Treating 4,000 diabetic patients in Cambodia, a high-prevalence but resource-limited setting: a 5-year study

Factors Influencing the Implementation of Remote Delivery Strategies for Non-Communicable Disease Care in Low- and Middle-Income Countries: A Narrative Review

Objectives: The COVID-19 pandemic has disrupted health care for non-communicable diseases (NCDs) and necessitated strategies to minimize contact with facilities. We aimed to examine factors influencing implementation of remote (non-facility-based) delivery approaches for people with hypertension and/or diabetes in low- and middle-income countries (LMICs), to inform NCD care delivery during health service disruption, including humanitarian crises.

Methods: Our narrative review used a hermeneutic and purposive approach, including primary studies conducted in LMICs, which assessed implementation factors influencing remote NCD care delivery. Results were analyzed using the Consolidated Framework for Implementation Research.

Results: Twenty-eight included studies revealed the strong influence of both internal organizational and broader contextual factors, such as community health worker policies or technological environment. Addressing patients’ specific characteristics, needs and resources was important for implementation success.

Conclusion: This review highlighted the multiple, complex, interdependent factors influencing implementation of remote NCD care in LMICs. Our findings may inform actors designing NCD care delivery in contexts where facility-based access is challenging. Implementation research is needed to evaluate context-adapted e-Health, community-based, and simplified clinical management strategies to facilitate remote NCD care.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

An innovative model for management of cardiovascular disease risk factors in the low resource setting of Cambodia

Non-communicable diseases are increasing in developing countries and control of diabetes and hypertension is needed to reduce rates of the leading causes of morbidity and mortality, stroke and ischaemic heart disease. We evaluated a programme in Cambodia, financed by a revolving drug fund, which utilizes Peer Educators to manage diabetes and hypertension in the community. We assessed clinical outcomes and retention in the programme. For all people enrolled in the programme between 2007 and 2016, the average change in blood pressure (BP) and percentage with controlled hypertension (BP < 140/<90 mmHg) or diabetes (fasting blood glucose (BG) < 7mg/dl, post-prandial BG < 130 mg/dl, or HBA1C < 7%) was calculated every 6 months from enrolment.  Attrition rate in the nth year of enrolment was calculated; associations with loss to follow-up were explored using cox regression. A total of 9139 patients enrolled between January 2007 and March 2016. For all people with hypertension, mean change in systolic and diastolic BP within the first year was −15.1 mmHg (SD 23.6, P < 0.0001) and −8.6 mmHg (SD 14.0, P < 0.0001), respectively. BP control was 50.5% at year 1, peaking at 70.6% at 5.5 years. 41.3% of people with diabetes achieved blood sugar control at 6 months and 44.4% at 6.5 years.  An average of 2.3 years [SD 1.9] was spent in programme. Attrition rate within year 1 of enrolment ranged from 29.8% to 61.5% with average of 44.1% [SD 10.3] across 2008–15. Patients with hypertension were more likely to leave the program compared to those with diabetes and males more likely than females. The programme shows a substantial and sustained rate of diabetes and hypertension control for those who remain in the program and could be a model for implementation in other low middle-income settings, however, further work is needed to improve patient retention.

Clinical outcomes in a primary-level non-communicable disease programme for Syrian refugees and the host population in Jordan: A cohort analysis using routine data

BACKGROUND

Little is known about the content or quality of non-communicable disease (NCD) care in humanitarian settings. Since 2014, Médecins Sans Frontières (MSF) has provided primary-level NCD services in Irbid, Jordan, targeting Syrian refugees and vulnerable Jordanians who struggle to access NCD care through the overburdened national health system. This retrospective cohort study explored programme and patient-level patterns in achievement of blood pressure and glycaemic control, patterns in treatment interruption, and the factors associated with these patterns.

METHODS AND FINDINGS

The MSF multidisciplinary, primary-level NCD programme provided facility-based care for cardiovascular disease, diabetes, and chronic respiratory disease using context-adapted guidelines and generic medications. Generalist physicians managed patients with the support of family medicine specialists, nurses, health educators, pharmacists, and psychosocial and home care teams. Among the 5,045 patients enrolled between December 2014 and December 2017, 4,044 eligible adult patients were included in our analysis, of whom 72% (2,913) had hypertension and 63% (2,546) had type II diabetes. Using visits as the unit of analysis, we plotted the following on a monthly basis: mean blood pressure among hypertensive patients, mean fasting blood glucose and HbA1c among type II diabetic patients, the proportion of each group achieving control, mean days of delayed appointment attendance, and the proportion of patients experiencing a treatment interruption. Results are presented from programmatic and patient perspectives (using months since programme initiation and months since cohort entry/diagnosis, respectively). General linear mixed models explored factors associated with clinical control and with treatment interruption. Mean age was 58.5 years, and 60.1% (2,432) were women. Within the programme's first 6 months, mean systolic blood pressure decreased by 12.4 mm Hg from 143.9 mm Hg (95% CI 140.9 to 146.9) to 131.5 mm Hg (95% CI 130.2 to 132.9) among hypertensive patients, while fasting glucose improved by 1.12 mmol/l, from 10.75 mmol/l (95% CI 10.04 to 11.47) to 9.63 mmol/l (95% CI 9.22 to 10.04), among type II diabetic patients. The probability of achieving treatment target in a visit was 63%-75% by end of 2017, improving with programme maturation but with notable seasonable variation. The probability of experiencing a treatment interruption declined as the programme matured and with patients' length of time in the programme. Routine operational data proved useful in evaluating a humanitarian programme in a real-world setting, but were somewhat limited in terms of data quality and completeness. We used intermediate clinical outcomes proven to be strongly associated with hard clinical outcomes (such as death), since we had neither the data nor statistical power to measure hard outcomes.

