QUALITY IMPROVEMENT PROJECT: DIABETIC

HEALTH EDUCATION
JACKSON C 201531653
BOPAPE M.E 200622850
MOHUBA B. 201513160
MALAI LB 201410483

GROUP 3 SOSHANGUVE CHC 2020

  
INTRODUCTION

Diabetes is one of the most common chronic conditions in South Africa leading to significant
morbidity and mortality in South Africa. Based on the 2015 statistics from the International
Diabetes Federation (IDF) there are approximately 2.3 million adults aged between 20 – 79 years
with type 2 diabetes in South Africa of whom 60% remain undiagnosed. It occurs in all sectors of
society with a similar prevalence in rural informal dwellers and urban formal dwellers.

Worldwide the number of people who die annually from diabetes exceeds the combined mortality
from HIV/AIDS, tuberculosis and malaria and that is expected to rise. For example, it is anticipated
that the number of people in Africa with type 2 diabetes will have increased by 140%.The diabetes
epidemic is driven by interrelated risk factors including positive family history, psychosocial
factors, overweight and obesity, and insufficient physical exercise. The rise in prevalence of type 2
diabetes is predominantly associated with modifiable risk factors, the important of these and one
that demands urgent attention is obesity.

In our 2 weeks of rotating in Soshanguve Community Health Care Centre we have come to realise
that 1 in every 6 patients (between the ages of 35 and 60) is a diabetic patient and most of them do
not know much about a diabetic diet and the major importance of diet in their condition. Diabetes
mellitus is defined as a chronic debilitating metabolic disorder with heterogenous aetiologies , it is
characterized by chronic hyperglycaemia and disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin secretion, insulin action or both. with serious acute and
chronic complications. As it is a disorder in the way the body processes glucose, diabetic patients
should really be cautious of the food they eat and have sufficient knowledge of what they should
and shouldn’t eat based on their source of income.

A diabetes diet simply means eating the healthiest foods that are naturally rich in nutrients and low
in fat and calories. Key elements are fruits, vegetables, and whole grains, in moderate amounts and
sticking to regular mealtimes. This is in fact the best eating plan for everyone.

1. forming the team

1.1. The team was formed by approaching each team member separately and explaining the
problem to them. We asked permission if they would like to be a part of the team and
explained what would be required from them. The team consists of 11 members.

1.2. TEAM MEMBERS AND THEIR ROLES

NAME ROLE AT CLINIC ROLE IN QIP

Sister Clinic Manager  Permission for the health talk and to put up
Dieketseng posters and hand out pamphlets
Msiza
Dr Mayisela Family Medicine  To assist with health education by handing out
Registrar pamphlets during consultations
 To offer guidance on our QIP
Dr Masango Senior Consultant  To approve our topic and offer guidance on our
QIP.
Lerato Zitha Dietician  To assist with health education by handing out
pamphlets during consultations
 To assist in spreading the word to the other
 doctors to do the same
 To offer guidance on our QIP
 Help identify problems on what to include in
the talk and pamphlets
Hector Chauke Chronic Nurse  To assist with health education by handing out
pamphlets during consultations
 To assist in spreading the word to the other
chronic nurses to do the same
Tsholo Tshikane Soshanguve Community  To assist with venue for health talk
Health Care Centre  To assist and be present at health talk
Health Promoter  To continue providing health talks and handing
out pamphlets in the morning while patients
are waiting in the que
 To arrange a microphone for the health talk.
 To assist with chairs and Prestik
 To arrange patients to speak to.
 To arrange the support group leader to attend
Anna Occupational Therapy  To speak about complications and
Madonsela Technician rehabilitation
Support group Daphne Kgoadi  To assist with spreading the word to the
leader community during her support group meetings
Linah Patient  To provide patient perspective
Mthimunye  To assist with spreading the word to the
community
Evah Bobape Final Year MBCHB  To hand out questionnaires.
student  To assist with translation at the health talk.
 To buy fruit and make fruit packages.
 To do the welcoming, introduction and
pathophysiology of diabetes and closing at the
health talk.
 To assist with printing and lamination of
posters and pamphlets.
 To do references in report.
Bertha Mohuba Final Year MBCHB  To hand out questionnaires.
student  To buy fruit and make fruit packages.
 To speak about complications of diabetes and
signs and symptoms of hypoglycaemia and
hyperglycaemia and what to do in this instant.
 To design poster.
Lesedi Malai Final Year MBCHB  To arrange team members.
student  To hand out questionnaires.
 To speak about diabetic foot care and the
importance of exercise.
 To assist with data interpretation and reporting.
Christie Final Year MBCHB  To arrange team members.
Jackson student  To hand out questionnaires.
 To speak about what a balanced diet entails
and when to eat, portion control and which
 foods to avoid.
 Pamphlet and questionnaire design.
 To type out report.

