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®-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.