The India Micro-Clinic Project
A Poverty Alleviation & Diabetes
Prevention and Management Program
Principle Investigators
 
  • Nihal Thomas
        Professor,
        Department of Endocrinology, Diabetes and Metabolism,
        Christian Medical College Hospital,
        Vellore-632004, Tamil Nadu, India.
    •  
  • Solomon Chelliah
        Medical Superintendent, CSI Hospital,
        Gadag-Bettgeri, Dharwad District,
        Karnataka, India.
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  • Daniel Zoughbie
        Founder and Chief Executive Officer, The Global Micro-Clinic Project
        Project Officers: Leila Makarechi , Ashmi Ullal
    • Background of the Collaborating Institutions
     
    Christian Medical College, Vellore, India and the Department of Endocrinology, Diabetes and Metabolism
    Basel Mission Hospital, Gadag-Bettgeri, Dharwad District, Karnataka, India
             The Basel Mission Hospital at Gadag was established in the year 1902. It has 150 inpatient beds and has an outpatient attendance of 250 per day. It caters to a relatively impoverished belt of North Karnataka over a 100km radius and does a significant amount of charitable health care for the farming community in this area.
    The Global Micro-Clinic Project
             The Global Micro-Clinic Project (GMCP) is a non-profit organization that aims to develop a health care strategie and infrastructure for diabetes management and treatment to reduce poverty and increase economic growth. The GMCP forges powerful government, university and non-profit, partnerships which create multidisciplinary project teams that focus on, health promotion, poverty reduction and academic research with the aim of promoting global health, and reducing the impact of chronic disease in developing countries.
    Specific Goals/Outputs
             At least 500 diabetic and non-diabetic individuals will benefit from the initial educational outreach component of the project (lectures and workshops), and approximately, 200 diabetic or at-risk individuals will benefit from participation in the micro-clinic groups. Furthermore, 50 community volunteers will lead each micro-clinic and will also receive training. Other non-project participants, including friends and family, will benefit from information passed on from micro-clinic members themselves, who are often eager to share what they have learned. Finally, a specially trained team will be responsible for leading the pilot project. These institutions are committed to taking lead efforts to scale-up the Micro-Clinic Project to reach other parts of India.

    Metrics & Milestones
                The impact of the micro-clinic project will be measured in the short and long term, by collecting a set of baseline patient data and comparing it with data collected after the completion of the project. The following evaluative tools will be used:
      • Number of participants attending micro-clinic meetings, educational lectures, and social events.
    • Analysis of behavioural changes using questionnaires (e.g. exercise activity, change in diet, frequency of self-testing etc.)
    • Medical evaluation: change in haemoglobin A1C levels, blood pressure and weight
    • Measurable increase in empowerment using a variety of validated diabetes empowerment surveys
    • Improvement in knowledge of diabetes using validated diabetes knowledge tests
    • Changes in the long term diabetes-related costs in target catchment areas, including number of visits, cost of medication, hospital visits, and associated procedures
    Methodology and Proposed Activities to Reach Goals/Outputs
                   It is estimated that developing countries will increasingly bear the burden of the diabetes epidemic. The GMCP aims to take on the challenge of curbing the increasingly daunting diabetes epidemic by adapting the existing Middle East diabetes micro-clinic system. This will be realized by establishing new micro-clinics in India and introducing new health technologies and strategies specifically aimed at reducing complications and death from diabetes in less urbanized locations, which are characterized as economically disadvantaged, and access to services, jobs, and technology are more prohibitive. GMCP will systematically evaluate the health and financial impact of the project on our participants and their families, and potential effects on the Jordanian health care system and economy. We aim to establish 200 micro-clinics with the following key features:

    Health Education
             The local medical team consisting of one doctor and three nurses will provide micro-clinic participants with access to validate diabetes educational materials and training on how to effectively manage and control diabetes with self-empowering activities. Special education on the differences between type I and type II diabetes mellitus will also be provided. Patients who have participated in the precursor to our educational program have been shown to significantly lower hemoglobin A1C values, weight, and need for oral medication. Among those who did not use insulin therapy, participants lost an average of 6.2 lb, reduced hemoglobin A1C values from 8.1 to 7.5 percent and the need for oral medication by half. Patients who used insulin therapy showed even more dramatic improvement, reducing hemoglobin A1C values from 9.7 to 8.2 percent.

