Today, the International Diabetes Federation purports that 245 million people Already diabetes is a major cause of morbidity, premature mortality and …
Gwen Sascha Fernandes
Year 2 University of Wales, BSc HONS Podiatry
Placement Report
Korle-Bu Teaching Hospital and Ridge Hospital, Accra, Republic of Ghana
Table of Contents
I Introduction
II Illiteracy and Patient Education
III Dispelling Pre-Conceived Notions
Healer Shopping
Diabetes: A sign of weakness in Males
IV Diabetes: An Economic Burden
V Reflective Log: Korle-Bu Teaching Hospital
Diabetes Educational Talk
Podiatric Management of Diabetes
Clinical Assesment: Neurological and Vascular Profiling
Medications: Oral Anti-Diabetic Drugs
VI Reflective Log: Ridge Hospital
Dietherapy Clinic
Wound Management
Reducing Cross-Infection Risks
Learning Curve
VII Overview of Ridge and Korle-Bu Hospitals
VIII Bibliography
Non-Insulin Dependent Diabetes Mellitus NIDDM and its pathological
presentation in patients at Korle-Bu Teaching Hospital and Ridges Hospital,
Greater Accra Region, Republic of Ghana
I Introduction
In 1901, Albert Cook reported, that in sub-Saharan
Africa, diabetes was a
rather uncommon and very fatal disease Today, the International Diabetes
Federation purports that 245 million people worldwide are living with
diabetes and about two-thirds of these people live in developing countries
such as Ghana, in Sub-Saharan Africa The limited statistics available are
disturbing Although communicable diseases such as malaria and tuberculosis
are currently the main priority of health-care systems, non-communicable
diseases such as hypertension, dyslipidaemia and diabetes will surpass
these in under two decades Therefore the looming threat of a major health
catastrophe cannot be undermined Already diabetes is a major cause of
morbidity, premature mortality and disability and as such is a costly
disease bearing individual, psychosocial and economical implications
In developed countries, such as the United Kingdom, the keys to diabetic
patient management are well-organized foot care, good diabetes control and
patient education Diabetes awareness programs, leaflets, the internet and
written and verbal advice from health care providers facilitate in
solidifying a patients knowledge
about the disease Therefore, patient
empowerment is fundamental to successful self-management of diabetes and as
a direct consequence improves health outcomes Cavan 2001 However, this
proves to be a first in a long line of obstacles facing diabetic patients
II Illiteracy and Patient Education
As of 2003, UNESCO estimates that 25 of Ghanaian adults are illiterate
This automatically hinders the possibility of patient empowerment with
regards to written documentation about the disease At Korle-Bu Teaching
Hospital, the diabetic clinic holds over 80,000 patient records and each
day, around 160 patients attend the clinic from in and around the
catchments area They assemble before their appointment times for a health
education talk which details the minutiae of basic foot care, blood
pressure regulation, diet and exercise as well as additional information to
family members of diabetic patients Their blood glucose levels and blood
pressures are also assessed However, a large majority of these patients
have returned for more medications simply because they could not afford the
initial 3-month oral anti-diabetic medication This
further contributes to
the burden of health resources both physician and nurses Alternative
methods of communication are therefore essential to the diabetes awareness
campaign The medium of television has proved a useful tool in highlighting
not only the signs and symptoms of the condition but explaining to the
public that the nature of the disease is not shameful or spiritual but
rather a manageable condition where severe complications such as
amputations can be avoided In a country as deeply devout as Ghana, using a
pulpit to spread the news of diabetes and raise the profile of the
condition is common practice
The Traffic Signal Book is an excellent example of improvised health care
provision in Ghana The booklet contains a record of a patients blood
glucose levels on each visit and if a patient is unable to comprehend
numerical values, the colors are an alternative measurement tool Green
represents the normal spectrum of blood glucose between 3mmol/L and
6mmol/L, yellow indicates a glucose level of between 6mmol/L and 9mmol/L
while red indicates any value above 10mmol/L Patients were clearly
capable
