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Case studies - diabetes

• Case study 1: Management of diabetes in the Aboriginal population. Eyre Peninsula Division of General Practice
• Case study 2: Aboriginal diabetes group. Adelaide Western Division of General Practice
• Case study 3: Management of diabetes and obesity in the Koori people of Balranald Mallee Division of General Practice
• Case study 4: Diabetes in Aborigines: avoidance and control. South East NSW Division of General Practice
• Case study 5: Koori Program. Goulburn Valley Division of General Practice and Rumbalara Medical Clinic
• Case study 6: Macleay Hastings Valley's diabetes pilot. Durri Aboriginal Corporation Medical Service and Port Macquarie Division of General Practice

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Case study 1: Management of diabetes in the Aboriginal population - Eyre Peninsula Division of General Practice

Overview

The Management of Diabetes in the Aboriginal Population project was initiated in 1994 to target the estimated 700 urban Aboriginal people who live in Port Lincoln. As a group, the Port Lincoln Aboriginal population preferred to access services outside of traditional service locations (including the Aboriginal Health Service). Initially, the project developed informal ties with Aboriginal community members. In the second stage, the relationship was formalised with the establishment of an advisory committee to advise the project team on ways to increase service provision and encourage access to the service. A range of strategies was introduced in order to provide patients with access to flexible service delivery and education.

Aim

The broad aim of the project was to provide a culturally appropriate service provision mechanism to improve the management of Aboriginal people with diabetes.

Strategies

The following strategies were found to be effective in providing access to diabetes health care services for the Port Lincoln Aboriginal community:

• A project Advisory Group was formed with the Aboriginal Health Service and four representatives from the Port Lincoln Aboriginal community to determine how best to encourage Aboriginal people to recognise and manage diabetes. This was seen as an important step in the establishment of strong links between mainstream health services, Aboriginal Health Services and the Aboriginal community.
• A flexible service delivery model or home/community based health care service was implemented. Screening was conducted at a number of different sites including: the Aboriginal Health Centre; private homes; worksites; special functions; Aboriginal group meetings; and through mainstream services. Aboriginal health workers and the diabetes educator monitored the progress of people known to have diabetes and provided on-site education and support. If there were concerns about the patient's condition, then the patient was referred to the GP manager or the patient's own GP.
• A diabetes database was commenced, recording details about the patient, their history and current management.
• A community education programme on healthy eating and diabetes care was developed.
• Two diabetes camps were held. Camps addressed issues such as, healthy eating, foot care, eye care, psychological support in the form of "Understanding your diabetes" with general question and answer sessions, exercise, and "Quit" promotion (smoking cessation). Screening and monitoring was also available. Healthy meals were provided with a focus on "native tucker".
• Podiatry, ophthalmology and dietetics services were provided through clinics to which GPs were invited. This was seen to have two key benefits: improvement in the continuity of care in managing patient's diabetes; and providing the opportunity for Aboriginal people to meet less formally with their GPs, building trust and confidence and encouraging them to use traditional services more frequently.
• During the first year 14 Aboriginal health worker training sessions were undertaken involving education in areas such as, what is diabetes, healthy eating, foot care and hygiene, and problems associated with diabetes.
• The project team attended community group meetings to talk about diabetes, such as the Aboriginal Adult Education classes at TAFE, the Mallee Park Community Club, Kuju-CDEP, Lincoln South Primary School, worksite screenings, Port Lincoln Aboriginal Health organisations and Port Lincoln Aboriginal organisations.
• Annual reviews were conducted with known clients and family members. A healthy lunch was provided as these reviews were usually held in the client's home and often involved a large number of people. The project's GP Manager attended as did a dietitian and Diabetes Nurse Educator. Benefits of this activity were: the screening of 'at risk' family members; an increased awareness of good food choices through lunch provided; and relaxed and culturally appropriate education and introduction to healthy food choices.

Challenges

A major difficulty highlighted by the project team was that Aboriginal advisory group members, consultants, health workers and patients set personal priorities that did not always coincide with that of the project team. This meant that some initiatives took longer to get off the ground than the project had initially envisaged. A substantial amount of the project's time was spent on training and re-training of Aboriginal health workers. Initially, the knowledge levels of Aboriginal health workers were over-estimated and many basic skills in diabetes care needed to be taught. Also, Aboriginal Health Workers were found to have a high attrition rate that meant that considerable time was spent on re-training. There was a lack of local Aboriginal educational resources and it was necessary for the project team to create posters and other informational materials such as newsletters and recipe books.

Sustainability

This project has now finished. An Aboriginal women's group has continued some activities such as the cooking sessions with Port Lincoln Community Health Centre Support. Through the course of the project, the continued contact with health professionals in the community has resulted in an increase in the number of Aboriginal people who are now comfortable attending formal clinics and appointments.