             In addition to diabetes education, the program will also provide education on the strong relationship between cardiovascular disease and insulin resistance. This includes culturally and contextually appropriate strategies on lowering the risk of cardiovascular complications. Our approach is holistic as it promotes a healthy diet, regular physical activity, and regular monitoring for hypertension and other diabetes-related complications, as well as linking our medical professionals with the current public medical infrastructure to ensure participants receive basic medical treatment for these conditions whenever necessary and possible.

    Empowerment & Social Support
             The cornerstone of the micro-clinic model is the combination of family and community support, basic health education, and simple, appropriate medical tools to empower individuals to manage their own health in a way that not only strongly shapes their future, but, in turn, influences those around them to take on the same challenge. Micro-clinics will regularly meet together in a home or business location to provide group support and have access to simple, inexpensive modern technologies, while attending regular workshops and educational social activities (i.e. healthy cooking potlucks, diabetes foot care demonstrations, aerobics, etc.), which will build and strengthen broader social cohesion through the development of powerful psycho-social collectives. This model promotes a self-empowerment approach to disease management and allows participants to be actively engaged, rather than passive and dependent, in taking care of their own health. In short, micro-clinics are models of preventative health care, as they are also support groups. As GMCP serves as a local education and health management program, it also forms a broader social community among its participants that empowers and sustains itself.

    Glycemic Monitoring: Glucose Monitors
             In addition to an intensive education and awareness program, glycemic management with the help of glucose monitors is the first line of defense against the deleterious effects of diabetes complications. These monitors make a quick and accurate assessment of blood glucose level and can provide those with diabetes with vital information about how well blood glucose is being controlled at a given moment. When tied to a vigorous health education program, these machines give patients critical feedback over time of the positive effects of managing their diet, exercise regimes, and treatment. This information, coupled with pro-active diabetes management strategies and appropriate medical oversight, can help patients keep their blood glucose steady and within a reasonable range. In fact, a 2000 study in the British Medical Journal found that simply monitoring blood glucose in type 2 diabetics increased the time free from diabetes complications by two years and significantly reduced the long-term cost of medical treatment.

    Glycemic Monitoring: Portable Hemoglobin A1C Machines
             Another critical tool in blood glucose management is monitoring hemoglobin A1C values (HbA1C). Portable hemoglobin A1C machines are now available to give diabetic patients and medical professionals—who would not normally have access to such a test—an assessment of the patient’s long term level of glycemic management. Where glucose monitoring gives a short-term assessment of glycemic control, HbA1C testing measures average values over the past 2-3 months This information is not only invaluable in terms of assessing the patient’s condition, but improving management and preventing complications. Immediate feedback of HbA1C results to patients has been shown to significantly improve glycemic control over the long term. In a study of 275 patients in an urban clinic, point of care monitoring reduced HbA1C values from 8.4 to 8.1 percent after two follow up visits, and an even more powerful study show that monitoring alone led to a .57 percent reduction in values after 6 months and .41 percent after a full year. Moreover, for every 1 percent reduction in HbA1C blood test results, the risk of developing microvascular diabetic complications is reduced by 40 percent

