Every year World Diabetes Day (WDD) is marked on November 14 globally. The first WDD was celebrated in 1991 by International Diabetes Federation (IDF) and World Health Organization (WHO) in response to growing concerns about the escalating health threat posed by diabetes. This year the theme of World Diabetes Day 2017 is “Women and diabetes - our right to a healthy future”.
This year’s campaign has aimed to promote the importance of affordable and equitable access for all women at risk for or living with diabetes to the essential diabetes medicines and technologies, self-management education and information they require to achieve optimal diabetes outcomes and strengthen their capacity to prevent type 2 diabetes.
Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. The most common is type 2 diabetes, usually in adults, which occurs when the body becomes resistant to insulin or doesn't make enough insulin. In the past three decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels. Type 1 diabetes, is a chronic condition in which the pancreas produces little or no insulin by itself. For people living with diabetes, access to affordable treatment, including insulin, is critical to their survival. There is a globally agreed target to halt the rise in diabetes and obesity by 2025.
Currently there are over 199 million women living with diabetes. It is projected to increase to 313 million by 2040. Diabetes is the ninth leading cause of death in women globally, causing 2.1 million deaths per year. Up to 70% of cases of type 2 diabetes could be prevented through the adoption of a healthy lifestyle.
In Nepal, obesity is found to be a cause of diabetes among 16.6 per cent female population and 13.6 per cent male as stated by World Health Organization. Likewise, dullness is identified to be another cause among 3.3 per cent population. Doctors have pointed that Nepal is at high risk of diabetes. According to the WHO, there is no exact data of patients with diabetes in Nepal. But, the 2016 Diabetes Profile has shown that 9.1 percent Nepali population are living with diabetes. It includes 10.5 percent men and 7.9 percent women.
With the increasing population and changing lifestyle, the burden of non-communicable diseases (NCDs) is very high especially in the urban areas. The basic treatment services for diabetes is now available in many places across the country but for major treatment, the patients have to come to the cities. The flow of the patients is also high at the central hospital. The treatment of these diseases require prolonged treatment and extra financial burden for families with low economic condition. The government has prioritized NCDs in the National Health Policy 2015 as well as National Health Sector Strategy 2015-2020, which also includes diabetes.
Non-Communicable Diseases (NCD) is one of the core areas of HERD International. We talked to two of our researchers about their experience of working on the issue.
Senior Qualitative Research Officer
Arjyal is leading the project entitled “Exploring what affects healthy lifestyle with type II diabetes patients in urban Kathmandu”.
What is your opinion regarding the level of awareness and seriousness among the people about diabetes?
As a part of the project, I had to interview few Type II diabetic patient between 25 to 50 years of age. Looking at that age group, it seems the awareness level is not that high. Perception regarding diabetes varied among different people. Some call it “sugar disease” and not everyone is aware about the cause. After suffering from the diabetes, they have tried changing their lifestyle. They still need a good level of information. They think they should not eat any sugary starch food at all which I think is not the case; they should eat balanced diet.
The way they diagnose diabetes is quite different. Some of them came to know that they have diabetes through urine. They said that, to check whether they have diabetes, they urinate on the ground and there were ants all around it (assuming that the ants came to the urinated place due to the sugar in the urine) and they learned that they have diabetes. The people have been adopting their own different ways. Some said they soak okra in the morning and have that. The people have different perceptions to decrease their diabetes.
When patients assume they have diabetes, they then go and conduct lab tests nearby. Then only they visit a doctor. In some cases the patient doesn’t even visit a doctor. The pharmacist looks at the level (sugar level in the blood) and informs them whether they are in the border line or are suffering from diabetes and gives medicines. Once the level of sugar level decreases, most of the diabetic patients mentioned not going for a follow up visit and diabetes check-up.
What is the acceptance level of food habit and physical activity by the community people?
We interviewed many men and women who lived in a family and they mentioned it is quite difficult for them to maintain a good food habit. Some prepare meal as suggested by doctor. But some don’t follow the suggested diet as it is tiring and takes a lot of time to prepare one type of food for the entire family and another for them. They think why compromise good food as they have to die someday.
