Effectiveness of a group diabetes education programme in under-served communities in South Africa: a pragmatic cluster randomized controlled trial

Evaluating the implementation of group empowerment and training (GREAT) for diabetes in South Africa: convergent mixed methods

OBJECTIVE

Type 2 diabetes is a leading contributor to the burden of disease in South Africa. Primary care is struggling to support self-management and lifestyle change. Group empowerment and training (GREAT) for diabetes is a feasible and cost-effective intervention in our setting. This study aimed to evaluate the implementation of GREAT for diabetes.

DESIGN

A convergent mixed-methods study evaluated a range of implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, reach and cost.

SETTING

Ten primary care facilities from a district in all nine provinces of South Africa.

PARTICIPANTS

Descriptive exploratory individual semistructured interviews were conducted with 34 key stakeholders from national policy-makers to primary care providers. Three focus group interviews were held with 35 patients.

RESULTS

The National Department of Health saw GREAT as an acceptable and appropriate intervention, but only five of the nine provinces adopted GREAT. District-level and facility-level managers also saw GREAT as an acceptable and appropriate intervention. Factors related to feasibility included physical space, sufficient staff numbers, availability of resource materials, the health information system, adaptation to the model of care (selection of facilities, patients, adjustment of patient flow and appointment systems, leadership from local managers and the whole clinical team) and inclusion in systems for quality improvement. No major changes were made to the design of GREAT and fidelity to the session content ranged from 66% to 94%. Incremental costs were US$494 per facility. Due to disruption from the COVID-19 pandemic, only 14 facilities implemented and reached 588 patients at the time of evaluation.

CONCLUSION

Key lessons were learnt on how to implement GREAT for diabetes in a middle-income country setting. The findings informed the design of a programme theory using a health system framework. The programme theory will guide further scale-up in each province and scale-out to provinces that have not yet implemented.

QUESTION

This study focused on evaluating how to implement GREAT for type 2 diabetes in primary care and to take it to scale in South Africa.

FINDING

The findings led to a programme theory on how to successfully implement GREAT for diabetes in the South African context.

MEANING

The study demonstrates relevant contextual factors that need to be considered in the implementation of group diabetes education programme in a middle-income country.

Improving patient-centred counselling skills among lay healthcare workers in South Africa using the Thusa-Thuso motivational interviewing training and support program

We developed a motivational interviewing (MI) counselling training and support program for lay counsellors in South Africa-branded "Thusa-Thuso-helping you help", commonly referred to as Thusa-Thuso. We present the results of a pilot study to determine the program's impact on MI technical skills and qualitatively assess the feasibility of a training-of-trainers (TOT) scale-up strategy among counselling staff of non-governmental (NGO) support partners of the human immunodeficiency virus (HIV) treatment program in South Africa. We enrolled adult (≥ 18 years) lay counsellors from ten primary healthcare clinics in Johannesburg (South Africa) selected to participate in the Thusa-Thuso training and support program. Counsellors attended the ten-day baseline and quarterly refresher training over 12 months (October 2018-October 2019). Each counsellor submitted two audio recordings of mock counselling sessions held during the ten-day baseline training and two additional recordings of sessions with consenting patients after each quarterly contact session. We reviewed the recordings using the MI treatment integrity (MITI) coding system to determine MI technical (cultivating change talk and softening sustain talk) and relational (empathy and partnership) competency scores before and after training. After 12 months of support with pilot site counsellors, we were asked to scale up the training to NGO partner team trainers in a once-off five-day Training of trainers (TOT) format (n = 127 trainees from November 2020 to January 2021). We report TOT training experiences from focus group discussions (n = 42) conducted six months after the TOT sessions. Of the 25 enrolled lay counsellors from participating facilities, 10 completed the 12-month Thusa-Thuso program. Attrition over the 12 months was caused by death (n = 3), site exclusion/resignations (n = 10), and absence (n = 2). MI competencies improved as follows: the technical skills score increased from a mean of 2.5 (standard deviation (SD): 0.8) to 3.1 (SD: 0.5), with a mean difference of 0.6 (95% confidence interval (CI): 0.04, 0.9). The MI relational skills score improved from a mean of 3.20 (SD: 0.7) to 3.5 (SD: 0.6), with a mean difference of 0.3 (95% CI: -0.3, 8.5). End-point qualitative data from the counsellors highlighted the value of identifying and addressing specific skill deficiencies and the importance of counsellors being able to self-monitor skill development using the MITI review process. Participants appreciated the ongoing support to clarify practical MI applications. The TOT program tools were valuable for ongoing on-the-job development and monitoring of quality counselling skills. However, the MITI review process was perceived to be too involved for large-scale application and was adapted into a scoring form to document sit-in mentoring sessions. The Thusa-Thuso MI intervention can improve counsellor motivation and skills over time. In addition, the program can be scaled up using an adapted TOT process supplemented with fidelity assessment tools, which are valuable for skills development and ongoing maintenance. However, further studies are needed to determine the effect of the Thusa-Thuso program on patient ART adherence and retention in care. Trial registration: Pan African Clinical Trials Registry No: PACTR202212796722256 (12 December 2022).

