Opportunities for community-based screening of diabetes mellitus in pilgrimages: An experience of the “Wari”

Ananya Khurjekar; Isha Tambolkar; Jagannath Dixit

doi:10.4103/mjhs.mjhs_106_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 11 | Issue : 1 | Page : 94-97

Opportunities for community-based screening of diabetes mellitus in pilgrimages: An experience of the “Wari”

Ananya Khurjekar, Isha Tambolkar, Jagannath Dixit
Department of Community Medicine, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India

Date of Submission	13-Sep-2022
Date of Decision	18-Nov-2022
Date of Acceptance	24-Nov-2022
Date of Web Publication	02-Feb-2023

Correspondence Address:
Isha Tambolkar
Department of Community Medicine, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune - 411 001, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_106_22

Abstract

Introduction: The Indian population is considered to have a high risk of developing diabetes mellitus. High-risk people are advised to undergo opportunistic screening since early detection allows for an early start of treatments targeted at improving glycemic control, thereby reducing or delaying the onset of complications. Through this study, we aim to utilize this golden opportunity for screening diabetes among apparently healthy individuals and thus determine the prevalence of diabetes among them.
Materials and Methods: In June of 2022, an opportunistic screening camp for diabetes was organized during the annual Wari procession by the ADORE trust in a hall at Saswad. Using a public address system, the people who voluntarily entered the premises of the hall were shown a poster exhibit briefed about general knowledge about diabetes including its risk factors, complications, the silent killer nature, and on the Dixit lifestyle to prevent and reverse diabetes. Following this, the people were encouraged to consent to a blood sugar test voluntarily. The team of volunteers used glucometers, systematically recorded random blood sugar level (Random BSL) readings of the participants, and contacted the people with Random BSL above 200 mg/dl to counsel them for further follow-up.
Results: Out of the 1734 people screened, 269 people were found to have a Random BSL above 200 mg/dl. Thus, 15.51% of the total people screened could be categorized into the “diabetic” category. Out of the 269 people who were found to have a Random BSL above 200 mg/dl, 195 were male and 94 were female.
Conclusion: An opportunistic screening program is cost-effective, feasible, and has large-scale implications. Such programs must be implemented on a national scale as part of various schemes to combat health issues such as, but not limited to, noncommunicable diseases. From our initiative of opportunistic screening for diabetes, 269 participants whose Random BSL was not in the normal range were picked up. With proper counseling, they can be set on a path to reverse their course and prevent unnecessary complications.

Keywords: Diabetes mellitus, Dixit lifestyle, opportunistic screening

How to cite this article:
Khurjekar A, Tambolkar I, Dixit J. Opportunities for community-based screening of diabetes mellitus in pilgrimages: An experience of the “Wari”. MRIMS J Health Sci 2023;11:94-7

How to cite this URL:
Khurjekar A, Tambolkar I, Dixit J. Opportunities for community-based screening of diabetes mellitus in pilgrimages: An experience of the “Wari”. MRIMS J Health Sci [serial online] 2023 [cited 2023 Mar 23];11:94-7. Available from: http://www.mrimsjournal.com/text.asp?2023/11/1/94/369038

Introduction

Known by its visitors as “Heaven on Earth,” Pandharpur is a small town in the district of Solapur in Maharashtra. Devotees undertake regular pilgrimages to Pandharpur throughout the year. In colloquial terms, the pilgrimage is called “Wari” and the devotees undertaking it are called “Warkaris.” The Wari is a holy procession for Warkaris and it has been going on for several centuries. There are four auspicious occasions for undertaking a Wari to Pandharpur, out of which the “Ashadhi Wari” attracts the maximum number of Warkaris. Every year about 10–12 lakh people undertake this Wari.^[1] This is a sizable number of people and is representative of the diversity of Maharashtra and its adjoining states.

The Warkaris are generally considered to be farmers, laborers, or those involved in manual labor and are thought to be fit enough for undertaking the long and arduous journey by foot. Thus, it is expected that their random blood sugar levels (Random BSLs) fall within the expected range for their age and sex. However, through this study, we aim to determine whether the Random BSL levels actually fall within the normal range for these people. The Wari, thus, provides a unique opportunity where several “apparently healthy people” gather together and halt at specific stops en route, thus making a large number of people accessible at one point in time to screen for diseases which are public health concerns.

