Using the Zimbabwe Hand Teaching Method With an Urban Austrian Population

Several years ago, I had the opportunity to share experiences in diabetes education with a group of health professionals from more than 20 countries at the Global Medical Conference on Diabetes Education held in Indianapolis, Ind. It was one of the most stimulating experiences in my career. Professionals from many countries exchanged information and stories about the structure, tools, and methods of their diabetes education programs. This exchange clearly showed that this disease causes many of the same challenges and problems wherever it occurs. We had much to learn from each other.

A country's economic progress affects how diabetes education is delivered, and so do many factors unique to its local health care systems. But of equal importance is the extent to which the people who deliver diabetes education are engaged in a quest to protect their patients from complications and death. The teaching tool described in this paper, the Zimbabwe Hand Teaching Method, was developed by a clinician determined to make a difference to his patients under some of the most challenging circumstances described at the conference.

Dr. Kazzim G.D. Mawji practices in Zimbabwe. Many of his patients live in the bush and are illiterate. Both physical resources and time are scarce, and printed materials often are of no use. Morbidity and mortality due to diabetes are high. In an attempt to address these challenges, Dr. Mawji wanted to make education practical and accessible to his population. He developed a teaching method based on a tool readily available to virtually every patient: their own hands. Through this method, the hands are used both as a memory device and as a measuring tool to help people remember diabetes tasks and implement their meal plans.

When the hands are used as a memory device for diabetes teaching, each finger represents an important self-care activity. For example, the ring finger of the right hand is the "insulin finger." Touching it each morning helps patients remember to take their recommended insulin dose.

The hands are also used as a visible point of reference for estimating food portions. For example, a closed fist is the size of the standard starch portion and is always readily available to compare to the amount of food served.

This teaching tool met Dr. Mawji's requirements of having no or low cost and freed him of any dependence on written materials. As a memory device, the hands have the great advantage of always being available­one can never forget his own hands! And as a measuring device, they are personalized to an extent, since larger people have larger hands and smaller ones have smaller hands.

Learning Needs in a Challenging Population
Austria's government-paid system of medical insurance assures access to medical advice, oral drugs, insulin, and self-care supplies. In spite of this, diabetes outcomes are generally poor. Dialysis, amputation, and heart disease rates are falling but still have not decreased to European and international levels.

Part of the cause of these poor outcomes undoubtedly relates to a subset of patients who do not seek out medical care. If they do not see a physician or diabetes educator, patients cannot benefit from the support and education available. However, for those who do access care, having appropriate interventions may prove helpful in making their interactions with the health care system more productive.

In Austria, standardized, structured teaching programs for both type 1 and type 2 diabetes are used throughout the country. However, many patients cannot benefit from these programs because they do not speak or read our language. Cultural barriers to the effective use of the standard programs, including issues such as ethnic food preferences and religious food requirements, are also a challenge. Poverty is often a factor, as well. Sometimes, only one family member is employed and insured, making resources for diabetes self-care more scarce.

I thought that the two-hand teaching method that I had learned from Dr. Mawji might be useful in this group. I decided to adapt it to the Austrian experience.

How the Method is Used in Austria
The many topics, actions, and reminders of the importance of self-care fall into two broad categories: general information and daily care. With the hand teaching method, general topics are assigned to the left hand and daily care to the right. Teaching is staged and individualized, based on patients' readiness to learn and current coping abilities. To support this, each hand can be used to teach two different sets of five items: one for each finger.

Use as a Memory Device
General Issues/Left Hand (one item for each finger)

Stage one: basic safety

1. See your doctor every (insert appropriate time frame for this patient)
2. Always keep enough insulin/pills on hand.
3. Instruct someone at home and at work in how to help you in an emergency.
4. Follow sick-day rules (know how to adjust medicine and food when ill).
5. Stay in touch with your diabetes educator.

Stage two: preventing complications

1. Maintain glucose control to stay healthy.
2. Get yearly screening exams for eyes, blood fats, and kidneys.
3. Get your blood pressure, glucose control, and feet checked when you see the doctor.
4. Check your urine for ketones when sick.
5. Protect and check your feet.

