Shajahan Yasin

Prevention of Type 2 Diabetes and Its Complications in Developing Countries: A Review

BackgroundType 2 diabetes mellitus (T2DM) is a significant global public health problem affecting more than 285 million people worldwide. Over 70% of those with T2DM live in developing countries, and this proportion is increasing annually. Evidence suggests that lifestyle and other nonpharmacological interventions can delay and even prevent the development of T2DM and its complications; however, to date, programs that have been specifically adapted to the needs and circumstances of developing countries have not been well developed or evaluated.PurposeThe purpose of this article is to review published studies that evaluate lifestyle and other non-pharmacological interventions aimed at preventing T2DM and its complications in developing countries.MethodsWe undertook an electronic search of MEDLINE, PubMed, and EMBASE with the English language restriction and published until 30 September 2009.ResultsNine relevant publications from seven studies were identified. The reported interventions predominantly used counseling and educational methods to improve diet and physical activity levels. Each intervention was found to be effective in reducing the risk of developing T2DM in people with impaired glucose tolerance, and improving glycemic control in people with T2DM.ConclusionsThe current evidence concerning the prevention of T2DM and its complications in developing countries has shown reasonably consistent and positive results; however, the small number of studies creates some significant limitations. More research is needed to evaluate the benefits of low-cost screening tools, as well as the efficacy, cost-effectiveness, and sustainability of culturally appropriate interventions in such countries.

Rethinking health-care systems: a focus on chronicity

450 www.thelancet.com Vol 377 February 5, 2011 Health-care systems, including those in countries of the Organisation for Economic Co-operation and Development, face a crisis of an increasing burden of chronic disease aggravated by ageing populations and complicated by the continuing risks of infectious diseases and global pandemics. The issues for health-care systems in low-income and middle-income countries are compounded by persistent diseases of poverty, and the inadequately understood comorbidities of both infectious and noncommunicable diseases. The structure of health-care systems refl ects an underlying understanding of health and disease in which acute episodes result in help-seeking, with the expected outcome of a cure or death. In this model, chronic conditions are treated as serial acute episodes with multiple interactions with the health-care system. As the capacity to manage acute phases of chronic conditions improves, disease prevalence rises, resulting in a fi nancial burden that will begin to dwarf costs in other parts of the health system. For example, Uganda, supported by international aid, has achieved 16% coverage of its HIV-positive population with highly active antiretroviral therapy (HAART), moving the treated few from the category of acute to chronic. The expectation follows of a lifelong commitment to the already treated few, with an implicit promise to manage the remaining 84% as funds become available. Without ongoing global health funding, and in view of the cost of HAART and the cost to the health system of lifelong treatment, it is hard to imagine that this situation will be sustainable. Similarly, the cost of diabetes care per patient in Cameroon was US

Universal coverage in an era of privatisation: can we guarantee health for all?

489 per year in 2002. This cost exceeds the annual per head income by 1·5 times, and exceeds the per-head governmental health spending by around 50 times. Cameroon is not alone with emerging evidence of a diabetes epidemic across many of the poorest countries in sub-Saharan Africa. In essence, as the technology to lengthen the lives of those with chronic conditions is developed, the fi xed costs of the health system increase. The fi nancial burden will necessitate socially and politically uncomfortable trade-off s. The current focus on health systems is therefore timely. However, discussions to date largely centre on delivering the familiar model of acute-centric care, albeit with some concentration on tackling the weaknesses in the six key components of health systems: service delivery, fi nance, governance, technologies, workforce, and information. Other issues under discussion include the need for universal coverage and equity. These issues are placed within the broader context of systems needed to deliver vertical disease-focused programmes for infectious and noncommunicable diseases. Although this approach might be appropriate for acute conditions, and arguably for higher-income countries, it is unaff ordable and unsustainable with the increasing burden of chronic disease in lowerincome and middle-income countries. And although reducing the burden of chronic diseases in younger and middle-aged people might succeed, the increasing burden of chronic conditions is an inescapable reality of ageing populations. The challenge for health-care systems is to explore and address the implications of chronicity which capture the complexity of addressing disease conditions—regardless of cause—characterised by long duration and often slow progression. Chronicity has wide-ranging implications for, among other things: health promotion and preventive strategies that address risk factors; fi nancing and planning of health-care systems; training of the health workforce; and the nature and location of health infrastructure. Chronicity provides a framework for exploring an Co bi s Published Online November 11, 2010 DOI:10.1016/S01406736(10)61856-9

