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Certificate Course in

Evidence Based Diabetes ManagementCYCLE–II (Dec. 2011–Nov. 2012)

REPORTEVALUATION

Supported by an educational grant from

Certificate Course in Evidence Based Diabetes Management

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Dr. Shivangi Vats Monitoring and Evaluation Coordinator


Dr. Shreyas Sharma Assistant Monitoring and Evaluation Coordinator


Mr. Saurabh Wadhwa Technical Associate


Prof. Sanjay Zodpey Advisor, Certificate Course in Evidence Based Diabetes Management

Vice President – North, Director, Public Health Education, Public Health Foundation of India

Director, Indian Institute of Public Health – New Delhi

Dr. Shifalika Goenka Lead Faculty - Curriculum Development

Certificate Course in Evidence Based Diabetes Management Associate Professor, Indian Institute of Public Health, New Delhi

Dr. Habib Hasan Lead Faculty – Program Management

Certificate Course in Evidence Based Diabetes Management Assistant Professor, Indian Institute of Public Health, New Delhi

Dr. Abhay Saraf Program Director

Certificate Course in Evidence Based Diabetes Management Director - Training Division and Health Systems Support Unit

Senior Public Health Specialist, Adjunct Additional Professor

Public Health Foundation of India, New Delhi

Dr. Sandeep Bhalla Program Manager

Certificate Course in Evidence Based Diabetes Management Public Health Specialist - Training Division

Adjunct Associate Professor Public Health Foundation of India, New Delhi

List of Contributors

CCEBDM Cycle-II (Dec 2011-Nov 2012)Evaluation

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Acronyms & Abbreviations

Preface

Executive Summary

Chapter 1: Introduction and Objectives

1.1 Introduction

1.2 Objectives of Evaluation

Chapter 2: Methodology

2.1 Design

2.2 Sampling

2.3 Data Collection

2.4 Data Processing and Analysis

2.5 Ethical Issues

Chapter 3: Findings

3.1 Profile of Participants

3.2 Findings: Participant Self – Administered Questionnaire

3.3 Findings: Participant Interview Schedule

Chapter 4: Conclusion & Way Forward Conclusions and Way Forward Limitations of the Study

References

Appendices

Appendix 1 – Team of Evaluators

Appendix 2 – Consent Form

Appendix 3 – Participant Self – Administered Questionnaire

Appendix 4 – Participant Interview Schedule

Appendix 5 – CCEBDM Cycle-II Modules

Appendix 6 - CCEBDM Cycle-II Regional Centers Location Map

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12-13

14 - 23

24 - 25

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27 - 44

Page Nos.

TABLE OF CONTENTS


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List of Figures

Figure 1.1: Gender Distribution

Figure 1.2: Participants’ Qualifications

Figure 1.3: Practice Sector

List of Tables

Table 1.1 Team of Evaluators

Table 1.2 State Wise Distribution of Sampled Participants

Table 1.3: Findings from Participant Self-administered Questionnaire

Table 1.4 to 2.1: Findings from Participant Interview Schedule

Table 1.4: Approximate Number of Patients Treated per Month and Approximate Number of Diabetic Patients Treated per Month

Table 1.5: Curriculum and Knowledge based Improvements and Value Addition of Course to Clinical Practice

Table 1.6: Knowledge Enhancement in Management of Drugs and Complications and Most Common Complications Managed

Table 1.7: Preferred Modules for Knowledge Enrichment

Table 1.8: Diagnosis, Treatment & Management of Special Case undertaken in Clinical Practice after Course Completion

Table 1.9: Professional Network

Table 2.1: Most Useful Topics in Curriculum

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CCEBDM Certificate Course in Evidence Based Diabetes Management

DBMS Data Base Management System

DM Doctorate in Medicine

DMDEA Doctor Mohan’s Diabetes Education Academy

DNB Diplomate of National Board

IDF International Diabetes Federation

IEC Institutional Ethics Committee

IIPH Indian Institute of Public Health

MBBS Bachelor of Medicine and Bachelors of Surgery

MD Doctor of Medicine

MI Myocardial Infarction

MSD Merck, Sharp and Dohme Pharmaceuticals India Private Limited

Ph.D Doctor of Philosophy

PHFI Public Health Foundation of India

PSU Public Sector Undertaking

UTI Urinary Tract Infection

Acronyms & Abbreviations


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PrefaceDiabetes has been described as an epidemic, but predictions for future increases in prevalence especially in developing countries point to a major healthcare crisis for the future. It is now seen as one of the main threats to human health in the 21st century. The past two decades have seen an explosive increase in the number of people diagnosed with diabetes world-wide. Considered as one of the major contributor to the global burden of disease, diabetes exemplifies the management challenge in non-communicable diseases. To deal with this epidemic a well-rounded robust solution needs to be adapted. The burgeoning load of diabetes is a real threat in India, underscored by the constraints of the health system in terms of skilled manpower and capacity. A balanced approach to equip primary care physicians with advanced and newer evidence based knowledge for better diabetes treatment and management along with its control is the urgent and fundamental need of the hour in India.

The Certificate Course in Evidence Based Diabetes Management (CCEBDM) is based on the principles of evidence based medicine. The fundamental objective of CCEBDM is to improve the treatment outcomes for patients by serving as evidence based guidance for clinical decision making in risk assessment, diagnosis, prognosis and management of diabetes. It is also an effort to translate and transfer emerging evidence from clinical research to clinical practice.

CCEBDM started its journey as Cycle-I in August 2010-July 2011 launched in 57 cities covering 18 states with 100 participating Regional Training Centers and the evaluation for Cycle-I was accomplished in two months (August 2011-September 2011).

After the overwhelming success of Cycle-I, Cycle-II was launched on 11th December 2011 in 65 cities across 19 states and one union territory. A group of 149 Regional Faculty was involved in training 1,568 candidates in 119 centers this cycle.

As we are executing the third cycle of this path-breaking course, we take this opportunity to share the results of the country-wide evaluation that was undertaken at the end of Cycle-II. This is the second evaluation in a row after Cycle-I. This report was made possible with the advice and contribution of many people, both inside and outside PHFI.

We are thankful to the team of 22 evaluators who undertook the extensive evaluation survey. We are also grateful to our esteemed National Experts and Regional Faculty for their constant support and technical expertise throughout the program. In addition we acknowledge the support of the Institutional Ethics Committee (IEC) for reviewing the study design and protocols and guiding us on the ethical safeguards and processes of the study. We would like to thank our funding partner MSD Pharmaceuticals Private Limited India for their unwavering support. Last but not the least, PHFI and the evaluation team would like to thank the participants who, despite their hectic schedule, took the time to talk to the evaluation team and helped them assess the project effectively.