of understanding this monitoring method and this comprehension also
extended to family members Hba1c testing is not routine and so this book
provides a valuable insight into the patients self-management of diabetes
compared to the previous months It goes without saying that daily testing
of blood glucose although ideal is not financially viable for the majority
of diabetics
III Dispelling Pre-conceived Notions
I Healer Shopping:
The spiraling diabetes figures have been blamed on a variety of factors
One of them is the inappropriate use of traditional medicine particularly
the practice of healer shopping The belief in a spiritual origin of a
chronic illness is prevalent in Ghana and is further compacted by belief in
the powers of traditional religious leaders and their apparent ability to
cure the effects of witchcraft In Korle-Bu traditional medicine proves a
bane to medical practitioners as it leads to non-compliance with
allopathically prescribed medication and a lack of lifestyle alteration in
terms of diet and physical activity However, Aikins 2005 stated that
healer shopping is a secondary practice in
Ghana, co-existing with
biomedical management, spiritual action and medical inaction
The crux of the matter is that people on low incomes are incapable of
bearing the cost of prescribed drugs and varied, modified diets and are
therefore driven to traditional ethno medical practitioners out of
necessity for medicines, psychosocial and spiritual support The study
therefore urged policymakers to focus on providing cheaper drugs, including
stringently-tested scientifically approved traditional drugs, and
establishing self-help groups for people with diabetes Interestingly, at
the Korle-Bu Diabetes Clinic, patients are encouraged to discuss their
illnesses with their peers thereby sharing experiences and breaking the
stigma attached to being diabetic This provides much needed psychosocial
support and encouragement
Another salient feature of the diabetes awareness campaign in Ghana is
breaking the various taboos associated with the disease This includes
dispelling the notion of the disease being contagious and/or shameful The
main focus therefore is basic health education: conveying the message
that
diabetes is a condition that is neither contagious nor shameful and as such
can be appropriately and successfully managed In this authors experience,
patients seem reluctant to report any anomalies with their health for fear
of the unknown/the worst Not all diabetic patients undergo amputations
Not all diabetic patients succumb to coronary heart disease CHD or heart
failure The following documents some of the myths and misconceptions
regarding diabetes in Ghana according to Diabetes Education Training Manuel
for Sub-Saharan Africa:
Eating too much sugar
Having sexual intercourse with a diabetic patient
Stepped on a Juju trap Juju refers to spirits or ghosts in African
lore
Juju House in the Gold Coast Harries 1873
Being bewitched
Being curses
Punishment by the gods
Diabetes is a disease of white men
Allopathic treatment cannot cure it but herbalists can
Understanding the culture of a country allows health
care providers to influence views on the disease and therefore determine
healing and prevention criteria Another example is the fact that obesity
is sometimes
considered as a sign of good health and prosperity This can
severely derail health eating patterns and increase the risk of diabetes as
well as create unnecessary obstacles for diabetes educational campaigns
II Diabetes: A Sign of Weakness in Males
Although diabetes is more common amongst males than females 77 vs
55, women comprise a majority of patients at the Korle-Bu Diabetes
Clinic Amoah 2002 The reasons for these seem deeply psychological Men
are less likely to seek medical attention due to embarrassment and
conviction of the superiority of their gender In the authors experience,
men less likely confided of their illness to family members and misconstrue
signs of diabetes eg erectile dysfunction as a sign of old age It is a
source of depression as many will call their masculinity into question and
this contributes to the pervading lack of understanding
Erectile Dysfunction ED in diabetes results from vascular disease and
autonomic dysfunction Prevalence of this condition varies from 30-70 from
40-70 years old and older However in developing countries such as Ghana,
erectile
dysfunction tends to be Intel Page 7 3/13/2008under-reported
The risk factors for ED include hypertension, type 2 diabetes, obesity,