Food habits also depends on who is suffering from diabetes, whether a male or a female. If both husband and wife are suffering from diabetes, then it is quite easy for both of them to manage their food habit. If the patient is male, the wife adapts the same diet but if the patient is female she has to cook a different kind of food for her husband which is very difficult. So, there is a difference in food habits of male and female.
Most of them are quite aware that they need to do some physical activity but they think that physical activity means walking, which should be only done during morning.
How difficult it is to go at the community level and address the issue of diabetes?
It is all about behaviour change. Changing something they have been doing for years is quite difficult for them. It takes time and a onetime intervention does not work. We need to motivate them to change their behaviour.
We need to identify how we can motivate them. Another challenging is to change their diet completely which I don’t think is the case. They feel they have to stop eating all sugary foods and they have to change their lifestyle completely. If they accept the change gradually. For example, if they have sugary starch food for one meal a day and try to control in other, it is okay. Then again we need to create awareness about what actually is a balanced diet for diabetes so that they feel it is doable.
Currently, people lack proper knowledge about controlling diabetes. When we say they have to change their behaviour they panic and take diabetes as a serious illness. It is important for them to understand that only if diabetes leads to serious problems only if it is not controlled. Diabetes itself is not a serious health problem if you control it and try and change your lifestyle.
When you talked to the patients, were they aware of what consequences occur if diabetes is not controlled?
Some of them were aware while some thought that when you have diabetes there is high chances that you will have other diseases which isn’t true. If you control diabetes, then you won’t have problems particularly eye problem or kidney failure or such. So, we need to aware them that when one suffers from diabetes, one won’t directly have eye problem or such; if diabetes is controlled, you can live a normal life. People take it as a serious problem as they believe their normal life will be completely changed if they have diabetes. So, awareness is the main thing that we need to do to change the behaviour and awareness cannot be done in a blanket approach. It needs to be contextualized because what we experienced was, there is a difference in male and female while looking at the cultural context of our country where females are the ones who are mostly engaged in cooking.
What do you think a health professionals can do to address the problem of diabetes and NCD as a whole?
I think awareness is the key to it but in addition to awareness, resources needs to be in place. When we suggest them to eat some food items we need to understand if it is available in the market. We also need to see if necessary health services are in place, is the health service affordable to all, can they come for a follow-up and also are people aware of the initial signs and symptoms of diabetes so that there is early diagnosis. All these things need to be taken into consideration. Nevertheless, I think the major factor for diabetes is lifestyle change for Type II diabetes. I think it is important to change the lifestyle; it does take time and quite an amount of effort to make people aware, understand and internalize.
Senior Research Officer
What is your observation about the level of awareness and seriousness among people about diabetes?
There is no any data or a survey as such done throughout the country but there was a step survey done by WHO and Ministry of Health (MoH) together in 2013 which is the only basis for NCD data. If we talk about the awareness of the general population, taking regards from the findings of the survey, one out of two (16-59 years of population) consume tobacco or tobacco products. The salt consumption rate is high among Nepalis. The WHO recommendation is 5 gram but our consumption is 11 gm. 50% of the 15-69 years of population have not taken any medication for diabetes. Roughly 90% of the same age group have not been tested with glucometer test i.e. blood sugar level test. 60% of total mortality contributes to NCD in Nepal. The awareness level is progressing slowly after certain programs being implemented in the country.
What is the level of awareness about diabetes?
They are quite aware about the signs and symptoms of diabetes. Various media and organizations have been advocating about diabetes in recent years and there has been focus on NCD including diabetes. So, in this regards, there has been slight change in the perception of people regarding such diseases.
What efforts has been made by the government in addressing or combating diabetes?