The Public Health Foundation of India, New Delhi and Dr. Mohan’s Diabetes Education Academy, Chennai


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Introduction and Objectives

Studies reveal that nearly one-fifth of all adults with diabetes in the world live in south-east Asia. In 2011, 8.3 percent of the adult population, of the region or 71.4 million people had diabetes, 61.3 million of who were in India. The number of people with diabetes in the region will increase to 120.9 million by 2030, or 10.2 percent of the adult population. The region is only second to China, which has the largest prevalence of diabetes in the world.

The number of people with diabetes in India, Bangladesh and Sri Lanka make up 99 percent of the total for the region {1}.

The estimated increase in regional diabetes prevalence to 10.2 percent in 2030 is a consequence of the following:

• increasing life expectancy in India (the proportion of the population over 50 years is expected to increase from 16 percent to 23 percent from 2011 to 2030)

• rapid urbanisation

To cater the approaching challenge, the medical fraternity needs to equip itself in managing the epidemic effectively.

To counter this challenge, an effort has been made in form of CCEBDM which will equip the physicians in evidence based diabetes management. This is a once-a-month, year-long 12-module course aiming at capacity building of primary care physicians.

The primary objective of this course is to identify challenges, barriers and potential solutions to improve the quality of evidence based diabetes care education offered by the CCEBDM. In

addition, it aims to describe the clinic structure and diabetes management strategies of diabetes clinics of the enrolled participants. Last but not the least, it intends to assess the potential for establishing networks between primary care physicians and existing specialized diabetes care centers for improving patient outcomes in diabetes care.

The first cycle of the course was launched on 8th August 2010 and was undertaken from August 2010 to July 2011.

The primary groups involved in the course were the following:

• 15 National Experts (nationally and internationally acclaimed diabetologists and endocrinologists involved in curriculum review and in deciding course modalities)

• 128 Regional Faculty (eminent diabetologists and endocrinologists)

• 1208 participants at 100 centers across India

• A team of 64 observers (all prominent medical practitioners and public health specialists deployed to monitor the centers for assuring quality standards of the program)

The evaluation of Cycle-I was conducted in two months (August and September 2011) after the completion of Module 12 in July 2011. The evaluation was conducted among CCEBDM participants who successfully completed Cycle-I of the program.

After the success of Cycle-I, Cycle-II was launched on 11th December 2011. Cycle-II encompassed a larger number of participants (1,568) with 119 centers, 149 Regional Faculty, 15 National Experts and 84 observers. Cycle-II was expanded to 65 cities covering the 19 states and one union territory.

Executive Summary


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This report encapsulates the mechanism adopted for the evaluation of Cycle-II and the outcomes of this distinctive program. The evaluation of Cycle-II was conducted in December 2012 and January 2013, after the completion of Module 12 in November 2012. The evaluation looked at the overall experiences of the participants during the program. It also thoroughly examined

all the aspects of the project. It measured the improvement in the knowledge and skills of all eligible participants of CCEBDM Cycle-II in the field of diabetes management. It was also very crucial in understanding the barriers and challenges of quality diabetes care. The results of Cycle-II evaluation has proved to be very critical for improvising the next program cycle.

A cross-sectional survey on diabetes management strategies practiced by 125 (randomly selected) CCEBDM participants at their diabetes clinics was conducted across the country. It was conducted by a team of 22 selected evaluators from the CCEBDM observers comprising of faculty from IIPH (Delhi, Gandhinagar, Bhubaneswar and Hyderabad), CCEBDM Program Secretariat Team, faculty from medical colleges and others (public health specialists).

The evaluation was conducted among CCEBDM participants who completed Cycle-II of the program. The participants were selected from all across the country, and the sample was made more illustrative by including an equal number of post-graduate (MD, PhD, DNB, diplomas) and graduate (MBBS) participants.

The two assessment tools developed by CCEBDM management team used for evaluation were:

• A self-administered participant questionnaire

• A participant interview

A four-level Likert scale was used for estimating most of the responses. These tools were pilot-tested and modified accordingly. Before proceeding for the survey an informed consent was sought from all participants before interviewing them.

MethodologyFindings: Participant Self-Administered Questionnaire

125 participants (64 percent males and 36 percent females) were interviewed for this evaluation. The sample was equally distributed as per the qualification (50 percent each for MBBS and post-graduates). 71 percent of the participants were private practitioners and 29 percent were associated with government hospitals and medical colleges.

• 66 percent of participants had provision for basic inpatient laboratory facilities providing routine blood screenings

• 53 percent of doctors had on-site dieticians who helped the diabetic patients

• 35 percent of the participants had a counselor to guide the patients

• 49 percent had DBMS

• 78 percent of the doctors had a full time receptionist

• 79 percent had full time nurses on duty

• 76 percent of the doctors used various forms of Patient Education Resources to elicit awareness among the patients

• 100 percent of the participants agree that the course contributed significantly to their


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knowledge of diabetes management and 99 percent agree that it added value to their current skills for managing diabetes

• 100 percent stated that the curriculum was up-to-date with the latest advances and guidelines

• Most of them agree that all relevant topics were included in the curriculum and appropriate time was allotted for studying them

• 100 percent corresponded that the curriculum was ideally constructed

• 95 percent agree that the case studies in the course were adequate for study

• All the participants agree that the teaching was effective. 66 percent strongly agree that the faculty’s personal clinical experience added to their teaching. 84 percent claimed that the faculty shared additional information during the sessions. The teachings were considered highly interactive and informative by 100 percent of the participants

• 100 percent cited that the environment was conducive to teaching

• 74 percent concurred that all concerns regarding clinical problems related to diabetes cases and management were resolved by the faculty

Findings: Participant Interview Schedule

• 38 percent of the sampled participants treat about 501 to 1,500 patients per month

• 44 percent stated that they treated about 101 to 500 diabetic patients/ per month

Furthermore, 100 percent were able to do better diagnosis in diabetic patients (76 percent strongly agree; 24 percent agree). 100 percent admitted that it has added additional value to their routine treatment planning for diabetic patients (76 percent strongly agree). 99 percent can now independently render dietary advice to patients.

All doctors agree that they can now independently manage hypoglycaemic patients (73 percent strongly yes). 100 percent have improved ability for clinical management of infections and complications in diabetes (66 percent strongly yes). 90 percent stated that they can now independently manage patients on insulin (66 percent strongly yes). Peripheral neuropathy (94 percent), skin complications (82 percent), sexual dysfunction (78 percent), diabetic foot (74 percent) and nephropathy (71 percent) were among the most independently managed conditions. 66 percent and 36 percent can now independently manage cardiac complications and retinopathy in diabetic patients respectively.