Daily Care/Right Hand

Stage one: safety--what to carry with you

1. Meter and strips
2. Insulin or pills
3. Food and/or glucose tablets to prevent and treat hypoglycemia
4. Diabetic identification
5. Tell someone where you are going and when you expect to return.

Stage two: daily activities

1.  Take your insulin or pills (give specifics)
2.  Test your blood glucose (when)
3.  Watch your meals, especially the carbohydrate content.
4.  Do some exercise daily.
5.  In case of hypoglycemia, eat a piece of banana as long as your thumb. Glucagon should be given if you are unresponsive.

Use as a Guide to Portion Control
The most valuable application for the hand teaching method seems to be as in aid in implementing a nutrition plan. Nutrition is one of the hardest parts of diabetes self-care. In my experience, very few patients persist in using a portion scale or in counting calories or carbohydrates.

The typical Austrian way of eating does not follow generally accepted guidelines for healthful nutrition. Austrians love to eat huge amounts of meat and generous amounts of animal fats, including butter and cream. Vegetable intake is lower than is desirable. Fish is eaten infrequently. Cereal portions are typically small. Alcohol is used regularly and in large quantities.

The large changes needed to bring this typical diet in line with health recommendations are a huge challenge. A simple teaching method, such as the hand teaching tool, is a welcome resource for many patients.

Nutrition specialists in our hospital worked with me to find a way to apply the hand teaching method to all the types of food choices that commonly face our patients. To test our success, we first used the method with nonmedical hospital staff members. When they reported that it was both easy to understand and usable, we began using it with our patients with diabetes.

Hand Teaching Method for Food Portions

• The palm of the hand shows the approximate size of both the bread and meat that one should eat at a meal. The thickness of the bread or meat is represented by the little finger.
• The cupped palm of the hand or the fist represents the size of a standard carbohydrate portion. The fist can easily be placed next to a served portion to judge its size. The fist portion applies to both starches, such as rice, noodles, potatoes, pasta, and dumplings, and fruits. More than one portion of either starch or fruit can be recommended to further individualize the nutrition plan to energy needs. The educator helps determine the right total amount of food and has the responsibility to communicate this to the patient.
• High-fat foods, such as chips and nuts, are limited to a portion that fits in the cupped hand.
• Both hands cupped together and overflowing represent a portion of vegetables or salad.

General Nutrition Rules Taught on the Hand (one item per finger)

1. Avoid alcohol. If you drink, limit it to two small glasses daily.
2. Have some reduced-fat milk or dairy products daily.
3. Do not use sugar, and try to avoid sweets.
4. Choose whole-grain carbohydrates.
5. Exercise daily to reduce or maintain weight.

Outcomes When Using This Method
The greatest success of this method has been with patients from Turkey and the former Yugoslavia who receive care and education in Austria and do not speak or read German. For these patients, written lists and the usual teaching discussions do not work due to communication barriers.

We also use the hand-teaching method with our Austrian patients. Even patients taking part in intensified, structured programs for type 1 diabetes have used and been satisfied with the method. We also use it routinely to teach nutrition to patients with type 2 diabetes. It is our experience that patients seem more willing to follow advice for healthier eating and drinking as long as they are not expected to use portion scales. We have also used this method for people planning to travel abroad, because it gives them a simple, portable meal planning tool to help them estimate unfamiliar foods and portions.

We have found that this simplified approach does not appeal to all clients, however. Recalling important daily care routines using this method seems overly simplified to some patients, who prefer more traditional approaches, including written instructions.

Some patients who like the simple approach and clear information also enjoy using the method to explain diabetes concepts to other patients.

The hand-teaching method is now taught to diabetes educators during their studies and is in use throughout the Austrian "jungle," giving patients and providers an alternative to traditional structured methods of instruction.

Eva Marie Baumer
Diabetes Nurse
Vienna, Austria

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Last updated: 9/99
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