion who respect

moderate physical activity level.

36

XI‐ CONCLUSION

Despite the limitations as described above, this study provides a first insight on the people living with diabetes in Davao

City. With almost 72% of diabetics having uncontrolled glycemia, this study shows the relevance of the CVD project. As a

baseline, this study provides comparison elements for the 2013 survey in order to test effectiveness of the CVD project

with the percentage of diabetics with HbA1c<6.5% as effectiveness criterion.

XII‐ SOME RECOMMENDATIONS FOR THE 2013 SURVEY

1‐ Use the same device to test HbA1c rate in order to ensure the comparability of results between the two surveys

2‐ As far as possible, try to re‐recruit the 2010 respondents to improve the power of statistical tests

3‐ If it is not possible to re‐recruit the 2010 respondents, try to recruit as many respondents as possible, especially in the

control area, for the same reason as above

4‐ Data analysis should take differences observed between the two groups into account. Statistical adjustment on

education and economic level is necessary.

37

XII‐ REFERENCES 1. Shaw JE. Sicree RA. Zimmet PZ.

Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010 Jan;87(1):4‐14

2. Roglic G. Unwin N.

Mortality attributable to diabetes: Estimates for the year 2010. Diabetes Res Clin Pract. 2010 Jan;87(1):15‐9

3. World Health Organization

WHO Diabetes [accessed on 2010‐10‐06] Available from: http://www.who.int/mediacentre/factsheets/fs312/en/index.html

4. International Diabetes Federation

Position Statement ‐ The diabetic foot ‐ International Diabetes Federation – IDF [accessed on April 29. 2010] Available from; http://www.idf.org/Position_statementsdiabetic_foot –

5. Samuel Dagogo‐Jack.

Primary Prevention of Type‐2 Diabetes in Developing Countries. J Natl Med Assoc. 2006 March; 98(3): 415‐9

7. Republic of the Philippines ‐ Department of Health‐ National Epidemiology center The 2005 Philippines Health Statistics [Accessed on 2010‐12‐10]

Available from: http://www.doh.gov.ph/files/phs2005.pdf 8. Jane C. Baltazar. Caridad A. Ancheta . Inmaculada B. Aban. Ricardo E. Fernando. Marina M. Baquilod.

Prevalence and correlates of diabetes mellitus and impaired glucose tolerance among adults in Luzon. Philippines. Diabetes Research and Clinical Practice 64 (2004) 107–115.

9. M. L. B. Soria. R.G. Sy. B.S. Vega. T. Ty‐Willing et al.

The incidence of type 2 diabetes mellitus in the Philippines: A 9‐year cohort study. Diabetes Research and clinical practice. 2009.86:130‐133

10. Official Web Site of Davao City [accessed on 2010‐10‐06]

Available from: http://www.davaocity.gov.ph/about/index.htm

11. Centers for Disease Control and Prevention Washington Group ‐ Washington Group on Disability Statistics [accessed on 2010‐10‐06] Available from: http://www.cdc.gov/nchs/citygroup.htm

12. International Diabetes Federation.

International standards for diabetes education. 3rd Edition [accessed on 2010‐10‐06] Belgium: International Diabetes Federation;2009. Available from: http://www.idf.org/webdata/docs/INTNL‐STANDARDS‐EN.pdf

13. International physical activity questionnaire General info [accessed on 2010‐10‐06]

Available from http://www.ipaq.ki.se/ipaq.htm 14. Lauritsen J M. Bruus M.

EpiData 3.1

http://www.who.int/mediacentre/factsheets/fs312/en/index.html�

http://www.idf.org/Position_statementsdiabetic_foot�

http://www.davaocity.gov.ph/about/index.htm�

http://www.cdc.gov/nchs/citygroup.htm�

http://www.ipaq.ki.se/ipaq.htm�

38

15. IDF clinical guidelines task force. Global guideline for type 2 diabetes. Brussels: International Diabetes Federation. 2005.

16. Fontaine KR. Redden DT. Wang C. Westfall AO. Allison DB.

Years of life lost due to obesity. Jama 2003;289(2):187‐93.