Of all the 12 modules, the following were highly rated:

• Module 3 (Non Pharmacological Management of Type 2 Diabetes) and Module 4 (Approach to Pharmacotherapy of Type 2 Diabetes-Part 1) scored the equal and highest ratings for knowledge enhancement with 100 percent agreement (68 percent strongly agree)

• Module 8 (Chronic Complications of Type 2 Diabetes-Part 2) with 67 percent strongly agree

• Module 7 (Chronic Complications of Type 2 Diabetes-Part 1) with 64 percent strongly agree

• Module 2 (Presentation & Initial Evaluation of Type 2 Diabetes) with 61 percent strongly agree

In terms of enhancements, addition of clinical case studies and knowledge on topics like dietary counseling, diabetic nephropathy, dosages of insulin, surgical interventions in diabetics, cardiac and sexual complications as well as updated international and national management guidelines was suggested by the participants.


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1.1 Introduction

According to the IDF Diabetes Atlas of 2012, the number of people with diabetes is increasing day by day in every country accounting more than 371 million people already suffering from diabetes. The report suggests that 4.8 million people die of diabetes every year. Four out of five people with diabetes live in low- and middle-income countries. South-east Asia contributes to 71.4 million diabetics across the world, out of which India contributes 61.3 million. In future India is predicted to have more than 100 million diabetics by 2030. India alone accounts to the regional mortality with 983,000 deaths attributable to diabetes [1]. These astounding numbers highlight the need of certain indispensable measures that are crucial to curtail the burden of this disease. The most important being, fortifying today’s primary care physicians with advanced knowledge and clinical skills to help effectively manage this uprising number of diabetic patients.

There is a paucity of continued education programs for physicians that keep them apprised of newer developments in diabetes care, within and outside India[2]. Global evidence shows that awareness strengthens national policy efforts and improves health outcomes [3]. Various studies done in India were aimed to estimate the costs of diabetes care and to assess the awareness of patients and healthcare professionals about the prevention and treatment of diabetes[4]. Such studies concluded that both patients and medical practitioners displayed a lack of comprehension

Chapter 1

Introduction and Objectives

of the need for constant disease monitoring and consistent approaches to tight glycaemic control. Studies in India [5] also highlight that there are variety of health care providers who lack national guidelines and protocols for health care services, including standards for health facilities, personnel and treatment protocols, which makes it difficult to monitor and assure quality services across the board. It also states that the implementation of evidence-based guidelines and restructuring of clinical care organization has rendered gains in some countries[5].

The CCEBDM program is one such evidence based initiative aimed at enriching the diabetes management practices of several physicians. This 12-module course is conducted once in a month on one designated Sunday for 4 to 6 hours by highly experienced and eminent diabetologists and endocrinologists. The CCEBDM Cycle-I was a country-wide initiative launched on 8th August 2010 in 57 cities across 18 states with a group of 128 Regional Faculty who trained 1,208 enrolled candidates in 100 centers. The ratio of trainer to participants was between 1:8 and 1:10. Among the participants, 61 percent had MBBS degree and 39 percent had post-graduate qualifications. The second cycle of the CCEBDM was launched on 11th December 2011 covering 65 cities across 19 states and one union territory. Cycle-II had 119 training centers with 15 national experts, 149 regional faculty, 84 observers, 89 single trainer centers and 30 merged centers and the ratio of trainer to participant was between 1:10 and 1:15. Out of 1568 participants, 52 percent had MBBS and 48 percent had postgraduate degrees.


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The evaluation for CCEBDM aimed at highlighting not only the performance of this course but also the need for advanced skill based trainings for various diseases. For Cycle-II, it was conducted in December 2012 and January 2013 following the completion of Module 12 in November 2012. The evaluation amalgamated the overall experiences of the participants during the program. It focused on assessing the extent to which the program attained its objective of enhancing the knowledge of primary care physicians in diabetes care and management. It was also crucial to understand the barriers and challenges facing quality diabetes care. The evaluation of Cycle-II of the CCEBDM has made it possible to establish improvements in the next program cycle.

1.2 Objectives of Evaluation

Primary:

1. To identify challenges, barriers and potential solutions to improve quality of evidence based diabetes care education offered by the CCEBDM.

Secondary:

2. To describe the clinic structure and diabetes management strategies of diabetes clinics of the enrolled participants.

3. To assess the potential for the establishment of networks between primary care physicians and existing specialized diabetes care centers for improving patient outcomes in diabetes care.


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Chapter 2

Methodology2.1 Design

A mix of quantitative and qualitative methodology was adopted to fulfill the study objectives. A cross-sectional study design was used in the 19 states and 40 cities where CCEBDM Cycle-II centers were located. The sample was made representative by randomly selecting participants from every state. In states with a larger concentration of centers and more cities, more participants were sampled. Two semi-structured questionnaires were designed to gather the necessary data. Findings were documented to assess the improvement in diabetes management and treatment strategies adopted by the participants after the completion of the course.

2.2 Sampling

The evaluation was conducted among 125 CCEBDM participants enrolled for Cycle-II of the program from all across the country. These participants had fulfilled the eligibility*** criteria for certification.

The sample was made more representative by including participants from city and town settings as well as MBBS participants and those having post-graduate qualifications.

For the purpose of this evaluation, the following definitions were considered:

1. Participants with post-graduate qualifications i.e. with M.D., Ph.D and/or D.N.B. degrees and diplomas

2. MBBS participants (with no additional degrees and diplomas)

While sampling participants from every state, an equal number of participants from both qualification pools were drawn in order to achieve uniform representation.

2.3 Data Collection

The evaluation was conducted using a participant self-administered questionnaire to assess self-perceived improvements in knowledge and clinical practices post completion of the CCEBDM course. The participant interview schedule was used by the evaluators for making on-site observations as well as interviewing the participants about how the course has helped them in making improvements in their diabetes management practices. For most questions a four-level Likert scale was used to evaluate the responses. The response options on this scale were Strongly Agree, Agree, Disagree and Strongly Disagree. These instruments were initially developed by the core Monitoring and Evaluation team and thereafter, finalized in consultation with rest of the CCEBDM team. The evaluation was conducted by a team of 22 evaluators selected from the CCEBDM team of Observers {both Internal and External Observers (Table 1.1)}. The evaluators were oriented to the evaluation plan and trained to use the tools in a two-day Endline Evaluation Meet held in Goa on 21st and 22nd September 2012.

