Clinical Audit on the Provision of Diabetes Care in the Primary Care Setting by United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)

OBJECTIVE: United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides primary health care services including care for diabetes and hypertension, with limited resources under difficult circumstances in Gaza, West Bank, Jordan, Lebanon and Syria. A total of 114,911 people with diabetes were registered with UNRWA health centres in 2011. The aim of this cross-sectional observational study was to assess the quality of diabetes care in the UNRWA primary health care centres. METHOD: The study population consisted of 1600 people with diabetes attending the 32 largest UNRWA health centres and treated there for at least one year. Between April and Sept. 2012 data from medical records, including results of clinical examinations and laboratory tests performed during the last one year, current management including self-care education and evidence of diabetes complications were collected and recorded in a previously validated data collection form (DCF). Patients were interviewed and clinically examined on the day of the audit and blood collected for HbA1c testing which was done at a central lab using High-performance liquid chromatography (HPLC) method (HLC&reg-723G8 Tosoh Corporation, Japan). Data was transferred from paper records into a computer and analysed with Epi-info 2000. RESULTS: Type 1 diabetes was present in 4.3% and type 2 diabetes in 95.7%. Co-morbid hypertension was present in 68.5%;90.3% were either obese (64.0%) or overweight (26.3%). Clinical management of diabetes was largely in line with UNRWA’s technical instructions (TI) for diabetes. Records for 2 hour postprandial glucose (2 h PPG), serum cholesterol, serum creatinine, and urine protein analysis were available in 94.7%, 96.4%, 91.4% and 87.5%, cases, respectively. Records of annual fundoscopic eye examination were available in 47.3% cases but foot examinations were less well documented. Most patients (95.6%) were on anti-diabetic drugs—68.2% oral anti diabetic drugs (OAD) only, 14.4% combination of OAD and insulin, and 12.9% insulin only. While 44.8% patients had 2 h PPG ≤ 180 mg/dl, only 28.2% had HbA1c ≤ 7%;55.5% and 28.2% had BP ≤ 140/90 and ≤130/80 mm of Hg respectively. Serum cholesterol ≥ 200 mg/dl, serum creatinine ≥ 1.2 mg/dl and macro albuminuria were noted in 39.8%, 6.4% and 10.3% cases respectively. Peripheral neuropathy (52.6%), foot infections (17%), diabetic retinopathy (11%) and myocardial infarction (9.6%) were the most common long term complications. One or more episodes of hypoglycaemia were reported by 25% cases in total and in 48% of those using insulin. 17.7% and 22.6% cases received no or ≥4 self-care education sessions respectively. CONCLUSION: The study confirmed that UNRWA doctors and nurses follow TI for diabetes and hypertension fairly well. Financial constraints and the consequent effects on UNRWA TI and policies related to diabetes care were important constraints. Key challenges identified were: reliance on 2 h PPG to measure control;non-availability of routine HbA1c testing, self-monitoring of blood glucose (SMBG) and statins within the UNRWA system;and high levels of obesity in the community. Addressing these will further strengthen UNRWA health system’s efforts of providing services for diabetes and hypertension at the primary care level. Given that most developing countries either have no or only rudimentary services for diabetes and hypertension at the primary care level, UNRWA’s efforts can serve as an inspiration to others.

Customized Standalone GIS-Based Tool for Ground Water Quality Assessment: Gaza Strip as a Case Study

Employing the full versions of GIS software with its numerous functions to manage case-specific applications is becoming inconvenient for many reasons. A convenient solution that is spreading worldwide to solve this problem is to develop customized tools that use the same GIS concept to meet specific applications. The water resource department in Gaza strip has been facing technical and financial difficulties in using the full GIS versions in managing groundwater resources. Thus, the objective of this paper was to develop a customized standalone GIS-Based ground water quality assessment tool (GWQAT) to be used by the water resources management department in Gaza strip. GWQAT was developed using Microsoft visual basic programming language, a regression mathematical model, map objects, and map files generated from ESRI ARC Info. GWQAT was designed to achieve many functions such as mapping, map overlaying, buffering, charting, soil hydro-geological profiling, and predicting future groundwater quality parameters variations. The simplicity and validity of GWQAT was demonstrated by its application on the groundwater quality parameters in Gaza strip wells with emphasis on chloride concentration.

Evaluation of the Microclinic Social Network Model for Palestine Refugees with Diabetes at UNRWA Health Centers

Background: UNRWA provides primary healthcare for around 5.9 million Palestine refugees (PRs) in Jordan, Lebanon, Syria, West Bank and Gaza. In 2015, UNRWA started, in cooperation with Microclinic International (MCI), to implement an innovative diabetes program, aiming at improving awareness about diabetes care among PRs with Diabetes Mellitus (DM). This program takes advantage of a unique model of “microclinic” MCI social network program, a novel social network based on diabetes education intervention. Methods: A quasi-experimental study was conducted to evaluate the impact of the UNRWA-MCI program in 115 UNRWA’s HCs in Jordan, Lebanon, West Bank and Gaza. 1000 participants were randomly selected from around 60,000 participants in the program. After training 996 nurses on UNRWA-MCI diabetes care modules, groups of 10 - 15 participants with their social networks (around 20 participants in each group) attended eight weekly sessions, during which the program was introduced. Anthropometric and blood pressure (BP) measurements were collected on weekly basis, while glycated hemoglobin (HbA1c) was tested before involvement in the program and after completion of sessions with a three month period between both measurements. SPSS Version 22 was used for data analysis. The study protocol was reviewed and cleared by UNRWA, Health Department ethical committee. Results: Out of 1000 patients randomly selected for the evaluation of the impact of the program, 969 (81.9% females, 18.1% males) have completed the study. The average weight loss was 2.0 ± 4.6 Kg and significant improvements were seen in waist circumference (WC), HbA1c and BP (p ≤ 0.001 for all). Overall drop in HbA1c was 0.6 ± 1.2 with 8.5% increase in patients with HbA1c < 7.0 and 9.8% decrease in those with HbA1c ≥ 7.0. About 10.0% of patients with abnormal BP (higher than 140/90 mg/dl based on UNRWA’s criteria for BP of diabetics) had shifted to normal BP. Conclusions and Recommendations: UNRWA-MCI program improved anthropometric measurements, HbA1c and BP in diabetic PRs. It improved diabetes care management for PRs, and led to the involvement of their social networks to support their behavior change for a healthy lifestyle.