1.3 SUCCESSES IN TEAM FORMATION

All team members were helpful and approachable. We met with the dietician directly where she
gave comprehensive advise on what to educate the patients on. She offered constructive criticism on
the questionnaire. She also suggested we include health promoters on in the team. Upon following
the dieticians advise, Dr Masango assisted us in finding the health promoter. The health promoter
who was very helpful and enthusiastic to help and be apart of the team. The team consist of a wide
variety of health care workers that can offer different perspectives and enable us to approach the
problem in a more holistic manner.

1.4 DIFFICULTIES IN TEAM FORMATION

Getting everyone together in a room at the same time was difficult as our team members are very
busy and already overloaded with work and patients. Some team members are also only available
on certain days. We instead decided to approach each team member separately which took extra
time from our side but we managed. Often, we were unable to get hold of team members as they
were busy in meetings or not available on that specific day and we would have to keep trying the
following day to get hold of them. This slowed down the process of implementing change.

3.1 PROBLEM DEFINED

 Patients lack health education on diabetes mellitus.

3.2 PROBLEM DESCRIPTION

Patients have difficulty in explaining what foods they are able to eat, which foods to avoid, how
much they are allowed to eat and how many times in a day they should be eating. When enquiring
about their diet one is able to pick up that they are not following a proper diet for their condition,
When observing snacks that they carry with them into the consultation room it is clear that the
patient does not have a thorough understanding of the correct diet that they should be following to
manage their condition. They are unaware of foot care and other diabetic complications.

3.3 HOW TOPIC WAS CHOSEN

While we assisted with taking anthropometry, we noticed that most diabetic patients are overweight
with an increased BMI. Many of these overweight or obese patients did not know how to lose
weight safely. One patient asked about only eating one meal a day and drinking water for the rest of
the day and if this was safe for them to do in order to lose weight and control their blood glucose.
There was another patient that was carrying scopas, fizzy sweets and a large fruit with a fizzy drink.
Her glucose was high at the time and she was also overweight. After seeing this patient, we became
more aware of other diabetic patients and started enquiring about their diets, especially uncontrolled
and or obese patients.

We also observed that doctors have very limited time to provide comprehensive diabetic health
education to their patients. While consulting with the dietician she mentioned that she is not there
every day and that she only sees complicated uncontrolled patients. Many patients also advised that
despite being diagnosed with diabetes they had never been referred or seen a dietician. This is
against the EDL guideline where all patients need to be seen annually if there is a dietician
available.
The health promoter admitted that since COVID 19 she has been unable to give health talks inside.
There are limited educational health materials in the clinic. There are no diet education posters up in
the clinic. The dietician has comprehensive diabetic pamphlets but has run out of copies.

4. SET STANDARDS

4.1 STANDARDS USED FOR ACCEPTABLE PRACTICE

According to the EDL, management for diabetes includes education about diabetes and its
complications, to know what dietary and lifestyle modifications to make and to be informed about
self-care practices3. In accordance with this, we set educational standards to achieve in our health
promotion. These include:
 To understand what having diabetes means and the lifestyle changes it requires to prevent
complications and to know what these complications are.
 To know and be able to use portion control.
 To know what to eat to have a balanced diet.
 To know healthier food options.
 To know which foods to avoid.
 To know what the normal blood glucose level is.

4.2 HOW STANDARDS WILL BE MEASURED

 After our health promotion, we will hand out questionnaires assessing patient knowledge
based on the above standards.