The Indian population is considered to have a high risk of developing diabetes mellitus. The prevalence of diabetes mellitus in India is 8.9% as of 2019.^[2] India ranks second after China in the global diabetes epidemic with a staggering 77 million people having diabetes. More concerning is that an estimated 43.9 million adults in India with diabetes mellitus remain undiagnosed, thus significantly adding to the disease burden.^[2] High-risk people are advised to undergo opportunistic screening since early detection allows for an early start of treatments targeted at improving glycemic control, thereby reducing or delaying the onset of complications.^[3]

Objectives of the study

Through this study, we aim to utilize this golden opportunity for the screening of diabetes among apparently healthy individuals and thus determine the prevalence of diabetes among them
We also aim to contact the newly detected cases and encourage them to avail the necessary medical interventions or help for the management of their condition.

Materials and Methods

Participant recruitment and study procedure

In June of 2022, an opportunistic screening camp for diabetes was organized during the annual Wari procession by the ADORE trust.^[4] A hall provided by “Purandar Doctors Association, Saswad” was utilized for the program. Using a public address system, the people were diverted to enter the premises. Upon entering voluntarily, a poster exhibit was shown to them. In this section, they were briefed about general knowledge about diabetes including its risk factors, complications, the silent killer nature, and finally, on the Dixit lifestyle to prevent and reverse diabetes. Following this, the people were encouraged to voluntarily consent to a blood sugar test. Around 80% of the total people who attended the exhibit consented to the test. The team of volunteers used glucometers and systematically recorded Random BSL readings of the participants. In 2 days, 1734 participants were screened and their data were recorded. The participants whose BSL was over 200 mg/dl were counseled on adopting the Dixit Lifestyle^®, namely, two meals a day and avoiding sweets. Over the next few weeks, volunteers of the trust telephoned participants whose BSLs were in the diabetes range according to the WHO criteria for diagnosis of diabetes.^[5] They explained the interpretation of the results and asked the participants to visit their nearest ADORE center for further counseling.

Data analysis

Primary data were collected in a paper-based pro forma and data were entered into Microsoft Excel spreadsheets 2013 and statistical analysis was done. The data were analyzed for normality of distribution using the Shapiro–Wilk test which revealed positively skewed data. Due to the skewness present in the distribution of the data, a median with an interquartile range was used. The Random BSL range was divided into two categories, namely, nondiabetic and diabetic as per the WHO guidelines 2020.^[5] Correspondingly, the proportion of people in each category was calculated and analyzed.

Ethical considerations

Informed written consent was taken from the study participants. The authors state no conflict of interest.

Funding

The study was funded by ADORE Trust.^[4]

Results

From [Figure 1], it can be seen that there is a right-sided skewness present in the data. Thus, the median value of the Random BSL levels of the “Warkaris” is found to be 126 (106–159) mg/dl. The cutoff for the diabetic range of Random BSL levels was taken as 200 mg/dl.

Figure 1: On the X-axis, random blood sugar levels of the Warkaris calculated using a glucometer is plotted against the number of people having a particular blood sugar level, taken on the Y-axis

Click here to view

Accordingly, it was observed that out of the 1734 people screened, 269 people were found to have a Random BSL above 200 mg/dl [Figure 2]. Thus, 15.51% of the total people screened could be categorized into the “diabetic” category and hence needed to be contacted immediately to counsel them for follow-up and further management.

Figure 2: Sex-wise distribution of the people found to have random BSL above 200 mg/dl. BSL: Blood sugar level

Click here to view

Out of the 269 people who were found to have a Random BSL above 200 mg/dl, 195 were male and 94 were female [Figure 2].

Discussion

In this section, the authors would like to explore the implications of these findings and simultaneously outline a national-level application of the study methodology as a measure to tackle the burden of noncommunicable diseases in India, such as but not limited to diabetes.