smoking, dyslipidaemia, alcohol, tobacco and medication abuse and elevated
high sensitivity C-reactive protein CRP CRP is a member of the class of
acute phase reactants and its levels rise dramatically during inflammatory
processes CRP binds to phophorylcholine on microbes American Heart
Association 2007 At the Korle-Bu Teaching Hospital, Dr Albert Amoah is
conducting a study on ED and its determinants in Ghanaian males with NIDDM
or hypertension who receive care at the National Diabetes Management and
Research Centre This is in order to quantify the prevalence of ED in the
Ghanaian population and by extrapolation understand the consequences of
this condition for individuals and devise strategies for awareness and
treatment programs
IV Diabetes: An Economical Burden
Willis 2007 stated that diabetes also has significant health-economic
consequences, and the costs involved have a considerable impact on the
economy by way of production owing to sick leave, early retirement,
and
premature death In Ghana, diabetes is indeed an epidemic of significant
economic implications as limited health resources are burdened by the cost
of diabetes complications such as cardiovascular disease and peripheral
neuropathy The latter is characteristic of the disease and if untreated
can result in ulcers, eventual infection, gangrene and amputation
At the Ridge Hospital, the dressings room is inundated with diabetic
ulcers and although the clinic is extremely popular, there is huge problem
with patients who cannot return for daily dressings due to limited
financial resources This in turn leads to the development of chronic
wounds and increases the risk of infection occurring as proper care is not
administered on a daily basis Therefore, patients are incapable of holding
down a job and not only does the affected individuals family suffer but
economical advancement is hindered Those patients who undergo amputations
have dramatic changes induced on their lifestyle; loss of independence,
permanent inability to work and life-threatening complications When the
International Diabetes Federation 2003 predicts that in
the 15 years
leading up to 2010 diabetes in Africa will increase by 93, inaction is not
an option
V Reflective Log: Korle-Bu Teaching Hospital
I Diabetes Educational Talks
At the Diabetes Clinic, patients are given a health talk about diabetes
with particular attention to diet and physical exercise These talks
encompass a broad spectrum of topics Firstly the signs and symptoms of the
disease are defined as patients may exhibit only some of these and what is
particularly important to consider is that these people might relay
information to family members or friends who may be undiagnosed The
initial signs are hunger, tiredness, loss of concentration and
irritability Latter signs include sweating, convulsions, palpitations and
nausea Severe signs are coma and cardiovascular implications such as
myocardial infarctions MI or Cerebrovascular Accidents CVAs and
Transient Ischemic Attacks TIAs
II Podiatric Management of Diabetes
The importance of foot care is also detailed during these discussions
Tinea Pedis is a very common fungal infection that is pertinent in the
diabetic patients as the likelihood
of developing cellulitis inflammation
of the connective tissue underneath the skin due to infection by pathogenic
microorganisms particularly Streptococcus bacteria is increased Perhaps
the most common feature of advanced diabetic neuropathy is the loss of
sensation which can be verified with the use of diabetic filaments of
various thicknesses especially the 10 mg filament which represents a
threshold beyond which neuropathy is confirmed Perry-Coon 2002 According
to research conducted by Collier et al 1996 if a patient cannot feel a
touch with a special sized nylon filament, they are at high risk of
developing foot ulcers and infections In addition to this, a patient may
present normally painful clinical complications such as onychocryptosis or
heloma durum which goes unnoticed Zapf 1999 This clinical beacon
should provoke a health care provider to manage the condition to
effectively minimise the risk of serious pathology such as ulceration,
sepsis and amputation developing Watkins 2003 However, the use of
monofilaments as an assessment tool in Ghana is rare due its scarcity and
time constraints on the
part of the physician
As 10 of all diabetes patients will develop ulcerations of the foot, it is
one of the most prevalent clinical traits of diabetic sensory neuropathy
Wijnandts 2000 The ulcerations commonly develop on the margins of the