17. World Health Organization ‐ Western Pacific Regional Office

The Asia‐Pacific perspective: Redefining obesity and its treatment. [Accessed on 2010‐10‐06] Geneva: World Health Organization; 2000. Available from: http://www.diabetes.com.au/pdf/obesity_report.pdf

18. World Health Organization ‐ Western Pacific Regional Office

Type 2 Diabetes. Practical targets and treatments. Fourth edition. Melbourne: Asian‐Pacific Type 2 Diabetes Policy Group. 2005. Available from: http://www.idf.org/webdata/docs/T2D_practical_tt.pdf

19. Whitworth JA; World Health Organization. International Society of Hypertension Writing Group.

World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003 Nov;21(11):1983‐92

20. Eide A. H.. Kamaleri Y.

Living Conditions among People with Disabilities in Mozambique: A National Representative Study‐January 2009 SINTEF Report no. A9348. Oslo: SINTEF Health Research;2009 Available from: http://www.ffo.no/upload/Dokumenter/Eksterne%20dokumenter/Report_Mozambique.pdf [accessed on 2010‐10‐06]

21 Menon VU. Guruprasad U. Sundaram KR. Jayakumar RV. Nair V. Kumar H. Natl.

Glycaemic status and prevalence of comorbid conditions among people with diabetes in Kerala. Med J India. 2008 May‐Jun;21(3):112‐5.

22. Howteerakul N. Suwannapong N. Rittichu C. Rawdaree P. Adherence to regimens and glycemic control of patients with type 2 diabetes attending a tertiary hospital clinic. Asia Pac J Public Health. 2007;19(1):43‐9.

23. Nitiyanant W. Chetthakul T. Sang‐A‐kad P. Therakiatkumjorn C. Kunsuikmengrai K. Yeo JP. A survey study on diabetes management and complication status in primary care setting in Thailand. J Med Assoc Thai. 2007 Jan;90(1):65‐71.

24. Mafauzy M. Diabetes control and complications in public hospitals in Malaysia. Med J Malaysia. 2006 Oct;61(4):477‐83.

25. Mafauzy M. Diabetes control and complications in private primary healthcare in Malaysia. Med J Malaysia. 2005 Jun;60(2):212‐7.

26. Eid M. Mafauzy M. Faridah AR. Non‐achievement of clinical targets in patients with type 2 diabetes mellitus. Med J Malaysia. 2004 Jun;59(2):177‐84.

http://www.diabetes.com.au/pdf/obesity_report.pdf�

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Whitworth%20JA%22%5BAuthor%5D�

http://www.ncbi.nlm.nih.gov/pubmed?term=%22World%20Health%20Organization%2C%20International%20Society%20of%20Hypertension%20Writing%20Group%22%5BCorporate%20Author%5D�

http://www.ffo.no/upload/Dokumenter/Eksterne dokumenter/Report_Mozambique.pdf�

39

27. Ng TP. Goh LG. Tan Y. Tan E. Leong H. Tay EG. Thai AC. Ethnic differences in glycaemic control in adult Type 2 diabetic patients in primary care: a 3‐year follow‐up study. Diabet Med. 2005 Nov;22(11):1598‐604.

28. Chuang L.‐M. Tsai S.T.. Huang B.Y.. Tai T.Y

The status of diabetes control in Asia – a cross‐sectional survey of 24 317 patients with diabetes mellitus in 1998. Diab. Med. 19. 978‐85 29. Lantion‐Ang LC.

Epidemiology of diabetes mellitus in Western pacific region: focus on Philippines. Diabetes Res Clin Pract. 2000 Oct;50 Suppl 2:S29‐34.

30. Mihardja L.. Delima. Siswoyo H.. Ghani L.. Soegondo S.

Prevalence and Determinants of Diabetes Mellitus and Impaired Glucose Tolerance in Indonesia (A Part of Basic Health Research/Riskesdas) Acta Med Indones‐Indones J Intern Med Vol. 2009 Oct; 41(4):169‐74

40

APPENDIX 1: THE QUESTIONNAIRE Thank you for coming. This survey is about your experiences as a person with diabetes.