***{Eligibility Criterion: a participant must have attended 10 modules out of 12, must have submitted the 3 assignments and have cleared the exit examination with minimum 50 percent marks}


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Table 1.1: Team of Evaluators

Type of Evaluator Number

1. External Evaluators 62. Internal Evaluators

a. Secretariat Staff 8 b. PHFI Faculty 2

c. IIPH - Delhi Faculty 3 d. IIPH - Hyderabad

Faculty1

e. IIPH - Gandhinagar Faculty

1

f. IIPH - Bhubaneswar Faculty

1

Total 22

Evaluation Tools used for Survey:

1. Participant Self-administered Questionnaire: The questionnaire consisted of four parts:

1. Participant information

2. Clinical practice structure information

3. Feedback about CCEBDM Curriculum

4. Feedback about faculty, teaching methods and environment

2. Participant Interview Schedule: This questionnaire was designed to obtain participants’ feedback regarding improvement of their knowledge in diabetes management practices after completion of the course. This tool allowed the evaluator to make some observations about the practice establishment of the participant, number of diabetic patients treated, etc

2.4 Data Processing and Analysis

All completed questionnaires were sent to the CCEBDM Program Secretariat located at IIPH-Delhi by the evaluators for processing. The data entry and maintenance was done manually in Microsoft Excel 2007, along with the generation of required graphs and tables. Appropriate themes and domains were identified and have been described accordingly.

2.5 Ethical Issues

Ethical clearance was obtained from the IEC of IIPH-Delhi on 24th November, 2012. An informed consent (Appendix 1) was sought from all participants before interviewing them. Anonymity of the participants with strict confidentiality was reserved while collecting the data.


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Chapter 3

Findings

Table 1.2: State-wise Distribution of Participants

Sampling SheetState No. of

participants

City No. of partici-pants

Andhra Pradesh

8Hyderabad 6Vizag 2

Assam 2 Guwahati 2

Bihar 3 Patna 3

Chhattisgarh 2 Raipur 2

Delhi 6 New Delhi 6

Gujarat 5Ahmedabad 2Rajkot 3

Haryana 2 Gurgaon 2

Jammu and Kashmir

2 Jammu 2

Jharkhand 4Jamshedpur 2Ranchi 2

Karnataka 8Bangalore 6Mysore 2

Kerala 9Chengannur 2Cochin 3Trivandrum 4

Madhya Pradesh

10Bhopal 4

Indore 6

Sampling Sheet

Maharashtra 19

Pune 4Mumbai 7Nagpur 2Thane 4Wardha 2

Odisha 4Bhubanes- war

2

Cuttack 2

Punjab 5Amritsar 3Ludhiana 2

Rajasthan 6Jaipur 4Udaipur 2

Tamil Nadu 11

Chennai 5Coimbatore 2Erode 2Salem 2

Uttar Pradesh

12

Lucknow 4Kanpur 2Ghaziabad 2Agra 2Noida 2

West Bengal 7 Kolkata 7

Grand Total 125

The participants’ sample consisted of 64 percent males and 36 percent females (Fig 1.1). The sample was equally distributed as per the qualification (50 percent each for MBBS and post-graduate qualifications) (Fig 1.2).

71 percent of the respondents were either private practitioners or associated with other private institutions, while 29 percent were affiliated to government hospitals or medical colleges (Fig 1.3).

3.1 Profile of Participants

125 participants from centers across 19 states and 40 cities were interviewed for this evalua tion. Table 1.2 illustrates the details of the number of participants selected from every state.


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Fig 1.1: Gender Distribution

Fig 1.2: Participants’ Qualifications

Fig 1.3: Practice Sector

50% 50% MBBS

Post graduate qualifications

Government

Private71%

29%


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3.2 Findings: Participant Self-administered Questionnaire

Treatment Facilities (Table 1.3)

Responding to the question of the treatment facilities available at the clinic (Table 1.3), 66 percent of participants had provisions for basic inpatient lab facilities with routine blood screenings, 53 percent and 79 percent of the practitioners had in-house dieticians and nurse respectively.

Findings suggest that 35 percent of the participants had counsellors to educate and guide the diabetic patients. Responding to the query on availability of the logistic personnel assistance, 78 percent said that they had receptionist to guide and manage patients visit. 76 percent provide Patient Education Resources like leaflets, flip-charts, handouts for patient awareness whereas to record the patient data 49 percent respondents utilise the Data Base Management System (DBMS).

Course Curriculum (Table 1.3)

To understand the effectiveness of the curriculum in making an impact on the participants’ day-to-day practice they were asked that to what extent the curriculum of this course has affected their knowledge and skills.

• 100 percent agree that this course has contributed significantly to their knowledge of diabetes management of which 76 percent had agree very strongly

• 99 percent agree to the value it added to their current skills for managing diabetes (63 percent strongly agree)

Table 1.3: Findings from Participant Self-administered Questionnaire

Questions on the structure of the curriculum revealed the following:

• 100 percent of the sampled participants agree that the curriculum was up-to-date with latest advances and guidelines (57 percent strongly agree)

• 98 percent agree that all relevant topics were included in the curriculum

• 95 percent thought that appropriate time was allotted for the same

• 100 percent considered the curriculum ideally built for learning

• 95 percent thought that the case studies in the course were adequate

The effectiveness of the teaching modalities was reiterated by 100 percent of the participants (70 percent strongly agree whereas 30 percent

Table 1.3: Faculty, Teaching Methods and Conduct of Sessions

Treatment Facilities Available (percent)

Not Available (percent)

Patient Education Resources 76 24

Receptionist 78 22

Nurse 79 21

DBMS 49 51


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Treatment Facilities Available (percent)

Not Available (percent)

Counselor 35 65

Dietician 53 47

Inpatient Lab Facility 66 34

Course CurriculumStrongly Agree

(percent)

Agree (percent)

Disagree (percent)

Strongly Disagree (percent)

Knowledge Addition 76 24 0 0

Skill Addition 63 36 1 0

Structure of CurriculumStrongly Agree

(percent)

Agree (percent)

Disagree (percent)


Up-to-date 57 43 0 0

Relevant Topics Included 66 32 2 0

Appropriate Time Given 57 38 5 0

Ideal for Learning 67 33 0 0

Adequate Case Studies 53 42 5 0

Teaching MethodsStrongly Agree

(percent)

Agree (percent)

Disagree (percent)


Effective 70 30 0 0

Relevant 66 30 3 1

Additional Material shared 50 34 14 2

Interactive & Informative 73 27 0 0

Session Conduction Rating Strongly Agree (percent) Agree (percent) Disagree

(percent)


Environment 78 22 0 0

Support Provided 74 25 1 0


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agree). 66 percent of the participant strongly felt the impact of the relevant personal clinical experience that the Faculty added to their teaching modalities which was reinforced by 30 percent of the ‘yes’ component as well. 84 percent of participants conveyed that the faculty also brought and shared additional relevant teaching material to the course sessions (50 percent strongly agree, 34 percent agree). The teachings were considered highly interactive and informative by 100 percent of the participants (73 percent strongly agree, 27 percent agree).