foot, tips of toes and heels, ie areas where intermittent compressive
stresses occur Due to the lack of sensation the hyperkeratotic lesion may
go unnoticed and eventually develop into necrotic tissue or ulcers Ulcers
can be secondarily infected by staphylococci, streptococci, Gram negative
organisms, and anaerobic bacteria; infection can quickly lead to
cellulitis, abscess formation, and osteomyelitis Hemstreet and Lapointe
2001 The clinical features present would be swelling, redness and pus
drainage through the skin London and Donnelly 2000 A health care
provider needs to identify the risk factors particularly with regards to
septic wounds as Watkins 2003 states that it can lead to gangrene of the
toes and in particular wet gangrene and its clinical connotations would be
swelling and discolouration Edmond and Foster 2006
III Clinical Assesment: Neurological and Vascular
Profiling
Clinical assessments are conducted on the basis of symptom presentation
This is due to limitations on available consultations times In my opinion,
these were extremely educational as I learnt to conduct complete
neurological and vascular profiling of a patient For example, testing for
effective cranial nerve conductivities by making the sign of the cross 20
centimeters above the supine patients face In addition to this I have
learnt to look for signs of organ disease quickly an effectively, for
example, yellow staining of the whites of the eyes suggesting jaundice
IV Medications: Oral Anti-Diabetic Drugs
Anti-diabetics drugs treat diabetes mellitus by lowering glucose levels in
the blood There are different classes of anti-diabetic drugs, and their
selection depends on the nature of the diabetes, age and situation of the
person, as well as other factors Sulphonylureas are widely used oral
hypoglycemic medications in Ghana Examples include Tolbutamide and
Glibenclamide These are only useful for treating NIDDM as they work by
stimulating endogenous release of insulin They work best for patients
under 40
years old, who have had diabetes for less than ten years but they
are contraindicated when there is severe renal or hepatic impairment,
pregnancy or ketoacidosis Biguanides such as Metformin are also commonly
prescribed as they are extremely effective in reducing hepatic glucose
output and increasing uptake of glucose by the peripheries, including
skeletal muscle
VI Reflective Log: Ridge Hospital
I Dietherapy Clinic
Medical nutrition therapy is an integral component of diabetes management
and diabetes self-management Its benefits are evident in both the long and
short term However, dietherapy intake needs to be highly individualized
and therefore a nutritional therapist is key in the diabetes management
team A dietician requires different information from both patient and
tertiary health care providers There are:
Age, Gender, Socio-economic circumstance, ethnicity, occupation,
literacy and numeracy
Ability and willingness to change nutritional habits and practices
Emotional implications of the disease
Clinical Information required includes: diabetes type, treatment
modality - insulin, oral
hypoglycaemic drugs or diet alone; current
physical activity levels; blood pressure; anthropometric measures:
BMI, waist circumference, alcohol consumption and tobacco use
At the Dietherapy Clinic I was able to learn how information is conveyed to
individuals with regards to the correct eating habits and choice of foods
The use of photos, colour posters, real models of food portions an fog
course reiteration is relied upon There is indeed a dearth of referrals to
the diabetic clinic which stems from inadequate referrals and lack of
Dietherapy resources As a result, the wrong information seems to spread
amongst diabetic patients and this in turns seeps through social circles
and family circles The Chinese whisper syndrome is further exacerbated
by the fact that nutritional knowledge is constantly being updates and this
can lead to an overwhelmed patient who is not only confused but demotivated
when it comes to making the necessary dietary changes The non-compliant
patient poses a bigger challenge to nutrition therapists as they are
seemingly too eager to please without realizing that change begins with
them Other
problems identified were: a balanced diet is not financially
viable for every patient, a patient is more likely to overeat if they are
arduous workers for long hours, and patients will alter diets based on non-
allopathic sources such as herbalists advice and local healer