CONCLUSIONS

Good treatment outcomes and reasonable rates of treatment interruption were achieved in a multidisciplinary, primary-level NCD programme in Jordan. Our approach to using continuous programmatic data may be a feasible way for humanitarian organisations to account for the complex and dynamic nature of interventions in unstable humanitarian settings when undertaking routine monitoring and evaluation. We suggest that frequency of patient contact could be reduced without negatively impacting patient outcomes and that season should be taken into account in analysing programme performance.

Factors associated with medication adherence among people with diabetes mellitus in poor urban areas of Cambodia: A cross-sectional study

Background

In Cambodia, the age-standardized prevalence of diabetes mellitus has increased in both men and women. The main objective of this study was to identify factors associated with diabetes medication adherence among people with diabetes mellitus in poor urban areas of Phnom Penh, Cambodia.

Methods

A cross-sectional study was conducted in 2017 using a structured questionnaire for face-to-face interviews by trained interviewers. The participants were people with diabetes mellitus who were the active members of a peer educator network, lived in poor urban areas of Phnom Penh, and attended weekly educational sessions during the survey period. Diabetes medication adherence was measured using four items of modified Morisky Medication Adherence Scale. Participants were classified into two groups based on their adherence score: 0 (high adherence) and from 1 to 4 (medium or low adherence). Sociodemographic characteristics; medical history; accessibility to health services; and knowledge, attitude, and practices related to diabetes mellitus were examined. A multiple logistic regression analysis was conducted adjusting for sex, age, marital status, and education levels.

Results

Data from 773 people with diabetes were included in the analyses. Of the total, 49.3% had a high level of diabetes medication adherence. A high level of adherence was associated with higher family income (≥50 USD per month) (adjusted odds ratio [AOR] = 5.00, 95% confidence interval [CI] = 2.25–11.08), absence of diabetes mellitus-related complications (AOR = 1.66, 95% CI = 1.19–2.32), use of health services more than once per month (AOR = 2.87, 95% CI = 1.64–5.04), following special diet for diabetes mellitus (AOR = 1.81, 95% CI = 1.17–2.81), and absence of alcohol consumption (AOR = 13.67, 95% CI = 2.86–65.34).

Conclusions

High diabetes medication adherence was associated with better family economic conditions, absence of diabetes mellitus-related complications, and healthy behaviors. It would be crucial to improve affordable access to regular follow-ups including promotion of healthy behaviors through health education and control of diabetes mellitus-related complications.

Treating Syrian refugees with diabetes and hypertension in Shatila refugee camp, Lebanon: Médecins Sans Frontières model of care and treatment outcomes

Background

Médecins Sans Frontières (MSF) has been providing primary care for non-communicable diseases (NCDs), which have been increasing in low to middle-income countries, in the Shatila refugee camp, Beirut, Lebanon, using a comprehensive model of care to respond to the unmet needs of Syrian refugees. The objectives of this study were to: 1) describe the model of care used and the Syrian refugee population affected by diabetes mellitus (DM) and/or hypertension (HTN) who had ≥ one visit in the MSF NCD clinic in Shatila in 2017, and 2) assess 6 month treatment outcomes.

Methods

A descriptive retrospective cohort study using routinely collected program data for a model of care for patients with DM and HTN consisting of four main components: case management, patient support and education counseling, integrated mental health, and health promotion.