Gender Male Female

Date of Birth

/ /

Month Day Year

A. Employment Status Check one q 1. Working full‐time (40 hours or more a week) q 2. Working part‐time (less than 40 hours a week) q 3. Unemployed or laid off and looking for work q 4. Unemployed and not looking for work q 5. Homemaker q 6. Retired/Pensioner q 7. Disabled, not able to work q 8. Others (Please specify): ______________ B. Educational Attainment Check one q 1. Some elementary q 2. Elementary q 3. Some high school q 4. High school q 5. College q 6. Some College/Vocational q 7. Postgraduate q 8. No formal education C. Family History of Diabetes Check all that apply q 1. Mother q 2. Father q 3. One sibling q 4. Two or more siblings q 5. Second degree relatives q 6. None q 7. I don’t know D. Economic status

1. In average what is the household income per month? _________ Pesos (Round off to the nearest 500)

2. In your household, do you have: Check all that apply

q 1. Ref

q 2. Computer

q 3. TV

q 4. Motorized vehicle

q 5. Washing machine

q 6. Aircon

q 7. None of the above

Date of Conduct

TD: M D Y

Patient Code

PC: B P

Blood Pressure

BP: L 1 R 1

2 2

3 3

A A

Remarks:

Anthropometry

H: W: 1 WC:

2

3

Gown Code

HbA1c

Comments

Quality Checked/Comments

Data gathered by:

Interview:

Blood Pressure:

Anthropometrics:

Blood Test:

QC:

The Diabetes Survey

41

Section 1 – Nature of Diabetes

1. When was it when you were first diagnosed with diabetes? (Your best estimate is fine)

M D Y

2. What were your symptoms during the time

that you were diagnosed? Please check all that apply. DO NOT READ ALOUD. q a. I frequently urinate q b. I am always thirsty q c. I am always hungry q d. I suddenly lost weight q e. I am easily fatigued q f. I have on and off blurring of vision q g. I have vaginal itchiness q h. My other symptoms are:

_________________________________

q i. I don’t remember.

3. What are the complications that you are diagnosed with now? Please check all that apply. DO NOT READ ALOUD. q a. Neuropathy / Nerve damage q b. Retinopathy / Eye damage q c. Nephropathy / Kidney damage q d. Hypertension q e. Heart disease q f. Erectile Dysfunction (for males) q g. I have vaginal itchiness q h. Others (please specify)

_________________________________

q i. None q j. I don’t know

If you checked (D) Hypertension, please proceed to No. 4. If you are not diagnosed with hypertension, please proceed to No. 7. 4. When was it when you were diagnosed with

hypertension? (Your best estimate is fine)

M D Y

5. Do you take prescribed medicines for your

hypertension?

q Yes, please proceed to No. 6. q No, please proceed to No. 7.

Section 2 – Diabetes Management and Care

6. What are your prescribed medicines for hypertension currently? Ask if they brought their meds or prescription. Write MMK if can’t remember one of two or more meds. q a. Metroprolol q b. Captopril q c. Others (please specify) _______________ q d. I don’t know

7. How many times did you have a regular

check‐up with any doctor regarding your diabetes in the past twelve months? Please exclude those times that you went because you felt ill. If none, please write 0. ______

8. How many times did you undergo the

following lab tests in the past twelve months? Please exclude those that were done because you felt ill. If no tests were done, please write 0. If none at all, please cross out the table.

Name of Test No. of tests

a. FBS using glucometer

b. FBS done in the lab

c. HbA1c

d. Blood pressure

e. Cholesterol or lipid profile

f. Foot exam using monofilament

g. Foot exam using a Doppler machine

9. What are your anti‐diabetes medications

today whether you are taking them or not? Please check all that apply. q a. Metformin

q b. Glibenclamide

q c. Others (please specify) ______________ q d. None q e. I don’t know

10. Do you currently smoke? q Yes q No 11. Did you ever see a nutritionist‐dietitian to

learn about a diabetic meal plan or diet?