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Case study 2: Aboriginal Diabetes Group - Adelaide Western Division of General Practice

Overview

The Aboriginal Diabetes Group project was initiated to encourage Aboriginal people in the North-West suburbs of Adelaide to participate in managing their own health. Patients who presented at the Parks Community Health Service were invited to attend fortnightly lunchtime Diabetes programmes involving the preparation of a healthy meal and the opportunity for participants to talk about issues related to diabetes. The project was begun in April 1995.

Aims

There were three aims of the program:

• To achieve better understanding and control of diabetes amongst a group of Aboriginal people with diabetes;
• To provide ongoing support amongst members of the group to make it easier to deal with diabetes;
• To discover the fears and concerns experienced by Aboriginal people who have diabetes and for these concerns to be addressed in an attempt to remove barriers to effective treatment and management of the condition.

Strategies that were found to be effective in providing access to diabetes health care services for the Parks Aboriginal community include:

• Employment of a part-time Aboriginal health worker to plan and organise the lunchtime meetings and other activities such as shopping for appropriate food.
• Free fortnightly lunchtime diabetes program meetings for the Aboriginal community with lunches modelled on an appropriate diet, organised excursions and guest speakers. The program was informal and would take place over lunch. The GP and Aboriginal health worker attempted to foster a friendly and supportive environment where problems with diabetes could be discussed in a culturally appropriate manner. The group gained in confidence with each meeting and by the end participants felt comfortable in sharing common understandings about diabetes and suggesting ways in which other group members could better manage their diabetes in the future.
• Transport was provided to and from the lunchtime meetings at the Parks Health Service.

Challenges

The project took considerably longer than was initially envisaged as the Aboriginal community set their own time-frames and priorities. The traditional medical perspective of the project team did not mesh with the Aboriginal community's group perspective that emphasised community activity over individual functioning and health. The project team learned to be flexible and to be aware of alternatives and other priorities, especially when related to family matters.

Sustainability

The programme had immediate effects in promoting access to mainstream health services for the local Aboriginal community, as a number of people who participated in the group subsequently made appointments to meet with the GP to discuss their health. The South Australian State Government has now taken on this programme.

Other issues

The project team believes that the involvement of family members in diabetes care is a key strategy for successful self-management of diabetes in the Aboriginal community. They found that whilst it was often difficult to get individuals to check their glucose levels, the time spent involving and informing family members, went some way to ensuring that this self-management task was supported and maintained. A visual poster model of diabetes appeared to work particularly well with the group. Participants were encouraged to ask questions and discuss complications associated with diabetes. The project found that the Aboriginal community approaches issues in a holistic way. If interventions are to be successful, health must be considered in connection with (for example), socio-economic and psychological concerns.

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Case study 3: Management of diabetes and obesity in the Koori people of Balranald Mallee Division of General Practice

The Management of Diabetes and Obesity in the Koori People of Balranald project was developed in response to concerns expressed by GPs working at the Aboriginal Co-operative that diabetes was not well controlled in the Balranald Koori community of North-west Victoria. GPs at the Aboriginal Co-operative had noted that Koori patients were not well informed about diet and that they did not have personal glucose meters or regular eye examinations. GPs were also concerned that random blood sugars conducted at the clinic were high. The project had initially aimed to also run the diabetes education and support groups with the Koori community at Robinvale in South-western NSW. This unfortunately did not eventuate due to resource restrictions. All Kooris with diabetes in the area were known to the general practitioners, and had expressed interest in learning more about the condition and its management. The project began in September 1995.

Aim

The aim of the project was to educate the local Koori populations in managing their own diabetes, through dietary education, encouraging weight reduction where needed, and education in the use of glucose meters, and provide information on the long-term complications of the disease.

Strategies

Strategies used to improve knowledge of diabetes management and encourage access to health care services for the Balranald Koori community included the following:

• A weekly diabetes group was held at the Aboriginal Co-operative. Koori patients with diabetes were invited by their GP to attend the group meetings. Participants were given a healthy meal, followed by presentations on diabetes management and instruction in the use of glucose meters by GPs with assistance from Koori family aid workers. The weekly sessions functioned as both an effective means for education and a support group. Each participant in the group was given a glucose meter. Group participants received instruction in the use of a simple and easy to operate meter.
• The weekly group meetings enabled participants to have their health monitored regularly by the team. Participant's weight, blood pressure and blood glucose levels were recorded at each session. Two information sessions from specialist care providers were provided for the group - a dietitian and podiatrist provided information and discussion on healthy eating and foot care, respectively. Transport was provided for group participants to the meetings.
• An Aboriginal health worker was seconded to facilitate transportation of group participants to the meetings, organise an 'appropriate diet' lunch and encourage group members to exercise. The Aboriginal health worker also acted as the contact person for group participants and the support person for family members.

