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The Dialogue on Diabetes and Depression (DDD) is an international collaborative effort to address the problems related to the comorbidity of depression and diabetes. The Association for the Improvement of Mental Health Programmes, a Swiss-based NGO, established the DDD to raise awareness, coordinate research, develop training materials, and organise scientific meetings and training courses. The DDD developed the Diabetes and Depression African Nursing Training Programme in collaboration with the International Council of Nurses to address identified needs of nurses in Sub-Saharan Africa to whom the delivery of primary healthcare often devolves. An international faculty of experts delivered the educational programme to nurses from seven countries in Sub-Saharan Africa and involved over 175 participants, most of whom have responsibility for the education or in-service training of nurses. Participants appreciated the programme - especially the opportunity to enhance their knowledge of these two common disorders and to practice new skills to recognise and manage comorbid conditions. This programme is an example of a unique and innovative educational effort regarding comorbidity with a practical clinical approach. It enables nurses to screen, recognise and treat diabetes and depression in Sub-Saharan Africa by promoting a patient-centred collaborative approach model with early recognition and management of these comorbid conditions in order to improve outcomes and life expectancy in this population.

The Dialogue on Diabetes and Depression (DDD), established in 2007, is an international collaborative initiative addressing research and healthcare needs related to the comorbidity of diabetes and depression [1]. Together with the International Council of Nurses, the DDD embarked on a capacity-building programme, focussing on nurse training in seven countries in Sub-Saharan Africa. The programme aimed at ‘training the trainers' to increase capacity in frontline healthcare staff to recognise and manage these comorbid conditions and to enhance the ability of nurses to promote and enact educational programmes of this nature within their own healthcare systems.

Thomas Willis, a 17th-century English physician and anatomist described the association between depression and diabetes, noting that diabetes appeared more frequently in those who suffered life traumas or long-term sorrow [2]. Contemporary epidemiological studies suggest that at least one third of this population suffer from depression [3,4] and up to 45% of those with diabetes have depressive symptoms not amounting to the ICD diagnosis of depressive disorders [5]. Additionally, those suffering from depression are at an increased risk of developing diabetes [6]. Studies now clearly point to a bidirectional relationship between diabetes and depression, which is complex in terms of the pathogenesis, pathophysiology and psychological mechanisms. Evidence from high-income countries suggests that depression with diabetes is associated with socio-economic status, marital status, physical activity and chronic somatic diseases. Psychosocial factors may impact on the relationship between socio-economic status and depression in people with diabetes, including social isolation, poor social support, limited coping ability and burden of work. Overall studies have shown an inverse relationship, i.e. the risk for depression in diabetes is higher with lower socio-economic status. However, the relationship may vary depending on the socio-economic context of the particular country. In low-income countries, a higher socio-economic status is generally associated with higher levels of chronic disease risk factors, whilst the poor often experience a higher burden of infectious and chronic diseases [7,8].

Contemporary evidence demonstrates that effective treatment of depression in people with diabetes depends on a multidisciplinary collaborative approach to optimise a comprehensive package of care ensuring the best outcomes in terms of physical and mental well-being [9,10]. International programmes have been introduced to manage diabetes in a range of settings, most notably those by the International Diabetes Federation (IDF) [11].

Within well-integrated healthcare services, programmes have been developed for the effective treatment of depression. By contrast, holistic programmes to manage people with comorbid depression and diabetes are not yet well established despite the evidence available for treating this specific comorbidity [12]. The quality of various conceptual frameworks varies depending on the personnel available and the resources within the healthcare system. The preparation and training of healthcare professionals to deal with such comorbid conditions is limited, and this situation is probably exacerbated within more deprived and challenging healthcare systems where both financial and human resources are more limited and where deep-rooted layers of stigma and stereotyping exist. As a result, the fragmentation of services with poor accessibility may lead to inadequate care pathways, lack of seamlessness and a delay in any meaningful interventions. This may culminate in more complications and overall a worse prognosis and clinical outcomes for those presenting with these two comorbid conditions [13,14]. It is often the case that mental healthcare professionals feel unable to provide adequate services for the physical health of the mentally ill population; however, the reverse is also probably true [15] due to training inadequacies and lack of experience.