MEASUREMENT OF PRESENT PRACTICE

5.1 Ten Questionnaires were handed out to random diabetic patients to assess their current
knowledge. See attachment for the questionnaire.

5.2 GRAPHS
From the tables, graphs and pie charts above it can be concluded that people did indeed have a lack
of health education on diabetes and after our interventions the knowledge did improve.
5.3 TEAM THOUGHTS ON RESULTS BOTH BEFORE AND AFTER

Feedback from one of the doctors was that we should translate the pamphlet into the local language.
Dr Mayisela was not surprised with the lack in the patients' knowledge about diabetes. She said that
many healthcare professionals don't spend the time to educate their patients and that healthcare
professionals take it for granted that patients know everything when actually they don't. She was
very impressed with the pamphlet and said it really helps her to direct her health education in a
quick manner. She likes that she is able to give the patient something to take home.

Sister Chauke was not alarmed by the poor knowledge reflected in the pre-questionnaire, as there is
not time to provide comprehensive health education and the clinic is also short staffed. He again
highlighted that the dietician is only available twice a week. He said it would be great if the heath
promoter was able to continue providing health education on diabetes on a more regular basis. He
also mentioned that poverty plays a big role in patients' diets.

Ms Tshikane was very interested in the results. She asked us to please send them to her. When
asking about her thoughts about the results, she didn't have any thoughts at that time but was very
happy to see there was improvement. She mentioned that although they are actually supposed to be
3 health promoters, one health promoter has moved to another clinic, and another is retiring soon
and very seldom at the clinic. She is the only one at the clinic. This makes it difficult for her to do
all the health promotion by herself, especially when she has to also do COVID -19 health promotion
in the community. She was keen to continue doing health promotion in the mornings in the parking
when she is able.

Sister Msiza was very impressed with the change. She was happy with our project and asked us to
please share the educational materials with her so that she is able to make copies of the pamphlets
when the clinic runs out. We will email these to her. She said that with COVID-19 the health
promoter is very busy and time is limited to educate patients and that the clinic will need to rely on
these educational materials i.e. posters and pamphlets. She confirmed that health care workers take
patient education for granted.

We would have liked to receive feedback and comments from other team members but they were
unfortunately not available at the time.

6 PLANS FOR CHANGE

Improve patient diabetic health education through the below interventions and actions:
 Health talk to be given while in the que outside.
 Improve health educational materials
◦ Make more copies of the dietician’s comprehensive pamphlet
◦ Design a smaller more summarised pamphlet to be given out during consultations
◦ Posters to be displayed in waiting areas and consulting rooms.

7. IMPLEMENTATION
7.1 CORRECTIVE ACTIONS/INTERVENTIONS
 Permission to have a health talk and to display posters and distribute pamphlets was
obtained from the manager.
 The health promoter was approached to assist with the health talk. She assisted with the
venue, the chairs and the microphone. She also assisted in arranging for the leader of the
support group to attend and benefit from the talk.
 The dietician was consulted with regards to the content for the health talk, poster and
pamphlets.
 Before the intervention, questionnaires were handed out to assess patient knowledge.
  An hour health talk was given on the 9 th of September while patients were waiting to go
inside the clinic.
Topics covered in the talk and the pamphlets and posters covered the standards set above as well
as extra topics included
 Pathophysiology of diabetes
 What it means to have diabetes and the lifestyle changes it requires to prevent complications
and what these complications are.
 What portion control is and how to measure food sizes easily.
 What a balanced diet entails, which are healthier food options and which foods to avoid.
 The symptoms of hypo and hyperglycaemia and what to do in these instances.
 Diabetic foot care

7.2 MONITORING OF CORRECTIVE PLANS

 We checked daily to see if the posters are still up.
 We checked to see if pamphlets have been given out by counting the number of pamphlets
left at the end of each day.
 We re-circulated a questionnaire for patients to fill in after the health talk to see if there has
been an improvement in the understanding of their condition and the diet they should be
following.