Challenges

The group program had a set structure and limited time-frame, which meant that it was important that program participants were available for all sessions. Structured program attendance did not appear to mesh with the goals and priorities of group participants from the Balranald Koori community. This problem was experienced first-hand by the Aboriginal health worker who reported that she became discouraged when it was difficult to locate group members for each session. The project team discovered that the Koori participants were reluctant to write down information. This necessitated the use of simple, clear language so that all concepts and management strategies could be explained, repeated and understood verbally.

Sustainability

The project finished in late 1996. Evaluation of the program revealed that the group participants were better informed regarding diet, exercise, eye and foot care and had a greater understanding of the relationship of activity and diet to blood sugar levels. Armed with this new information and glucose meters the project team hoped that the people involved in the group would continue to monitor their own glucose levels and manage their health appropriately.

Other issues

A maximum of 16 people attended the group. Group members consisted of middle-aged to elderly Koori women; and with the exception of one man, Koori men did not access the group. This may have been because female GPs and allied health workers/providers facilitated the group sessions. The project team developed evaluation forms of the program to be completed individually by group participants. Participants however preferred to make comments and suggestions on the program collectively as a group.

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Case study 4: Diabetes in Aborigines: avoidance and control - South East NSW Division of General Practice

Overview

The Diabetes in Aborigines: Avoidance and Control project was developed to increase Aboriginal community knowledge about diabetes prevention, detection and management in the South-eastern area of NSW (South Coast, Southern Tablelands and Monaro districts). The project sought to provide broad based community level education about diabetes, diet and nutrition and to develop a diabetes screening and registration program. This project involved the Division of General Practice, staff of the Health Districts of south east NSW, and the independent medical services staff with the local Aboriginal community. The project commenced in July 1996.

Aims

Using a community development based approach the project aimed to:

• Provide health promotion information on diabetes and a healthy lifestyle;
• Screen for diabetes and complications;
• Provide education about diabetes avoidance and management, and introducing integrated diabetes management plans;
• Improve access to high quality primary care services for Aboriginal people with diabetes.

Strategies

Strategies that were used to increase Aboriginal community knowledge about diabetes and access to services included the following:

• A process of orientation and education for project staff was initiated 6-weeks prior to the implementation of the project. Project staff spent time with diabetes educators and dietitians, observing clinical sessions, accompanying them on fieldwork as well as receiving one-to-one briefing. Project staff also spent time with community Aboriginal health education officers, observing education sessions and attending community health staff planning meetings.
• A multidisciplinary Project Steering Committee was established which monitored and reviewed the progress of the project
• Employment of two Aboriginal Field Workers to implement the education and screening programs. One Aboriginal field worker was located on the South Coast and the other was based in Goulburn to cover the Southern Tablelands and Monaro areas. These two workers were be based in NSW Health facilities and had additional management support, access to vehicles etc. provided by NSW Health. They took program direction from the Health Outcomes Council.
• Ten Aboriginal diabetes community screening and education workshops were run across the Southern Area. Broad based community level education about diabetes, diet and nutrition was given using the Aboriginal Nutrition manual developed by Aboriginal Health Promotion Branch, WA Health Department, in conjunction with Aboriginal artists and Aboriginal health workers.
• A screening and registration program was developed and implemented at the workshops. This screening program linked into an integrated management plan incorporating GPs and Aboriginal health workers to ensure availability of therapeutic options and adequate review of diabetes control.
• Diabetes educators provided support to the project through training and education of the Aboriginal field officers and attended the workshops to assist with the screening program.
• Significant support and assistance with organising and holding the workshops was provided by the Katungal Aboriginal Medical Service and Aboriginal Health Service staff. The Southern Health Service provided office facilities, equipment and access to two vehicles.

Challenges

The project had initially envisaged the running of a diabetes camp. However, the Steering Committee decided that it was too premature to try and run a diabetes camp before sufficient education and information had been provided to the Aboriginal community to ensure adequate attendance at such a camp. The Steering Committee also considered that there were insufficient funds in the budget to hold a diabetes camp as most of the human and material resources would have to be brought in, as there were no Aboriginal people locally with the requisite skills to run such a camp.

The project was initially to be overseen by a GP management committee. However, GPs agreed locally that having two separate committees would be a waste of resources and GPs would be unlikely to attend meetings of two different committees. In order to ensure sufficient GP involvement there were four GP members of the Project Steering Committee. It proved difficult at times to retain Aboriginal consumer representation on the Project Steering Committee, however other members of the Committee gave considerable time and effort to ensure that there was representation from the Aboriginal community.

The project experienced some difficulties with staff retention. With three months of the project left to run both Aboriginal field officers and the project officer had left the division. The Steering Committee decided that the remaining funds could best be used to employ a consultant to develop an Aboriginal Diabetes Education Kit in consultation with the Aboriginal community.