Another challenge in dealing with the complexity of chronic comorbid conditions is the need for a range of skills and the expertise of a multicondition collaborative care approach by a multidisciplinary team working together across specialities, clinics and distances [10]. The patient with comorbid conditions presents with complex challenges requiring education to enhance engagement in self-care management to achieve optimal outcomes. This is especially important in areas of the world where access to care systems is challenged with limited capacity and skill mix.

To initiate programmes addressing multimorbidity, it was decided to select a commonly occurring comorbidity and to use the experience gained to design other programmes managing multimorbidity in general. Both diabetes and depression are common disorders with increasing incidences and are associated with a high cost burden to society. Both disorders are relatively easy to diagnose and have recognised effective treatments which have had an impact on reducing the stigma associated with them.

Nurses are an essential part of the interdisciplinary team and were selected for this training programme because of their broad reach and potential impact on care for patients with such conditions. Nurses are the largest group of healthcare professionals in most low- and middle-income countries, and are at the critical interface with patients and their carers. This scenario was considered especially pertinent for Africa. Hence, the aim of the programme was to strengthen the nurses' core competencies in the assessment and management of patients with comorbid diabetes and depression. The programme adopted a train-the-trainer approach - empowering nurses to train others and to enact countrywide and local programmes that address healthcare problems related to comorbidity.

The African Nurse Training Programme on Diabetes and Depression was a collaborative effort co-ordinated by the DDD and engaged a number of organisations including support from the Lundbeck Institute and the International Council of Nurses, which represents nursing associations from 135 countries and is made up of more than 13 million nurses worldwide. The International Council of Nurses works to ensure high quality in nursing care and the advancement of nursing knowledge, and promotes the nursing profession as a competent workforce worldwide.

A steering group was set up that included representatives from the DDD, the International Council of Nurses, Lundbeck Institute and international experts to support the implementation of the project. The group used a logic model framework to steer the project work within stipulated timeframes. The logic model focuses on achieving planned actual change and has been extensively used in planning, application and evaluation of a range of programmes [16,17,18,19]. It forces careful reflection on the relationships between outcomes (short and long term), the rationale and assumptions within the unique context of the programme to be delivered with the necessary actions and resources required to achieve such outcomes. Immediate and direct outputs versus long-term impacts are also outlined.

The steering group provided the leadership for the design and rollout of the DDD African Nurse Training Programme. The first series of training sessions included nurses from five countries in Africa, namely South Africa, Uganda, Botswana, Lesotho and Swaziland. The steering group reconvened after this first set of sessions to review feedback and to further fine-tune the programme to meet the needs of nurses and patients in clinical practice. They then conducted a second set of training sessions in Ethiopia and Kenya. The IDF recommended local diabetes educators from South Africa and Kenya to participate in the workshops to strengthen local knowledge and relevance of the skills and to assist in understanding local attitudes and values.

In planning the educational curriculum, the steering group was mindful of the importance of the context of the African countries and considered political, economic, social and psychological factors when designing the programme. The steering group also considered how the diagnosis and treatment of diabetes or depression, or both, needed to fit into different cultural value systems and social practices. The complex status of the healthcare system and the seemingly poor integration of mental and physical healthcare in many of the countries required careful consideration. It was also recognised that there might be limited integration between primary and secondary care systems as well as a lack of integration between the medical and nursing competency frameworks in such a multiprofessional initiative.

The nurses who participated in the programme were exposed to a total of ten educational modules. Interactive sessions included role-play, interviewing and assessment, self-management, and train-the-trainer guidance to implement the programme and deal with the environment. The International Faculty Steering Group prepared the educational materials in a modular format with each participant receiving a binder containing the programme outline, module outline, narratives, fact sheets, instruments and tools, and evaluation forms. The content used the evidence-based integrated approach to the recognition and management of diabetes and depression with the most up-to-date literature in the field.