Results

Of 2644 Syrian patients with DM and/or HTN, 8% had Type-1 DM, 30% had Type-2 DM, 30% had HTN and 33% had DM + HTN. At intake, patients had a median age of 53, were predominantly females (63%), mostly from outside the catchment area (70%) and diagnosed (97%) prior to enrollment. After 6 months of care compared to intake: 61% of all patients had controlled DM (HbA1C < 8%) and 50% had controlled blood pressure (BP: < 140/90 mmHg) compared to 29 and 32%, respectively (p < 0.001). Compared to intake, patients with Type-1 DM reached an HbA1C mean of 8.4% versus 9.3% (p = 0.022); Type-2 DM patients had an HbA1C mean of 8.1% versus 9.4% (p = 0.001); and those with DM + HTN reached a mean HbA1C of 7.7% versus 9.0%, (p = 0.003). Reflecting improved control, HTN patients requiring ≥3 medications increased from 23 to 38% (p < 0.001), while DM patients requiring insulin increased from 21 to 29% (p < 0.001). Loss-to-follow-up was 16%.

Conclusions

The MSF model of care for DM and HTN operating in the Shatila refugee camp is feasible, and showed promising outcomes among enrolled individuals. It may be replicated in similar contexts to respond to the increasing burden of NCDs among refugees in the Middle-East and elsewhere.

A Review of Hypertension and Diabetes Protocols for Medical Service Trips (MSTs) in Latin America and the Caribbean

BACKGROUND

Hypertension and diabetes are among the most common chronic conditions that may be managed on short-term, primary care medical service trips (MSTs) in Latin America and the Caribbean (LAC), but the quality of patient care delivered remains unclear.

OBJECTIVE

This study summarizes protocols that Western volunteer clinicians use in managing these patients, and highlights their commonalities, differences, and potential limitations.

METHODS

A systematic web search was used to identify organizations operating MSTs in LAC. Organizations were contacted by email or through their websites to obtain clinical protocols intended for use on their brigades. These protocols were qualitatively analyzed, and recommendations were categorized into clinical assessment, non-pharmacologic recommendations, and pharmacologic recommendations.

FINDINGS

Two hundred twenty-five organizations were identified and contacted, and protocols were obtained for 20 of these. Eleven (55%) of these protocols discussed hypertension, and 10 (50%) discussed diabetes. Only one protocol provided any literature support for its recommendations.

CONCLUSIONS

The analyzed protocols may give insight into context-specific realities of practice on MSTs, but they often neglected key aspects of clinical management that are emphasized in international guidelines. This study is an initial step in clinical guidelines development for MSTs operating in LAC.

A Review of Hypertension and Diabetes Protocols for Medical Service Trips (MSTs) in Latin America and the Caribbean

Background:

Hypertension and diabetes are among the most common chronic conditions that may be managed on short-term, primary care medical service trips (MSTs) in Latin America and the Caribbean (LAC), but the quality of patient care delivered remains unclear.

Objective:

This study summarizes protocols that Western volunteer clinicians use in managing these patients, and highlights their commonalities, differences, and potential limitations.

Methods:

A systematic web search was used to identify organizations operating MSTs in LAC. Organizations were contacted by email or through their websites to obtain clinical protocols intended for use on their brigades. These protocols were qualitatively analyzed, and recommendations were categorized into clinical assessment, non-pharmacologic recommendations, and pharmacologic recommendations.

Findings:

Two hundred twenty-five organizations were identified and contacted, and protocols were obtained for 20 of these. Eleven (55%) of these protocols discussed hypertension, and 10 (50%) discussed diabetes. Only one protocol provided any literature support for its recommendations.

Conclusions:

The analyzed protocols may give insight into context-specific realities of practice on MSTs, but they often neglected key aspects of clinical management that are emphasized in international guidelines. This study is an initial step in clinical guidelines development for MSTs operating in LAC.

Global Corner Spotlight: Perspectives on Diabetes Care in Cambodia as Seen Through an Ngo-Run Healthcare System

ABBREVIATIONS

CMC = Community Medical Center; SGLT2 = sodium-glucose cotransporter 2; SHCH = Sihanouk Hospital Center of Hope.

Evaluation of a multi-faceted diabetes care program including community-based peer educators in Takeo province, Cambodia, 2007-2013

INTRODUCTION

Early detection and treatment for diabetes are essential for reducing disability and death from the disease. Finding effective screening and treatment for individuals living with diabetes in resource-limited countries is a challenge. MoPoTsyo, a Cambodian non-governmental organization, addressed this gap by utilizing a multi-pronged approach with community-based peer educators, access to laboratory procedures, local outpatient medical consultation, and a revolving drug fund. This study evaluated outcomes of MoPoTsyo's diabetes program in Takeo Province by assessing glycemic and blood pressure outcomes for individuals diagnosed with diabetes over a 24-month follow-up period between 2007-2013.

METHODS

This is a retrospective cohort analysis of records without a comparison group. We calculated the mean fasting blood glucose (FBG) and blood pressure (BP) at regular intervals of follow-up. The proportion of patients reaching recommended treatment targets for FBG and BP was assessed.

