Mitigating the burden of type 2 diabetes in a low income setting in Nepal
Bishal Gyawali's PhD research proves that proper training of community health volunteers decreases the burden of type 2 diabetes in a low income population in Nepal.
The latest addition to the team here at University of Copenhagen's Global Health Section is Nepalese postdoc Bishal Gyawali. Born, raised and partly educated in Nepal, Bishal has focused most of his work and research on Nepalese health issues. For two years, he worked with health and rights of trafficked women in Nepal and his latest PhD research proves that proper training of community health volunteers mitigates the burden of type 2 diabetes in a low income population in Nepal. There are defiantly lessons to be learnt from this research and scalable models to be implemented in similar settings elsewhere in the world.
Text: Morten Mechlenborg Nørulf / Pictures: Bishal Gyawali
Improving sexual health and rights for Nepalese trafficked women
Before Bishal embarked on his international master and PhD education, he worked for two years as a coordinator for the Family Planning Association of Nepal (FPAN) – funded by the United Kingdom’s Department for International Development (DFID) – on a project about sexual and reproductive health and rights of Nepali women and girls who have returned to Nepal after being trafficked.
Trafficking in Nepal is a major issue. Every year between 5,000-12,000 girls and women are being trafficked, often to India or the Gulf Countries. Bishal worked in a district called Nuwakot – situated approximately 93 km north of the capital city, Kathmandu – where he was leading the project and supervising more than 70 members of staff:
“The place we worked was one of the most vulnerable when it comes to human trafficking. Women and girls are sold into Indian brothels by their family members, lured with the promise of work and a new life, and eventually forced to become prostitutes. Not only did we have to implement measures that could stop the trafficking but we also had to help women and girls who returned to Nepal after being trafficked."
Many girls manage to come back to Nepal, either because they escape, are helped by organisations like Maiti Nepal or because they are suffering from serious physical and mental health problems, unwanted pregnancies, sexual transmitted infection, such as HIV/AIDS and are in the need of treatment. FPAN handles the health care of these girls and women and make sure that they get integrated back into Nepalese society through different empowerment programmes, such as micro credit and cooperative organisational work.
The double burden of disease is increasing in Nepal
After finishing a master in public health in Denmark, Bishal turned his eye back on Nepal for his PhD. Communicable diseases are quickly developing in low income settings but the burden of non-communicable diseases (NCDs), such as type 2 diabetes, cancer and hypertension is also increasing in these settings.
This double burden of diseases puts pressure on the health care systems – also in Nepal. Treatment and management of NCDs has not been a part of the education and training of health care workers in many low income settings. There is a weak referral system, interrupted supply of essential drugs, poor quality of health services, geographic remoteness of health facilities, shortage of health workers as well as poor retention efforts, especially in rural areas of Nepal.
Nearly 25% of the Nepalese live below the poverty line. About 81% of Nepal's population live in rural areas and depend on subsistence farming for their livelihoods. In these areas, the majority have less than a dollar per day. So it goes without saying that this population have a hard time affording the often costly NCD treatment.
“Keeping this increasing double burden of diseases in mind, my interest was to explore accessible and affordable approaches for NCD management in primary care settings and develop an evidence- based solution from there. How could we develop a model to reduce the burden of NCDs in the general population in a resource-poor setting that is effective and feasible? One promising solution could be to involve the community health volunteers and Nepal was the obvious choice for the study, as both my supervisor, Associate Professor Per Kallestrup from the department of Public Health, Aarhus University, and I had work experience from there.”
Female community health volunteers in Nepal
Nepal has one of the weakest health care systems in the world. There is only 0.67 health professionals (doctors, nurses, midwifes) per 1000 inhabitants. The World Health Organization benchmark is 2.3 health professionals per 1000 inhabitants.
In the primary health care system, we find the female community health volunteers (FCHVs). The FCHV-system was implemented in 1988, and includes more than 50,000 FCHVs today. The FCHVs are local women aged 25 years or above who act as lay members of their communities. They have limited formal education and they serve voluntarily within the government system in all the villages of Nepal. FCHVs are selected by a so-called mothers’ group - a group of mothers that has been appointed by the government of Nepal for maternal and child health care services. They are an integral part of many community-based health programs and their roles are instrumental in linking families and communities to community health workers and primary health facilities.
The government introduced both genders in the FCHV programme in the beginning but it proved to be too difficult to include men in some health care services needed by female patients. FCHVs in Nepal were at that time not trained in managing NCDs so this was here the idea for Bishal’s evidenced based solution manifested itself:
“Why not include the treatment and prevention of NCDs, including type 2 diabetes in an already existing and functioning system - the community health volunteers? The smart thing about using them is that they are already familiar with the households in their community, and therefore it could be an effective way to implement NCD prevention programs. So we set out to assess the effectiveness of an FCHV-delivered intervention to reduce the burden of type 2 diabetes in a low-income population. Next step was to recruit, involve and train FCHVs in a selected semi-urban area 188 km from Kathmandu.”
Training community health volunteers in type 2 diabetes prevention and management
Bishal and his team decided to design a training programme for a selected group of FCHVs.
“The FCHVs had poor knowledge of diabetes when we started the training. So we gathered them in a local hospital for one week's intensive training on type 2 diabetes management. All training was in Nepali.”
Bishal and his colleagues designed the week as follows:
- Day 1: Theoretical aspects of diabetes
What is diabetes (types, risk factors, and signs and symptoms)? How prevalent diabetes is in Nepal and globally? - Day 2: Prevention and treatment information
What are the management aspects of type 2 diabetes? What are the available treatment strategies for type 2 diabetes? What is the role of community health volunteers in diabetes prevention and control? - Day 3: Measurement of blood glucose
FCHVs were taught to measure blood glucose level using a glucometer. This was the first time for them to use such tool, and they expressed a high level of interest in this. They were also taught to classify normal, pre-diabetic and diabetic conditions and referral procedures for those who have high blood glucose levels to the nearest health facility. After a demonstration they went on to practice on each other. They were trained to perform anthropometric measurements, such as measure blood pressure using digital monitor, measure height using stadiometer and measure weight using personal scales. - Day 4: Counselling and health promotion message on major risk factors
FCHVs were taught about various techniques to deliver health promotion counselling on diabetes management, such as how to inform patients and households about the diabetes risk factors and management activities, such as importance of physical activity, avoiding alcohol and smoking, having a healthy diet, and importance of regular use of medication as well as how to seek help from the health care system. - Day 5: Recording data and visiting households
Information on how to identify the houses selected for the study, how to conduct a visit, and how to fill out a data sheet on the history of the patients (medication, blood pressure, blood glucose, and if patients have been referred to the health care facility. On this day the FCHVs were also given their own personal bag with all the materials they needed for the assigned task, which consisted of glucometers, digital blood pressure monitors, lancets, weighing machines, measuring tapes, recording registers, writing materials etc).
A scalable solution for type 2 diabetes management elsewhere
As Bishal is putting the final touches on his PhD publication, it is evident from the findings of his research that they have come up with a model for type 2 diabetes management that could be scaled to other similar settings.
“Our intervention of training community health volunteers for diabetes prevention and management has shown to be effective and this approach could also be feasible to scale-up in countries with similar socio-economic features with a strong network of community health volunteers. Bishal is already talking to the health authorities in Nepal about upscaling this intervention to other parts of the country.
Bishal will be continuing his research focusing on community-based management of non-communicable disease in Tanzania and Nepal at Section of Global Health, University of Copenhagen. As a postdoc he will also be writing funding proposals, supervising master students and coordinating the course in Cardio-Metabolic Health and Disease.