The co-ordinators of each of the workshops promoted an interactive and participatory teaching and learning approach including opportunities for role-play, assessment and interviewing under their supervision. The last session in each of the programmes focused on the development of an action plan for the participant to ensure a focus on changes in clinical practice and a commitment by each nurse to meet their goals and expected outcomes from the course. The International Council of Nurses monitors these action plans and the steering group use them for ongoing evaluation of the impact of the programme on the practice of these nurses.

In reflecting on the outcomes as stated by the logic model, the following challenges presented themselves in the designing and planning of the programme.

Teaching the management of a patient with comorbid conditions presented a unique educational challenge because the relevant skills and knowledge had to be imparted to groups of nurses who were either from a mental health or a general nursing background. It was important to integrate the new knowledge and skills with the baseline of knowledge and skills that the nurses had in their area of expertise. A questionnaire was sent to prospective participants in advance to establish baseline knowledge and clinical practices. The data from this survey assisted in informing the development of the theoretical and applied content. Comprehensive slide sets, narratives and fact sheets were prepared to provide the necessary documentary support for all participants, and emphasis was placed on interactive teaching and learning practices, such as through the use of case studies and role-plays to strengthen critical thinking and problem-solving skills.

The selection of the participants in the courses was given careful attention because it was expected that the nurses participating in the course would become ambassadors for the programme, drivers of initiatives for better care of patients with comorbid diseases and trainers - using the educational material provided as a resource and basis.

The steering group considered the rollout of the programme and public involvement as important aspects of the programme. In most cases, a representative of the DDD preceded the arrival of the faculty to the country to meet the organisers from the national nursing association and to make contact with policy makers, patient and family organisations, and key contacts in the media. The DDD representative organised interaction with local government officials and senior healthcare advisors, and considered them as critical to assist in or facilitate policy change. The faculty members also assumed the roles of advocates, participating in local media opportunities (including local radio and television interviews) and discussions with local politicians. Where feasible, the national nursing associations invited important stakeholders and the media to public meetings where patients told their own stories, seamlessly integrating their personal experiences of, for example, stigma, assessment and treatment.

Within the programme, the faculty made participants aware of their own responsibilities working in the field of diabetes and depression. They encouraged them to consider the potential barriers hindering the patients' commitment to changes in lifestyle as well as engagement with self-help and treatment. They advocated reflection on their own clinical practice and the need to embrace evidence-based competencies. The organisation of the workshops with their unique exposure to international experts, well-designed material, and contemporary teaching and learning strategies was intended to make a difference in the lives of all concerned. The sessions promoted networking as a strong conduit to address quality issues by encouraging collaborative work in groups, organisations and within the regional political structures.

The course placed particular importance on the recognition of the role of stigma in the management of comorbidity [20]. Although stigmatisation was not addressed in a specific module, the faculty and participants within the group work explored the realities of stigma from avoidance of recognition to management of the comorbid conditions. It was important to discuss the stigmatisation issues within the wider cultural context and how they applied to diabetes and depression. Context-specific strategies were discussed, especially in relation to personal and public campaigns and collaborative actions. It is, however, a challenge to change the way healthcare users with comorbid disease are perceived, assessed and treated. These challenges are even more pronounced in lower income countries, in less-effective healthcare systems and in the presence of stigmatisation and stereotyping.

A total of 175 clinical nurse practitioners and nurse educators were trained in the six workshops held in South Africa, Botswana, Swaziland, Uganda, Ethiopia and Kenya. The DDD, the International Council of Nurses and the Lundbeck Institute provided the logistical support for the identification of participants and organisation of workshops. The International Council of Nurses worked closely with local nursing organisations to identify and select nurses representing a range of educational and healthcare settings. The International Council of Nurses accredited the workshops and provided each participant with a formal certificate of completion. As follow-up, each participant developed an action plan to guide them in the incorporation of the new knowledge and skills into their practice.

