Lifestyle Interventions for Prevention, Early Diagnosis and Self-Management of Diabetes in Mumbai City

Partnership objectives

  • To educate community target groups (unorganised sector workers, public health workers and municipal school teachers)  on vital aspects pertaining to Diabetes through workplaces  interventions
  • To provide testing facilities for early diagnosis of diabetes for target groups
  • To provide counselling services and carry out sensitisation activities for self and family management of diabetes among the target groups 
  • To establish and sustain follow up for treatment compliance and support among the diabetic persons identified during the project
  • To cement city wide awareness campaign which increases level of awareness among the citizens for control and prevention of diabetes  

Diabetes is rapidly emerging as a major health-care problem in India Diabetes is rapidly emerging as a major health-care problem in India Copyright BMS

What are the health needs and challenges? 

Diabetes is rapidly emerging as a major health-care problem in India, especially in urban areas. Furthermore, there is an equally large pool of people with impaired glucose tolerance (IGT), many of whom will go on to develop Type 2 diabetes in the future. (A person has impaired glucose tolerance (IGT) when their blood glucose (sugar) levels are higher than normal, but below the level of a person with diabetes. Most people with IGT are at increased risk of developing Type 2 diabetes.)

India is in the midst of a diabetes epi­demic. Diabetes requires life-long treatment and impacts upon people's daily lives. It carries the risk of chronic complications.

These worrying figures of diabetes prevalence in India can only hint at the terrible burden of diabetes carried by adults affected by this condition in India. Millions of adults in India are leading their lives or are set to enter life afflicted by chronic and potentially life-threatening complications of diabetes.

Given the scenario of Diabetes in Urban India especially in Mumbai city and an impending health care disaster, this project aimed at the following target groups:

Working adults in Unorganized Sector Units in Mumbai slums:

The Indian Economy is characterized by the existence of a vast majority of informal or unorganized labour employment. It accounts for over 68% of labour employment in Mumbai (National Sample Survey Organization, 2010). Workers engaged in this urban informal sector form the bulk of the urban poor and they work in small and privately owned enterprises such as; leather work, weaving, artisans, saw mills, preparation of food items for wholesale, recycling units, rag pickers, handicraft artisans, handloom weavers etc. The labor laws and policies have minimal control over these types of industries. Such enterprises operate vastly in the slum communities of the city and employ the people from the nearby communities and other parts of city of Mumbai. These enterprises are characterized by lack of space, poor working conditions with minimal or no facilities for the welfare of the workers and numerous work related health hazards. As a result of irregular and stretched work hours, stress at work, in-sufficient and irregular sleep/ rest hours, irregular food intake, absence of balanced diet due to lack of knowledge as well as lack of resources, lack of easy access to health care services, etc. pose threat of various lifestyle diseases including Diabetes among the lives of these workers. 

Public Health Workers:

In order to ensure widespread awareness and education among the community members about Diabetes; it is crucial to integrate and coordinate medical, non-medical as well as policy efforts at the community level. Thus, the project engaged Integrated Child Development Scheme (ICDS) under the aegis of Women & Child Development Department, Government of Maharashtra, which has a cadre of health care workers (recruited from the local communities) termed as “Anganwadi Workers” for providing health education and nutritional services to the community members with special focus on maternal and child care. The ICDS has a very wide network for providing these health care services in the city of Mumbai. Given below is the structure of ICDS scheme in Mumbai city.  These volunteers operate largely in the congested slum communities to reach the health care services to the masses including health education, immunization, etc. These workers normally are from the slum communities itself and have in depth knowledge of the community needs and challenges. However; Anganwadi wokers are paramedics and have limited knowledge and skills to diagnose, detect and inform the community members on the chronic diseases such as diabetes. Hence there is need to train them as Diabetes Educators who can reach out to the community members who have limited access to formal health care systems. The project also works on providing testing services to the CHVs and provide support for self management of diabetes. 

Teachers of Municipal/ Public/ NGO Run School:

Diabetes is common chronic disease of childhood, affecting infants, toddlers, children and teens. According to the conclusions amassed by the Indian Chapter of World Health Organisation, prevalence of Type 1 Diabetes is 12% in the age group above 10- 20 years India. Most of these children go on to develop Type 2 Diabetes; which is alarming. Yet, most people are unaware of the signs and symptoms of diabetes in children, and as a result, the diagnosis is often delayed or missed altogether. Children and adolescents spend significant amount of their time in schools and the teachers have great amount of influence on their lives. Thus, it is essential that these school teachers are educated with the basic information about the Diabetes, its causes, symptoms and the treatment available. With this knowledge, the teachers shall be able to identify the diabetic symptoms among the children at an early stage and counsel the parents for availing medical treatment. The project targets to train the teachers from public i.e. municipal schools, or the schools run by Non Governmental Organizations (NGOs) which cater to the children from the underprivileged sections of society. Most of the children in these schools belong to economically poor, less educated families with lack of access to quality health services. Thus, the trained teachers serve as health educators for early detection and prevention of diabetes among the children thereby creating a more informed next generation. The project also provide testing services to the teachers and provide support for self management of diabetes.  

