The post of Community Diabetes Specialist Nurse (CDSN) was developed in 2005 to improve access to diabetes services for the ethnically diverse population living in Barton, Tredworth and White City. Initially instigated and funded by Community Counts, a local government pathfinder organisation. Gloucestershire PCT has now mainstreamed the role and the CDSN works alongside another CDSN in Gloucester City. Their diverse roles include:
- Supporting and educating health care professionals to provide quality diabetes care
- Developing policies and guidelines for diabetes
- Reviewing people with diabetes
- Providing structured group education for people with diabetes
As part of the CDSN role, the Khush Dil (which is Hindi for Happy Heart) Project has been developed to address some of the specific diabetes-related health needs for local communities.
The project commenced in November 2006 to provide culturally appropriate diabetes information to local people, but particularly targeting Black and Minority Ethnic (BME) residents. The Khush Dil Project is collaboration between Gloucestershire Primary Care Trust and Takeda UK Ltd, a pharmaceutical company who provide initial training support and has continued ongoing resourcing of the project.
The 2007-2008 phase of Khush Dil has consisted of two services:
- Clinic based at an inner-city surgery
- Weekly physical activity sessions for women
Although both services were aimed at all ethnic groups, the physical activity sessions have worked particularly well with the local South Asian community.
1. Khush Dil Clinic held at Bartongate Surgery
Bartongate Surgery is based in the inner city of Gloucester with a practice population of 8679 with 405 people with diabetes, which is an above average percentage of 4.6%. The lead diabetes GP and the Practice Manager agreed to pilot a regular Khush Dil clinic led by the CDSN. The clinic aimed to provide intensive, culturally appropriate diabetes care to BME people with Type 2 diabetes within the practice with an HbA1c of greater than 8%.
A search was performed to identify all of the practice clients with an HbA1c greater than 10%. 14 people with diabetes from differing BME backgrounds were identified as suitable for the clinic.
The clinic was initially held at a community venue next to the surgery, this was to try to de-medicalise the clinic experience and due to restricted room availability, but moved to the surgery when a regular room became available. This has made clinic administration easier as data was able to be inputted directly onto the surgery IT system and made clinical decisions easier as the CDSN had access to the full medical records and blood results, ensuring that treatment changes were made on the day of the consultation. The CDSN is an independent nurse prescriber, and regularly prescribes for the clinic clients using PCT and the surgery protocols.
Clinic structure and personnel: It was agreed that the clinic would be held fortnightly and 4 clients would be seen per session. The clinic dates were set for 12 months in advance. The CDSN ensured that all appointments were for 45 minutes to allow for the extra time required when assessing and educating people through interpreters.
The issue of language was identified as the main potential barrier and one of the multi-lingual practice receptionists was approached and agreed to participate in the clinics as clinic assistant. This provided many benefits: she was familiar with the clients, was able to translate for most of the clients, and was familiar with the IT system within the surgery (EMIS). It was agreed that her role would include telephoning the clients to book the initial appointment, arranging blood tests 2 weeks prior to the appointment if necessary, telephoning the clients the day before to remind them to attend, and translating and supporting the CDSN within the clinic. She also books interpreters for clients who speak languages she is not personally able to support.
2. Physical Activity Sessions
Previous reports have identified that members of BME groups in Gloucester city are less likely to access mainstream physical activity (particularly women due to lack of female only provision). It is well documented that BME communities (in particular people of South Asian origin) are more likely to develop Type 2 diabetes, hypertension and other cardiovascular risk factors (UKADS 2004). To address some of these issues the Khush Dil team liaised with local community groups to establish a weekly exercise group. Although the sessions would be open to people from all ethnicities, it was decided to provide women-only sessions initially as there is a large Muslim community locally, meaning that it is not always possible for men and women to exercise together.
The main challenge initially was encouraging women to attend. The sessions were publicised in a variety of ways, including distributing flyers outside local schools and displaying posters in local shops as well as promoting through Gloucester surgeries.
The instructor has successfully maintained the membership of the class, and between 13 and 20 women are currently attending regularly. The current sessions focus on improving strength and flexibility with a variety of chair-based exercises, improving strength with the use of resistance bands, and also incorporate some breathing and relaxation. The women attending have decided themselves to increase the intensity, and often request circuits of the room at either a fast walk or a jogging pace to increase their heart rate.
The women have also requested that their weight is recorded weekly. This is supplemented by quarterly health checks undertaken by the local Community Diabetes Specialist Nurse. The health checks incorporate blood pressure, waist circumference and blood glucose measured via a capillary blood sample.
The clinics commenced in April 2007 and to date 35 clients have been seen and only 5 non-attenders (DNAs) (as of January 2008 which was when the last audit was performed).