Process Evaluations of Diabetes Self-Management Programs: A Systematic Review of the Literature

OBJECTIVE

To conduct a systematic review of process evaluations (PEs) of diabetes self-management programs (DSMPs).

DATA SOURCE

An electronic search using Medline (Ovid), Embase (Ovid), CINAHL (Ensco), Academic Search (Ebsco), and APA PsycInfo (Ebsco).

STUDY INCLUSION AND EXCLUSION CRITERIA

Peer-reviewed, empirical quantitative, qualitative, or mixed-method studies were included if they (1) were a traditional, group-based DSMP, (2) involved adults at least 18 years with T1DM or T2DM, (3) were a stand-alone or embedded PE, and (4) published in English.

DATA EXTRACTION

The following process evaluation outcomes were extracted: fidelity, dose delivered, dose received, reach, recruitment, retention, and context. Additional items were extracted, (eg, process evaluation type, data collection methods; theories; frameworks or conceptual models used to guide the process evaluation, and etc).

DATA SYNTHESIS

Due to heterogeneity across studies, studies were synthesized qualitatively (narratively).

RESULTS

Sixty-eight studies (k) in 78 articles (n) (k = 68; n = 78) were included. Most were mixed methods of low quality. Studies were typically integrated into outcome evaluations vs being stand-alone, lacked theoretical approaches to guide them, and incorporated limited outcomes such as dose received, reach, and retention.

CONCLUSION

Future research should 1) implement stand-alone theoretically grounded PE studies and 2) provide a shared understanding of standardized guidelines to conduct PEs. This will allow public health practitioners and researchers to assess and compare the quality of different programs to be implemented.

Nurse-led self-management education and support programme on self-management behaviour and quality of life among adults with type 2 diabetes: A pilot randomized controlled trial

AIM

This study examined the preliminary effects of a nurse-led self-management education and support programme on the self-management behaviours and quality of life among people with type 2 diabetes in Western Ethiopia.

METHODS

A pilot randomized controlled trial was conducted between January and August 2021. Participants were recruited in the hospital and randomly assigned to the control arm to continue usual care (n = 38) or the intervention arm to receive usual care and the diabetes self-management education and support programme (n = 38) in the community. Self-management behaviours and quality of life were assessed using a 10-item summary of diabetes self-care activity (expanded) scale and a 34-item diabetes quality of life measure, respectively, at baseline and 2 months after follow-up. Generalized estimating equation models were used to examine the preliminary effects of the programme on the outcomes.

RESULTS

Preliminary results indicated that the programme outperformed usual care in self-management practise, with large effect sizes immediately postintervention and at 2 months after the intervention, and quality of life at 2 months after the intervention.

CONCLUSION

A nurse-led diabetes self-management education and support intervention, including the families of people with diabetes, may be an option to boost the self-management practise and quality of life of patients with diabetes.

