Reaching communities in the West Bank  Community work. Home visits to poor and disabled people with diabetes is one important mission in working with rural communities.   Situated between prosperous Europe and impoverished Africa, the health profile of the Occupied Palestinian Territories (OPT) carries the characteristics of both continents. The West Bank alone is home to 2.4 million people of whom an estimated 11% live with diabetes and another 15% have hypertension – a risk factor for developing diabetes. Yet, while diabetes is often connected to an affluent lifestyle, diseases attributable to poverty – such as stunting, pneumonia, perinatal deaths and diarrhoea - also dominate the health profile. Getting public health attention to diabetes in the developing world is as such a great challenge; achieving this in the West Bank would seem an insurmountable task with the long ongoing dispute and strife adding further woes to an already overstretched and underfunded health system. Nonetheless, a dedicated group of health professionals and a Palestinian non-governmental organisation have set out to overcome these obstacles. Since 2003, the World Diabetes Foundation has given support to improve access to diabetes care for the Palestinian population. The first two projects were based in Jerusalem at the Augusta Victoria Hospital (AVH) and focused on capacity building and the establishment of a Diabetes Care Center in AVH. This third project takes place in the communities in the Ramallah District in the West Bank. It is designed to reach people where they live and facilitate access to health care for those who may have difficulties reaching Jerusalem. Specialised clinics in the communities The project entitled “Community based diabetes management” is a collaboration between AVH, the Danish non-governmental organisation (NGO) DanChurchAid and the Juzoor Foundation for Health and Social Development, a Palestinian NGO. The World Diabetes Foundation co-funds the project which runs from October 2007 until November 2010.  Two specialised diabetes clinics have been set up under the project in the towns of Shouqba and Beit Leqia in the Ramallah District through a collaboration between the diabetes team from AVH and community health workers from Juzoor. AVH provides the specialised knowledge, while Juzoor is responsible for establishing contact to the community and for education and group counselling of patients in the clinic.  On an every day basis, the clinic in Shouqba serves as a regular primary health care centre set up by the Palestinian Ministry of Health and AVH. Every Wednesday, the diabetes team from AVH arrives, comprising of a diabetes specialist, a foot specialist, diabetes nurses, a dietician, a lab technician and a health worker from Juzoor. On this particular day, diabetes patients are booked for appointments and are given full comprehensive services. To date, the clinic has 200 patients registered; the majority being diagnosed with type 2 diabetes and above the age of 40. A comprehensive model for care The high prevalence of diabetes in the West Bank means a heavy burden on the health budget, especially for treating complications. According to the Palestinian Ministry of Health, around 50% of their budget expenditure is spent on chronic diseases care and referral abroad for these conditions. “We decided to go into the community and disseminate a model which is effective in prevention and early detection, and to integrate diabetes prevention in primary care,” Dr. Tawfiq Nasser, CEO at the Augusta Victoria Hospital explains. The model he refers to is called comprehensive diabetes care model – as opposed to traditional diabetes treatment (biomedical model). Traditional diabetes treatment is clinic-based, i.e. people with diabetes go for follow-up visits at their practitioner’s who prescribes medicine based on their current state of physical symptoms and illness – without taking social and psychological factors into account. The comprehensive diabetes care model applied by the AVH Diabetes Care Centre and at the two model clinics in the community covers all aspects of diabetes care from prevention, screening and early detection to treatment and counselling on lifestyle and management of diabetes and foot care. “It is like a buffet of services at display to the patients who come in,” says Programme Coordinator of the World Diabetes Foundation Ms. Hanne Strandgaard who recently visited the clinic in Shouqba. Since the project is new and the data is limited, it is a little premature to fully evaluate the comprehensive model and its impact. But the reduction of HbA1c-levels in 99 patients over three follow-up visits is a very good indicator that the lifestyle modifications and counselling on diabetes management have a positive impact. The average HbA1c-level for 99 patients at their first visit was 10.2%, and at their third visit the same had fallen to 8.5% (the optimal cut off level is 7%). Diet. A dietician from the Augusta Victoria Hospital demonstrates a selection of healthy foods and how to prepare it.   Gestational diabetes as an entry point Part of the community-based diabetes management project is to screen all pregnant women for gestational diabetes. To date, 25 primary health care centres in the Ramallah District have been trained to carry out such screenings. Apart from its medical relevance, another reason for including gestational diabetes is that it is connected to the reproductive age and women in this age enjoy a certain respect because they are the bearers of the future offspring. “Children are seen as a kind of social security in a society with no established social security,“ explains Dr. Salwa Najjab, Director of Juzoor. “We do screening and support women in the reproductive age – and use the opportunity to empower  women to seek care as part of the screening procedure. Our aim is to improve the outcome of pregnancy, and screening is an important entry point,” says Dr. Najjab, who is a trained obstetrician and gynaecologist. “More than half of all marriages in the West Bank are so-called closed marriages, i.e. relatives marrying relatives. Although we have no official data on this, we know that it causes disabilities in the offspring. Another challenge to women’s health is that one third of women marry before the age of 18. When teenage girls are married off and get pregnant, they are not empowered to seek care and because they are not yet physically developed, their pregnancies are at high risk. The typical complications we see are hypertension and preeclampsia,” she explains. Although the prevalence of gestational diabetes is only 3%, Programme Coordinator Ms. Hanne Strandgaard believes that the gestational diabetes screening has a great potential for improving women’s health. “The regular training of health care personnel enables them to better counsel the women and deliver comprehensive care. This again means that women who do not normally prioritise their own health - due to heavy work load or responsibilities in the household – experience support and this encourages and motivates them to come back and search for more information,” she says. Positive spin-off effects The point about information is essential for Dr. Salwa Najjab: “I believe that information is the key to enlighten and educate the women,“ she explains.  “We started with this project because no one else in the health system works with women and diabetes. We use it as an entry point to women’s empowerment and capacitate them about health, their body, and their lifestyle. Now we really experience a change with the women enrolled in the project. They leave the house and take responsibility for the health of the family. They exercise and walk. This is actually a great improvement,” she says. While screening for gestational diabetes is a way of getting women to the health centre, it also provides momentum for educating them on nutrition and physical activity and this has a number of positive spin-off effects on their general health. Juzoor has introduced gym clubs for women in Shouqba and Beit Leqia and provided gym materials such as dumbbells, hula hops rings and gym balls. In spite of poor attendance to the first few classes, Juzoor Project Coordinator, Dr. Nadim Barghuthi has no doubt that the outreach activities have already brought about a change. “In the communities, we now see women doing more physical activity and losing weight. They have better HbA1c results. And we see women talking and with more power to manage. Some women are even able to manage the diabetes of their neighbours and that is an important change in comparison to not leaving the household or having any feeling of control at all,” he says.  DanChurchAid’s Programme Manager, Ms. Malene Sønderskov is hopeful that the good habits taught in the community-based project will stay with the women and help pave the way for better well-being and improved level of maternal care in the long term. “It is every mother’s wish to have healthy children – and to have a healthy pregnancy leading up to safe motherhood,” she says. Based on the success of this approach, this project model will be expanded throughout the West Bank. The World Diabetes Foundation will support a northern base in Nablus while DANIDA, the Danish Development Assistance, will support the southern base in Hebron. Both projects will be anchored in the Ministry of Health to ensure long term sustainability Read more about the project

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