Prospects of diabetes registry and standard care at primary health facilities in Nigeria: experiential note

INTRODUCTION

Nigeria is the most populous country in Africa with an estimated number of 1.7 million people with DM (International Diabetes Federation, 2017). The current pooled prevalence of DM in Nigeria is 5.8%, and in the Ndokwa local government area of Delta state, it has been observed to be 5.0%.^1,2 Globally, many countries are establishing diabetes registers as a tool for management of diabetes, and development of clinician decision support system.^3-6 However, the establishment of diabetes register in a low resource setting such as Nigeria has not gained national prominence and organizational behavioural change wheel is a probable factor. The Primary Healthcare Centre (PHC) is the first tier of the Nigeria health system closest to the people, especially rural dwellers and can be a good resource for diagnosis and management of diabetes.⁷ It is indicated that diabetes cannot be handled at the primary health care centres in Nigeria due to shortage of facilities and inadequate healthcare personnel.^7-9 Nevertheless, there is yet to be clinical observational study regarding diabetes register or the potential to establish the registry.

Therefore, in the project of establishing diabetes register, it would be appropriate to pilot the establishment of a diabetes register at the PHC level in Delta State. The aim of the study is to evaluate the development of diabetes registers at the primary healthcare level in Delta State Nigeria. The three specific research objectives are to determine the:

• • Diabetes services that are available to patients
• • Level of completeness of data for the patients’ follow-up
• • Percentage of persons with probable diabetes mellitus and/or high blood pressure.

METHODS

Study design

The study was a clinical observational study of diabetes care that doubled as community needs assessment.

Study setting

Novena Health Centre, Amai; and Ogume community PHC both in Delta State. The study areas were Amai and Ezionum communities and Novena University health centre in Ukwani Local Government Area as well as Ogume community in Ndokwa West Local Government Area.

Selection criteria

Members of the three communities who were screened for diabetes during the community-based screening and their information entered into the developed diabetes register at Novena University health centre and Ogume primary health centre. Participants included both gender and were all adults.

Data collection

As part of the series, all data were collected based on the template diabetes register that was used to initiate development of diabetes registry in the healthcare facility. Participants were invited to the health centre. For this report, data were collected between October 2018 and April 2019.

Statistical analysis

All cases of diabetes identified during the screening and were entered into the developed diabetes register at the two facilities formed the sampled population. The collected data was analysed using Microsoft Excel Data Analysis Tool Pak 2010.

RESULTS

Objective 1: Diabetes services that are available to patients at the health facility

Services available are in terms of equipment and tests defined by the list of clinical measure that constitute standard of care,10 which includes seven expected items (Table 1). Results show that blood glucose and blood pressure measurements were carried out but not body mass index.

*Albumin/creatinine ratio, but urinalysis is routinely performed.

Objective 2: Level of completeness of data for the diabetes patients’ follow-up

Missing data to either warrant recall of patient, or reference on next check-up were observed (Table 2). There was one case with just the first name i.e. without surname, and two cases of no blood glucose results. In this study, complete contact details was defined to include medical record number, house address (street and/or postal) and telephone number. 81% of cases were missing home addresses, 62% of clients cannot be contacted due to lack of phone numbers (Figure 1). Eight participants provided street or office addresses, while 29/42 gave incomplete home address and another 5/42 are not associated with any home address (Figure 2).

Objective 3: Percentage of persons with probable high blood glucose and/or pressure

All participants (n=42) were invited for diabetes screening. Since blood glucose test was performed mainly for screening purpose, probable diabetes was implied from FBS ≥110 mg/dl (6.1 mmol/l) or RBS ≥200 mg/dl (11.1 mmol/l). Probable high blood pressure was defined as any reading above both 120 mmHg systolic and 80 mmHg diastolic. Evaluation revealed that 19 cases that were high in either systolic and/or diastolic blood pressure. While 17 of the 19 were hyperglycaemic, but 3 of the 17 had normal systolic pressure; and additional eight (i.e., 3/17+8/17=11/17) showed normal diastolic pressure (Table 3). Conversely, 82% of the hyperglycaemic cases showed systolic pressure greater than 120 mmHg including 35% also showing high diastolic pressure to imply probable high blood pressure (Figure 3).

DISCUSSION

The findings of the study in terms of first objective show that blood pressure and glucose level were being assessed, which indicates capacity as well as opportunity. However, it is noteworthy from results of second objective that the completeness of data for patients’ follow-up is quite low; hence indicative of limited motivation. In the context of translating knowledge attitude and practice into behavioural change wheel; these findings indicate presence of knowledge for capacity as well as opportunity for practice, attitude vis-à-vis motivation is probably what is needed to improve diabetes services at the primary healthcare facility.^11,12 The main purpose of a diabetes register is to document patients’ information to facilitate recall and proper follow-up of patients. That is, enhance management of the disease to improve quality of life.^3,4,13,14 Therefore, completeness of patient information during development of the register is key in achieving the long-term goal of developing the register.