The Diabetes Survey

42

12. From which health facility is the nutritionist with whom you consulted? Please check all that apply. Then proceed to No. 14. q a. Private clinic q b. Hospital q c. District health center q d. Others (please specify) _______________ q e. I don’t know

13. Why haven’t you seen a nutritionist‐dietitian?

Please check all that apply. q a. Consultation is expensive. q b. It was not recommended by my doctor. q c. I did not feel it was important. q d. I did not know I was supposed to q e. I don’t need it because my doctor tells me

about my diet already. q f. Others (please specify) _______________

14. How many times have you attended a

diabetes education session since diagnosis? If none, please write 0 and proceed to No. 16 _________

15. From which health facilities were the diabetes

educators? Please check all that apply. q a. Private clinic q b. Hospital q c. District health center q d. Others (please specify) _______________ q e. I don’t know

16. What are the health care services of your

barangay health center? Please check all that apply. DO NOT READ ALOUD. q a. TB consultation and medications q b. Pre‐natal care/ mother’s classes q c. Immunization/Well‐baby q d. General medical consultations q e. Dental Services q f. Others (please specify) _______________ q g. None of the above q h. I don’t know

17. What is the very best way for the health center to notify you of upcoming events? Choose only one. Do not read aloud. q a. House‐to‐house visit q b. Poster q c. Leaflets q d. Parade q e. Meeting q f. Recorrida q g. Others (please specify) _______________ q h. None of the above q i. I don’t know

18. Have you ever had a problem in paying for

your diabetes care?


19. Have you ever had to do any of the following to pay for your diabetes care? Please check all that apply. q a. Loan or borrow money from anybody q b. Pawn any property you have (cellphone,

jewelry, appliance, etc.) q c. Sell any property you have (cellphone,

jewelry, appliance, etc.) q d. Ask for money from anybody (including

your children) q e. Lingap and other government programs q f. Other means to pay for diabetes care

outside of your means (please specify) ____________________________

20. OBSERVE ONLY: Write 0 if none.

Right Left

Above knee

Below knee

Partial foot

The Diabetes Survey

43

Section 3 – Diabetes and Disabilities Introductory phrase: The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM. 21. Do you have difficulty seeing, even if wearing

glasses? q 0. No difficulty q 1. Some difficulty q 2. With a lot of difficulty q 3. Cannot at all

22. Do you have difficulty hearing, even if using a

hearing aid? q 0. No difficulty q 1. Some difficulty q 2. With a lot of difficulty q 3. Cannot at all

23. Do you have difficulty walking or climbing

steps? q 0. No difficulty q 1. Some difficulty q 2. With a lot of difficulty q 3. Cannot at all

24. Do you have difficulty remembering or

concentrating? q 0. No difficulty q 1. Some difficulty q 2. With a lot of difficulty q 3. Cannot at all

25. Do you have difficulty with self‐care such as

washing all over or dressing? q 0. No difficulty q 1. Some difficulty q 2. With a lot of difficulty q 3. Cannot at all

26. Using your usual (customary) language, do

you have difficulty communicating, for example understanding or being understood?

q 0. No difficulty q 1. Some difficulty q 2. With a lot of difficulty q 3. Cannot at all

Section 4 – Diabetes Knowledge Introductory phrase: The next questions are intended to measure the level of diabetes knowledge. Kindly give the best answer for each item. 27. My target fasting blood sugar level is

1. 5 mmol/L or 90 mg/dL and below 2. 6 mmol/L or 108 mg/dL and below 3. 7 mmol/L or 126 mg/dL and below 4. 8 mmol/L o 144 mg/dL and below