    Supplies and Equipment
    Micro-clinics participants will be provided with the following technology:
      • Glucose monitor, strips and needles.
      • Educational manuals on diabetes management
      • Logbook to help set goals and track progress
    Micro-clinic nurses will be equipped with the following technology:
      • Glucose monitor, needles, and strips.
      • Newly developed portable HbA1c machines, which they will use to periodically conduct tests, in conjunction with educational events and home visits.
      • Portable blood pressure monitors
      • Scales and measuring tape to calculate the body mass index (BMI) of project participants.
    ACTIVITIES
    Step 1 [2 Months]: Assessment, field visits, focus groups, and planning efforts undertaken to identify existing resources, social networks, and local leadership. This stage includes planning and training sessions for medical staff. The training sessions will be led in cooperation with locally hired staff and project manager, and the GMCP India Coordinator. The micro-clinic medical team will be trained in effectively caring for and educating diabetic patients, as well as implementing micro-clinics. This team will be responsible for overseeing 200 micro-clinics and 100 volunteer group leaders. Local medical experts, student volunteers from local universities, as well as other community volunteers will also be enlisted in project efforts.
    Step 2 [1 Month]: A pilot micro-clinic project will be established in a specially selected region. Though the MCs are self-sustaining shortly after their establishment, during the first year, the micro-clinic team will meet with MC participants on a regular basis providing educational support, advice, and overseeing general activities to ensure high quality outcomes. Local staff will lead an outreach effort via media, and grassroots efforts to spread the word on the Global Micro-Clinic Project as well as upcoming events.
    The MC team (doctors and nurses working with a project manager) will provide large diabetes awareness and diabetes screening events open to the community and distribute supplemental educational materials. The topics will include causes, complications, early symptoms, and management of diabetes, diet, and exercise. These events will be held in central locations such as a community center or social hall, and will be supplemented with educational materials for each individual. Educational materials will include detailed information from the aforementioned lectures (diet, exercise, etc.) in addition to other relevant information and discussion topics including “preventing diabetes in your family,” “ideas for social micro-clinic activities,” and “top 10 changes I can make to improve my health.” After lectures, there will be a question and answer session, a free diabetes screening, and registration for the GMCP program.
    Step 3 [1 Month]: Diabetic or at-risk individuals are divided into “micro-clinics,” which are organically formed, self-selected groups of friends, family, and neighbours, who are given a glucose monitor to share in a designated location, such as a home or business. The micro-clinics are self-selected support groups, comprised of approximately 3-8 individuals who know each other as family or friends, and are led by a volunteer “staff” member (usually a son or a daughter responsible for assisting in documenting readings, administering tests, and leading discussions). Micro-Clinic members will be trained in 4 training sessions over the course of a month on how to manage their diabetes, and its associated cardiovascular risks. After training, a start-up kit will be distributed to each MC, which includes a project manual for each member, a logbook to record progress, a glucose meter, strips and needles.
    Step 4 [3 months] After MC initiation, nurses will follow up with each micro-clinic over the next 3 months to help them put into action the new skills participants have learned during their diabetes education, solidify as a support group, to monitor participants for complications and to address any participant questions or concerns. The micro-clinics will operate independently one month after establishment (members will meet regularly, share support and supplies) and will continue to participate in broader activities of project (i.e. social events, association, periodic evaluations, etc...). Each micro-clinic will have the opportunity to meet with a nurse regularly who will use portable technology to check for diabetes complications and measure health improvements.
    Step 5 [6 Months]: Each month micro-clinic groups will meet together for social events and specialized medical consultations in a community center as the “Diabetes Micro-Clinic Association.”
    In addition to these events, the medical team will establish weekly medical days where patients can come ask questions, address concerns and receive medical advice from the medical team. These follow up meetings will provide an opportunity for nurses to collect medical and behavioural data from MC members, including survey data, weight, cardiovascular measures and fasting blood sugar values. Nurses will also have time built into their schedule to follow up with patients to collect data and do field visits if necessary. At this stage, the efficacy of the micro-clinics will periodically be evaluated using hemoglobin A1C tests, surveys, and in-depth interviews in the first year.
    Main Accomplishments so Far
    1.Ms Leila Makarechi ,Ms Ashmi Ullal Have Played a Major role in setting up this Programme along with Ms Ruth Daniel from CMC Vellore and Ms Sylvia and Ms Mary from CSI hospital ,Gadag.
     
  • large community events (average participation between 50-100 people) were held in villages as well as throughout Gadag-Betgeri.
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  • Screening of about 250 people from villages and Gadag-Begeri
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  • Creation of educational materials: posters, pamphlets, exercise handouts.
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  • Nurses received additional training from Mrs. Ruth ( Diabetes Educator from CMC)
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  • Needs Assessment has been completed.
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  • Meetings with 8 local leaders, including District Health Officer have been held.
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  • Local contacts ( have been established for project support (i.e. Xerox, IT assistance, transportation, translation, etc)
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  • Two full-length educational skits have been created (and performed 5 times) by nursing students.
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  • Nursing students/staff have received weekly follow-up training on diabetes.
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