Sustainability

The project was completed in 1997. At the time of data analysis, almost half of the people referred to GPs from the workshops presented at GP surgeries. The project team believes that the real rate may in fact be significantly higher (approaching 85%) as more people presented to GPs after the date of data analysis. The project also developed some specific culturally appropriate material such as pamphlets, flyers and a poster which have been distributed to various outlets across the area including general practices, community health centres, land councils and Aboriginal organisations. Development has also begun on an Aboriginal Diabetes Resource Kit for use by Aboriginal Health Workers in providing diabetes education to the Aboriginal community.

Other issues

A considerable amount of time was taken at the beginning of the project introducing the project to the relevant people and groups, both Aboriginal and non-Aboriginal. The preparatory work provided a sound basis for the subsequent stages of the project. This was an important process in order to achieve good communication and networking relations with the Aboriginal community. Even though a considerable amount of time was spent on this, the division reported that it probably underestimated the time it would take to meet with and establish a relationship with the Aboriginal community.

A multidisciplinary and intersectoral approach to the project was taken at all times with a range of allied health workers involved in the education and screening workshops as well as government and non-government agencies and Aboriginal organisations. This approach was seen to be necessary to the successful implementation of the project. It also opened channels of communication for GPs to have a greater role in local health policy decision making in regard to diabetes management and control in the Aboriginal community.

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Case study 5: Koori Program - Goulburn Valley Division of General Practice and Rumbalara Medical Clinic

Overview

The Goulburn Valley Division of General Practice has worked previously with the Rumbalara Medical Clinic in an multidisciplinary model to provide podiatry care and a diabetes educator for the local Aboriginal community. The Koori Program encompasses a number of activities designed to educate GPs in Aboriginal culture and increase the profile and accessibility of GPs in the local community. The introduction of GPs to the Rumbalara community is seen as a gradual process, with subsequent activities building in patient contact. Improvements in diabetes management are subsumed within a wider patient care initiative. Planning for the Koori Program began in late November 1997.

Aim

The Koori Program aims to improve the local Aboriginal community's access to mainstream health care services and high quality diabetes care, and strengthen links between the Division and the Rumbalara Co-operative.

Strategies

The following strategies were used to increase awareness amongst GPs of Aboriginal cultural, health and social issues as well as to increase General Practitioner profile and accessibility to the local Aboriginal community.

• A cultural awareness day for GPs was held at Rumbalara in November 1998 to promote respect and understanding of Aboriginal culture. Planning of this activity took place in consultation with Aboriginal elders. The cultural awareness day began with an information session covering Aboriginal history and culture - this was presented by staff at Rumbalara and local Aboriginal community members. Traditional foods were served at lunch and a local Aboriginal group performed traditional dances. After lunch, GPs and members from the local Aboriginal community formed groups to discuss the pros and cons of working with each culture. A process of upskilling GPs who work in the area of Koori health was initiated in February 1999.
• GPs have given presentations to members of the Aboriginal community on various aspects of health care at a Koori Men's Health night.
• Establishment of a Women's Health Clinic at the Rumbalara Aboriginal Cooperative Medical Centre.
• Development of locally relevant diabetic management guidelines and diabetic care proformas in conjunction with clinic staff.

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Case study 6: Macleay Hastings Valley's diabetes pilot - Durri Aboriginal Corporation Medical Service and Port Macquarie Division of General Practice

• promote the early diagnosis of Type 2 diabetes in 'at risk' individuals and groups;
• ensure all people with diabetes in the Macleay Hastings district had access to regular complications screening and appropriate management and services;
• measure the health outcomes of people with diabetes in the Macleay Hastings district.

• A number of successful diabetes clinics have been run over the past few years. Patients were not required to book ahead for these clinics, and access was provided to a GP, diabetes educator, dietitian and some podiatry.
• Three to four day diabetes camps are run annually. These camps are available to both people with diabetes and family members. Participants are given the opportunity to explore lifestyle issues and develop support networks. They receive education about diabetes complications and also learn stress management techniques.
• A diabetes complications game has been developed to help people learn about diabetes care and risk factors in a fun and relaxed way.
• Diabetes literature and brochures have been 'personalised' to fit the specific needs of the community.
• Durri provides diabetes talks at schools and TAFE in conjunction with a GP. They also conduct inservice training for school staff about diabetes.
• Funding from the pilot program provided training for an Aboriginal diabetes educator who is based at Durri.
• An important issue for Aboriginal health workers are the related social problems that Aboriginal communities face, such as poor housing, lack of refrigeration and in some cases electricity, and lack of transport. Durri has attempted to address some of these with outreach clinics to out-lying communities, exercise groups, a weekly fresh vegetable co-operative, shopping tours, and cooking demonstrations (occasionally providing bush tucker options).