RESULTS

Of the 3411 patients enrolled in the program, 2230 were included in the study. The cohort was predominantly female (68.9%) with a median age of 54 years. Median follow-up time in the program was 16 months (4.9-38.4 months). Mean FBG decreased 63.9 mg/dl in mean FBG (95% CI 58.5 to 69.3) at one year of follow-up (p<0.001). After one year, 45% (321/708) of patients achieved goal FBG < 126. Of the 41.6% (927/2230) with elevated BP at enrollment, systolic and diastolic BP levels significantly decreased (p<0.001) by 16.9 mmHg (95% CI 1.2 to 22.9) and 10 mm Hg (95% CI 0.7 to 12.9) respectively between enrollment and one year of follow-up. At one year of follow-up, 51.1%% (183/355) of these patients reached the BP goal < 140/90.

CONCLUSION

The improved outcome indicators of diabetes care for MoPoTsyo's Takeo program evaluation showed promise. The program demonstrated a reasonable and practical approach to delivering effective diabetes care in a rural area and may serve as a model for other low-income communities. Future prospective evaluations with more complete data are necessary for longer-term outcomes.

Limited understanding, limited services, limited resources: patients' experiences with managing hypertension and diabetes in Cambodia

INTRODUCTION

Health system responses to the emergence of non-communicable diseases (NCDs) in many Southeast Asian nations, Cambodia included, have been insufficient. Little is known about how people suffering from such conditions behave in constrained contexts. We examined the experience of patients with NCDs as they seek care for their conditions and manage them.

METHODS

In-depth interviews with 28 purposively selected patients with hypertension and/or diabetes using an interview guide to capture the trajectory followed by interviewees from the development and recognition of symptoms to adherence to treatment. A general outline of major topics to be discussed was used instead of a predetermined list of specific questions.

RESULTS

All interviewees had experienced symptoms for a substantial period of time, sometimes many years, before being diagnosed. Initial treatment focused on symptoms instead of underlying conditions, often at considerable financial cost. Following diagnosis, many struggled to take medicines daily for their condition and adhering to the required behaviour changes. Many resorted to complementary medicine. Lack of financial resources was a common reason to discontinue treatment. Many reported loss of income and assets such as livestock and productive land and increasingly relied on others.

CONCLUSION

In order to assist people with NCDs in Cambodia, there is a need for a multipronged approach focusing on communities and healthcare providers. Information campaigns could focus on the timely recognition by communities of symptoms indicative of the conditions, together with instigating demand for routine screening at qualified health providers. Peer support is considerable, and locally adjusted approaches based on this principle should be considered.

A mixed-methods needs assessment of adult diabetes mellitus (type II) and hypertension care in Toledo, Belize

BACKGROUND

Non-communicable diseases, including diabetes mellitus and hypertension, continue to disproportionately burden low- and middle-income countries. However, little research has been done to establish current practices and management of chronic disease in these settings. The objective of this study was to examine current clinical management and identify potential gaps in care of patients with diabetes mellitus and hypertension in the district of Toledo, Belize.

METHODS

The study used a mixed methodology to assess current practices and identify gaps in diabetes mellitus and hypertension care. One hundred and twenty charts of the general clinic population were reviewed to establish disease epidemiology. One hundred and seventy-eight diabetic and hypertensive charts were reviewed to assess current practices. Twenty providers completed questionnaires regarding diabetes mellitus and hypertension management. Twenty-five individuals with diabetes mellitus and/or hypertension answered a questionnaire and in-depth interview.

RESULTS

The prevalence of diabetes mellitus and hypertension was 12%. Approximately 51% (n = 43) of patients with hypertension were at blood pressure goal and 26% (n = 21) diabetic patients were at glycemic goal based on current guidelines. Of the patients with uncontrolled diabetes, 49% (n = 29) were on two oral agents and only 10% (n = 6) were on insulin. Providers stated that barriers to appropriate management include concerns prescribing insulin and patient health literacy. Patients demonstrated a general understanding of the concept of chronic illness, however lacked specific knowledge regarding disease processes and self-management strategies.

CONCLUSIONS

This study provides an initial overview of diabetes mellitus and hypertension management in a diverse patient population in rural Belize. Results indicate areas for future investigation and possible intervention, including barriers to insulin use and opportunities for lifestyle-specific disease education for patients.

Is adjunctive naturopathy associated with improved glycaemic control and a reduction in need for medications among type 2 Diabetes patients? A prospective cohort study from India

BACKGROUND

With an estimated 65 million Diabetes Mellitus (DM) patients, India ranks second in the world in terms of DM burden. The emphasis of current medical practice has been on pharmacotherapy but, despite the best combination therapies, acheiving glycaemic control (reduction of blood sugar to desirable levels) is a challenge. 'Integrated Naturopathy and Yoga'(INY) is an alternative system of medicine that lays emphasis on the role of diet and physical exercise. We assessed the short term effect of INY as an adjunct to pharmacotherapy on glycaemic control among type 2 DM patients.

