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Health Surveillance and Disease Management / Noncommunicable Diseases / CARMEN

Trinidad and Tobago: Current Activities in CNCD Risk Factor Reduction, Diabetic Foot Care, and Wellness

(CARMEN Biennial Conference, Nassau, Bahamas, 4–8 November 2007)

CARMEN Meeting 2007

National Plan for Risk Factor Reduction in the Prevention and Control of Noncommunicable Diseases in Trinidad and Tobago

Dr. Mohamed Azam Rahaman, Medical Officer of Health,
County St. George Central, North West Regional Health Authority (NWRHA)

Introduction

The Ministry of Health has embarked on an action plan whereby an integrated approach focusing on the indicators of decision making for health choices are addressed. The authorities understand that to delight in health, individuals must have employment or job creation opportunities, a high-quality education, a wholesome family and community environment, and sufficient knowledge to make healthy choices. This involves the gathering of stakeholders who contribute to the mental, social, physical and economic environment in the country. At the helm is policy-making and action-oriented decision-making at institutional, community and public policy levels. Instituting legislation, regulation, public and professional education, guidelines development, media interventions, and research are continuous processes needing immediate attention.

The Ministry of Health of Trinidad and Tobago aims to create a quality health system that is reliable and ensures the best health outcomes for all people. The strategies developed serve to guarantee that the health sector can respond to changing demands in health care needs—currently, an increasing number of chronic disease cases.

Activities and Strategies

  1. Establish a multisectoral task force and a National Coordinator.
  2. Conduct a national survey (using the WHO STEPS methodology) on lifestyle behaviour, levels of obesity, and other risk factors.
  3. Construct a problem tree for baseline data.
  4. Use a force field and SWOT analysis and properly evaluate the country's situation.
  5. Establish an objective tree.
  6. Design a programme for risk factor reduction and the communication for behavioural impact (COMBI) for implementation.
  7. Training and multi-skilling of staff.
  8. Monitoring and evaluation of the program.

Specific Program Components

  1. Wellness and screening for CNCD risk factors.
  2. School Screening Program.
  3. One-stop shopping for comprehensive holistic care with the appropriately multi-skilled staff.
  4. COMBI program for behaviour change within communities using lay community health workers.

Diabetic Foot Care Management Programme in County St. George Central, Trinidad and Tobago

Dr. H. Singh, Dr. M.A. Rahaman, Dr. A. Ramcharitar Maharaj, Dr. B. Armour,
County St. George Central, North West Regional Health Authority (NWRHA)

Justification

Diabetes mellitus is a serious chronic disease affecting an estimated one hundred thousand people in Trinidad and Tobago1 and millions worldwide2. The prevalence of diabetes is expected to increase as a consequence of longer life expectancy, sedentary lifestyle and changing dietary patterns. Although many serious complications, such as kidney failure or blindness, can affect individuals with diabetes, it is the complications of the foot that take the greatest toll.2 One in every eight patients afflicted with diabetes have had a foot ulceration and one in twenty five have had an amputation.3 Gulliford et al. estimated that, in Trinidad, the annual financial cost for all patients admitted with diabetes was TT $10.7 million, including TT $3.1 million for patients admitted with foot problems.4

Consequently, County St. George Central, in conjunction with the Health Research, Planning and Development Department of the NWRHA, decided that a suitable Diabetic Foot Care Management Programme was needed to develop interventions at the Primary Care level to reduce the incidence of foot disease among diabetics by improving foot care and foot care education.

Objective: To reduce the incidence of foot disease among diabetics by improving foot care and foot care education.

Methodology

A team of UK-trained Podiatrists from Ottawa, Canada, with particular experience in diabetic foot care, were chosen to train a selected group of health care professionals (HCPs) working in the County who would ultimately be responsible for establishing and maintaining the Diabetic Foot Care Management Programme. These HCPs included five primary care physicians (PCPs) and seven nurses. Phase I training was conducted during the period from 30 January 30 – 9 February 2006.

Subsequently, Diabetic Foot Clinics were established at two health centers in the county: El Socorro and Santa Cruz. These clinics have been operating on the following tenets:

  1. Establishment of a Dedicated Diabetic Foot Clinic: A dedicated Diabetic Foot Clinic is held each week at the two Health Centres, with an average of ten appointments given. Each patient is assigned a unique Diabetic Registry Number (DRN), which is independent of their routine clinic registration number, for easy identification. Patients requiring superficial debridement of foot ulcers, shaving of calluses and/or off-weight bearing footwear modifications are given appointments to attend the next Dressings Clinic, unless earlier intervention is necessary.
  2. Special Screening of Diabetic Patients: This is done to profile the history of each patient and assist in the early detection of potential foot care issues through standardised questioning and specialised examination. A standard screening form, developed by the team, is filled out for each patient on their first visit to the clinic. A 10-g monofilament is used to detect the presence of abnormal sensation or neuropathy, while a hand-held Doppler is used to detect patients with Peripheral Vascular Disease (PVD).
  3. Patient Education: A pamphlet Diabetic Foot Care & You was prepared by the team for distribution to patients at the Health Centres. This is geared at increasing awareness of the issues related to diabetes and foot care.
  4. Links with Port-of-Spain General Hospital (POSGH) Vascular Outpatient Clinic: Patients with PVD are referred to the vascular outpatient clinic at POSGH for further evaluation and co-management.

Conclusion: The Diabetic Foot Clinics have been very well received by the patients at both Health Centres. During the period 18 January – 31 July 2007, a total of 361 diabetic patients were documented as attending the Diabetic Foot Clinics at both Health Centres, with 214 seen at the El Socorro and 162 of these on the database and 147 at Santa Cruz with 51 on the database. There is an estimated total of 1,000 diabetics who attend clinics at these two Health Centres. The patient attendance rate at the Diabetic Foot Clinic was 83%. 56.5% of the patients screened at both Health Centres had an increased or high risk of developing an ulcer, while 4% actually developed an ulcer. 54% of the ulcers attended to during the period under review were completely healed. Most amputations in diabetics begin with a foot ulcer.5 Hence by ensuring that these ulcers heal, we will be indirectly reducing the amount of diabetic patients requiring an amputation.

References
1 Marsha Mokool. 'Sugar' isn't sweet - Managing Diabetes. The Trinidad Guardian [Online] 2004 Oct [cited 2007 Jul 31]; [6 screens]. Available from: URL: http://www.guardian.co.tt/archives/2004-10-11/features1.html.
2 Bakker K. Diabetes and the foot. [Online]. 2005 [cited 2006 Jul 26];[2 screens]. Available from: URL: http://www.worlddiabetesday.org/go/2005-campaign/Diabetes-and-the-foot/
3 Gulliford MC Mahabir D. A study of health status in diabetes mellitus in Trinidad and Tobago. [Online]. 1998 [cited 2006 Jul 26]; Available from: URL: http://www.kcl.ac.uk/depsta/ccm/abs1998.pdf.
4 Gulliford MC, Ariyanayagam-Baksh SM, Bickram L, Picou D, Mahabir D. Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad. Diabet Med. 1995 Dec; 12 (12): 1077-85.
5International Diabetes Federation. Foot Facts. [Online]. 2005 [cited 2006 Jul 26];[1 screen]. Available from: URL: http://www.kcl.ac.uk/depsta/ccm/abs1998.pdf.

Wellness Programme for Risk Factor Reduction in the Prevention and Control of Noncommunicable Diseases in Trinidad and Tobago

Dr. Mohamed Azam Rahaman, Medical Officer of Health,
County St. George Central, North West Regional Health Authority (NWRHA)

Introduction

The World Health Organization in 1948 defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Worldwide reporting has indicated the change in trends previously from an epidemiology of mortality and morbidity from communicable diseases to one of chronic noncommunicable disease e.g. cardiovascular diseases, diabetes, hypertension and cancer, with obesity and lifestyle-related behaviours as an underlying component.

As we move into a new millennium of care regarding primary and secondary prevention, risk factor reduction with behavioural and environmental modification and a multisectoral approach are essential components for impact.

The Wellness Programme is therefore being formulated and introduced to achieve these goals.

Objectives

  1. To introduce a screening service that detects the prevalence of risk factors for CNCD in the Country in the adult and school population.
  2. To develop strategies for early intervention towards risk factor reduction.
  3. To empower communities with the necessary knowledge to promote self-management and risk factor reduction.

Methodology

  1. Activities include the use of a mobile clinic and health center services with health personnel to screen for CNCD risk factors and educate the communities and school population to effect lifestyle and behavioural change.
  2. Screening is being conducted for obesity and risk behaviours regarding diet and sedentary lifestyle. Cholesterol, blood pressure and diabetes testing are also being done.
  3. Referrals are to a multidisciplinary team for interventions.
  4. Training of lay community health workers to act as resource persons for behavioural change and as a link between the department of health and the communities.

Monitoring and Evaluation: A system for monitoring and evaluation is currently being established. Contact with referred clients will be made quarterly and records checked against health centre records to determine changes in client health status.

Conclusion and Expected Outcome: It is anticipated that this cost-effective strategy for CNCD prevention and control will assist in early risk factor detection and reduction—thus improving morbidity, longevity, and the quality of life.