8. EVALUATE EFFECT OF CHANGE

 Posters are still on the walls and the pamphlets are less in the consulting rooms.
 After our health promotion talk, the patients were able to answer the questionnaire based on
our above standards correctly. There was an improvement in patient knowledge as indicated
in the graphs above. Surprisingly, before the health intervention, the lowest scores were
achieved on knowledge about what diabetes is and how to do portion control. We feel these
are simple things to explain in a consultation or in the waiting area. We feel it is necessary
for every diabetic patient to know what their condition is.

9. DISCUSSION
What was going on throughout process:
 We were constantly in contact with each other as group members and held meetings
amongst ourselves weekly as students and would then approach the other team members
separately and update them as the process unfolded. We sat and discussed the content of our
health promotion together after consulting the dietician.
 We were originally unsure of how to set our standards but after consulting Dr Masango and
referring to the EDL were had a better understanding on how to approach them and we
agreed upon these standards together.

Describe Pains:
 Arranging funds for our educational materials and fruit packages was painful.
 Time management to meet every week with everyone was very difficult. We had to find
each team member separately. It was also not always easy to find our team members and
they were always busy.
 The COVID-19 fumigation the day before our health talk made it very difficult to locate all
our team members at the clinic was empty. We were also unable to find the health promoter
that day and we wanted to finalize arrangements before our health talk the next day.
 It was painful to have to sanitize each pencil between use when handing out the
questionnaires.
 There was no shade where we gave the health talk and many patients got hot.
 There were not enough chairs
  The backlog of patient from the previous day when there was the fumigation made the
crowd really large and disorganised but the health promoter assisted with finding order.
 Some of our standards cannot be measured as yet and need a longer time.

Describe Gains:
 The audience participation and interaction with all their questions during the health talk was
encouraging. It gave us a sense that they take their condition seriously and wanted to know
more about it. We were able to clarify misunderstandings and misconceptions that they had
that we had not even thought of. In this sense, the health talk became more patient centred
where everyone was relaxed and felt comfortable to ask for clarity.
 Many of the patients did not know about the support group and they were keen to join it and
to help further spread the word.
 After hearing about a glucometer, a few of the patients were interested in purchasing one for
themselves, this also indicated that they take their condition seriously and that we had made
an impact and were heard.
 We improved our team working skills and how to accommodate with each other and meet
each other halfway.
 We improved our own knowledge on diabetes.
 More patients know how to avoid complications and how to manage their plate and glucose.
 We assisted the health promoter and dietician in health promotion. We gave the health
promoter a copy of one of our posters and pamphlets to assist her with continuing the health
promotion.
 The leader of the community vegetable garden also attended and we gave them seeds to
assist with their healthy-eating food project.
 By providing pamphlets to give to patients we are able to give them something to look at
and read at home, it also assists the doctors during their consultations to help educate the
patients.

Have we been able to improve: by how much and in what areas?

Yes, there has been an improvement. Patients are more knowledgeable about their condition and the
diet and lifestyle modifications it requires. The knowledge improved as seen in the graphs above.
We have improved the health education material at the clinic by putting up posters and making
pamphlets to hand out. We have also given the health promoter these materials to continue with
diabetic health promotion.

What are bottlenecks?

Some of the doctors forget about the pamphlets and need reminding to hand them out.

10. CONCLUSION

As described by the WHO, quality means the best health outcomes that are possible, given the
available resources, and that are consistent with patient values and preferences. To achieve the best
health outcomes, we need to make quality assurance a routine part of daily practice. It is important
enough to allocate time and resources to a process of continuous quality improvement. Most of
South Africa’s health districts , family physicians work in poor resourced circumstances. Many
quality improvement systems such as standard setting, audit, peer review, and quality assurance, can
be seen as controlling and even punitive measures. Quality improvement system, needs to be a
positive experience. Doing this QIP has equipped us with knowledge and the importance of health
education in diabetes patients. By improving the health education of diabetic patients, it will be
possible to reduce diabetic related complications and thereby lower the burden on the already
struggling healthcare system. As future physicians we have realised the importance of proper health
education for prevention and will make sure to properly educate our diabetic patients.
Health promotion is something that has to take place continuously and is time consuming especially
when there is a high patient load and only a few doctors. Since our health talk was a success, we
recommend that the health promoter continues to give health talks on diabetes outside the clinic
while patients are waiting to go in. If these take place outside there will be enough space for social
distancing and many patients can be addressed simultaneously. These can be done on a weekly or
at least every 2-week basis in the form of the “opt in opt out” technique. A summarised version of
the health talk takes 30 minutes which is a very little sacrifice in comparison to the time and
resources that will be used to manage preventable complications.