The following were the participants’ response on the session environment:

• 100 percent considered the session strongly conducive to learning (78 percent strongly agree, 22 percent agree)

• 74 percent strongly agree that the Regional Faculty were effortlessly able to address their concerns regarding clinical problems related to diabetes cases and management. An additional 25 percent also agree upon the same whereas one percent disagree (cumulative agreement = 99 percent)

3.3 Findings: Participant Interview Schedule

Number of Patients Treated (Table 1.4)

38 percent of the sampled participants treated around 501 - 1,500 patients per month. Also in a given month about 44 percent of the doctors said that they have treated about 101 to 500 diabetic patients.

Table 1.4: Approximate Number of Patients treated per Month & Approximate Number of Diabetic Patients treated per month

Number of Patients Treated Per Month (percent)More than 3500 22501-3500 61501-2500 11

501-1500 38

100-500 34

Less than 100 9

Number of Diabetic Patients Treated Per Month (percent)

1001-1500 3

501-100 8

101-500 44

50-100 21

Less than 50 24


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Curriculum and Knowledge Based Improvisation (Tables 1.5, 1.6 and 1.7)

All the participants agree that they were now able to diagnose diabetic patients better (76 percent strongly agree, 24 percent agree). Also 100 percent claimed that it added additional value to their routine treatment planning for diabetic patients. This group had 76 percent strongly agree component.

When questioned further, 82 percent of the participants said, they still refer few patients with complications. Almost all participants (99 percent) find themselves equipped in giving dietary advice to patients.

On managing oral hypoglycemia, all doctors expressed that they can now independently manage these patients (73 percent strongly agree and 27 percent agree). 100 percent participants agree that they now have improved ability for clinical management of infections and complications in diabetes (66 percent strongly agree). Also, 90 percent indicated that they could now independently manage patients on insulin (strongly agree= 66 percent). (Table 1.5).

Upon citing common diabetic complications, participants indicated that peripheral neuropathy (94 percent), skin complications (82 percent), sexual dysfunction (78 percent), diabetic foot (74 percent) and nephropathy (71 percent) were the most independently managed conditions by them. Also 66 percent and 36 percent of participants respectively said they could independently manage cardiac complications and retinopathy in diabetic patients (Table 1.6).

The sampled participants were asked about the modules that specifically helped them to enrich their knowledge and skills further. All modules were very highly rated overall (Table 1.7).

• Module 3 and Module 4 scored equal and highest ratings with 100 percent (68 percent strongly agree).

• Module 8 with 67 percent strongly agree

• Module 7 with 64 percent strongly agree and Module 2 with 61 percent strongly agree.

In comparison to all the Modules, only 24 percent participants strongly agree with the utility of the software taught under Module-12 whereas 8 percent strongly disagree with the same.

Curriculum and Knowledge Based Improvements

Strongly Agree

(percent)

Agree (percent)

Disagree (percent)


Knowledge Enhanced 76 24 0 0

Value Addition in routine treatment 76 24 0 0

Value Addition of Course to Clinical Practice

Agree (percent)

Disagree (percent)

Could suggest dietary advice to diabetic patient

99 1

Required referral for management of some type of diabetes cases

82 18

Table 1.5: Curriculum and Knowledge based Improvements & Value Addition of Course to Clinical Practice


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Table 1.6: Knowledge Enhancement in Management of Drugs & Complications and Most common Complications Managed

Knowledge Enhancement in Management of Drugs and Complications

Strongly Agree

(percent)

Agree (percent)

Disagree (percent)


Able to manage hypoglycemic patients 73 27 0 0

Improved ability for clinical management of infection and complication

66 34 0 0

Able to manage patients on insulin therapy

66 24 10 0

Most Common Complications ManagedAgree

(percent)Disagree (percent)

Periphery Neuropathy 94 6

Nephropathy 71 29

Retinopathy 36 64

Cardiac Complications 66 34

Diabetic Foot 74 26

Skin Complications 82 18

Sexual Dysfunction 78 22

Any Other 30 70

Preferred Modules for Knowledge Enrichment

Strongly Agree (percent)

Agree (percent)

Disagree (percent)


Module – 1 56 43 1

Module – 2 61 39

Module – 3 68 32

Module – 4 68 32

Module – 5 61 36 3

Module – 6 51 48 1

Module – 7 64 35 1

Module – 8 67 33

Module – 9 57 43

Module -10 56 44

Module -11 46 52 2

Module -12 24 55 13 8

Table 1.7: Preferred Modules for Knowledge Enrichment


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Special Cases in Everyday Practice for Diagnosis, Treatment and Management (Table 1.8)

As a part of the evaluation we requested the participants to share with us cases from their everyday practice which they were able to effectively diagnose, treat and manage due to the additional knowledge/ tips for treatment covered in the modules of this course. Out of 56 responses received:

• 15 respondents said that this course helped them on a daily basis in the correct diagnosis and management of diabetic patients and diabetic complications

• 10 participants mentioned that this course was most effective in helping them in managing allied diseases in diabetic patients. They

cited cases of ketoacidosis, diabetic foot, nephropathy, UTIs, diabetes with respiratory infections, MI and gestational diabetes which were better managed by them after the CCEBDM training.

• 14 participants mentioned that this course particularly helped them with better understanding of the different types of insulin, insulin regimens and administration and also with better management of patients on insulin. For instance, they could now confidently modify regimes for patients who might be fasting due to religious reasons

• 8 participants committed that they feel more confident while treating diabetic patients.

