Introduction
As the underdeveloped agrarian India of yesteryears is giving way to a modern rapidly
developing techno-smart India, type 2 diabetes mellitus is becoming a major health
concern. The North Eastern states are no exception to this disturbing trend. A purely
pharmacological approach to successfully contain the scourge of diabetes may be considered
insufficient at best! Factors beyond the pale of pharmacology, which include psychological,
social, and emotional challenges faced by people with diabetes, must be given due
consideration.
It has been acknowledged recently that management of chronic disease in general and
diabetes mellitus in particular is futile if the psychosocial factors are not given
due weightage. To this end, the recently published national guideline on “Psychosocial
Management of Diabetes in India”[1] is a commendable and timely step, to say the least! This is an improvement over
the other guidelines suggested by national and international stakeholders. However,
there is too much of generalization, and poor ′cross-cultural′ applicability is an
inadvertent limitation of the currently available guidelines. No wonder, they contribute
little to the local understanding of diabetes.
India is a vast country with diverse psychosocial environment. The linguistic, social,
cultural, economic, and ethnic heterogeneity of the North East India′s population,
and the unique presentations of the diabetes epidemic in the North East India justify
the development of guidelines for psychosocial management, sensitive to such needs
and limitations cogent to the North East India, and based on the region′s socio-cultural
strengths and resources.
Psycho-Socio-Cultural Landscape of the North East India
The North East India is an ethnographer′s paradise, where mind boggling diversity
in society, culture, language, religion, literacy, dress, and economy can be seen
amongst its over 220 tribes and ethnic groups, who live in 8 states: Arunachal Pradesh,
Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura. Assam includes
four distinct areas: Lower Assam, Upper Assam, Hill Districts, and Barak Valley. Each
state is home to multiple ethnic groups and tribes with rich cultural heritage. Many
unique factors affect diabetes management, by modifying availability, access to, affordability
of, and acceptance of modern health care.
Geography
Patients often face difficulty in access to health care. Although road density is
claimed to be fairly high in Mizoram and Manipur (43.97 and 42.95 m/km2, respectively), placing them at position 2 and 3 amongst all Indian states, most
of other states are not as fortunate. For example, Sikkim has an abysmally low road
density (8.74 m/km2), making it a challenge to access diabetes care facilities.[2] It is also notable that road density may not always translate to good connectivity.
Electrification is poor in Assam (37.1%) as compared to India (67.3%). The other North-eastern
states fare much better, but fall significantly short of the optimal requirement.
Naturally, it may be difficult to maintain cold chain in remote parts of the region,
thus making insulin or incretin use a challenge. This should be factored in while
choosing appropriate therapy for diabetes. Insulated pens, for example, can be used
to deliver insulin, or novel methods of insulin storage can be popularized. Extreme
climatic conditions are a challenge for health care providers as well. Mawsynram in
Meghalaya has the world record for maximum rainfall. Arunachal Pradesh and Sikkim
experience severe Himalayan winters, which leaves many areas snow-bound, and makes
it difficult to follow lifestyle modification and access medical care or drugs.
Human development index
North-East India (excluding Assam) scores 0.573 on the Human Development Index, thus
achieving 6th rank amongst all Indian states, comfortably above the all India average of 0.467.
Assam ranks 16th amongst all states, with a score of 0.444. This makes it relatively easier to propagate
psychosocial aspects of diabetes care, as communities, on the whole, accept and appreciate
“softer” markers of human development, such as quality of life.
Economic factors
Sikkim is the only north-eastern state with a per capita gross domestic product greater
than the national average (US $1,469 vs. $1,219). All other states have lower GDPs,
though Arunachal Pradesh, Meghalaya, and Nagaland are almost at the national mean
(US $1, 126, 1,025, and 1,015, respectively).[2] This means that financial factors will play major role in determining diabetes care
and cannot be ignored.
Literacy
Literacy of almost all NE states is higher than that of the national average. Aizawl
has a nearly 100% literacy rate (98.80% as per 2011 census). However, there do exist
pockets of high illiteracy.[2] There is a lack of educational material related to diabetes in local languages.
Media exposure is extensive in Manipur and Tripura, both of which have a higher percentage
of people exposed to media than the all-India average. Manipur in fact ranks 2nd amongst all states in this respect. Meghalaya and Arunachal Pradesh have poor exposure
to media, limiting its use as a vehicle for dissemination of diabetes awareness. Similarly,
television ownership is above 50% only in Mizoram.
Gender
Gender discrimination, mercifully, is less obvious in the North East of India. Many
tribes of Meghalaya, including the Khasis, Garos, and Jaintias, live in a matriarchal
society. Even here, however, the impact of diabetes on female care providers in family
is greater, as women shoulder the burden of supporting people with diabetes.
Medical Care
The North East India has a low doctor: Population ratio. Mizoram is the only state,
which has achieved the required number of doctors.
