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.

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,

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.

Main Accomplishments so Far

Micro-clinic nurses will be equipped with the following technology