Table 1.8: Diagnosis, Treatment & Management of Special Case undertaken in Clinical Practice after Course Completion (N = 56*)

Diagnosis, treatment and management of any special case undertaken in clinical practice after course completion

Number of Participants

Correct diagnosis and management of Diabetes & its complications 15

More confident in treating Diabetes patients 8

Better disease management 10

Better disease management, administration and understanding of insulin therapy

14

No special cases so far 3

No difference 6

* Inclusive of multiple responses


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Professional Networking (Table 1.9)

Keeping in mind one of the prime objectives of the program is building a strong professional network,

• 78 percent of the participants said that this course helped them tremendously to build a strong network

• 85 percent said that they would strongly recommend this course to their peers

Table 1.9: Professional Networking

Professional Networking

Yes (percent)

No (percent)

Professional Network Building

78 22

Recommending the Course to Peers

85 15

Table 2.1. : Most Useful Topics in Curriculum (N = 75)

Most Useful Topics in Curriculum Number of Participants

Introduction of Type 2 Diabetes 5

Treatment of DM 10

Acute Complications of Type 2 Diabetes

5

Chronic Complications of Type 2 Diabetes

10

Special Complications of Type 2 Diabetes

25

Epidemiology 5

Pharmacological Treatment 15

Most Useful Topics in Curriculum (Table 2.1)

Out of the 75 responses we received to this question, special complications of Type 2 diabetes topped as the most useful topic in the entire curriculum (n= 25 participants). 15 doctors said that pharmacological treatment of diabetes was extremely useful as well. Other topics that participants found most useful were chronic complications of diabetes and treatment of diabetes (n= 10 each).

The evaluation, overall, uncovered and emphasized many value additions that this course made to the participants approach towards diabetic patient management. Several participants mentioned how they could now establish effective communication with patients. Some mentioned that they were now able to deliver substantial treatment to patients inclusive of diet and lifestyle and were also able to engage the families in treatment.

Almost all participants acknowledged that the interaction during the sessions was most effective in resolving some long standing queries they had harboured. The case study discussions were most beneficial as they mirrored the real life scenarios they faced in their clinical practice. They mentioned that these sessions were unique opportunities in which professionals gathered together and had the chance to share, learn and discuss vital information which they otherwise had no access to.

Some of the doctors (5 percent participants) from remote areas had travelled large distances to attend the sessions at the closest centers to their location. These have particularly mentioned that this course place them in touch with the professional network once again. All claimed that the highlight of these sessions was the personal communication access they developed with the experienced faculty.

Since this course aimed at private practicing physicians, the course provided them with hands on knowledge for identification of diabetic complications. Several participants shared how


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better they were now able to identify early signs of diabetic complications, after undertaking the course, which they would have routinely missed. The biggest asset of the course, as considered by several participants, was the in-detail knowledge of pharmacological management of diabetes, specifically insulin preparations and their administration. They shared many cases in their daily practice for which they modified

treatment plans after undertaking the course. All the interviewed doctors commended CCEBDM for its exceptional standardized delivery of the program. They appraised the very prompt and regular communication from the program management. Many mentioned that this was the most professionally conducted training program they had enrolled for in their experience with the most updated curriculum.


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Chapter 4

Conclusion & Way ForwardThe evaluation of CCEBDM Cycle-II highlight some key aspects of the on-site training program undertaken for practicing primary care physicians. It highlights the need for providing the practicing physician with updated and newer concepts emerging globally in the field of diabetes care. This is especially important for a country like India which is currently a leader in the global prevalence of diabetes.

The evaluation showed that the program was very successful in achieving its learning objectives. Notably, all the participants agree that this advance course added significant knowledge enhancement to their daily practice. It enabled them to make better diagnoses, effectively determine treatment plans, modify and individualize treatments based on individual patient needs, and most importantly, manage complications that arise from diabetes.

The other very important benefit provided by this course to the participants was the updated pharmacological knowledge of insulin and other diabetic drugs. It made the participants more confident about selection, planning and customized administration of insulin regimens and other drugs to their patients as per the needs. This showed that the course helped to enhance the diabetes management competencies of the participants wherein their overall clinical practices improved as well. The course highly encouraged general physicians to treat diabetic patients in their routine practices too.

The interaction with the participants also revealed few improvisations that would help enhance the content of this course even further. A need for more clinical scenario case studies on various aspects of diabetes management was expressed by the doctors. More practical information and updated data was requested on topics like dietary counselling, surgeries useful in diabetes, diabetic retinopathy, indepth discussion over the insulin dosages, diabetic nephropathy, cardiac and sexual complications. The participants strongly suggested integrating on-site hospital sessions as part of the curriculum. More emphasis was given by the participants for inclusion of all recent international as well as national guidelines developed based on evidence based management.

Considering these needs of the participants, it is of utmost importance to maintain exposure to the newer practices of diabetes management. This model of teaching with the active involvement of all the regional faculty has proved to be highly successful in the training of practicing physicians at the national level. It proved to be an ideal teaching model in which doctors have an opportunity to connect with their peers, and at the same time strengthen their clinical concepts and practices for delivering better diabetes care. During this evaluation, a nation-wide need was strongly expressed for such a teaching program in varied fields like cardiovascular diseases, hypertension, HIV and respiratory diseases.


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Limitations of the Study

1. The current evaluation was limited in its scope as it involved only 125 participants due to time and budgetary constraints. However, an effort was made to have a representative sample by including all types of participants, and the sample was also selected keeping in mind the type of providers: postgraduates and primary care physicians. Also a sample of the centers was visited on a regular basis by a pool of observers, as part of ensuring quality and monitoring, which helped to gather information about the conduct of the sessions and obtain feedback from the participants and the regional faculty.

2. The evaluation was primarily meant for effective improvements in Cycle-III and to assess the perspectives of participants who have undergone the complete Cycle-II. It is difficult for us to quantify the change in competencies of participants in terms of knowledge, skills and improvement in diabetes care and management, as a result of this course, owing to the absence of baseline data and the difficulty in ascertaining skills of providers in different aspects of diabetes care.

Further evaluation cycles of CCEBDM will improve on these limitations.


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1. International Diabetes Federation. IDF Diabetes Atlas, 5th edn. Brussels, Belgium: International Diabetes Federation, 2012 update. http://www.idf.org/diabetesatlas

2. Joshi S.R., Das A.K., Vijay V.J. and Mohan V., Challenges in Diabetes Care in India: Sheer Numbers, Lack of Awareness and Inadequate Control. Department of Endocrinology, Lilavati Hospital, Mumbai; 2008 Jun;56:443-50.

3. Yadav N.K., Sathian B. and Kalai R.S., Assessment of Diabetes Mellitus in India and Nepal. Webmed Central BIOCHEMISTRY 2012;3(6):WMC003544

4. Bjork S., Kapur A., King H., Nair J. and Ramachandran A., Global Policy: Aspects of Diabetes in India. Novo Nordisk A/S, Krogshoejvej 31, D-2880 Bagsvaerd, Denmark; 2003 Oct;66(1):61-72.