Since the demography of north east India is predominantly rural, even with a lower
rate of prevalence, rural population in India can be expected to constitute a larger
proportion of the diabetes population. The urban: Rural gradient in diabetes prevalence
is especially steep in Nagaland. Affirmative action is required on the part of diabetes
care professionals to ensure that no section of society is discriminated against,
as far as diabetes care is concerned.
Traditional and alternative medicine
The region has a wide range of alternative healthcare systems, which are patronized
by the general population. A considerable number of patients still utilize the indigenous
forms of medicine. Each tribe has its own medical system, and the rich ethno botany
of the region is just being uncovered. Plants used to manage diabetes include touch-me-not
and passion fruit in Meghalaya, ′bhadailata′ in Assam, turmeric in Manipur, and neem,
fenugreek, and jamun across the region. ′Puinam′ plant is used in Mizoram for management
of hypertension.
Methodology
The recommendations, specific to the North Eastern states, have been developed as
an add-on to the national Indian guidelines for psychosocial management of diabetes
in India.[1] The target is all diabetes care professionals in the region, but it is hoped that
this document will serve as an inspiration for all indigenous communities across the
world. The current recommendation has been developed partly in accordance to the American
Association of Clinical Endocrinologist (AACE) Protocol for clinical practice guideline
production.[3] Recommendations are assigned a grade for strength, but evidence level ratings (on
the basis of the quality of supporting evidence) have not been mentioned because of
lack of publications in this area. The guidelines have been written by a core group
of 15 authors, during a focused group meeting held at Sonapur, Assam, on 9 February
2013, and reviewed by a committee of six multidisciplinary experts from India. It
has been refereed by a South Asian panel of six reviewers from the neighboring countries
of Myanmar, Nepal, and Bangladesh, all of which have conterminous borders with North
East India, and by an international panel of four reviewers.
The recommendations try to transcribe the subjectivity of a complex psycho-socio-cultural
scenario into the objectivity demanded by modern evidence-based medicine. As mentioned
in the national guidelines, individual patient circumstances and psychosocial environments
differ. The ultimate clinical management should be based on what is in the best interest
of the individual patient, and what is appropriate for the local scenario, involving
shared decision making by patient and clinician. In the absence of local evidence,
health care professionals should follow “logical empiricism” while deciding appropriate
psycho-socio-cultural interventions.[4]
Recommendations on Psychosocial Assessment and Management
The guidelines mentioned in this communication follow the arrangement of the national
Indian guidelines. This work highlights unique North Eastern psychosocial recommendations,
while remaining a part of the larger, national, picture, to present a flavor of the
guiding principles of psychosocial management. Only fresh recommendations are presented
and have been broadly narrated in three clinical domains:
-
General assessment and intervention
-
Psychological assessment and management
-
Socio-cultural assessment and management
General
The social fabric of the North East is very strong and can be utilized to help improve
diabetes awareness and diabetes care. Peer support and community support can be generated
for better outcomes in diabetes management. A beginning should be made at healthcare
profession and at community levels.
Improving awareness/skills of healthcare professionals
Recommendation 1
Healthcare professionals must ensure linguistic and cultural competence to as great
a degree as possible (Grade A).
Recommendation 2
Physicians should be trained in patient empowerment, psychology of diabetes, co-existence
with traditional medicine, health economics, qualitative research, and medical writing
(Grade B).
Improving awareness among persons with diabetes
Recommendation 3
There is a need to create interactive educational modules for North East India, in
local language, using pictorial designs (Grade A). Pictorial visual aids are necessary
for some areas such as interiors of Nagaland, as Nagamese is only a (spoken) dialect,
not a formal (written) language with proper alphabet.
Recommendation 4
Services of ′lay′ diabetes educators picked up from amongst various supportive areas
of the existing health care delivery system such as anganwadi workers, auxiliary nurse
and midwife, pharmacist, phlebotomist, malaria workers etc., can be put into meaningful
services through empowerment and encouragement. Additionally or ′peer′ support from
well-motivated and intelligent diabetic patients can be utilized to improve diabetes
care. Such measures should help overcome the acute shortage of diabetic counselor
and educators prevailing in the region (Grade A).
Community-oriented approach
Recommendation 5
Given the huge respect shown to their individual commune amongst all ethnic population
of the North East India, the community should be targeted as a unit, to dissipate
education on healthy nutrition, physical activity, and lifestyle through multiple
approaches (Grade A).
Recommendation 6
Improving community awareness about diabetes should be done through community leaders,
religious organizations, youth groups, and non-governmental organizations such as
weekly sermons by churches, discourses by Moulvis after ′Namaz,′, street dramas in
Manipur, discussions in ′Namghars,′ small music festivals in Nagaland and Mizoram
etc., (Grade A).
Recommendation 7
School children should be sensitized to the importance of preventing diabetes and
other non-communicable diseases, through health education, included in school curricula
(Grade B).