Prevalence of diabetes distress among type 2 diabetes mellitus patients in India: a systematic review and meta-analysis

Introduction

The burden of type 2 diabetes mellitus (T2DM) in India is on the rise, with projections indicating a staggering 134 million cases by 2045. Managing T2DM demands strict adherence, often resulting in mental strain and burnout. Diabetes distress (DD), a unique psychological burden, significantly affects motivation and self-care, contributing to increased morbidity and mortality.

Material and Methods

This study was conducted by doing a comprehensive literature search using PubMed (MEDLINE) and EMBASE databases for studies published from their inception to 14th August 2023 by using relevant keywords. The protocol is registered in PROSPERO and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Selected articles were meticulously screened based on predetermined inclusion and exclusion criteria. Joanna Briggs Institute (JBI) Critical Appraisal scale for cross-sectional study was used for assessing the study quality. Data analysis was done by using Jamovi 2.3.24 software.

Results

Following the systematic search and screening process, 10 cross-sectional studies were identified, comprising a total of 2,107 Type 2 Diabetes Mellitus patients. All studies employed the Diabetes Distress Scale-17 (DDS-17) for measurement. The prevalence of DD varied, ranging from 8.45% to 61.48%. The pooled prevalence of DD in T2DM patients in India was estimated at 33% (95% CI: 21%-45%) with substantial heterogeneity observed (I2 = 97.33%, P < 0.001). While an asymmetric funnel plot suggested potential publication bias, sensitivity analysis reinforced the robustness of our findings.

Conclusion

Policymakers, clinicians, and researchers can leverage these insights to prioritize the psychological well-being of T2DM patients, ultimately improving their overall health outcomes. This study aligns with the Sustainable Development Goals (SDGs) and India's national health policy, emphasizing the urgency of screening and treating diabetes-related distress by 2025.

The effectiveness of diabetes self-management education intervention on glycaemic control and cardiometabolic risk in adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

Diabetes mellitus (DM) poses a significant challenge to public health. Effective diabetes self-management education (DSME) interventions may play a pivotal role in the care of people with type 2 diabetes mellitus (T2DM) in low- and middle-income countries (LMICs). A specific up-to-date systematic review is needed to assess the effect of DSME interventions on glycaemic control, cardiometabolic risk, self-management behaviours, and psychosocial well-being among T2DM across LMICs. The MEDLINE, Embase, CINAHL, Global Health, and Cochrane databases were searched on 02 August 2022 and then updated on 10 November 2023 for published randomised controlled trials (RCTs) and quasi-experimental studies. The quality of the studies was assessed, and a random-effect model was used to estimate the pooled effect of diabetes DSME intervention. Heterogeneity (I2) was tested, and subgroup analyses were performed. Egger's regression test and funnel plots were used to examine publication bias. The risk of bias of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trial (RoB 2). The overall assessment of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. A total of 5893 articles were retrieved, and 44 studies (n = 11838) from 21 LMICs met the inclusion criteria. Compared with standard care, pooled analysis showed that DSME effectively reduced the HbA1c level by 0.64% (95% CI: 0.45% to 0.83%) and 1.27% (95% CI: -0.63% to 3.17%) for RCTs and quasi-experimental design studies, respectively. Further, the findings showed an improvement in cardiometabolic risk reduction, diabetes self-management behaviours, and psychosocial well-being. This review suggests that ongoing support alongside individualised face-to-face intervention delivery is favourable for improving overall T2DM management in LMICs, with a special emphasis on countries in the lowest income group.