METHODS

In this prospective cohort study with a 3 month follow-up, DM patients consecutively admitted to a hospital in India from May-October 2014 for either 15 or 30 days were offered INY - a package of vegetarian diet with no added oil, sugar and salt, yoga-based exercise, patient counselling and rest. A 'favourable outcome' was defined as glycaemic control (glycosylated hemoglobin (HbA1c) < 7 % or absolute reduction by 1 %) along with at least 50 % reduction in antidiabetes medication at 3 months relative to baseline. Compliance to diet was scored by self-report on a scale of 0-10 and categorized into poor (0-5), moderate (6-8) and excellent (9-10).

RESULTS

Of 101 patients with 3-month follow-up data, 65(65 %) achieved a favourable outcome - with 19(19 %) stopping medication while sustaining glycemic control. Factors associated with favourable outcome were baseline HbA1c and compliance to diet, which showed a significant linear relationship with mean HbA1c reductions of 0.4 %, 1.1 % and 1.7 % in relation to poor, moderate and excellent dietary compliance respectively.

CONCLUSION

INY, adjunctive to pharmacotherapy, was associated with a significant beneficial effect on glycaemic control and reduced the overall need for antidiabetes medications. These early results are promising. Further studies with long-term follow-up and using more rigorous randomized controlled trial designs are needed.

Managing non-communicable diseases at health district level in Cambodia: a systems analysis and suggestions for improvement

Background

Cambodia developed its public health system along the principles of the district model and geared its services towards managing communicable diseases and maternal and child health issues. In line with other countries in the region, non-communicable diseases have emerged as a leading cause of adult mortality. We assessed the current capacity of the Cambodian district health system to manage hypertension and diabetes, with a focus on access to medicine for these chronic conditions.

Methods

A case study whereby in three purposely selected districts in an equal number of provinces a total of 74 informants were interviewed: 27 health care providers and administrators, 30 community representatives and 17 managers of specific non-communicable diseases interventions and social health protection schemes. Questions related to the World Health Organization’s health system building blocks. Data analysis involved coding, indexing, charting and mapping the data. Following these exercises all information was analysed by kind of respondent and their respective answer to the question concerned. Responses by respondents of three groups of interviewees were compared when appropriate. At 14 health centres and 3 district hospitals the availability of key medicines for hypertension and diabetes in accordance with the National Essential Drug List was assessed. This was also done for essential tools and equipment to diagnose these two conditions.

Results

Although there was agreement amongst nearly all interviewees that non-communicable diseases were prevalent, the district health system, including all health systems building blocks and the referral system, was inadequately developed to effectively deal with these conditions. Medicines supply was erratic and the quantity provided allowed for few patients to be treated, for a short period only, mainly at secondary or tertiary level.

Conclusions

Because of the public health, social and economic importance of non-communicable diseases, a rapid response is required. Given the current Cambodian situation, such response may initially be a diagonal approach, with non-communicable diseases services integrated in the National HIV/AIDS Programme. This should happen together with a reorientation of the health system to enable a horizontal approach to non-communicable diseases management in the long term.

Access to Treatment for Diabetes and Hypertension in Rural Cambodia: Performance of Existing Social Health Protection Schemes

Background

Non-communicable diseases (NCD) pose challenges to Cambodia’s health system. Medicines for NCD are on the National Essential Medicines List but no clinical guidelines support their utilization. Two social health protection schemes aimed at the informal sector population exist (Health Equity Funds and Insurance) together with two disease-specific interventions (a Peer Educator Network and Chronic Diseases Clinics) targeted at NCD patients. This study examines performance of these various schemes in relation to NCD.

Methods

Cross-sectional household survey among 709 individuals self-reporting diabetes and/or hypertension in three geographical locations in rural Cambodia using a structured questionnaire investigating diagnostic and treatment pathways, health seeking behaviour, health expenditures, and financial coping mechanisms.

Results

Two third of respondents with NCD were female and 55% did not belong to any scheme. The majority (59%) were diagnosed in the private sector and only 56% were on allopathic treatment that was mainly sought in the private sector (49%). Outpatient treatment cost was higher in the private sector and when using multiple providers of care. The majority were indebted, 11% due to health-related expenses. Contrary to social health protection schemes, disease-specific interventions offered better access to allopathic treatment and provided medicines in accordance with NEML.

Conclusion

The benefit packages of existing social health protection schemes and services in the public health sector should be adjusted to cater for the needs of people living with NCD in rural Cambodia. Initiatives that offer active disease management strategies and promote patients and community participation appear more successful in increasing treatment adherence and decreasing the risk of financial hardship.