28. My target blood pressure is 1. Below 110/70 2. Below 120/80

3. Below 130/80 4. Below 140/80

29. The time I spend daily for exercise should be

1. 10 minutes 2. 15 minutes

3. 20 minutes 4. 30 minutes

30. The blood test ideal for monitoring my blood

sugar is 1. HbA1c 2. FBS

3. OGTT 4. RBS

31. My target waist circumference should be

1. Below 70 cm 2. Below 80 cm

3. Below 90 cm 4. Below 100 cm

32. The best way to prevent my foot from being

amputated is to 1. Take the antibiotics prescribed by my

doctor if I have a wound 2. Check and wash my feet everyday 3. Have my feet inspected by my doctor

every time I visit 4. Wear proper shoes for protection

33. My kidneys should be monitored through

1. Blood creatinine once a year 2. Routine urinalysis once a year 3. Blood cholesterol once a year 4. ECG once a year

34. During regular meals, one‐half of my plate

should be filled with 1. Rice 2. Meat such as fish, pork or beef 3. Vegetables 4. Fruits

The Diabetes Survey

44

Section 5 – Physical activity Introductory phrase: The following questions refer to physical activities that you did in the last seven (7) days.

There are no right or wrong answers.

Vigorous activities are those that take hard physical effort and make you breathe much harder than normal. Example: heavy lifting, digging, aerobics, or fast bicycling

35. During the last 7 days, on how many days did

you do vigorous physical activities for at least 10 minutes at a time?

days q No vigorous physical activities. Please go to No. 37.

36. How much time did you usually spend doing

vigorous physical activities on one of those days?

Minutes

Hours

q Don’t know or not sure

Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Examples: carrying light loads, bicycling at a regular pace, or doubles tennis

37. During the last 7 days, on how many days did

you do moderate physical activities like? Do not include walking.

days q No moderate physical activities. Please go to No. 39.

38. How much time did you usually spend doing

moderate physical activities on one of those days?

Minutes

Hours


Walking includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

39. During the last 7 days, on how many days

did you walk for at least 10 minutes at a time?

days q No walking. Please go to No. 41.

40. How much time did you usually spend

walking on one of those days?

Minutes

Hours


Sitting includes time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

41. During the last 7 days, how much time did

you spend sitting on a week day?

Minutes

Hours


‐‐‐ End of Questionnaire ‐‐‐

Thank the respondent. Take the BP and note values on the first page. Give this to the respondent and

ask him/her to proceed to the measurements area with this

questionnaire.

45

APPENDIX 2: BLOOD TESTING FOR HEMOGLOBIN A1C General

1. Blood should be collected only by a hired nurse or medical technologist trained on this protocol and the use of the HbA1c analyser.

2. Capillary blood from a finger prick will be tested. 3. Results will be released immediately after the blood test. 4. Patients will be advised that fasting is not required.

Materials / Equipment

1. HbA1c Analyzer ( Clover A1c) 2. Lancing Device 3. Disposable Lancets 4. 70% Ethyl alcohol 5. Cotton balls 6. Extra HbA1c Test Result Forms 7. Blood test result summary form 8. Glue / Stapler with staple wires

Principle behind the HbA1c Analyzer (Clover A1c)

Clover A1c System is a fully automated boronate affinity assay certified by the National Glycohemoglobin

Standardization Program due to its traceability to the Diabetes Control and Complications Trial Reference Method. It determines the percentage of haemoglobin A1c in human whole blood. The test cartridge is composed of a Cartridge and a Reagent Pack containing the reagents with a collection leg for blood sample collection. The Reagent pack is pre‐filled with reaction solution and washing solution. The reaction solution contains agents that lyses erythrocytes and bind haemoglobin specifically, as well as a boronate resin that binds cis‐diols of glycated haemoglobin. Blood sample is collected at the collection leg of the Reagent Pack. The Reagent pack is inserted into the Cartridge, where the blood is instantly lysed releasing the haemoglobin and the boronate resin binding the glycated haemoglobin The assembled Cartridge is inserted into the analyser and rotated so that the blood sample mixture is placed at the measurement zone of the Cartridge, where the amount of total haemoglobin in the blood sample is measured by the reflectance of the photo sensor LED (Light Emitting Diode) and PD (Photo Diode). Then, the assembled cartridge is rotated so that the washing solution washes out non‐glycated haemoglobin from the blood sample, thus the amount of glycated haemoglobin can be photometrically measured. The ratio of glycated haemoglobin with respect to total haemoglobin in the blood sugar is calculated. Calibration

1. Calibrate the analyser at the start of every blood testing day. 2. Perform calibration of the analyser using the calibrator cartridge provided with the machine. 3. Do not perform blood tests when the LCD displays shows ERROR. 4. Common reasons for ERROR in calibration are: defective calibrator or low light / defective light 5. Inform the data‐gathering head once this occurs 6. 2 sets of machines with calibrators will be prepared for the research in preparation for this.