Area-level deprivation and individual-level socioeconomic correlates of the diabetes care cascade among black south africans in uMgungundlovu, KwaZulu-Natal, South Africa

South Africa is experiencing a rapidly growing diabetes epidemic that threatens its healthcare system. Research on the determinants of diabetes in South Africa receives considerable attention due to the lifestyle changes accompanying South Africa's rapid urbanization since the fall of Apartheid. However, few studies have investigated how segments of the Black South African population, who continue to endure Apartheid's institutional discriminatory legacy, experience this transition. This paper explores the association between individual and area-level socioeconomic status and diabetes prevalence, awareness, treatment, and control within a sample of Black South Africans aged 45 years or older in three municipalities in KwaZulu-Natal. Cross-sectional data were collected on 3,685 participants from February 2017 to February 2018. Individual-level socioeconomic status was assessed with employment status and educational attainment. Area-level deprivation was measured using the most recent South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and hypertension diagnosis. The prevalence of diabetes was 23% (n = 830). Of those, 769 were aware of their diagnosis, 629 were receiving treatment, and 404 had their diabetes controlled. Compared to those with no formal education, Black South Africans with some high school education had increased diabetes prevalence, and those who had completed high school had lower prevalence of treatment receipt. Employment status was negatively associated with diabetes prevalence. Black South Africans living in more deprived wards had lower diabetes prevalence, and those residing in wards that became more deprived from 2001 to 2011 had a higher prevalence diabetes, as well as diabetic control. Results from this study can assist policymakers and practitioners in identifying modifiable risk factors for diabetes among Black South Africans to intervene on. Potential community-based interventions include those focused on patient empowerment and linkages to care. Such interventions should act in concert with policy changes, such as expanding the existing sugar-sweetened beverage tax.

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

BACKGROUND

Type 2 diabetes (T2D) poses a growing public health burden, especially in low- and middle-income countries (LMICs). Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems (CDSS) are promising approaches to tackle the current T2D care gap in LMICs. However, evidence on the effectiveness of lay worker-led T2D care models, in which VHWs initiate and monitor drug treatment in addition to community-based screening and referral services, is lacking.

METHODS

We are conducting a cluster-randomized trial nested within the Community-Based Chronic Disease Care Lesotho (ComBaCaL) cohort study (NCT05596773) using the trial within cohort (TwiC) design to assess the effectiveness of a VHW-led, CDSS-assisted T2D care model in rural Lesotho. Participants are non-pregnant members of the ComBaCaL cohort study with T2D. The ComBaCaL cohort study is conducted in approximately 100 villages in two rural districts in Lesotho and is managed by trained and supervised VHWs. In intervention villages, VHWs offer a community-based T2D care package including lifestyle counselling, first-line oral antidiabetic, lipid-lowering, and antiplatelet treatment guided by a tablet-based CDSS to participants who are clinically eligible, as well as treatment support to participants who prefer or clinically require facility-based T2D care. In control clusters, all participants will be referred to a health facility for T2D management. The primary endpoint is the mean glycosylated haemoglobin (HbA1c) 12 months after enrolment. Secondary endpoints include the 10-year risk for cardiovascular events estimated using the World Health Organization risk prediction tool.

DISCUSSION

The trial was launched on May 13, 2023, and has enrolled 226 participants at the date of submission (October 6, 2023). To our knowledge, the trial is the first to assess task-shifting of T2D care to VHWs at the community level, including the prescription of first-line antidiabetic, lipid-lowering, and antiplatelet medication in sub-Saharan Africa, and will thus provide the missing evidence on the effectiveness of such a T2D care model in this setting. The study is operating within the established Lesotho VHW programme. Similar community health worker programmes which exist across sub-Saharan Africa may benefit from the findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05743387. Registered on February 24 2023.

The effect of health behavior interventions to manage Type 2 diabetes on the quality of life in low-and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Behavioral interventions targeted at managing Type 2 diabetes mellitus (T2DM) may have a positive effect on quality of life (QOL). Limited reviews have synthesized this effect in low- and middle-income countries (LMICs). This review and meta-analysis synthesised available evidence on the effect of behavioral interventions to manage T2DM on the QOL of people with T2DM in LMICs.