An evaluation event was held to assess how the women would like the group to develop. A variety of questions were asked and the feedback highlighted that in addition to the weekly exercise, the women would like information on education about food, weight loss advice and improving diet, weight management.
The finding shows a reduction in HbA1c and clients have reported enjoying attending the clinics and several clients have requested appointments at the recommendation of their friends and family. Clients are also demonstrating an increased understanding of their diabetes, particularly relating to the impact of health eating, activity and regular medication in controlling their condition.
1. The clinic room is supplied free of charge by Bartongate surgery and the additional cost is that of the Clinic Assistant/Interpreter. Takeda UK Ltd provided additional support in the form of educating practice staff to perform in-depth searches and audits relating to the clinic. They also provide ongoing financial support to pay for the clinic assistant, and initially for the hire of the community venue. Any equipment and literature required has been supplied by the DSN.
2. CDSN time for education sessions and health checks has been provided free of change as part of the CDSN role.
1. Khush Dil Clinic held at Bartongate Surgery
The findings shows a reduction in HbA1c but the reduction in blood pressure, cholesterol and weight were not as large for the Khush Dil clinic. The potential reasons for this may be due to the CDSN only prescribing for glycaemia (individuals identified with hypertension or abnormal lipids are referred back to the GP – these consultations do not have the benefits of long appointment slots and an interpreter to explain the mechanisms of the tablets, which may potentially affect concordance). Another reason is that the CDSN has not routinely recorded weight or blood pressure at the appointments unless there was a clinical need, therefore there is not as much data recorded.
Issues were also identified from the clinic; many people with diabetes feel that information given to them by health staff is difficult to apply to their lifestyle. An example of this is the situation of early morning prayers for Muslim clients, as some of them do not want to eat early in the morning (which may increase their risk of hypoglycaemia), or may have 2 breakfasts as they rise early for prayers then return to bed and have a second breakfast later in the morning. The recommendations of ‘regular mealtimes’ to maintain stable glucose control can therefore be difficult to attain using regular medications. It was also found that the South Asian Muslim clients commonly use a large amount of oil when preparing their food.
Within the Eastern European community it emerged that many people work long shifts and are not granted paid leave to attend diabetes appointments. This has resulted in appointments being missed. Shift work can also pose problems for people who need to regulate their eating patterns to control their diabetes.
Dietary problems affect all communities. However, the specific issues relating to Eastern European communities include lack of facilities to prepare healthy meals when living in shared accommodation, and erratic eating patterns due to working long hours. The cardio-protective message regarding dietary fat intake is often difficult to translate to the local population.
Another issue that has been identified is several people with diabetes seen in clinic reported discontinuing their diabetes medication for a number of reasons. It appears anecdotally that many Asian clients will take half the amount of all tablets recommended by practice staff. This potentially causes problems for health care professionals as they are reviewing blood results and individual outcomes on a different treatment than is documented in the client’s records.
Other South Asian people with diabetes have more faith in traditional medication to control their diabetes. An example of this is a husband and wife who have stopped taking their Western medication in favour of traditional Indian medication.
Moreover, upon assessment many people with diabetes of all cultures and ethnicities attending the clinic do not have a good comprehension of their diabetes. Many of the appointments are focussed on basic education about the mechanisms, complications and treatments of diabetes. People with diabetes are demonstrating improved concordance with their lifestyles and medicines (as shown by reductions in cholesterol, blood pressure and HbA1c) which they verbally attribute to understanding how the tablets work and why they need to take them regularly.
The success of the clinic has depended upon the motivation and ability of the clinic assistant who facilitates all of the clinics and follow up, enabling the CDSN to focus on assessment, care and education. The clinic assistant also offers cultural and religious advice, ensuring that interventions suggested by the CDSN are appropriate to each individual. An additional benefit of the clinic is the length of consultations that enables full assessment and identification of barriers to improving control, making the CDSN’s recommendation for change more holistic.
The audit also identified that the DSN was not frequently monitoring and recording weight. It would be beneficial to ensure that this is undertaken at each consultation due to the potential health benefits to be gained by weight control.
2. Physical Activity Sessions
The weekly activity sessions have been specifically effective with the South Asian community and the model has been considered to apply to other communities and areas of Gloucester. It has also highlighted the need to develop the capacity of local residents to become fitness instructors and the PCT are currently exploring how this could be developed.
Participants report enjoying the clinic experience, DNAs are low, and diabetes-related clinical outcomes are good. However, it would be useful to monitor the long-term effects of the intervention to assess if diabetes control deteriorates once people with diabetes are discharged from the clinics.