The rural bite in population pyramids: what are the implications for responsiveness of health systems in middle income countries?

A government that claims to provide universal health coverage (UHC) needs to establish that access to health services is available for the whole population for the full spectrum of services without risk of undue financial hardship. Embedded within the idea of UHC are two distinct notions. First, access to the full spectrum of health services needs to include access to preventive care through to palliative care and rehabilitative services. Second, access to services for a whole population means that everyone should be able to enjoy the benefits of the health system, regardless of individual economic, social, or geographic position. Those in favour of UHC see health as a public good not simply an individual benefit, and they recognise that, as a consequence of this view, the implementation of UHC requires a level of regulation and a kind of investment that is inconsistent with an unconstrained free market. The challenge for government is in selecting the mix of regulatory and financing mechanisms for the chosen, universally available, health services. This also presupposes that the parcel of health services that will be available has been identified, and there are systems in place to monitor and evaluate the system. It was around these issues that the International Symposium on Universal Health Coverage in Malaysia, convened by Global Public Health at the School of Medicine and Health Sciences, Monash University Sunway Campus on 3 – 4 October 2011 cohered. The symposium provided an opportunity for lively and robust discussions between the private health care sector, including private health care and insurance providers, government and academics. The proceedings of the symposium are expected to feed into the background papers for the Second Global Symposium on Health Systems Research to be held in Beijing, 31 October to 3 November 2012 and copies of presentations are accessible [1]. The gathering also presented the opportunity for the Monash 2011 Global Health Oration on the topic, presented by Professor Timothy Evans [2]. This supplement presents a compilation of select papers from the symposium which attempt to examine the concept of UHC from a series of different perspectives. 1. Equity and vulnerability; 2. Insurance and financing; 3. Coverage and satisfaction; and 4. Implementation. These perspectives necessarily overlap and the insights from one perspective help to inform the considerations from another perspective.

Cohorts and community: a case study of community engagement in the establishment of a health and demographic surveillance site in Malaysia

BackgroundHealth services can only be responsive if they are designed to service the needs of the population at hand. In many low and middle income countries, the rate of urbanisation can leave the profile of the rural population quite different from the urban population. As a consequence, the kinds of services required for an urban population may be quite different from that required for a rural population. This is examined using data from the South East Asia Community Observatory in rural Malaysia and contrasting it with the national Malaysia population profile.MethodsCensus data were collected from 10,373 household and the sex and age of household members was recorded. Approximate Malaysian national age and sex profiles were downloaded from the US Census Bureau. The population pyramids, and the dependency and support ratios for the whole population and the SEACO sub-district population are compared.ResultsBased on the population profiles and the dependency ratios, the rural sub-district shows need for health services in the under 14 age group similar to that required nationally. In the older age group, however, the rural sub-district shows twice the need for services as the national data indicate.ConclusionThe health services needs of an older population will tend towards chronic conditions, rather than the typically acute conditions of childhood. The relatively greater number of older people in the rural population suggest a very different health services mix need. Community based population monitoring provides critical information to inform health systems.