The steering group developed an evaluation instrument that addressed the outcomes of each module and items related to the teaching methods. The latter items were kept constant to facilitate ease of use. Participants evaluated each item using a Likert scale with 5 being the highest or best scoring. An opportunity for open-ended responses was also provided for each module and a final part of the evaluation instrument allowed the participants to reflect on the workshop as a whole.

The system of formal participant feedback was explained to participants at the start of the programme. At the time of writing this chapter the first 146 sets of evaluation forms were received, but individual item responses varied from 106 to 146 because of various factors. Survey Monkey software was used to analyse the quantitative data whilst the qualitative responses were transcribed and categorised, and themes developed from the data.

The participants' overall evaluation of the workshop was positive with mean scores not lower than 4.69 of a maximum of 5. Participants especially appreciated the useful exchange of knowledge, values and skills, and considered the public event an important achievement. The qualitative responses echoed these positive results with clear reference to the value of and approach to the workshops. Participants considered the workshops to be ‘eye opening' and ‘straightforward' - appreciating the presence and approach used by experts throughout. The quality of the organisation was also highlighted.

Within the first rollout, participants made a number of recommendations that resonated well with the experience and expressed opinions of the steering group. These included:

• Provision of further support and monitoring of actions, such as drug fact sheets, conversation maps and the involvement of local multidisciplinary teams in further training

• Introduction of even more interactive work such as role-plays and group work

• Refining some workshop material, the flow of certain modules and time allocation for the modules on diagnosis and assessment of depression in people with diabetes

• Fine-tuning of the workshop evaluation format and the management of post-workshop expectations

• Identification of barriers to change and mechanisms to deal with such; mostly through new partnerships and community capacity building

It was meaningful that the participants highlighted specific skills and tools in their feedback. The demonstration and introduction of the Patient Health Questionnaire (PHQ9) for the assessment of depression was considered useful for their practical clinical setting [21]. The participants considered the PHQ9 ‘wonderful and will be embraced'. The nominal group technique [22,23] as adapted by the educational expert in the steering group was viewed as meaningful for enhancing group participation. Motivational interviewing was considered an essential technique to be included in future nursing curricula.

Participants and facilitators considered the first phase of this project as successful and the feedback guided the final phase of the programme that incorporated the above. The integration of training about the two conditions of depression and diabetes within the context of comorbidity was challenging and this series of workshops provided valuable pointers on how to achieve this effectively. It was clear that nurses and most other healthcare professionals still undergo training that emphasises systems-based or disease-oriented models. The comorbidity framework provides new insights and ways of thinking and implementation - both in education and clinical practice [10]. This model encourages multiprofessional working with case management, a structured management plan and enhanced interprofessional communication. There is now growing evidence that collaborative care can successfully improve depression and diabetes outcomes with cognitive behaviour therapy enhancing diabetes self-management, reducing diabetes morbidity, improving stability and treating depression effectively. In addition, other risk factors, such as low-density lipoprotein and cholesterol levels as well as high blood pressure, can be better controlled by adoption of this person-centred collaborative model of care [9]. Rushton et al. [24] confirmed the need for health professionals to rethink how to manage patients with multiple healthcare conditions, given that the care environment itself remains fragmented.

It was clear to the steering group that the selection of participants for such programmes should be more focused and differentiated; for example, there is a need to focus more on nurse educators in future programmes and to provide a variety of modules to meet the needs and backgrounds of different groups at different times. It was also acknowledged that multiprofessional collaboration is critical and that specific sessions and applied exercises are needed to drive home the complexities of comorbid disease assessment and treatment.

Being the first round of this type of programme, it was considered important to provide participants with an evaluation form for each module and one for the overall workshop. The feedback provided valuable insights to the steering group, but it is acknowledged that data collection instruments of this nature tend to elicit more subjective responses. The Likert scale is relatively easy to use, but suffers from traditional concerns such as participant honesty, interpretation of the scale, feeling-bias and (in this case) a laborious analysis process. It is, however, important to note that the qualitative data provided by participants corresponded well with the Likert-type scale findings.