Patient-centred innovation to ensure access to diabetes care in Cambodia: the case of MoPoTsyo

BACKGROUND

The increasing prevalence of chronic diseases puts a high burden on the health care systems of Low and Middle Income Countries which are often not adapted to provide the care needed. Peer support programmes are promoted to address health system constraints. This case study analyses a peer educator diabetes programme in Cambodia, MoPoTsyo, from a health system's perspective. Which strategies were used and how did these strategies change? How is the programme perceived?

METHODS

Data were collected through semi-structured interviews with patients, MoPoTsyo staff and peer educators, contracted pharmacy staff and health workers, health care workers and non-contracted pharmacists and managers and policy makers at district, provincial and national level. Four areas were purposively selected to do the interviews. An inductive content analysis was done independently by two researchers.

RESULTS

MoPoTsyo developed into three stages: a focus on diabetes self-management; a widening scope to ensure affordable medicines and access to other health care services; and aiming for sustainability through more integration with the Cambodian public system and further upscaling. All respondents acknowledged the peer educators' role and competence in patient education, but their ideas about additional tasks and their place in the system differed. Indirectly involved stakeholders and district managers emphasized the particular roles and responsibilities of all actors in the system and the particular role of the peer educator in the community. MoPoTsyo's diagnostics and laboratory services were perceived as useful, especially by patients and project staff. Respondents were positive about the revolving drug fund, but expressed concerns about its integration into the government system. The degree of collaboration between health care staff and peer educators varied.

CONCLUSION

MoPoTsyo responds to the needs of people with diabetes in Cambodia. Key success factors were: consistent focus on and involvement of the target group, backed up by a strong organisation; simultaneous reduction of other barriers to care; and the ongoing maintenance of relations at all levels within the health system. Despite resistance, MoPoTsyo has established a more balanced relationship between patients and health service providers, empowering patients to self-manage and access services that meet their needs.

A first country-wide review of Diabetes Mellitus care in Bhutan: time to do better

Background

There is an increasing trend of non-communicable diseases in Bhutan including Diabetes Mellitus (DM). To address this problem, a National Diabetes Control Programme was launched in 1996. There is anecdotal evidence that many patients do not visit the DM clinics regularly, but owing to lack of cohort monitoring, the magnitude of such attrition from care is unknown. Knowledge of the extent of this problem will provide a realistic assessment of the situation on the ground and would be helpful to initiate corrective actions. In this first country-wide audit, we thus aimed to determine among type 2 DM patients registered for care the i) pre-treatment attrition ii) one-year programme outcomes including retention in care, died and Lost–to-follow-up (LTFU, defined as not having visited the clinic at least once within a year of registration) iii) factors associated with attrition from care (death + LTFU) and iv) quality of follow-up care, measured by adherence to recommended patient-monitoring protocols including glycaemic control.

Methods

A retrospective cohort study involving a review of records routinely maintained under the National Diabetes Control Programme. All type 2 DM patients registered between 1st January and 31st December 2012 in 18 district hospitals of Bhutan were included. Glycaemic control was defined as glycosylated haemoglobin of <7 % or [Fasting Blood Sugar of <130 mg/dl and, Post-prandial Blood Sugar of <180 mg/dl].

Results

Of 350 registered DM patients (52 % female, median age 55 years), 63(18 %) were LTFU before treatment initiation (pre-treatment attrition). Of the remaining 287 individuals who started treatment, 226(79 %) were retained in care while 61(21 %) either died or were LTFU. Glycaemic control was achieved in 85(38 %) patients retained in care. Between 7 and 98 % of monitoring parameters had missing data.

Conclusion

Nearly one-third of DM patients were LTFU and there were short comings in monitoring. Qualitative research is urgently needed to find out the reasons for high attrition. Given the high political commitment by the Royal Government of Bhutan, the findings provide ample grounds for instituting corrective measures and propelling DM care further. It is time to do better!

Content, participants and outcomes of three diabetes care programmes in three low and middle income countries

AIMS

To improve access and quality of diabetes care for people in low-income countries, it is important to understand which elements of diabetes care are effective. This paper analyses three diabetes care programmes in the DR Congo, Cambodia and the Philippines.

METHODS

Three programmes offering diabetes care and self-management were selected. Programme information was collected through document review and interviews. Data about participants' characteristics, health outcomes, care utilisation, expenditures, care perception and self-management were extracted from a study database. Comparative univariate analyses were performed.

RESULTS

Kin-réseau (DR Congo) is an urban primary care network with 8000 patients. MoPoTsyo (Cambodia) is a community-based peer educator network, covering 7000 patients. FiLDCare (Philippines) is a programme in which 1000 patients receive care in a health facility and self-management support from a community health worker. Content of care of the programmes is comparable, the focus on self-management largest in MoPoTsyo. On average, Kin-réseau patients have a higher age, longer diabetes history and more overweight. MoPoTsyo includes most female, most illiterate and most lean patients. Health outcomes (HbA1C level, systolic blood pressure, diabetes foot lesions) were most favourable for MoPoTsyo patients. Diabetes-related health care expenditure was highest for FiLDCare patients.

