Fifty million people in India have diabetes.1 This is nearly double the estimated 26 million in the United States who have the disease.2 Although 8 percent of the global diabetes population live in the U.S., America’s diabetes care spending totals more than 50 percent of total world expenditures on the disease.3 In contrast, only 10 percent of the 1.3 billion people in India have healthcare insurance.4
Podiatric medicine is one of the most neglected aspects of diabetes care in India. The United States has 10 schools of podiatric medicine and reportedly over 13,000 podiatrists. The Indian subcontinent does not have a single practicing podiatrist with a foot and ankle qualification.
Every 30 seconds, a patient somewhere in the world undergoes an amputation due to diabetes yet 85 percent of diabetic foot amputations are preventable.5 Education plays an important role in amputation prevention. Diabetes self-management education is associated with improved diabetes knowledge and self-care behavior, as well as improved clinical outcomes such as lower HbA1c, lower self-reported weight, improved quality of life and lower costs.
Rendering effective diabetes education to all becomes quite challenging. Different people with diabetes require different types of education. Someone with neuropathic symptoms in feet should receive special education regarding diabetic foot care while someone with gestational diabetes needs different education. Conventional education methods like group lectures and printed literature distribution are often boring and less effective.
The result is that we have a significant number of people with diabetes who have myths and misconceptions about diabetes, and related issues like diet, exercise, insulin, etc. An ideal method for diabetes education should be simple, economical, effective and require no special training.
Enhancing Connections Between Doctors And Patients
Keeping these principles in mind, our team at the L.K. Diabetes Centre in Lucknow, India, discovered a solution in 2001. We call it the Samadhan System of Diabetes Education (SSDE). The word “samadhan” means “solution” in Hindi. With this system, we use mobi-films (videos made with mobile phones) for diabetes education. We have mobi-films focused on doctor to doctor communication, doctor to patient communication, patient to doctor communication and patient to patient communication.
The mobi-films from doctors to doctors focus on clinical diabetes care and demonstrate foot examination and procedures such as debridement of foot lesions, etc. The mobi-films from doctors to patients focus on transferring knowledge and skill to patients regarding self care, such as foot care or self insulin administration.
The mobi-films from patients to doctors are simple video clips recorded by patients at home. In these clips, patients try to record their day-to-day diabetes-related activities like the exercise they do at home, their diet, how they dress their lesions at home or how they administer insulin to themselves. The video can also include any other activity recorded by them either on their own or on request by the treating medical professionals (diabetologist, medical nutrition therapist, diabetes educator, etc). When the patients visit the diabetes center, they show these video clips to the medical professionals, who in turn point out mistakes and suggest corrections.
The fourth group of mobi-films from patients to patients has inspirational messages or lessons from one patient to the other. One mobi-film may feature a kid with type 1 diabetes explaining that doing insulin administration yourself is not as scary as it appears on first instance. Another video could show a person who lost his foot explaining how he neglected his foot lesions since they were painless and how smoking added fuel to fire. Another video could be how an obese person lost significant weight because he diligently followed recommended diet and exercise prescriptions.
Patients make the mobi-films using simple cell phones with a basic camera and can transfer the videos from one cell phone to another. To make a mobi-film, one needs a basic mobile phone with a camera and a computer. The phone will record the audio and video clippings. One can use a computer to edit these audio and video clippings. Patients can easily take the mobi-films home in their phones and watch them at leisure or when required. They can also share the videos with others.
Doctors can transfer the education videos onto a DVD/memory stick and display them in the waiting room of a diabetes center or during diabetes camps. Patients can forward the films to other mobiles as multimedia messaging services (MMS) and also upload them to the Internet. Our diabetes center has its own video channel called “diabetologist” on a common video upload website.
Assessing The Impact Of Mobi-Films
The L.K. Diabetes Centre is the first center in the world to use mobi-films for diabetes education. Since 2001, we have been taking pictures and videos in diabetes care clinical work. We maintain a well-catalogued audio/video library. People with diabetes, obesity, hypertension, diabetic foot lesions and others have donated a large number of pictures and video clips associated with their medical conditions, and these teach us many lessons.
The SSDE is simple, economical, effective and needs no special training. This system provides an opportunity for two-way communication between diabetes care professionals and people with diabetes. Over the years, we have seen a sea change in the knowledge and day-to-day diabetes care skills of people visiting our center and benefiting from our diabetes education films.
My colleagues and I have experience in conducting diabetes education movie-making workshops for people with diabetes and healthcare professionals in India and abroad.We encourage the development of more workshops so people interested in diabetes care could receive basic training in video making, followed by a series of diabetes care movie making contests to further popularize this concept.
By encouraging better communication between patients and physicians with the SSDE, and using that same method to share insights and lessons between patients with diabetes, we can make significant progress in emphasizing and promoting better self-care behaviors in this high-risk population of patients.
Dr. Shankhdhar is a diabetologist who established the first diabetic foot clinic of North India at the Lucknow Diabetic Foot Care Clinic and Research Centre, L.K. Diabetes Centre, in Lucknow, India. He is the Secretary of the Uttar Pradesh Madhumeh Association (UPMA) in Uttar Pradesh, India. Dr. Shankhdhar is also a Fellow and Member of the Medical Advisory Board of the American Professional Wound Care Association (APWCA). He is also the Director for Outreach to Developing Countries for the APWCA International Committee.
Dr. Shankhdhar is currently working with the UPMA to help establish the first exclusive podiatry center of India with both clinical and teaching facilities. He notes that the charitable center would offer low cost but quality clinical services and education. For those interested in donating to help establish this charitable podiatry center in India, contact Dr. Shankhdhar at firstname.lastname@example.org .
Dr. Steinberg is an Associate Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.
1. World Diabetes Foundation. Available at http://www.worlddiabetesfoundation.org/composite-35.htm
2. American Diabetes Association. Available at http://www.diabetes.org/diabetes-basics/diabetes-statistics/
3. World Diabetes Today. Available at http://www.worlddiabetesday.org/files/docs/DATASHEET_Health_expenditures...
4. World Resource Institute. Micro health insurance working for India. Available at http://www.nextbillion.net/newsroom/2006/11/09/micro-health-insurance-wo... .
5. International Working Group on the Diabetic Foot. Available at http://www . nextbillion.net/newsroom/2006/11/09/micro-health-insurance-working-for-india/