46

Performing the blood test and releasing the result.

1. Apply alcohol to the finger and let dry before pricking. 2. Place the blood sample in the tip of the collection leg. 3. Place cotton ball with alcohol on the pricked finger once enough blood is collected. 4. Let the respondent wait for the results. 5. Write the result in the Result Form and check the corresponding interpretation and recommendations. 6. Show the filled up Result form to the data‐gathering in‐charge for verification before giving the result to the

respondent. 7. Write the result on the front‐page of the survey questionnaire. 8. Record the result in the Blood test summary sheet.

47

APPENDIX 3: OTHERS SYMPTOMS DECLARED BY PARTICIPANTS Table 18 Other Symptoms (%)

Intervention Control

Dizziness 24.06 22.73

Limb numbness 13.68 9.09

Itchiness 8.02 13.64

Weakness 7.08 4.55

Fever or sweating 7.08 3.03

Headache 5.66 7.58

Pain 4.72 1.52

Slow healing wound 4.72 9.09

Cannot sleep 2.83 1.52

Foot problems 2.83 4.55

Vomiting 2.36 1.52

Cough 1.89 3.03

Dryness 1.42 3.03

Cramps 1.42 0

Urine system problem 0.94 0

Rashes 0.94 1.52

Gestational diabetes 0.94 0

Slow weight loss 0.94 0

Pale 0.94 0

Felt like floating 0.94 1.52 Discovered during other examinations 0.94 1.52

Collapsed 0.94 1.52

No appetite 0.94 0

Difficulty in breathing 0.47 1.52

Asthma 0.47 0

Mild stroke 0.47 0

Did not feel well 0.47 0

Swelling 0.47 3.03

Skin lesion 0.47 0

Oedema 0.47 0

Tachycardia 0.47 0

Nausea 0 1.52

Irritable 0 1.52

Diarrhoea 0 1.52

Table 19 Others complications (%)

Intervention

group Control group

Lungs problem 1.59 2.21

Gastropathy 0.80 0.00

Dizziness 0.40 0.00

Fatty liver 0.40 0.74

Gallbladder 0.40 0.00

Goiter 0.40 0.00

Tuberculosis 0.40 0.00

Anemia 0.20 0.00

Asthma 0.20 0.00

Cannot Sleep 0.20 0.00

Difficulty breathing 0.20 0.00

Foot infection 0.20 0.00

Headache 0.20 0.00

Hypercholesterolemia 0.20 0.00

Numbness 0.20 0.74

Rheumatic arthritis 0.20 0.00

Tinnitus 0.20 0.00

Mild stroke 0.00 1.47

48

Table 20 Other antihypertensive drugs (%)

Intervention

area Control area

Amlodipine 9.54 5.15

Losartan 7.95 8.09

Nifedipine 3.38 5.88

Enalapril 2.78 1.47

Aspirin 1.79 1.47

Telmisartan 1.19 0.74

Felodipine 0.99 1.47

Irbesartan 0.80 0.00

Atenolol 0.60 0.00

bepridil 0.60 0.00

Imidapril 0.60 0.00

Verapamil 0.40 0.00

Lacidipin 0.40 0.00 Lozartan + Hydrochlorothiazide 0.40 0.00

Candesartan 0.20 0.00

Furosemide 0.20 0.00

Hydrochlorothiazide 0.20 0.00 Imidapril + Hydrocholorthiazide 0.20 1.47

Indapamide 0.20 0.00

Moexipril 0.20 0.00

olmesartan 0.20 0.00

Perindopril 0.20 0.00

Ramipril 0.20 0.00

Atorvastatin 0.20 0.00

Clonidine 0.20 0.00

Potassium 0.20 0.00

Valsartan + Hydro 0.20 0.00 Benidipine hydrochloride 0.00 0.74

Rauwolfia_alkaloids 0.00 0.74

49

APPENDIX 4: OTHER ANTI‐DIABETICS DRUG THAN THOSE PRELISTED

Table 21 Other anti‐diabetic drugs (%)