CONCLUSIONS

This study shows it possible to maintain a diabetes programme with minimal external resources, offering care and self-management support. It also illustrates that health outcomes of persons with diabetes are determined by their bio-psycho-social characteristics and behaviour, which are each subject to the content of care and the approach to chronic illness and self-management of the programme, in turn influenced by the larger context.

Poor thiamin and riboflavin status is common among women of childbearing age in rural and urban Cambodia

BACKGROUND

Thiamin deficiency in infancy is the underlying cause of beriberi, which can be fatal without rapid treatment. Reports of thiamin deficiency are common in Cambodia; however, population representative data are unavailable. Because B-complex vitamin deficiencies commonly occur in combination, riboflavin was also investigated.

OBJECTIVE

We determined the biomarker status of thiamin and riboflavin in women of childbearing age in rural and urban Cambodia.

METHODS

We measured thiamin (erythrocyte thiamin diphosphate; TDP) and riboflavin (erythrocyte glutathione reductase activity coefficient; EGRac) status in a representative sample of Cambodian women (aged 20-45 y) in urban Phnom Penh (n = 146) and rural Prey Veng (n = 156), Cambodia, and, for comparison purposes, in a convenience sample of women in urban Vancouver, British Columbia, Canada (n = 49).

RESULTS

Thiamin insufficiency (TDP ≤ 90 nmol/L) was common among both urban (39%) and rural (59%) Cambodian women (P < 0.001), whereas <20% of Vancouver women were thiamin insufficient (P < 0.001). The prevalence of suboptimal and deficient riboflavin status (EGRac ≥ 1.3) was 89%, 92%, and 70% among women in Phnom Penh, Prey Veng, and Vancouver, respectively (P < 0.001).

CONCLUSIONS

Suboptimal status of both thiamin and riboflavin were common in Cambodian women, with substantially higher rates among women living in rural Prey Veng than in urban Phnom Penh. Strategies may be needed to improve the thiamin and riboflavin status of women in Cambodia. The unexpected finding of high riboflavin inadequacy status in Vancouver women warrants further investigation.

Innovations in research ethics governance in humanitarian settings

BACKGROUND

Médecins Sans Frontières (MSF) is one of the world's leading humanitarian medical organizations. The increased emphasis in MSF on research led to the creation of an ethics review board (ERB) in 2001. The ERB has encouraged innovation in the review of proposals and the interaction between the ERB and the organization. This has led to some of the advances in ethics governance described in this paper.

DISCUSSION

We first update our previous work from 2009 describing ERB performance and then highlight five innovative practices: • A new framework to guide ethics review • The introduction of a policy exempting a posteriori analysis of routinely collected data • The preapproval of "emergency" protocols • General ethical approval of "routine surveys" • Evaluating the impact of approved studies. The new framework encourages a conversation about ethical issues, rather than imposing quasi-legalistic rules, is more engaged with the specific MSF research context and gives greater prominence to certain values and principles. Some of the innovations implemented by the ERB, such as review exemption or approval of generic protocols, may run counter to many standard operating procedures. We argue that much standard practice in research ethics review ought to be open to challenge and revision. Continued interaction between MSF researchers and independent ERB members has allowed for progressive innovations based on a trustful and respectful partnership between the ERB and the researchers. In the future, three areas merit particular attention. First, the impact of the new framework should be assessed. Second, the impact of research needs to be defined more precisely as a first step towards being meaningfully assessed, including changes of impact over time. Finally, the dialogue between the MSF ERB and the ethics committees in the study countries should be enhanced.

SUMMARY

We hope that the innovations in research ethics governance described may be relevant for other organisations carrying out research in fragile contexts and for ethics committees reviewing such research.

Caseload, management and treatment outcomes of patients with hypertension and/or diabetes mellitus in a primary health care programme in an informal setting

OBJECTIVE

In three primary health care clinics run by Médecins Sans Frontières in the informal settlement of Kibera, Nairobi, Kenya, we describe the caseload, management and treatment outcomes of patients with hypertension (HT) and/or diabetes mellitus (DM) receiving care from January 2010 to June 2012.

METHOD

Descriptive study using prospectively collected routine programme data.

RESULTS

Overall, 1465 patients were registered in three clinics during the study period, of whom 87% were hypertensive only and 13% had DM with or without HT. Patients were predominantly female (71%) and the median age was 48 years. On admission, 24% of the patients were obese, with a body mass index (BMI) > 30 kg/m2. Overall, 55% of non-diabetic hypertensive patients reached their blood pressure (BP) target at 24 months. Only 28% of diabetic patients reached their BP target at 24 months. For non-diabetic patients, there was a significant decrease in BP between first consultation and 3 months of treatment, maintained over the 18-month period. Only 20% of diabetic patients with or without hypertension achieved glycaemic control. By the end of the study period,1003 (68%) patients were alive and in care, one (<1%) had died, eight (0.5%) had transferred out and 453 (31%) were lost to follow-up.