We recommend the following

 recruiting more health promoters if possible since she is the only one.
 We also suggest the sisters that take the vital signs, while they take vitals, they re-enforce
patient education received and screen for patient knowledge based on an UPBOV score we
designed.
There are currently no tools to measure the above standards of diabetic health education. We thus
designed and propose the below score sheet to assess patient knowledge on diabetes.
We propose that in future, during the time vital signs are done, the vital signs sisters assess the
above standards through asking the patient screening questions and giving the patient a score out of
10, called the UPBOV score. We designed the score based on the general measures from the EDL
guidelines.
0=no idea, 1=some idea, 2=good idea
Any standard less than one requires the doctor or nurse to spend more time educating the patient on
that aspect and hand out a pamphlet.

0 1 2
U-understanding of illness
e.g. Do you know what it
means to have DM?
P-portion control
e.g. How much pap should
you put on your plate?
B-balanced diet
e.g. What is a balanced diet?
O-options that are healthy
e.g. Describe a healthy food
option
V-void certain foods
e.g. What food should you
avoid
TOTAL

 Patients can then be flagged to receive further education if needed.

 We also recommend that all diabetic patients should have a yearly consult with a dietician
and not only complicated cases as recommended in the EDL. We recommend a record of
dietician visits should be kept in the patient's file.
 A register should be kept at dietician’s office on all diabetic patients seen and if these were
new cases, annual check-ups and if the case was a complicated uncontrolled case.
 At primary health care level, we should be aiming to prevent complications and not waiting
 for them to occur before intervening. Although health promotion takes time, at the end of
the day it will save time and resources by preventing unnecessary complications.

11.REFERENCES
1. SEMDSA Type 2 Diabetes Guidelines Expert Committee. SEMDSA 2017 guidelines for the
management of type 2 diabetes mellitus. J Endocr Metab Diabetes S Afr. 2017;22(1 Suppl
1):S1-96.
2. Parrish AG, Bamford L, Kaswa RP, Patterson J, Balme K, Gunter H et a.Standard treatment
guidelines and essential medicines list for South Africa.Pretoria: The National department of
health; 2019. http://www.health.gov.za/edp.php (accessed 27 August 2020).
3. Varkey P, Reller MK, Resar RK. Basics of quality improvement in health care. InMayo Clinic
Proceedings 2007 Jun 1 (Vol. 82, No. 6, pp. 735-739). Elsevier.
4. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S. Publication guidelines for quality
improvement in health care: evolution of the SQUIRE project. BMJ Quality & Safety. 2008 Oct
1;17(Suppl 1):i3-9.
5. Bartunek JM. Intergroup relationships and quality improvement in healthcare. BMJ quality &
safety. 2011 Apr 1;20(Suppl 1):i62-6.

12.COMMENTSas per 5.3

SIGNATURES FROM TEAM

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General Knowledge regarding Diabetes Mellitus

Instructions: Tick in the applicable column. Circle where applicable.

YES NO
Do you understand what diabetes mellitus is?
Do you know that there is a dietician in Soshanguvwe CHC?
Have you ever received dietary counselling/education?
If yes, specify by who- CIRCLE the option
DOCTOR NURSE DIETICIAN FRIEND HEALTH PROMOTER
FAMILY OTHER specify_________________

Do you follow the diet ?

If not, what are the challenges
________________________________________________________________
________________________________________________________________
________________________________________________________________

Are you aware of how many meals a day is advisable to control your sugar?
Do you know about portion control?
Do you know what a balanced diet is?
Do you know what snacks to avoid?
Were you ever given any information/pamphlets about how to manage your
sugar?
Do you own a glucometer?
Are you aware of the normal sugar/glucose level target?
Do you know what the symptoms of high sugar/glucose are?
Do you know what the symptoms of low sugar/blood glucose are?
Do know any complications of diabetes mellitus?