Problem: The majority of children in Nicaragua with Type 1 diabetes live a very difficult life and typically die in their late teens or early twenties. The main reason is that proper management is unaffordable, and often inaccessible, for the poor. This involves both the cost of blood glucose testing materials, as well the difficulty of bringing those patients who live outside of Managua to that city each month to receive their insulin medication. Insulin and syringes are provided by the government. Daily testing of blood sugar levels is also necessary, and the test strips used for this purpose are not provided by the government. Most of the patients are from poor families (many of them extremely poor) who cannot afford the testing materials, which does not allow them to regulate metabolic control of their blood sugar levels.
A non-diabetic person normally has blood sugar levels around 100mg/dL. The Type I diabetic children in Nicaragua typically have blood sugar levels in the 300 to 500mg/dL range. With sustained levels this high they become lethargic, depressed and sick. The reason that they cannot test their blood is that the cost of one test strip in Nicaragua currently ranges from $0.30 to $0.80. It is recommended that they be tested four times a day, with an absolute minimum of two times per day. With subsistence wage being around $3 a day, there is not enough money for even one test strip when the rest of a family's needs must also be met. The government has only been able to afford the provision of insulin and syringes. The result is suffering and an early death for these children. The only way to delay the onset or progression of diabetes complications is to establish and maintain good metabolic control.
Objective of the Overall Project: The objective of the overall project is to revolutionize the care of Type I diabetes in Nicaragua, and replace the present situation that is not working with one that allows persons with Type I diabetes to live healthy and productive lives and is within the resources of the country of Nicaragua. The primary objective of this program focuses on Type 1 diabetes, which is in a crisis situation. However, the incidence of Type 2 diabetes is a rapidly growing problem and the human and other resources developed in this program would be a critically important component of an expanded program in the future addressing the prevention and management of Type 2 diabetes and other diseases of an endocrine origin.
Collaborating Partners: We have assembled a team of collaborating partners that have been developing project elements since mid-2015. These partner organizations are:
1. Association of the Parents of Children and Youth with Diabetes in Nicaragua (APNJDN)
2. Catholic University of Nicaragua "Redemptoris Mater" (UNICA)
3. National Ministry of Health of Nicaragua (MINSA)
4. Foundation for Worldwide Health (FWWH)
5. Loma Linda University (LLU)
The FWWH has led brigades of health professionals and students affiliated with Loma Linda University on annual mission-of-mercy trips to Nicaragua since 2000. We have collaborated closely with UNICA since 2008 and operate clinics with students of both organizations working together providing free care in poor neighborhoods. We were approached by the APNJDN during the June 2015 trip for help in addressing the problem of Type I diabetes in children. At that time, the team of Collaborating Partners was formed and began working on potential solutions. Over the ensuing year, members of the partner organizations communicated regularly via conference calls, emails, shared draft documents, and developed an outline of the different components that would comprise the project. This outline was discussed and refined through multiple face-to-face meetings and site visitations in the FWWH trip to Nicaragua during 10-19 June 2016.
Project Elements: Several major project elements have been identified:
1. An educational component that includes developing appropriate protocols and quick reference guides for professionals and parents, This is a train-the-trainers approach that will allow dissemination of this education throughout the country.
2. Conducting a collaborative project in communities outside of Managua to develop a standard of care for extending diabetes management to regional centers, and
Objective of the Educational Program: revolutionize the care of Type 1 diabetics in Nicaragua by developing a cadre of healthcare workers throughout the country trained in the issues of Type 1 diabetes management and by having an effective education program for parents of Type 1 children so they can more effectively manage this disease at home.
