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Five years on… Improvements in diabetes care in Trinidad and Tobago

Diabetes is a serious public health problem in the Caribbean region, causing around 13 percent of deaths. It affects one in five adults and accounts for substantial health service costs. Although type two (non-insulin-dependent) diabetes can be treated effectively, the poor quality of healthcare services may result in inadequate patterns of care and sub-optimal treatment outcomes. How can the quality of care be improved?

Researchers from Kings College London and the Trinidad and Tobago Ministry of Health (MoH) addressed this question. They conducted a baseline survey of 690 people with diabetes at nine health centres in Trinidad and Tobago in 1993 and reported the results to the MoH. Over the next five years they issued guidelines on diabetes management to health centres and conducted annual training workshops for healthcare staff. To assess the impact of these changes, they surveyed 1579 patients with diabetes attending 23 health centres in 1998. They also received questionnaire responses from medical officers and nurses at the participating health centres.

The survey showed that:

22 percent of patients were given foot examinations in 1998 compared with six percent in 1993. The proportion receiving eye inspections increased from one to nine percent over this period.
Dietary guidance was given to 54 percent of new patients in 1998 compared with 35 percent in 1993. The proportion receiving exercise advice rose from three to 34 percent.
63 percent of medical officers and 85 percent of nurses thought that the quality of care had improved over the five-year period.
31 percent of medical officers and 60 percent of nurses felt that more resources were now available.
There were favourable changes in drug utilisation, with greater use of shorter-acting drugs to control blood sugar and more appropriate selection of agents to reduce blood pressure.
However, there were no changes in indicators of metabolic control, body weight or blood pressure control among patients.

The authors noted that:

Other changes over this period, such as health sector reforms, changes in staffing and pharmaceutical company promotions may have contributed to the observed changes.
Preventative care of the feet and eyes deserves greater emphasis.
Improvements in health outcomes are likely to take longer than five years to achieve.

Some policy-relevant conclusions of this study include:

Clinical interventions for type two diabetes are generally thought to be relatively cost-ineffective. However, the increasing burden of illness means that some investment in diabetes care is required.
Preventative care is likely to be more cost-effective than the use of hospital services for late stage complications of diabetes, but poor quality of care may lessen the effectiveness of preventative interventions without reducing their costs.
An audit study linked with educational interventions for healthcare staff may contribute to improving standards of diabetes care in a middle-income country like Trinidad and Tobago.

Source(s):
'A five year evaluation of intervention in diabetes care in Trinidad and Tobago' by M. Gulliford and D. Mahabir, Diabetic Medicine 16 (1999)
Related sources: 'The rising global burden of diabetes and its complications: estimates and projections to the year 2010' by A. Amos, D. McCarty and P. Zimmet, Diabetic Medicine 14 (1997)
'Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS33) by the UK Prospective Diabetes Study Group, The Lancet 352 (1998) Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 22 February 2002

Further Information:
Martin Gulliford
Department of Public Health Sciences
GKT School of Medicine
Kings College London
Capital House
42 Weston Street
London SE1 3QD
UK

Tel: +44 (0)20 7848 6631
Fax: +44 (0)20 7848 6620
Contact the contributor: martin.gulliford@kcl.ac.uk

Guy's, King's and St. Thomas' School of Medicine, UK

Deepak Mahabir
Specialist Medical Officer
Nutrition and Metabolism Division
Ministry of Health
Laventille
Trinidad and Tobago

Tel: +868 625 2296

Trinidad and Tobago Ministry of Health

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