5. Kavita Venkataraman, A. T. Kannan, Viswanathan Mohan. Challenges in Diabetes Management with Particular Reference to India. Int. J Diabetes Dev Ctries. 2009 Jul-Aug; 29(3): 103–109.

References


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Appendix 1

Team of EvaluatorsSr. No.

Name of Evaluators

Designation

1 Dr. Abhay SarafDirector: Training Division and Health Systems Support Unit Senior Public Health Specialist, Adjunct Additional Professor, Program Director, CCEBDM, Public Health Foundation of India

2Ms. Aishwarya Rathore

Program Coordinator, CCEBDM

3 Ms. Anjali SharmaAssistant Program Coordinator, CCEBDM, Public Health Foundation of India

4 Dr. Habib HasanAssistant Professor, Indian Institute of Public Health, Delhi, Lead Faculty, Program Management: CCEBDM

5 Ms. Kanika OberoiAssistant Program Coordinator, CCEBDM, Public Health Foundation of India

6 Dr. Manoj PatkiSenior Program Manager, Health Systems Support Unit, Public Health Foundation of India

7 Dr. Partha GangulyAdditional Professor, Indian Institute of Public Health, Gandhinagar, Lead Faculty: CCEBDM

8Dr. Reshma Masood

Deputy Director, U.P. State AIDS Control Society, Lucknow

9Dr. Rupali Bharadwaj

Chief Executive Officer, Primary Health Solutions Pvt. Ltd, Nagpur

10Dr. Ruplal D. Lanjewar

Regional Consultant, IPHS

11 Dr. Sairu Philip Additional Professor, T.D. Medical College, Alapuzza, Kerala

12 Dr. Sameer PathanAssistant Program Coordinator, CCEBDM, Public Health Foundation of India

13 Dr. Samir BeleAssistant Professor, Dept. of Community Medicine, Prathima Institute of Medical Sciences, Karimnagar

14 Dr. Sandeep BhallaPublic Health Specialist, Training Division, Adjunct Associate Professor, Program Manager, CCEBDM, Public Health Foundation of India

15Prof. Sanjay Zodpey

Vice President – North, Director, Public Health Education, Public Health Foundation of India, Director, Indian Institute of Public Health – New Delhi

16Dr. Saumendera Bagchi

Senior Program Manager, Health Systems Support Unit, Public Health Foundation of India


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Sr. No.

Name of Evaluators

Designation

17Dr. Shifalika Goenka

Associate Professor, Indian Institute of Public Health, Delhi, Lead Faculty, Curriculum Development: CCEBDM

18Dr. Shivangi Vats

Monitoring and Evaluation Coordinator, CCEBDM, Public Health Foundation of India

19 Dr. Shreyas Sharma

Assistant Monitoring and Evaluation Coordinator- CCEBDM, Public Health Foundation of India

20 Dr. Shridhar Kadam

Assistant Professor, Indian Institute of Public Health Bhubaneswar, Lead Faculty: CCEBDM

21 Dr. Vishwajeet Bharadwaj

Co-founder & Chairman, Primary Health Solutions Pvt. Ltd, Nagpur

22Dr. Vivek Singh

Assistant Professor, Indian Institute of Public Health, Hyderabad. Lead Faculty: CCEBDM


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Appendix 2

Consent Form

Evaluation of Certificate Course of Evidence Based Diabetes Management(CCEBDM) Cycle-II

Principal Investigator : Dr. Abhay Saraf

Name of Organization : Public Health Foundation of India

Name of Sponsor : MSD Pharmaceuticals Private Ltd., India

Name of the Project : End-line Evaluation Survey for the Cycle II of CCEBDM

PURPOSE OF STUDY: The evaluation of this program aims to document the experiences of the Participants upon completion of the Cycle II of the CCEBDM. This sharing of experiences of the physicians in diabetes care and management will propagate improvisations in Cycle III of the program.

PROCEDURES: By agreeing to participate in this evaluation, our Observer will complete two questionnaires with you in person. One of the questionnaires is self-administered that you will be asked to fill on your own. The second is a questionnaire in which the Observer will ask you certain questions about your CCEBDM experience. The process should take about 30 minutes to 1 hour to complete both the sets.

RISKS/DISCOMFORTS: We anticipate no risk and discomfort as questions will only involve Participant experiences during the conduction of sessions of the Certificate Course in Evidence Based Diabetes Management.

BENEFITS: The proposed evaluation exercise intends to identify facilitating and challenging experiences during and after undertaken the course. This will enable us to suitably modify the content and delivery of future cycles of this course thus strengthening the quality further.

CONFIDENTIALITY: All information collected for this study will be kept strictly confidential. This means that your answers to the questions will not be shared with anyone in the community or with anyone outside of the evaluation team. All confidential data will be stored in locked files or password protected electronic records at the CCEBDM Program Secretariat. Your name will not appear on any of

Confidential


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the study data in any way. Also, your name will not appear on any reports or publications associated with this study.

COMPENSATION: There will be no compensation for participating in this study.

RIGHT TO WITHDRAW: Your participation in this assessment is voluntary. You are not obligated to participate in this. You are free to withdraw your consent at any time. Refusal to participate will not have any bearing in any way to the results, but your insights will be critical for us in bringing out further improvements in the content and delivery of CCEBDM

If you agree to participate in the evaluation study, please sign below:

Name of Participant: Name of Evaluator:

______________________ __________________________

Signature Signature

Date:

For further information please contact:

Dr. Abhay Saraf(Principal Investigator)Director- Training Division & HSSU, Senior Public Health Specialist Adjunct Additional Professor Program Director- CCEBDMPublic Health Foundation of India (PHFI), Institute for Studies in Industrial Development Campus,4, Institutional Area, Vasant Kunj, New Delhi-110070 INDIA+91 11 49566000, Extn 6003; [email protected]


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Appendix 3

ParticipantSelf-Administered

QuestionnaireConfidential


Date:

Basic Information

Name: (In block letters)

Address

Gender: Male Female

Age:

Qualification

Your Reaginal Faculty Name

Clinical Practice

Years of clinical experiance

Number of places of practice


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Specialised Practise

Availablity of patient ducation resources

(Check appropriate box) Yes No

If yes, Please specify type of patient education resources:

1. Leaflets Yes No

2. Flipcharts Yes No

3. Books Yes No

4. Flims/Videos Yes No

5. Others

Given below are few statements which ask you, your perception about the course. Please rate your level of agreement or disagreement with each statement and explain your answer in the box provided.