METHODS

Electronic databases PUBMED/MEDLINE, SCOPUS, CINAHL, Embase, Web of Science and PsycINFO were searched from May to June 2022. Studies published between January 2000 and May 2022, conducted in LMICs using randomized controlled trial design, using a health behavior intervention for T2DM management, and reporting QOL outcomes were included. Difference in QOL change scores between the intervention and control group was calculated as the standardized mean difference (SMD) of QOL scores observed between the intervention and control groups. Random-effects model was used for meta-analysis.

RESULTS

Of 6122 studies identified initially, 45 studies met the inclusion criteria (n = 8336). Of them, 31 involved diabetes self-management education and 14 included dietary and/or physical activity intervention. There was moderate quality evidence from the meta-analysis of mean QOL (n = 25) that health behavior intervention improved the QOL of people with T2DM (SMD = 1.62, 95%CI = 0.65-2.60 I2 = 0.96, p = 0.001). However, no significant improvements were found for studies (n = 7) separately assessing the physical component summary (SMD = 0.76, 95%CI = -0.03-1.56 I2 = 0.94, p = 0.060) and mental component summary (SMD = 0.43, 95%CI = -0.30-1.16 I2 = 0.94, p = 0.249) scores. High heterogeneity and imprecise results across studies resulted in low to moderate quality of evidence.

CONCLUSION

The findings suggest that health behavior interventions to manage T2DM may substantially improve the QOL of individuals with T2DM over short term. However, due to low to moderate quality of evidence, further research is required to corroborate our findings. Results of this review may guide future research and have policy implications for T2DM management in LMICs.

Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial

BACKGROUND

In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania.

METHODS

In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688.

FINDINGS

Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted).

INTERPRETATION

In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV.

FUNDING

European Union Horizon 2020 and Global Alliance for Chronic Diseases.

Intervention development of 'Diabetes Together' using the person-based approach: a couples-focused intervention to support self-management of type 2 diabetes in South Africa

OBJECTIVES

Type 2 diabetes (T2D) is a growing concern in South Africa, where many find self-management challenging. Behaviour-change health interventions are enhanced by involving partners of patients. We aimed to develop a couples-focused intervention to improve self-management of T2D among adults in South Africa.

DESIGN

We used the person-based approach (PBA): synthesising evidence from existing interventions; background research; theory; and primary qualitative interviews with 10 couples to ascertain barriers and facilitators to self-management. This evidence was used to formulate guiding principles that directed the intervention design. We then prototyped the intervention workshop material, shared it with our public and patient involvement group and ran iterative co-discovery think-aloud sessions with nine couples. Feedback was rapidly analysed and changes formulated to improve the intervention, optimising its acceptability and maximising its potential efficacy.

SETTING

We recruited couples using public-sector health services in the area of Cape Town, South Africa, during 2020-2021.

PARTICIPANTS

The 38 participants were couples where one person had T2D.

INTERVENTION

We developed the 'Diabetes Together' intervention to support self-management of T2D among couples in South Africa, focussing on: improved communication and shared appraisal of T2D; identifying opportunities for better self-management; and support from partners. Diabetes Together combined eight informational and two skills-building sections over two workshops.

RESULTS

Our guiding principles included: providing equal information on T2D to partners; improving couples' communication; shared goal-setting; discussion of diabetes fears; discussing couples' roles in diabetes self-management; and supporting couples' autonomy to identify and prioritise diabetes self-management strategies.Participants viewing Diabetes Together valued the couples-focus of the intervention, especially communication. Feedback resulted in several improvements throughout the intervention, for example, addressing health concerns and tailoring to the setting.

CONCLUSIONS

Using the PBA, our intervention was developed and tailored to our target audience. Our next step is to pilot the workshops' feasibility and acceptability.

Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review

BACKGROUND

Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations.

METHODS

We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively.

RESULTS

Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively.

CONCLUSION

Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.

Retention in care for type 2 diabetes management in Sub-Saharan Africa: A systematic review

OBJECTIVE

Diabetes prevalence has risen rapidly in Sub-Saharan Africa, but rates of retention in diabetes care are poorly understood. We conducted a systematic review and meta-analysis to determine rates of retention in care of persons with type 2 diabetes.