Description of partnership activities and how they address needs and challenges 

Project Component I: Activities for Testing, Early Diagnosis & Medical Referral Stakeholders:

This project component encompasses vital aspects such as sensitization activities, testing, diagnosis, medical referral etc. for Diabetes. UWM has carried out outreach activities with all three target groups of the communities i.e. Unorganised sector workers,  public health workers and municpal schoolteachers across the city of Mumbai.  Following project activities were carried out as part of outreach to these stakeholders. 

Method for two hours education session on critical aspects of Diabetes for the target community members:

  • Answering Pre- test and Post-test Forms: Pre-test and Post-test forms are answered by all community members. They answer these questions before and after the session. It is conducted to compare the knowledge of participants about diabetes before and after session. This process helps UWM to modify the flow and content of the awareness sessions and helps in evaluation of the effectiveness of the session. This also helps UWM in breaking myths related to Diabetes and in understanding effectiveness of the training conducted.
  • Documentary and Presentation: An easy to understand documentary in Hindi is shown to participants at the beginning to introduce the topic. After that UWM team discusses different aspects of Diabetes shown in documentary with the participants.
  • Blood Glucose Testing: After the session, random blood glucose level of participants is tested by Nucleus Lab - testing partner of UWM. Testing is done by use of Glucometer.

 

Based on this methadology following number of stakeholders were reached out for each of the traget groups:

Unorganised Sector workers

  • Total of 10502 workers have been educated with information on Diabetes and 10502 workers have been tested.
  • 675 Workers were found at risk of Diabetes and hence, they were further advised for detail investigation.
  • Post detailed investigations; 182 workers were confirmed as Diabetic.


Public Health Workers

  • 2055 public health workers have been educated with information on Diabetes through 44 trainings and 1993 have been tested.
  • A total of 89 publich health workers were found at risk of Diabetes during the testing camps. All these workers were referred to Municipal Health posts for further investigation and follow up.
  • Post detailed investigations, 3 were confirmed as Diabetic.
  • UWM is undertaking constant follow up with those confirmed as diabetic for undergoing treatment at the nearest municipal health posts or health facility.  Along with the referrals interventions for self and family management of Diabetes were also undertaken. 


Municipal School teachers

  • Total 2008 teachers have been trained as peer health educators and 1967 teachers tested for Diabetes.
  • 114 Teachers were found at risk for Diabetes and hence, they were further advised for detailed investigation.
  • Post detailed investigations, 38 teachers were confirmed as Diabetic.
  • UWM is following up with those confirmed as diabetic for undergoing treatment at the nearest municipal health posts or health facility.  Along with the referrals, interventions for self and family management of Diabetes were also undertaken.


Project Component II: Monitoring and Follow up of the Diabetic Patients:

All community memers who report high levels of blood glucose during the testing camps are immediately counselled by UWM by insisting on the need for detailed investigation, importance of a healthy lifestyle and healthy food habits. These persons were also counselled so as to prepare them psychologically to accept the fact that, they are at risk for Diabetes. Also they are referred to the nearest municipal dispensary where the treatment is available at free of cost. Family visits are being conducted to further sensitize and educate the patients as well as their family members for better management of diabetes.


Regular maintenance of records:

A robust mechanism of patient diagnosis, treatment and follow up has been adopted by UWM in order to ensure efficient outreach. For this following tools and processes have been adopted and followed rigorously for all the project activities.

These are as follows:

  • Attendance Sheet: Each awareness session starts with filling of the attendance sheets by participants. This help in keeping record of the participants attending the session and in follow up for other activities.
  • Pre-Test and Post-Test Form: A simple objective test is conducted with all the participants at the beginning of training and at the end of the training. This is mainly to capture the level of awareness about Diabetes and the impact of the training in increasing this awareness levels. The responses of all who participated in the test are collated, responses analysed and the awareness level of participants before and after the training is computed in percentage. Thus guiding UWM in modifying content of the awareness sessions to suit the requirements of the target community groups.
  • Patient card for people who found at risk of Diabetes: This card is to capture primary information of persons who are found at risk during the testing camps. It is used by UWM representatives for future references and follow up.
  • Reference card: It is meant for the persons who are found to at risk of Diabetes during the testing camps. The details of testing, random blood glucose levels found in test and address of the nearest municipal dispensary (for patient) are mentioned for further investigation on card. This card remains with patient as a reference note which can be used by UWM in future as well.
  • Patient follow-up Register: For all those who are diagnosed with high levels of blood glucose during the testing camps, they are shortlisted for further follow up by UWM team for ensuring that they undergo detailed investigations to determine their blood glucose level and further help them with guidance for self-management and family management. Patient follow-up register helps keep a track of the schedule for follow up calls and home visits, etc.
  • Information Handout: UWM has also developed pamphlets that give information about symptoms, causes, prevention and control of Diabetes Type II in easy to understand pictorial format. These handouts are to help the participants in Self-Management of the disease and also educate their acquaintances and community members.
  • Feedback form: Project has developed feedback form to get feedback and suggestions on the overall awareness session and testing camp organized by the team. Usually school principal, head of ICDS project site and owner of unorganized unit fills it. The form is meant to receive feedback for improvements in the methodology and the content of the sessions so as to be able to maintain and improve the quality of the awareness session over a period of time.      