Recommendation 8
Community support must be garnered for people with diabetes, as part of normal praxis,
by involving village headmen, gamboras in Assam, pastors, and village councils (Grade
A). The Mizo code of ethics or dharma focuses on “Tlawmngaihna,” which means that
it is the obligation of all members of society to be hospitable, kind, unselfish,
and helpful to others. Tlawmngaihna is that moral force, which finds expression in
self-sacrifice for the service of others, and can be invoked to encourage community
support for people with diabetes.
Recommendation 9
Physicians should increase noise level regarding diabetes in the community, and unite
to curb misleading advertisements and propaganda by alternative therapy practitioners,
regarding cure for diabetes, must be curbed (Grade A).
Optimization of access to medical care
Recommendation 10
Therapy should be tailored to the unique geographical characteristics and seasons,
e.g., availability of monitoring facilities, drug supplies, and frequency of follow-up
visits (Grade A).
Psychological assessment and management
The North-eastern Consensus suggests the use of simple, less time-consuming instruments
for psychological assessment. The easiest tools for use in primary care settings [and
diabetes clinics] are the Whooley questions and the WHO-5. The two Whooley questions[5] are:
“During the last month, have you often been bothered by feeling down, depressed, or
hopeless?”
“During the last month, have you often been bothered by little interest or pleasure
in doing things?”
Recommendation 11
The Whooley questions and the WHO-5 are appropriate tools for psychological screening.
Screening and management should preferably be done by diabetes care professionals
(Grade A).
Recommendation 12
To be reliable, validated translations of these tools must be available for health
care professionals (Grade A).
Coping and counseling therapy
Recommendation 13
It is recommended that people with diabetes, their healthcare professionals, and family
members should receive coping skills training.
High-risk behavior counseling
Diabetes is frequently associated with human immunodeficiency virus (HIV) infection.
Recommendation 14
Physicians should be trained to evaluate for HIV in diabetes and for diabetes in HIV.
They should be trained to provide related counseling (Grade A).
Social assessment and management
In north-east India, diverse social, cultural, as well as religious economic, psychological,
regional, educational, and familial factors impact the clinical progression, treatment,
and outcome of any disease management. Thus, one needs to lay emphasis on working
on the environment (eco-sensitivity) and medical anthropology for better management
of diabetes. Physicians must not overlook the concept of ethno pharmacy, which largely
refers to variability of perceptions of patients from different social background
(ethnicity) to the same therapeutic agent.[6] Diabetes care professionals must also be aware of the ethno botany of the area they
practice in, as some plants used for the management of diabetes may cause hypoglycemia.
The influence of social background or ethnic group on the incidence and management
of diabetes is observed nationally as well as in the North-East. Fibrocalculous diabetes
mellitus, for example, is more common among the Bodo tribe, but is not observed in
other ethnic groups inhabiting the areas in and around Bongaigaon, Assam.
Recommendation 15
Physicians must be sensitive to socio-cultural environment of patients while choosing
therapeutic options to promote greater adherence to therapy and improve outcome (Grade
B).
Custom/Religion
Different religions including Christianity, Hinduism, Buddhism, Islam and traditional
religions are followed in the North East. This information is necessary for health
care providers, who may wish to use religious sayings to motivate patients to follow
better healthcare-related practices. The Galos of Arunachal feel that disease is caused
by malevolent spirits called Uyos, who have to be worshipped with help of village
priests or Nyibos. Instead of trying to displace such age-old customs, modern diabetes
care professionals should learn to co-exist with them. Burha-cha (god of healing)
is worshipped in Tripura and can be invoked to help increase the efficiency of modern
diabetes care.
Folk music and song are integral part of North-eastern culture. For example, Shumang
Lila and Phampak Lila of Manipur can be harnessed to improve diabetes awareness by
requesting composers and organizers to include health promotional messages. Indigenous
outdoor sports such as mukna, mukna Kangjei (Khong Kangjei), sagol Kangjei (Polo),
yubi lakpi (Coconut Rugby), oo-Laobi, hiyang-Tannaba, arambai Hunba should be encouraged
as a means of physical activity.
Festivals and feasts, like the ′Losar′ in Sikkim and Arunachal Pradesh, ′Losoong′
in Sikkim, ′Choskar′ in Arunachal, ′Bihu′ in Assam, and Durga Puja and Christmas and
Eid across the region, can be utilized as platforms for dissemination of diabetes
care-related messages. At the same time, diabetes therapy has to be modified during
these festivals to manage the swings between feasting and fasting that inevitably
occurs.
Recommendation 16
Indigenous forms of folk dance, music, and theater must be utilized to promote healthy
practices related to diabetes (Grade B).
Recommendation 17
Indigenous sports should be promoted as a means of socially acceptable physical activity
(Grade B).
Recommendation 18
Diabetes therapy should be tailored to specific needs during periods of fasting and
feasting (Grade B).