Intervention group Control group

Glicazide 29.62 19.85

Glimeperid 7.36 2.94

Insulin 2.98 0.74

Glipizide 1.79 1.47

Herbal medicines 0.40 2.21

Rosiglitazone 0.40 0.00

Sitaglitin 0.40 0.00

Acarbose 0.40 0.74

Cilostazol 0.20 0.00

Imidapril 0.20 0.00

Losartan 0.20 0.00

Metoprolol 0.20 0.00

Pioglitazone 0.20 2.94

Vildaglipin 0.20 0.00

Unknown generic 0.99 1.47

50

APPENDIX 5: OTHER REASONS FOR NOT VISITING THE NUTRITIONIST Table 22 Other reasons for not visiting the nutritionist (%)

intervention group control group

Busy/ no time 3.78 2.94

Do not know 2.39 0.74

Seminar/meeting 1.79 0.00

Informed by acquaintance 0.99 0.74

Read 0.99 0.74

Lazy to consult 0.80 0.00

Controlled by himself 0.40 0.74

Informed by BHW 0.40 0.74

Forgot 0.20 0.00

Do not like it 0.20 0.00

Do not where to consult 0.20 0.74

Do not have the chance to consult 0.20 0.00

Cannot move around 0.20 0.00

No money 0.20 0.74

Too far 0.00 0.74

APPENDIX 6 : OTHER BARANGAY HEALTH CENTER SERVICES DECLARED BY RESPONDENTS Table 23 Other services available at the Barangay health office (%)

Intervention

group Control group

Diabetes consultation 38.77 8.09

Other services 6.16 2.94

Family planning 1.99 1.47

Nutritional consultation 1.19 0.74

Vaccine 0.8 0

Hypertension consultation 0.6 0

Seminar 0.4 0.74

51

APPENDIX 7: PHASE 1 LOGICAL FRAMEWORK: FURTHER DETAILS The very specific nature of diabetes means that certain important strategic choices have had to be made concerning the implementation of the project. On the one hand this is a severe and relatively recent epidemic. Indeed, diabetes has only recently become an issue in developing countries (over the past twenty years). According to experts, despite its rapid exponential spread, the epidemic is really only just beginning, given the huge lifestyle changes that are currently taking place. This very particular situation means that healthcare services, which are already struggling to deal with public health problems, will be saturated by the growing demand for care for chronic diseases. It is therefore important to anticipate these issues and modify care strategies accordingly. Using a cross‐disciplinary approach, the project aims to strengthen skills and put people with diabetes at the heart of the process by building their capacities to control and self‐manage their disease. This should, in turn, take the pressure off healthcare services and avoid the complications and morbidities which can represent a heavy financial burden for the family and healthcare services in general. On the other hand, the very nature of diabetes as a chronic disease means it is crucial to start educating the population from a very early age. This requires behavioural change in terms of lifestyle but also in terms of the consumption/use of healthcare. This means people have to be vigilant on a daily basis, even if they do not yet have any apparent symptoms. For all these reasons, the project’s overall objective is for people with diabetes to be able to self‐manage their disease and live a normal life. In order to meet this objective, three areas of action will be developed over the course of the project:

1. Primary prevention: Avoiding the onset of the disease amongst people at risk.

The objective is to control the epidemic and slow down its spread by warning and educating people at risk as early as possible. Two specific groups will be included in the activities. Firstly, people immediately at risk of developing diabetes (people who are overweight, have a family history of diabetes, people who do little or no physical exercise, people with poor life hygiene etc.); and secondly, other children and adolescents, through targeted awareness‐raising in schools and the promotion of maintaining good health. Several activities will take place in order to reach this objective:

- An education and prevention kit on health, life hygiene and nutrition. This will be produced for use in primary and secondary schools