The absence of data collection to assess BMI is quite concerning, especially since PHCs are owned and operated by local governments with a focus to providing basic preventive, promotive, and acute treatment services albeit suboptimal.⁷ It is known that in the three tier system of public health in Nigeria, the quality of primary healthcare services constitute a major concern.^7,8 This report contributes further data with regards to diabetes care and identifies availability of service that is limited by completeness of patient’s anthropometric and demographic data collection i.e. as one of the areas to improve. The logistics of adoptability of most of equipment for screening chronic diseases can involve long term bureaucracy, but very rewarding. Indeed, given the existing capacity to assess blood sugar and blood pressure tests, acquiring weighing scale and creating height measuring unit on a wall is easy. Therefore, this study makes a case for inclusion of diabetes screening service in the PHCs. This will help in the development of functional diabetes register especially in rural areas that host more than 50% of the national population.

CONCLUSION

Similar to the observations at the private general practice reported as #3 in this series, it can say that most patients invited for diabetes screening do attend, but data collection which translates to services being provided are limited. This limitation is even buoyed by incompleteness of records that are considered to be significant in diabetes clinics. It draws attention to the need for staff retraining in order to harness their potentials for diabetes services.

ACKNOWLEDGEMENTS

This is part of the project “development of diabetes register in low-mid income country”, which was done under the aegis of ethical approval granted to global medical research and development organization (GMRDO) in collaboration with public and community health department, Novena University. Ndubueze and Okwelum participated in the work as part of their academic research works. The support of staff at Novena University Health Centre is highly appreciated. Christabel Ogbolu, Godswill Adoh, Chinedu Obodo and Fortunatus Gbeinbo are hereby acknowledged for support during data collection in this collaborative work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Ethical approvals for this project included Novena University as well as Ndokwa West local government both in Delta State Nigeria

REFERENCES

1. 1. Uloko AE, Musa BM, Ramalan MA, Gezawa ID, Puepet FH, Uloko AT, et al. Prevalence and risk factors for diabetes mellitus in Nigeria: A systematic review and meta-analysis. Diabetes Ther. 2018;9:1307-16.
2. 2. Nwose EU, Richards RS, Bwititi PT, Igumbor EO, Oshionwu EJ, Okolie K, et al. Prediabetes and cardiovascular complications study (PACCS): international collaboration 4 years' summary and future direction. BMC Res Notes. 2017;10:730.
3. 3. Cook JA. Using a diabetes register to improve care and outcomes. Collaborative support Programs of New Jersey Wellness Symposium: Diabetes preventtion and wellness self-management. Edison, NJ; 2012.
4. 4. Australian Institute of Health and Welfare. The national (insulin-treated) diabetes register 2013; Quality statement, 2015. Available at: http://meteor.aihw.gov.au/content/index.phtml/itemId/608449. Accessed on 24 August 2017.
5. 5. Health Service Executive. Setting up a diabetes register using GP practice management system, 2017. Available at: https://www.hse.ie/eng/health/hl/living/diabetes/Diabetesregister.html. Accessed 20 February 2019.
6. 6. Ballotari P, Ranieri SC, Vicentini M, Caroli S, Gardini A, Rodolfi R, et al. Building a population-based diabetes register: an Italian experience. Diabetes Res Clin Pract. 2014;103:79-87.
7. 7. Uzochukwu BSC. Primary health care systems (PRIMASYS): Case study from Nigeria, 2017. Available at: https://www.who.int/alliance-hpsr/projects/alliancehpsr_nigeriaprimasys.pdf?ua=1. Accessed on 20 August 2019.
8. 8. Fasanmade OA, Dagogo-Jack S. Diabetes care in Nigeria. Ann Global Health. 2015;81:821-9.
9. 9. Otovwe A, Oyewole OE, Igumbor EO, Nwose EU. Diabetes care in delta state of Nigeria: An expository review. Diabetes Updates. 2018;1:1-8.
10. 10. World Diabetes Foundation. List of standard medical and laboratory equipment for type 2 diabetes clinics. Available at: https://www.worlddiabetesfoundation.org/sites/default/files/List%20of%20medical%20and%20laboratory%20equipment.docx. Accessed on 30 October 2017.
11. 11. Johnston M. Using behaviour change theory and techniques in implementation research. In: The 4th Biennial Society for Implementation Research Collaboration conference Seattle, 2017. SIRC; 2017.
12. 12. Nwose EU, Digban KA, Anyasodor AE, Bwititi PT, Richards RS, Igumbor EO. Development of public health program for type 1 diabetes in a university community: preliminary evaluation of behavioural change wheel. Acta Biomed. 2017;88:281-8.
13. 13. Engström MS, Leksell J, Johansson UB, Gudbjörnsdottir S. What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored patient-reported outcome measure for the Swedish National Diabetes Register. BMJ Open. 2016;6:e010249.
14. 14. Health Service Executive. Setting up a diabetes register using GP practice management system. Available at: https://www.hse.ie/eng/health/hl/living/diabetes/Diabetesregister.html. Accessed on 28 November 2019.