Family Management of Diabetes

This intervention has proven to be successful for management of Diabetic patients through family support and care.  As part of this intervention periodic home visits are undertaken to follow up on treatment compliance and sensitisation of family members for management of diabetic person in the family.  These visits consist of one to one discussions with family members and sensitisation on diet plan for diabetic person in the family, easy and cost effective methods of preparing nutritious meals, psychosocial support the etc. 

Summary of impact and forward looking information

ICDS Aanganwadi Workers 

  • Project target – Targeted medical interventions and education: 2000
  • Actual completion: 2055


Municipal School Teachers 

  • Project target – Targeted medical interventions and education: 2000
  • Actual completion: 2008


Unorganised Workers Sector

  • Project target – Targeted medical interventions and education: 10000
  • Actual completion: 10502

 

It is pertinent to note that interventions for project target group of unorganised sector workers were undertaken at the workplace itself.  Being unorganised sector workplaces, these areas have limited space and challenges of noise, poor visibility due to inadequate lighting etc. Hence UWM could accommodate only 15-20 workers for the sessions at a time which meant increased efforts to be put in for each of the awareness session and testing activities. Moreover this being workplace interventions, UWM targeted early morning hours or late evenings to undertake these activities. This was done to ensure that the workers do not lose their hourly income during work time and could participate in the awareness session on wholeheartedly. Through such simple but effective strategies, UWM could overcome these challenges and have been able to manage the project outreach in the stipulated timeline. 


Diabetes Disease burden: 

Based on the analysis of the stakeholders, it was found that the high glucose level was 4% among the ICDS Aanganwadi workers, 6% among the municipal schools teachers and 7% among the unorganised sector workers.  This clearly validates the need for such interventions among these project stakeholders.

While implementing these interventions, UWM realised that there was no or very little awareness of this  disease among these stakeholders. Moreover there was clear dearth of public private interventions for advocacy on Diabetes among these project stakeholders. Hence it is imperative that such interventions are continued with long term engagement. This was a one of its kind of projects where UWM undertook interventions with unorganized sector workers, ICDS Aanganwadi workers and Municipal school teachers and could achieve significant impact.  

Especially with the unorganized sector workers, our experiences have been very revealing. Through the interventions we could break the myth (largely prevalent in India) that Diabetes affects only rich communities who have comfortable lifestyle.  Through this project with the unorganized sector workers, we could prove that people from underprivileged societies are just as at risk for diabetes. They work at enterprises which are characterized by lack of space, poor working conditions with minimal or no facilities for the welfare of the workers and numerous work related health hazards. As a result of irregular and stretched work hours, stress at work, in-sufficient and irregular sleep/ rest hours, irregular food intake, absence of balanced diet due to lack of knowledge as well as lack of resources, lack of easy access to health care services, etc. pose threat of various lifestyle diseases including Diabetes among the lives of these workers. These workers are generally ignorant about Diabetes or the ways to manage it or an understanding that they too are at risk for diabetes.

While implementing these interventions, UWM had a better understanding of the complete lack or very little awareness of this disease among these stakeholders. Moreover there is clear dearth of public private interventions for advocacy on Diabetes among these project stakeholders, and a necessity to scale up interventions with long term engagement. 

Measurement of progress towards objectives: 

Estimated overall value of partnership: USD $205,362 (INR  10,268,097) 

Estimated amount of people impacted: 

ICDS Aanganwadi Workers 

  • Direct Outreach: 2055
  • Indirect Outreach: 10000


Municipal School Teachers 

  • Direct Outreach: 2008
  • Indirect Outreach: 40000


Unorganised Workers Sector

  • Direct Outreach:10502
  • Indirect Outreach:50000
 

Partnership information

Company(ies) Bristol-Myers Squibb

Partner(s) Association of Vegetable Vendors, Dabbawalla (Tiffin Carriers) Association, Diabetes testing Partner- Nucleus Medical Centre, Education Department- Municipal Corporation of Greater Mumbai, India, Integrated Child Development Scheme, National Domestic Workers' Movement, Nirman, Stree Shakti Kendra, United Way of Mumbai, Western Railway Porters’ Association, Yuvak Pratishthan

Type of Partner(s) Academia / Hospitals, Government, NGOs

Therapeutic Focus Non-Communicable Diseases, Other, Women and Children's Health

Disease(s) Children's Health, Diabetes, General Health

Program Type(s) Health System Infrastructure - Outreach & Medical Services, Health System Infrastructure - Training, Prevention Programs - Awareness & Outreach

Region(s) South Asia

Number of Countries 1

Country(ies) India

Start Date 2013

Anticipated completion date 2017

« I came to know about my diabetes status after getting educated and tested through a camp by UWM. I am happy to learn that with healthy lifestyle and diet, I can manage this disease »

Mrs. Kalapana Pote, Project Beneficiary