recommendations
II Wound Management
Ive had several days practical experience at the Ridge Hospital which have
been the highlight of my trip Wound Management is an important facet of
diabetic patient management Keeping the wound dry and clean increases the
chances of healing and reduces the risk of infection It also will in the
long term reduce the cost of patient management However, there are various
problems associated with this facet of treatment Limited financial
resources means that ultimately the use of dressings and antiseptics are
modulated There is a lack of running water and generally the protocol for
maintaining good primary and secondary fields was not as stringent as it
could be Also a large majority of patients are incapable of paying for
daily dressings particularly those who cannot buy into the National Health
Insurance policies
thereby creating dilemmas for practitioners at this
secondary level due to professional and moral obligation to treat patients
despite the fact that patients cannot afford costs This is a salient
feature at Ridge where patients are followed up in the dressings room is
they have any outstanding balances in the hospitals There are allowances
made for those who genuinely cannot afford to pay and where there is a
desperate need for treatment
Using saline baths is a good practices for maintaining a clean wound and to
reduce infection rates but this is rarely done in Ghana This is because
only the wealthy can afford a boiler and patients often come to the clinic
just before their appointment in order to make use of their warm water
supply and therefore self-management of the wound is limited Therapeutic
benefits of bathing salts have been known for centuries King Solomon
presented the Queen of Sheba with Dead Sea salts on her visit to the Holy
Land and Cleopatra used beauty formulations including bath salts Saline
Baths sitz help de-slough a wound and present a dry base to the wound
thereby reducing consultation and treatment
times and allowing more time to
assess wounds It also has antiseptic properties as it disturbs the PH
balances of pathogenic microorganisms
III Reducing Cross Infection Risks
The risk of cross infection is significantly reduced by following simple
protocols that should be highlighted to all health care providers who enter
the septic room, aseptic room and injection room Maintaining primary and
secondary fields are obviously paramount with a one-way flow system from,
tray to patient A sterile green bag is used for discarding waste materials
such as old dressings Gloves should be changed if it has been
contaminated Cleaning the wound should be thorough always moving in a
direction away from a wound This reduces the risk of opportunistic
pathogens which naturally reside on the skin to gain entry into the ulcer
Good no-touch technique was demonstrated and as a new dressing pack is not
removed for each patient, this is imperative in order to avoid cross-
contamination
Bleach is used to wipe down surfaces while instruments are dropped in a
diluted bleach solution and gloves are dipped into a diluted
bleach
solution and then discarded In my experience, there isnt always a black
bin bag and so the need to reduce cross-infection is pressing Forceps are
not used in every circumstance as these are limited and are therefore
optional for a more serious wound, larger in size and depth The
instruments are scrubbed at the end of every day and then placed for 20
minutes in boiling water before being taken to CSSD in order to be
sterilized
Hand washing techniques are very different to those used in the Wales
Centre for Podiatric Studies Here the focus is mainly on the palms and
interdigital spaces and this was an area where I was able to use my
knowledge to improve existing techniques at Ridge Hospital Effective hand
washing can improve infection rates, reduce mortality figures and
positively impact patient throughput
IV Learning Curve
Working at Ridge was an informative experience and allowed me to gauge my
own abilities as a practitioner I was more aware of the need to be
vigilant, observant, compassionate and professionally competent It allowed
me to realize my own capabilities particularly
when the student nurses and
I were left to manage the diabetes clinic on our own for a few hours It
allowed me to be a part of the multi-disciplinary team and gave me an
insight into professional working life
Additionally I was able to appreciate that each professional, diabetes
educator, nurses, physicians surgeons, ward assistants, each of these had
