Nurse-led continuum of care approach for addressing diabetes, Nepal

Objectives

Develop a culturally tailored and locally contextual diabetes training programme for nurses
Improve diabetes awareness in the community through nurse-led diabetes awareness campaigns
Detect diabetics early and link patients to quality health care provided through a nurse-led diabetes management programme

Approach

First the project will develop a diabetes nurse curriculum. The curriculum will be based on IDF and ADA guidelines and will be developed by the project advisory board and steering committee with members from all stakeholder groups during a national level workshop. Once the curriculum has been developed it will be accredited.

Subsequently, nurses will be recruited from the partner base hospital, outreach and primary clinics and trained in smaller groups during a two-week training programme. The trainings will be conducted by endocrinologists and other specialists. The trained nurses will be certified as ‘diabetes-nurses’. Community health workers (CHWs) will also be recruited and trained during a five-day diabetes training programme. The trained CHWs will serve as a link between the communities and the health care level and they will also support the roll out of various project activities.

Once the training is completed the implementation of the nurse-led diabetes prevention and care model across two selected districts will be rolled out. Screening sessions will be arranged by the trained nurses at outreach/primary clinics and the CHWs will mobilise the communities to participate. A referral mechanism will be established and diabetes cases diagnosed at screening camps will be referred to the partner hospital for treatment and care. The diabetes nurses will provide counselling of patients at group meetings at community level, and ‘patients clubs’ will be established.
Electronic patient registry will be developed and implemented at the base hospital and at outreach/primary clinics.

A community awareness programme on diabetes will also be rolled out by the trained nurses and CHWs incl. through radio and written media, awareness camps and community events.

Advocacy efforts will be undertaken to promote scale-up by continuously coordinating with health authorities. At the end of the project the results will be presented at a national conference

Results at completion

2 primary level clinics strengthened with improved diabetes care capacity
44 nurses trained as diabetes nurses
181 community health volunteers trained and mobilised.
8,558 people screened for diabetes
1,381 people diagnosed with diabetes and referred to care
An estimated 500,000 people reached through awareness raising via radio, written media and community outreach
Baseline/mid-line/end-line evaluations conducted