CONCLUSION

Good management of HT and DM can be achieved in a primary care setting within an informal settlement. This model of intervention appears feasible to address the growing burden of non-communicable diseases in developing countries.

The glycemic status of diabetes in an urban area of Cambodia

Recently the Korea Diabetes Association participated in the 'Cambodia-Korea Twinning Project' to help Cambodia establish its own modernized diabetes center and to raise awareness of the seriousness of diabetes. Here we report the status of diabetes in an urban area of Cambodia as obtained through this project.

Participative decentralization of diabetes care in Davao City (Philippines) according to the Chronic Care Model: a program evaluation

AIM

To assess the effectiveness of the Diabetes Project in Davao City, Philippines, regarding diabetes care access, diabetes management and cardiovascular risk factors. The project was developed in accordance with the Chronic Care Model (CCM) framework.

METHODS

A non-randomized cross-sectional survey was conducted in nine intervention and five control Barangays (villages). People with diabetes aged ≥20 years were interviewed using a structured questionnaire; height, weight, waist circumference, and blood pressure were measured; HbA1c was tested with a NSGP-certified point-of-care device. Logistic regression models were used to compare the two groups.

RESULTS

The intervention group (n=503) scored better than the controls (n=136) on the following (OR, 95% CI): percentage of patients taking metformin (1.5, 1.0-2.2); and in the last 12 months: laboratory test for fasting blood sugar (1.6, 1.1-2.3), HbA1c (6.0, 2.4-15.1), lipid profile (1.7, 1.1-2.5), nutritionist visit (1.6, 1.0-2.5) and therapeutic education session (2.7, 1.8-4.0). Glycemic control (HbA1c<7%) was also better in the intervention Barangays (1.6, 1.0-2.4). There were no statistical differences between the two groups for number of visits, and levels of other cardiovascular risk factors.

CONCLUSIONS

Our findings support the effectiveness of implementing the CCM framework in a low-to-middle income country on glycemic control and diabetes management.

Burden of Stroke in Cambodia

In Cambodia, stroke is not ranked among the top 10 leading causes of death, but infectious disease are among the top three leading causes of death. This finding could be attributed to a lack of awareness among Cambodians of the signs and symptoms of stroke or to poor reporting, incomplete data, lack of neurologists and neurosurgeons, or low accessibility to the hospitals. The only study of stroke in Cambodia is the Prevalence of Non-Communicable Disease Risk Factors in Cambodia survey, which identified several stroke-related risk factors in the population. Tobacco chewing or smoking is the main risk factor for stroke in Cambodia. Traditional therapies, such as oyt pleung (moxibustion) and jup (cupping), are widely practiced for stroke rehabilitation. In Cambodia, there are few neurologists and few important equipment, such as magnetic resonance imaging machines and computed tomography scanners. The Cambodian government should cooperate with the World Health Organization and the United Nations Children's Fund to attract foreign expertise and technologies to treat stroke patients.

Treatment of hypertension in rural Cambodia: results from a 6-year programme

This study was aimed to describe the outcomes of a hypertension treatment programme in two outpatient clinics in Cambodia. We determined proportions of patients who met the optimal targets for blood pressure (BP) control and assessed the evolution of mean systolic and diastolic BP (SBP/DBP) over time. Multivariate analyses were used to identify predictors of BP decrease and risk factors for LTFU. A total of 2858 patients were enrolled between March 2002 and June 2008 of whom 69.2% were female, 30.5% were aged ≥64 years and 32.6% were diabetic. The median follow-up time was 600 days. By the end of 2008, 1642 (57.4%) were alive-in-care, 8 (0.3%) had died and 1208 (42.3%) were lost to follow-up. On admission, mean SBP and DBP were 162 and 94 mm Hg, respectively. Among the patients treated, a significant SBP reduction of 26.8 mm Hg (95% CI: 28.4-25.3) was observed at 6 months. Overall, 36.5% of patients reached the BP targets at 24 months. The number of young adults, non-overweight patients and non-diabetics reaching the BP targets was more. Older age (>64 years), uncontrolled DBP (≥90 mm Hg) on last consultation and coming late for the last consultation were associated with LTFU, whereas non-diabetic patients were 1.5 times more likely to default than diabetics (95% CI: 1.3-1.7). Although the definite magnitude of the BP decrease due to antihypertension medication over time cannot be assessed definitely without a control group, our results suggest that BP reduction can be obtained with essential hypertension treatment in a large-scale programme in a resource-limited setting.