an important and unique role to play in processing patients and making
sure they were receiving the most comprehensive treatment possible On a
surgical round, I was able to talk to several amputees and learn how their
life has changed as a result of the operation and of course the aftercare
available to them
VII Overview of Korle-Bu and Ridge Hospital
The trip has been invaluable on both a personal and professional level The
reason I chose Ghana was two-fold: its reputation as a friendly, hospitable
country where English was the national language and secondly, the fact that
a large proportion of patients admitted into hospitals are diabetics both
known and previously undiagnosed cases In the United Kingdom, diabetes
patients are well cared for with excellent follow-up programs and a
variety
of resources available to them Comparing Ghana would indeed be foolish
because as a developing country it still has a long way to go However, I
have learnt the problems that the health sectors face not just from
diabetes but from more pressing communicable diseases such as Tuberculosis
or HIV A Herculean effort is necessary Therefore the UNite for Diabetes
Campaign which culminated in World Diabetes Day November 14th is
important because it will highlight that diabetes is a pandemic and needs
immediate attention if countries are to develop and advance economically
The International Diabetes Federations has consistently reported on the
dearth of podiatrists on the African Continent and this trip has allowed me
to learn first-hand the diabetic pathologies effecting patients in Ghana
Diabetes is a global disease and therefore should be a global concern
Countries such as the United Kingdom have excellent diabetes management
systems and if these can be mimicked, diabetes can be controlled and
successfully managed I am already anticipating my next trip perhaps when I
am qualified so that as a rounded practitioner I
have a solid knowledge
base and skill set that I can draw from and thereby allow my colleagues in
both developed and developing countries to benefit from these and my
experiences, to ultimately provide the best possible solution for my
patients
VIII Bibliography
Aikins, AD, 2005 Healer Shopping in Africa: new evidence from rural-
urban qualitative study of Ghanaian diabetes experiences British Medical
Journal, 331-737
Amoah, AGB, Owusu,SK, Adjei, S, 2002 Diabetes in Ghana: a community
based prevalence study in Greater Accra Diabetes Research and Clinical
Practice, 563, 197-205
Anon, 2007 Ghana Illiteracy United Nations Educational, Scientific and
Cultural Organisation [online] Available from: http://globalisgvuunuedu
[Accessed 31st August 2007]
Anon, 2007 Inflammation, Heart Disease and Stroke: The role of C-reactive
protein American Heart Association [online] Available from:
http://wwwamericanheartorg [Accessed 1st September 2007]
Cavan, D, 2001 Giving power to the patients Modern Diabetes Management,
24, 15-16
Collierm JA, Kinion, ES and Brodbeck, C, 1996 Evolving Role of CNSs
in Developing Risk-Anchored
Preventative Interventions Clinical Nurse
Specialist, 10 3, 131-137
Edmonds, ME and Foster, AVM, 2006 Diabetic Foot Ulcers British
Medical Journal, 33 2, 407-410
Harries, 1873 Wanderings in Africa, from Liverpool to Fernando London:
Messrs Tinsley
Hemstreet, B and Lapointe, M, 2001 Evidence for the use of gabapentin in
the treatment of diabetic peripheral neuropathy Clinical Therapeutics, 23
4, 520-531
International Diabetes Federation, 2006 Diabetes Educational Training
Manual for Sub-Saharan Africa Dubai: Jumana Printers Ltd
International Diabetes Federation, 2006 The Diabetes Strategy for Africa
Dubai: Jumana Printers
International Diabetes Federation, 2006 Type 2 Diabetes: Clinical Practice
Guidelines Tanzania: City Printers
Perry-Coon, T, 2002 Free Diabetes Foot Screening Materials Department of
Health Medicaid Update, 17 9
Watkins, PJ, 2003 ABC of diabetes: The Diabetic Foot British Medical
Journal, 326, 977-979
Wijnandts, M, 2000 International Consensus on the Diabetic Foot British
Medical Journal, 321:642
Willis, M, Persson, U, Odegaard, K, 1999 Economics of a new treatment
for diabetic foot ulcers - The cost effectiveness of
Beclapermin in Sweden
European Association for the Study of diabetes Available from:
http://wwwigese [Accessed 1st September 2007]
Zapf, M, 2006 Sole Survivors-Preventing the Ultimate Tragedy Diabetic
Neuropathy [online] Available from: http://wwwzfootdoccom/newpage27htm
[Accessed 17th October 2006]
Source:cosyfeet.com