Contextualizing chronicity: a perspective from Malaysia

Background Community engagement is an increasingly important requirement of public health research and plays an important role in the informed consent and recruitment process. However, there is very little guidance about how it should be done, the indicators for assessing effectiveness of the community engagement process and the impact it has on recruitment, retention, and ultimately on the quality of the data collected as part of longitudinal cohort studies. Methods An instrumental case study approach, with data from field notes, policy documents, unstructured interviews, and focus group discussions with key community stakeholders and informants, was used to explore systematically the implementation and outcomes of the community engagement strategy for recruitment of an entire community into a demographic and health surveillance site in Malaysia. Results For a dynamic cohort, community engagement needs to be an ongoing process. The community engagement process has likely helped to facilitate the current response rate of 85% in the research communities. The case study highlights the importance of systematic documentation of the community engagement process to ensure an understanding of the effects of the research on recruitment and the community. Conclusions A critical lesson from the case study data is the importance of relationships in the recruitment process for large population-based studies, and the need for ongoing documentation and analysis of the impact of cumulative interactions between research and community engagement.Background Community engagement is an increasingly important requirement of public health research and plays an important role in the informed consent and recruitment process. However, there is very little guidance about how it should be done, the indicators for assessing effectiveness of the community engagement process and the impact it has on recruitment, retention, and ultimately on the quality of the data collected as part of longitudinal cohort studies. Methods An instrumental case study approach, with data from field notes, policy documents, unstructured interviews, and focus group discussions with key community stakeholders and informants, was used to explore systematically the implementation and outcomes of the community engagement strategy for recruitment of an entire community into a demographic and health surveillance site in Malaysia. Results For a dynamic cohort, community engagement needs to be an ongoing process. The community engagement process has likely helped to facilitate the current response rate of 85% in the research communities. The case study highlights the importance of systematic documentation of the community engagement process to ensure an understanding of the effects of the research on recruitment and the community. Conclusions A critical lesson from the case study data is the importance of relationships in the recruitment process for large population-based studies, and the need for ongoing documentation and analysis of the impact of cumulative interactions between research and community engagement.

Community-based blood pressure measurement by non-health workers using electronic devices: a validation study.

The increasing prevalence of chronic Non Communicable Disease (NCD) around the world is well documented and projections suggest a frightening increase in prevalence around the world. The majority of new patients with chronic disease are expected to occur in developing countries. Effective management of chronic disease is a complex process that involves a proactive health care team working within an integrated healthcare delivery system supporting a well informed and confident patient skilled in self-management of the condition. There is increasing evidence especially from western countries that methods of implementation that use these principles work. Widespread and not contextualized dissemination of these approaches especially to less developed countries, however, would pose particular challenges. These challenges relate to a number of factors; a lack of resources, poorly functioning healthcare systems and their ability to cope, the rise of private financing for healthcare with increasing out-of-pocket payments for accessing healthcare, rapid industrialization and urbanization with attendant breakdown in support relationships and the general lack of support services including a social support model. We discuss some of these health system issues, using diabetes as the indicator condition, and the relating this to the Malaysian health system to illustrate the challenges of translating evidence from better resourced countries. Malaysia is a middle-income country with a well-functioning public health system designed primarily for control of communicable disease and Maternal and Child health. While a population approach in dealing with NCDs is key, we have highlighted an individual high-risk approach in this commentary. A number of patient support systems by professionals have been tested successfully in developed countries. In most developing countries, individuals especially the elderly depend on families to provide support. This and support from peers may be areas that may require further study especially in the area of self-management.

Effectiveness of Personalized Feedback Alone or Combined with Peer Support to Improve Physical Activity in Sedentary Older Malays with Type 2 Diabetes: A Randomized Controlled Trial.