1) Education Component: The objective of this component is to develop a cadre of healthcare workers throughout the country trained in the issues of Type 1 diabetes management. A great deal is known about the proper care of children with Type I diabetes. The most important components of care include early recognition of signs and symptoms, proper insulin dosing and administration, balanced nutrition, exercise, and comprehensive psychological care. What is desperately needed is a methodology for a program that works in a resource-poor setting like Nicaragua. There is need for an effective platform to present and receive information for the providers of care, as well as Type 1 diabetic children and their parents. The FWWH has developed a Quick Reference Guide in Spanish that has been printed as pocket-sized flip charts to be used by clinicians, and another to be provided to the parents of diabetic children. Modifications of these would be printed in poster-size format to be used in educational presentations to the public. This pocket guide is a key element in the program. It provides on-the-spot clinical information to healthcare personnel working with diabetic patients, and the parents' guide is an invaluable reference tool for helping their children survive and lead productive lives.The goal for FWWH is close involvement with this educational effort through 2018 to ensure widespread training of individuals from all parts of the country. Having a core of persons well trained in managing diabetes will allow this program to "scale up" so that a tested and verified management approach can be implemented throughout the country. There will be pre- and post-session surveys of participants to get feedback on the value of the program and to solicit suggestions for improvement. This component of the initiative Will cost $19,250 for participation of FWWH and local personnel in the June 2017 Educational Conference, the 2017 November National Diabetes Conference, printing and distributing the Quick Reference Guide for healthcare personnel throughout the country, and administrative costs within the country of Nicaragua.
2) Collaborative Project in Outlying Communities: The objective of this component is to test and implement a treatment protocol that works and is appropriate for a resource-limited country like Nicaragua. This will be a collaborative project in outpatient settings in cities and communities outside of Managua. It will start in the city of Matagalpa (population of 150,000), which is located in a mountainous region north of Managua and is approximately a two-hour drive from Managua. It will expand to a total of five locations, with 20 patients at each, for a total of 100 patients enrolled. This program will test a strategy for establishing a standard of care for managing Type 1 diabetic children. The title of this effort is "Two Drops for Hope: A collaborative project on the implementation of a standard of care for Type 1 diabetic children in a Nicaraguan community." This collaborative project is also a critical element of the overall program. Having a management protocol that has been tested and verified will allow the health officials and the Nicaraguan healthcare community to roll out this program with confidence that it will work.
This pilot project is projected to last for two years, and involves in-country training sessions with FWWH professional staff. This is an extremely important part of the overall strategy because the existing system of care has to change.The collaborative project will start at the Hospital Escuela Cesar Amador Molina in Matagalpa. At present, there is no outpatient clinic of any type at this hospital, which is also a teaching hospital for medical students. The plan is to involve physicians and nurses who have already attended one of the educational conferences discussed in the preceding section. A total of 20 families with a Type 1 child will participate in the study, with the intent of developing a two-strip per day protocol that keeps patients' blood sugar within acceptable levels.Developing a system of outpatient care at regional hospitals is a critical need, and this is typically complicated by the lack of an outpatient clinic, as noted above. Thus, a primary goal of this collaborative project involves identifying what facilities are needed and securing sustainable supplies for blood sugar level testing and insulin distribution for such outlying areas. All the information developed during the collaborative project will be helpful in achieving this goal. If the model developed proves successful, it can be rolled out to the rest of the country with confidence. The cost of this component of the project will be $44,700 For participation in the February 2017 Collaborative Program training in Matagalpa, purchase of the diabetic testing supplies that will be used in the two-year program, and administrative costs within the country.
Collecting data and assessing the outcomes of these two components are critically important components of the program. The overall goal is to develop a protocol for effective management of Type 1 diabetes that is sustainable with existing resources in Nicaragua. An important consideration is that developing a program that works in Nicaragua should have important implications for developing similar programs in other resource-poor countries.
Rotarians from two clubs in Nicaragua will be overseeing the project and the dispensing of the funds. They will be visiting the hospitals, interacting with the local partners, and participating in the assessment of the community needs and outcomes of the project. Rotarians from District 5330 will be traveling to Nicaragua periodically to participate in the program.