The devotees who take part in the Wari procession are generally said to be hailing from semiurban or rural areas. This sector of the population is generally considered to have higher physical activity than urban areas since they are thought to be involved in physically demanding work such as farming or labor. If in such a subset of the population, such alarming values are found it is a matter of concern since one can estimate that the values would be much higher in urban populations who are already predisposed to developing diabetes by virtue of risk factors such as obesity and sedentary lifestyle.^[6]

Second, the highest level recorded in our study of 635 mg/dl is an eye-opening cry for help. Upon inquiry, the participant did not give a history of any specific symptoms or even complications that would impede his daily life. This brings to light the harsh reputation of diabetes as the silent killer. On account of this, a frightening number of cases go undiagnosed and thus community-based active interventional diagnostic camps are fundamental to fighting this epidemic.

This screening camp could only assess a fraction of the devotees since it was done on a voluntary basis. Considering people who voluntarily show up for health checkups tend to be relatively more conscious of their health, the large number of devotees who did not participate owing to a certain hesitancy may have worse findings.^[7] Screening programs, in contrast to diagnostic programs, invite people without symptoms to get screened which is of utmost importance in diabetes since it is infamous for being asymptomatic for years in diseased patients.

Studies have shown that people with a low risk of disease and higher socioeconomic status tend to participate more in screening programs.^[8] This secludes a huge sector of the population and creates a breeding ground for inequitable health care. Screening camps like these which are based in towns and involve people of the lower socioeconomic class would draw these people who traditionally would not volunteer for screening, thus advancing a utilitarian approach.

In a study done by Majra and Verma in Haryana, India, opportunistic screening revealed 4% of people to be unknown diabetics.^[9] In a similar study conducted by Raghuveer et al. in Karnataka, 22% of people screened were diagnosed with diabetes and 76% of those were initiated on treatment.^[10] There are other novel methods to conduct such opportunistic screenings. One such method was employed by Simpson et al., wherein opportunistic screening of pathology samples was performed to reveal a 2.7% rate of unknown diabetes.^[11]

Research has shown that screening is a cost-saving measure as compared to no screening at all from a medical perspective and a cost neutral from a societal perspective as the future costs related to disease progression and complications are reduced.^[12] A systematic review concluded that in India, the total expenditure by a diabetic patient was 5%–25% of an average Indian household.^{[13],[14],[15]} The increasing menace of diabetes in India also has consequences on the nation's economy as a whole.^[13] Dixit lifestyle, in particular, would prove to be highly effective economically since the costs of all medications right from metformin would be omitted.

From our initiative of opportunistic screening for diabetes, 269 participants whose Random BSL was not in the normal range were picked up. Moving forward, with proper counseling, they can be set on a path to reverse their course and prevent unnecessary complications. If this feat can be achieved in mere 2 days, the nation can achieve wonders with the formulation of a robust screening schedule.

The authors would like to highlight the cost-effectiveness, feasibility, and large-scale implications of such a screening program and humbly put forth the suggestion to implement this on a national scale as part of various schemes to combat health issues such as, but not limited to, noncommunicable diseases. This can especially be useful to curb diseases endemic to a particular area or those that are likely to spread from a particular area due to the frequency with which several people move in and out of that area. The same model can also be slightly modified and made applicable to tackle an array of diseases differently. In general, devotees undertake pilgrimages and pass through various checkpoints in a matter of a few days. Screening stations can be setup at multiple sites and devotees can be assessed for the same health-based parameter over several days. This can be especially useful for diseases such as hypertension, where more than one reading of blood pressure is required.

The mass gathering of devotees from geographically dispersed areas of the countries at a specific place for a definite period of time is an ideal opportunity to carry out screening of high-burden diseases. In fact, not capitalizing on this could very well be termed a “missed opportunity” in preventing a particular disease.

Conclusion

An opportunistic screening program in the background of a holy pilgrimage or “Wari” is cost-effective, feasible, and has large-scale implications. Such programs must be implemented on a national scale as part of various schemes to combat health issues such as, but not limited to, noncommunicable diseases. Using the holy pilgrimage or the “Wari” as an opportunity for screening people for high-burden diseases provides a golden opportunity in reducing the disease burden of several diseases such as diabetes as well as reducing the long-term complications and sequelae to the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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