Introduction Population monitoring and screening of blood pressure is an important part of any population health strategy. Qualified health workers are expensive and often unavailable for screening. Non-health workers with electronic blood pressure monitors are increasingly used in community-based research. This approach is unvalidated. In a poor, urban community we compared blood pressure measurements taken by non-health workers using electronic devices against qualified health workers using mercury sphygmomanometers. Method Fifty-six adult volunteers participated in the research. Data were collected by five qualified health workers, and six non-health workers. Participants were randomly allocated to have their blood pressure measured on four consecutive occasions by alternating a qualified health worker with a non-health worker. Descriptive statistics and graphs, and mixed effects linear models to account for the repeated measurement were used in the analysis. Results Blood pressure readings by non-health workers were more reliable than those taken by qualified health workers. There was no significant difference between the readings taken by qualified health workers and those taken by non-health workers for systolic blood pressure. Non-health workers were, on average, 5–7 mmHg lower in their measures of blood pressure than the qualified health workers (95%HPD: −2.9 to −10.0) for diastolic blood pressure. Conclusion The results provide empirical evidence that supports the practice of non-health workers using electronic devices for BP measurement in community-based research and screening. Non-health workers recorded blood pressures that differed from qualified health workers by no more than 10 mmHg. The approach is promising, but more research is needed to establish the generalisability of the results.

Interventions to Promote Physical Activity in Older People with Type 2 Diabetes Mellitus: A Systematic Review

Introduction Regular physical activity is an important aspect of self-management among older people with type 2 diabetes but many remain inactive. Interventions to improve physical activity levels have been studied but few studies have evaluated the effects of personalized feedback (PF) or peer support (PS); and there was no study on older people of Asian heritage. Hence, this trial evaluated whether PF only or combined with PS improves physical activity among older Malays with type 2 diabetes (T2DM) compared to usual care only. Materials and methods A three-arm randomized controlled trial was conducted in a primary healthcare clinic in Malaysia. Sixty-nine sedentary Malays aged 60 years and older with T2DM who received usual diabetes care were randomized to PF or PS interventions or as controls for 12 weeks with follow-ups at weeks 24 and 36. Intervention groups performed unsupervised walking activity and received written feedback on physical activity. The PS group also received group and telephone contacts from trained peer mentors. The primary outcome was pedometer steps. Secondary outcomes were self-reported physical activity, cardiovascular risk factors, cardiorespiratory fitness, balance, quality of life, and psychosocial wellbeing. Results Fifty-two (75.4%) completed the 36-week study. The PS group showed greater daily pedometer readings than the PF and controls (p = 0.001). The PS group also had greater improvement in weekly duration (p < 0.001) and frequency (p < 0.001) of moderate intensity physical activity, scores on the Physical Activity Scale for Elderly (p = 0.003), 6-min walk test (p < 0.001), and social support from friends (p = 0.032) than PF and control groups. Conclusion The findings suggest that PF combined with PS in older Malays with T2DM improved their physical activity levels, cardiorespiratory fitness, and support from friends. Trial registration Current Controlled Trials ISRCTN71447000.

Promoting physical activity in sedentary elderly Malays with type 2 diabetes: a protocol for randomised controlled trial

Introduction: Type 2 diabetes mellitus (T2DM) among people aged 60 years and above is a growing public health problem. Regular physical activity is one of the key elements in the management of T2DM. Recommendations suggest that older people with T2DM will benefit from regular physical activity for better disease control and delaying complications. Despite the known benefits, many remain sedentary. Hence, this review assessed interventions for promoting physical activity in persons aged 65 years and older with T2DM. Methods: A literature search was conducted using Ovid MEDLINE, PubMed, EMBASE, SPORTDiscus, and CINAHL databases to retrieve articles published between January 2000 and December 2012. Randomized controlled trials and quasi-experimental designs comparing different strategies to increase physical activity level in persons aged 65 years and older with T2DM were included. The methodological quality of studies was assessed. Results: Twenty-one eligible studies were reviewed, only six studies were rated as good quality and only one study specifically targeted persons aged 65 years and older. Personalized coaching, goal setting, peer support groups, use of technology, and physical activity monitors were proven to increase the level of physical activity. Incorporation of health behavior theories and follow-up supports also were successful strategies. However, the methodological quality and type of interventions promoting physical activity of the included studies in this review varied widely across the eligible studies. Conclusion: Strategies that increased level of physical activity in persons with T2DM are evident but most studies focused on middle-aged persons and there was a lack of well-designed trials. Hence, more studies of satisfactory methodological quality with interventions promoting physical activity in older people are required.