- Community awareness‐raising work will be carried out with the help of community workers and the "Diabetes Club", an organisation made up of people with diabetes

- Work will be carried out in partnership with the Davao town council in order to implement local legislation on diabetes prevention

2. Secondary prevention: Ensuring that people with diabetes do not develop complications

The objective is to ensure that people with diabetes fully understand their illness and can develop day‐to‐day strategies for living a normal life and controlling their blood sugar levels. The following activities will be put into place:

- Strengthening local medical services, both on a community level via community health workers, and in district hospitals. Specialised training will be provided for healthcare staff in order to set up a system for support and accompaniment

- Improving financial access to medication and laboratory tests. Within the framework of this action, two special activities will take place. Firstly, an economic study into the financial burden on families that the purchase of medication and laboratory tests represents. This study will also aim to provide financial information for setting up a system to reimburse the cost of medication and laboratory tests for the poor. Following these recommendations, a system will be developed

52

and tested to demonstrate to local authorities how the system would work and how much it will cost, in order to integrate it into the council budget

- Implementation of daily accompaniment for people with diabetes through the development of peer‐to‐peer activities

- Definition and implementation of diabetes screening protocols amongst at risk groups

3. Tertiary prevention: Preventing morbidity or mortality in diabetics with complications.

The objective is to improve care management for patients who have developed complications and to avoid disabling situations. Several activities will be put into place: Within the tertiary medical services (Davao Medical Center) for medical care:

- Definition and implementation of intervention protocols concerning complications linked to diabetes, and the training of those involved in this work

- Improving the coordination between specialised services by putting into place coordination tools - Setting up a referral and counter‐referral system for the different people and services involved,

both within the hospital and also in district and community services - Creation and circulation of information tools for existing services

With those involved in rehabilitation work, for the care‐management of impairments linked to complications brought on by diabetes:

- Community‐based rehabilitation services developing tools designed for the care‐management of impairments brought on by diabetes and for the prevention of secondary complications (repeat amputation, ulcers etc.)

- Training for Community Based Rehabilitation workers in using these tools - Research into the appropriate technology to be used for dealing with orthopaedic complications

in the field of footware, orthoses designed to unload/deweight, adapted socket prostheses and special mobility aids for people with diabetes in developing countries. Training for all those involved (orthopaedic technician, chiropodist, physiotherapist etc.)

- Definition and implementation of monitoring protocols in rehabilitation centres, for rehabilitation interventions designed to treat complications

4. Follow‐up and assessment of the action taken to improve diabetes care management.

Given the innovative nature of the project, careful attention will be paid to epidemiological monitoring and the assessment of the impact of the different interventions undertaken.

- Firstly, specific indicators will be defined - A comprehensive data collection system will be set up by providing a target population sample of

diabetics with follow‐up records (these follow‐up records will also allow people with diabetes to follow‐up and control their illness themselves)

- The data will then be analysed and an annual report on the diabetes situation in Davao will be produced

__________

53

with the support from Sanofi‐Aventis

CVD project evaluation:

Baseline diabetes study

Davao, Philippines 2010

HANDICAP INTERNATIONAL

14, avenue Berthelot

69361 LYON Cedex 07

T. +33 (0) 4 78 69 79 79

F. +33 (0) 4 78 69 79 94

[email protected]

This report presents the baseline evaluation

study of the Cardiovascular Diseases (CVD)

project conducted in Davao, Philippines in

2010.

The study’s aim was to gather baseline data

for indicators 5 and 6 of the expected results

1 of the 2010-2013 CVD project.

This study also concerned gathering

information on the nature of diabetes and

common practices in diabetes management

and care, to improve project implementation

strategy and data on promoting health care

services in the community.

The present study is the first part of a

before-after here-there study conducted in

10 intervention villages and 5 control villages

of Davao City.

Date post:	10-May-2018
Category:	Documents
Upload:	vuongquynh
View:	220 times
Download:	0 times

CVD Project evaluation: Baseline diabetes study … RE CVD Project evaluation: Baseline diabetes...

Documents