Recently, government has started a program Package of Essential Non-Communicable Disease (NCD PAIN package) which is run by MoH. In the past, the burden of communicable disease was high in Nepal, so the infrastructure, human resource was developed to focus on those disease Slowly, the pattern of disease has changed. Now Non-Communicable diseases are also in increasing trend and the government is not capacitated to deal with NCDs. Since, the trend of NCDs has rigorously increased from 2015, the programmes for NCDs have also started. One of the newly initiated programme NCD PAIN package. This programme itself is not new, but it is new to the health system because the government focuses on four Non-Communicable diseases i.e. cancer, COPD, cardio vascular disease and diabetes in the PAIN package.
There were treatments done for these four diseases in the health facility but now it has come forward in the form of a package and services are being provided. This program has been started in two districts since last fiscal year and was expanded to additional eight districts in the same year. And now, in this fiscal year, it is scaled upto twenty more districts and the government has aimed to gradually scale up the program in a phase wise approach throughout the country.
What kind of orientation or trainings has been given to the health workers or the community people regarding diabetes?
Under this PAIN package, the capacity of health workers needs to be built. So, in regards to that, government has been providing training to health workers. Along with that, they have also been conducting stakeholder’s meeting to raise awareness of the people. They have also been reaching to the Female Community Health Volunteers (FCHVs) and providing them orientation and disseminating awareness messages. The government has also been producing IEC materials like pamphlets, posters etc. National Health Education, Information and Communication Centre (NHEICC) has been producing radio jingles and TV programs to reach to wider audience and aware people about diabetes and NCD as a whole.
What is the project you are involved in doing to combat diabetes?
We have been organising health worker’s training. We are implementing this program in two districts viz. Nuwakot and Dhading. We first facilitate the health workers by providing them four days orientation and then we supply the logistics i.e. glucometer set and other recording/reporting forms and format. Apart from that, we also train school teachers. Throughout the project period, we will train roughly 400 school teacher about NCD. These teachers will then take classes regarding diabetes in their respective schools. We’ve been orienting media people in two districts and we will be orienting roughly 80 media personnel combined in both districts. They will be raising awareness, publishing case studies etc.
We are building capacity and strengthening the health system and making them deliver services. We are creating awareness among the people via media and school teachers. We plan to reach to the FCHVs and orienting them. We will also be doing stakeholder’s meeting and we have plenty of mass media campaigns. Recently we also placed a stall in Saptah (7 days long religious ceremony of Hindus), and did screening of diabetes and provided awareness. Similarly, we carried out screening of people during the period of prayers in church. These are few examples of the activities we have been doing.
Did community people, health workers or the media people readily accepted the orientation and training?
In context of the response of community people, it will be quite early to tell anything about how community perceives because we have been recently implementing the activities. The health workers and teachers have accepted the orientation very well and the school teachers were very happy to have an opportunity to learn about diabetes and taking classes to the school children. The media people were also very happy as they were first to be getting such orientation.
Is there any challenges?
At HERD International we do every activity in close co-ordination with the government. When our project was introduced during 2015, our target was to take one component i.e. diabetes and reach to four districts: Kathmandu, Kavrepalanchok, Nuwakot and Dhading. During that time, the NCD PAIN package was introduced in Nepal. So the government suggested to take all the four NCDs and reach out to district rather than taking one component. So, at that point of time, we had to change the modality of our project. We took all four components of NCDs and started implementing the program. On the first phase, we provided orientation to health workers of two district; Nuwakot and Dhading. We have a technical working group at the central level. After providing the first batch of training, there were concerns from the district as we were implementing project activities in certain health facilities of two districts. So, there was strong advice and recommendation from the district to carry out the activities throughout the district rather than certain health facilities. Thereafter, we changed the modality again and dropped two districts. Now, we are trying to implement the project throughout two districts; Nuwakot and Dhading. These were the modifications made during the project period and that is why the project implementation was delayed than what was initially planned. Apart from that, since Nepal is in a transition phase and is moving to federalism. Thus, there has been changes within the structure of the health system and health workers are employed within the rural and urban municipalities. So, we take this as challenge and these are the things which has caused delay in implementation of our project.
Contributors: Kritagya Regmi and Aanchal Parajuli