CCEBDM Curriculum

1. The Curriculum added value to your knowledge about diabetes

Strongly Agree/ Strongly Yes Agree/Yes Strongly Disagree/Strongly No Disagree/No

Can you explain your answer

2. The curriculum added value to your skills about diabetes management


Can you explain your answer in the box provided

3. The curriculum was updated in its content



33


4. Appropriate time was allotted for content in all sessions



5. Appropriate time was allotted for content in all sessions



6. The structure of the curriculum ideal for learning



7. The case studies were adequate in initiating discussions for replicating real-life clinical scenarios


If no, what kind of case studies would you like to have added

Could you like to suggest any additional improvements in the curriculum:


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Faculty and Teaching Methods/Environment:

8. The teaching methods adopted by the faculty were effective



9. The faculty brought relevant personal clinical experience to the teaching session



10. The faculty shared additional teaching material during the sessions



11. The sessions were interactive and informative



12. The training environment was conducive to learning (e.g. quiet, well-lit, air-conditioning, Ventilatiown)




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13. The faculty was able to address your concerns regarding clinical problems related to diabetes cases and management



14. Would you like to share any other comments on improvisation and delivery of the course and content. Please feel free to pen down any other feedback you would like to give to us.

15. Was the faculty teaching you able to understand ur requirements?? ( Connect with you and your practice)

Thank you!


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Appendix 4

Participant Interview Schedule


Participant Interview Schedule

1. Name of Observe

2. Date of Visit

3. Place of Visit

4. Name of

Participant

5. Address of

Participant

Interview Questions:1. Type of practice (Please circle the appropriate option below)

A. Government B. Private for profit

C. Private for Non Profit D. Other ______________________

Optional (if applicable)

Confidential


37

2. Treatment Facilities provided at area of practice (Please observe and confirm by checking X the appropriate box):

1. Inpatient Laboratory facility Yes No

2. Dietician Yes No

3. Counselor Yes No

4. Data Management System (Computer Software) Yes No

5. Nurse Yes No

6. Receptionist Yes No

7. This course has helped you in enhancing your diagnosis in diabetic patients?


8. Can you please explain your answer. Incase you agree could you also give a real life case study example?

3. If you provide lab/investigation facility in your clinic; what kind of facilities are you able to provide yourself ?

4. For what lab/investigation services do you refer your patients outside your clinic?

5. Approximate number of patients treated in the last month

6. Approximate number of Diabetes patients treated in the last month


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9. Do you think that this course has added value to your routine treatment planning system for diabetes patients ?


10. Can you please explain your answer. Incase you agree could you also give a real life case study example?

11. Do you think that you require referral for management of some type of diabetes cases?

Agree/Yes Disgree/No

If yes, can you specify what kind of cases require referral?

12. Are you able to suggest dietary advise to patient with diabetes?


Can you provide a real life study example?

13. Are you able to manage oral hypoglycemic patients on your own (Dose and side effects) ?


If no, can you please explain what difficulties you face (probe for specific details)


39

14. Are you able to manage patients on insulin on your own (initiation, dose adjustment and side


If no, can you please explain what difficulties you face (probe for specific details)

15. Do you agree that this course has improved your ability for clinical management of infections and com-plications in diabetes ?


If you agree, what kind of complications do you feel can be managed by you?

1. Peripheral neuropathy Yes No

2. Nephropathy Yes No

3. Retinopathy Yes No

4. Cardiac complications Yes No

5. Diabetic foot Yes No

6. Skin complications Yes No

7. Sexual Dysfunction Yes No

8. Any other Complication Yes No

16. Do you believe that this course has helped you in enriching your knowledge and skills in the following area

Introductory Rerview of Diabetes Mellitus


Metabolic Abnormalities in Type 2 Diabetes



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Presentation & Initial Evaluation of Type 2 Diabetes


Approach to Treatment of Type 2 Diabetes: Part 1


Approach to Treatment of Type 2 Diabetes: Part 2


Non-Pharmacological Adjunct Treatment Measures


Acute Complications of Type 2 Diabetes


Chronic Complications of Type 2 Diabetes


Special Complications of Type 2 Diabetes


Special Topics in Care of Patients Type 2 Diabetes


Other Types of Diabetes Mellitus


In-Clinic Record Maintenance


17. Could you share with us any special case in your everyday practice which you were able to effectively diagnose, treat and manage due to the additional knowledge/ skill for treatment covered in the modules of this course ?


41

18. Can you please tell me certain topics that were found most useful in this course ?

19. Can you please tell me certain topics that were not found most useful in this course ?

20. Are there any specific topics that you think should be added and / or deleted for this educational course, can you please name them?

21. Are there any particular changes in facilities provided by you in your place of practice that you have un-dertaken after completion of this course ? (probe for additions in lab facilities, ICE material, updated soft-wares etc. Please request for copies of ICE material if available)

22. Do you feel this course has helped you form a professional network with other diabetes management physicians in your area ?


If yes, could you explain in detail?


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23. Would you recommend this course to your fellow colleagues?


Total time taken to complete interview:________________________

Thank you!


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Appendix 5

CCEBDM Cycle II ModulesModule No. 1 Introductory Overview of Diabetes Mellitus

Module No. 2 Presentation & Initial Evaluation of Type 2 Diabetes

Module No. 3 Non Pharmacological Management of Type 2 Diabetes

Module No. 4 Approach to Pharmacotherapy of Type 2 Diabetes- Part 1

Module No. 5 Approach to Pharmacotherapy of Type 2 Diabetes- Part 2

Module No. 6 Acute Complications of Type 2 Diabetes

Module No. 7 Chronic Complications of Type 2 Diabetes- Part 1

Module No. 8 Chronic Complications of Type 2 Diabetes- Part 2

Module No. 9 Other Complications of Type 2 Diabetes

Module No. 10 Special Topics in Care of Patients with Type 2 Diabetes

Module No. 11 Other Types of Diabetes Mellitus

Module No. 12 In-Clinic Record Maintainance


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Appendix 6

CCEBDM Cycle-II Regional Centers Location Map

Map of India * Not to Scale

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PUBLICHEALTHFOUNDATIONOF INDIA

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Public Health Foundation of India

Program Secretariat - CCEBDM

Indian Institute of Public Health - Delhi

Plot-34, Sector-44, Institutional Area, Gurgaon-122002, India

Tel: +91 0124 4722965 (Direct), 4722900 (Extn. 365), Fax: +91 0124 4722971

Email: [email protected] Web: www.ccebdm.org

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