Organising the delivery of services in such a way that collaborative and coordinated care is possible requires the buy-in of not only the other relevant healthcare professionals, but also those in a position to restructure the health system and delegate responsibilities appropriately. Subsequent skill and knowledge training of other primary and secondary healthcare professionals would be necessary and is recommended as a follow-up to nurse training. Additional resources and the commitment of the trained trainers to cascade the learning from the African Nurse Training Programme to other new and practicing nurses will be essential to the institutionalisation of the concepts and the broad-scale benefits to affected patients.

The International Council of Nurses and the national nursing associations should prioritise the further dissemination of the knowledge and skills from the African Nurse Training Programme by establishing regional centres of excellence to institutionalise the concepts and maximise their adoption in nursing practice.

The programme as designed forms a good baseline to be adapted for other healthcare professionals and multiprofessional groups. Such a rollout would provide further strength to the initiative to better manage and support patients with comorbid conditions. Material would also be coded for use as half day, full day or 2.5 days - depending on participant needs, timeframe and resources available.

To further support this aim, an integrated manual, which will serve as a comprehensive reference, is in process. This manual will also include guidelines for logistical and other arrangements of such a programme, pre-workshop material and action plans. Heuristic hints for the development of good case studies, role-plays and other teaching and learning activities would provide further guidance.

Another action relates to the strengthening of multiprofessional, and especially nursing, research relating to comorbidity within Africa. An example would be PhD and Masters research projects that strengthen care outcomes for patients with comorbid disease.

Using the comorbidity of disease framework as a legitimate springboard for redesigning both formal and informal educational programmes is warranted, feasible and acceptable. The framework rings true to the clinical challenges of medicine in the 21st century, with the increasing prevalence of comorbidity and how patients present in healthcare systems. Stigmatisation remains a serious concern in many cultural contexts, and good research and clinical work that addresses this issue directly and indirectly within a comorbidity of disease framework would contribute to equitable access and better-quality healthcare.

Further follow-up of the participants' progress from the African experience in relation to changes in clinical practice will help to inform and optimise the benefits of such future programmes. Given the positive African experience, the faculty is better equipped and more confident in their ability to deliver such comorbidity programmes in other culturally challenging environments.

The authors would like to acknowledge the important contributions and/or support of the following entities and/or persons:

• Expert faculty members: Professor N. Sartorius (President AIMHIP, Switzerland), Professor R. Holt (UK, Endocrinology and Diabetology), Dr. H.L. Millar (UK, Consultant Psychiatrist) and Dr. Tesfamicael Ghebrehiwet (Consultant in Nursing and Health Policy, ICN)

• Expert academic and technical facilitators: Dr. J. Hayes (USA, Psychiatry), Larry Cimino (USA, Programme Director), André Joubert (Director, Lundbeck Institute) and Marianne Helwigh (Operational Manager, Lundbeck Institute)

• Regional experts: Professor S. Rataemane (University of Limpopo, Pretoria, South Africa), Dr. S. Bahendeka (IDF Uganda) and Dr. I. Westmore (Consultant Psychiatrist, South Africa)

• IDF educators: B. Majikela-Dlangamandla (South Africa) and A. Jalang'o (Kenya)

• The International Diabetes Federation (IDF)

• The Dialogue on Diabetes and Depression (DDD)

• The Association for the Improvement of Mental Health Programmes (AIMHP)

• International Council of Nurses (ICN)

• The Lundbeck Institute

• Eli Lilly and Company

• The World Federation for Mental Health (WFMH)

• The University of Southampton Faculty of Medicine

• The School of Nursing, Faculty of Health Sciences, University of the Free State, South Africa

• Democratic Nursing Organisation of South Africa (DENOSA)

• Ethiopian Nurses Association (ENA)

• Lesotho Nursing Association

• National Nursing Association of Kenya (NNAK)

• Nursing Association of Botswana

• Swaziland Nurses Association

• Uganda Nurses and Midwives Union (UNMU)

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