Project: Community-Based Diabetes Control Programme at a Primary Health Centre

1. Title

2. Background and justification

3. Area and target population

• Area: Entire PHC catchment area, including all sub-centres and villages.
• Primary target group: All adults aged 30 years and above.
• High-risk groups: Persons with obesity or central obesity, family history of diabetes, hypertension, previous high blood sugar, sedentary lifestyle, tobacco/alcohol use, history of gestational diabetes, and women delivering a large baby.
• Known diabetes cases: All registered persons with diabetes, including those lost to follow-up.

4. Goal

5. Objectives

1. Screen at least 90% of adults aged 30 years and above for diabetes risk and raised blood glucose.
2. Create a line list and electronic/physical diabetes register for all diagnosed patients.
3. Ensure that at least 80% of diagnosed patients receive regular follow-up and essential medicines.
4. Provide lifestyle counselling to all high-risk persons and diagnosed patients.
5. Screen registered diabetes patients annually for blood pressure, kidney disease, foot problems and eye complications.
6. Reduce treatment default and improve glycaemic control among registered patients.
7. Build community awareness regarding healthy diet, physical activity, tobacco cessation and early symptoms of diabetes.

6. Baseline assessment

A. Community assessment

• Obtain village-wise population, age and sex distribution from ASHAs and sub-centres.
• Estimate adults aged 30 years and above.
• Identify vulnerable villages, urban slums, tribal areas or places with poor access to care.
• Map available resources: PHC laboratory, glucometers, medicines, referral hospital, ophthalmology services, diet counselling and transport.

B. Baseline survey

• Known diabetes and hypertension cases
• Family history of diabetes
• Overweight/obesity and physical inactivity
• Tobacco and alcohol use
• Dietary practices
• Treatment adherence and reasons for default
• Availability of blood glucose testing and medicines

C. Baseline indicators

• Number and percentage of adults screened
• Number at high risk
• Number with raised blood glucose
• Known diabetes patients on treatment
• Number with uncontrolled diabetes
• Number screened for eye, kidney and foot complications

7. Strategy and activities

A. Primordial and primary prevention

Health education and behaviour-change communication

• Village Health, Sanitation and Nutrition Days
• Gram Sabha meetings
• Schools, anganwadi centres, self-help groups and workplaces
• Posters, wall paintings, local-language leaflets and folk media
• World Diabetes Day activities
• Village walks, health rallies and healthy-cooking demonstrations

• Maintain healthy body weight and waist circumference.
• Walk, cycle, farm, exercise or play actively for at least 30 minutes on most days.
• Reduce sugar-sweetened beverages, sweets, refined flour foods and highly processed foods.
• Encourage vegetables, fruits, pulses, whole grains and other fibre-rich foods.
• Limit saturated and trans fats.
• Stop tobacco use and avoid harmful alcohol intake.
• Encourage adequate sleep and stress management.

Community supportive actions

• Organize village walking groups and yoga/exercise sessions.
• Promote healthy food options at schools, meetings and local shops.
• Encourage kitchen gardens and use of locally available vegetables and pulses.
• Coordinate with panchayats for safe walking spaces and community playgrounds.
• Encourage schools to reduce sugary drinks and junk food around school premises.

B. Secondary prevention: screening and early diagnosis

Population-based screening

• ASHAs will enumerate adults aged 30 years and above household-wise.
• Risk assessment will be done using the approved community NCD risk-assessment form.
• High-risk persons and all eligible adults will be mobilized to sub-centre/Health and Wellness Centre/PHC screening days.
• Measure:
  • Weight, height and body mass index
  • Waist circumference
  • Blood pressure
  • Random blood sugar or capillary blood glucose as per local protocol
  • Fasting blood glucose/HbA1c confirmation where indicated

Screening schedule

• Monthly village or sub-centre NCD screening sessions.
• Weekly PHC NCD clinic.
• Special camps for remote villages, workplaces and underserved populations.
• Opportunistic screening of adults attending PHC for any reason.

Confirmation and registration

1. Be called for confirmatory testing as per national protocol.
2. Be clinically assessed by the Medical Officer.
3. Be entered in the diabetes register and NCD digital platform where available.
4. Receive a patient-held card containing diagnosis, medicines, test results and follow-up date.

C. Treatment and continuing care

PHC NCD clinic

• Clinical assessment and prescription/refill of medicines
• Blood glucose and blood pressure monitoring
• Weight and waist measurement
• Diet, exercise and medication-adherence counselling
• Identification of hypoglycaemia, infection, foot problems and danger signs
• Review of complications and referral needs

Standard care package

• Individualized lifestyle advice
• Medicines according to approved national/state treatment protocol
• Blood pressure assessment and management
• Cardiovascular risk assessment
• Counselling on adherence and avoidance of self-discontinuation of treatment
• Foot-care education
• A definite next follow-up date

D. Prevention of complications and tertiary prevention

• Inspect feet daily.
• Wash and dry carefully, especially between toes.
• Do not walk barefoot.
• Use properly fitting footwear.
• Do not cut corns/calluses at home.
• Report any wound, redness, swelling, fever, numbness or colour change immediately.

8. Referral system

Refer urgently to CHC/district hospital if there is:

• Very high blood glucose with dehydration, vomiting, altered sensorium or suspected ketoacidosis/hyperosmolar state
• Severe hypoglycaemia or repeated hypoglycaemia
• Diabetic foot ulcer, gangrene, cellulitis or absent pulses
• Sudden visual loss or suspected proliferative retinopathy
• Pregnancy with diabetes
• Renal impairment or heavy proteinuria
• Uncontrolled diabetes despite treatment
• Suspected myocardial infarction, stroke or severe infection

9. Human resources and responsibilities

10. Recording, reporting and follow-up

• Village-wise screening register
• Diabetes case register
• High-risk/pre-diabetes register
• Defaulter register
• Drug-stock register
• Referral and feedback register
• Monthly NCD report/dashboard

• Unique identification number
• Patient-held treatment card
• Follow-up appointment
• ASHA contact details

11. Monitoring indicators

Process indicators

• Percentage of adults aged 30+ enumerated
• Percentage screened for diabetes
• Number of NCD clinics/camps conducted
• Number of ASHAs/ANMs trained
• Availability of essential medicines and test strips
• Number of health-education sessions conducted

Output indicators

• Number and percentage of high-risk persons identified
• Number of suspected cases tested for confirmation
• Number of new diabetes cases diagnosed and registered
• Percentage of registered patients receiving regular treatment
• Percentage screened for foot, kidney and eye complications
• Percentage of defaulters traced

Outcome indicators

• Percentage of registered patients with acceptable glycaemic control according to local clinical protocol
• Reduction in missed follow-up visits
• Reduction in diabetes-related emergency referrals
• Reduction in new foot ulcers and preventable amputations
• Improvement in knowledge and healthy lifestyle practices in the community

12. Time plan

13. Evaluation