METHODS

We searched MEDLINE, Global Health and CINAHL online databases for cohort studies and randomised control trials (RCTs) published up to 12 October 2021, that reported retention in or attrition from care for patients with type 2 diabetes in Sub-Saharan Africa. Retention was defined as persons diagnosed with diabetes who were alive and in care or with a known outcome, while attrition was defined as loss from care.

RESULTS

From 6559 articles identified, after title and abstract screening, 209 articles underwent full text review. Forty six papers met the inclusion criteria, comprising 22,610 participants. Twenty one articles were of RCTs of which 8 trials had 1 year or more of follow-up and 25 articles were of non-randomised studies of which 19 had 12 months or more of follow-up. A total of 11 studies (5 RCTs and 6 non-randomised) were assessed to be of good quality. Sixteen RCTs were done in secondary or tertiary care settings. Their pooled retention rate (95% CI) was 80% (77%, 84%) in the control arm. Four RCTs had been done in primary care settings and their pooled retention rate (95% CI) was 53% (45%, 62%) in the control arm. The setting of one trial was unclear. For non-randomised studies, retention rates (95% CI) were 68% (62%, 75%) among 19 studies done in secondary and tertiary care settings, and 40% (33%, 49%) among the 6 studies done in primary care settings.

CONCLUSION

Rates of retention in care of people living with diabetes are poor in primary care research settings.

Factors influencing insulin initiation in primary care facilities in Cape Town, South Africa

BACKGROUND

Type 2 diabetes (T2DM) is a leading cause of mortality in South Africa and resistance to the use of insulin is common. This study aimed to explore factors that influence the initiation of insulin in patients with T2DM in primary care facilities in Cape Town, South Africa.

METHODS

An exploratory descriptive qualitative study was conducted. Seventeen semi-structured interviews were held with patients eligible for insulin, on insulin and primary care providers. Participants were selected by maximum variation purposive sampling. Data were analysed using the framework method in Atlas-ti.

RESULTS

Factors related to the health system, service delivery, clinical care and patients. Systemic issues related to the required inputs of workforce, educational materials, and supplies. Service delivery issues related to workload, poor continuity and parallel coordination of care. Clinical issues related to adequate counselling. Patient factors included a lack of trust, concerns about injections, impact on lifestyle and disposal of needles.

CONCLUSION

Although resource constraints are likely to remain, district and facility managers can improve supplies, educational materials, continuity and coordination. Counselling must be improved and may require innovative alternative approaches to support clinicians who face high number of patients. Alternative approaches using group education, telehealth and digital solutions should be considered.Contribution: This study identified key factors influencing insulin initiation in patients with T2DM in primary care. These can be addressed by those responsible for clinical governance, service delivery and in further research.

Comprehensive patient education and counselling for non-communicable diseases in primary care, Western Cape

BACKGROUND

Treatment of non-communicable diseases (NCD) requires patient education and counselling (PEC). Initiatives have focused on Group Empowerment and Training (GREAT) for diabetes and Brief behaviour change counselling (BBCC). However, the implementation of comprehensive PEC in primary care remains a challenge. The aim of this study was to explore how such PEC could be implemented.

METHODS

This was a descriptive, exploratory, qualitative study at the end of the first year of a participatory action research project to implement comprehensive PEC for NCDs at two primary care facilities in the Western Cape. Focus group interviews were held with healthcare workers and reports from co-operative inquiry group meetings were used as qualitative data.

RESULTS

Staff were trained in GREAT for diabetes and BBCC. There were problems with training appropriate staff and sufficient numbers and a need for ongoing support. Implementation was limited by poor internal sharing of information, staff turnover and leave, rotation of staff, lack of space and fears of disrupting the efficiency of service delivery. Facilities had to embed the initiatives into appointment systems and fast track patients who attended GREAT. For those patients that were exposed to PEC, there were reported benefits.

CONCLUSION

Group empowerment was feasible to introduce, while BBCC was more challenging as it required extra time in the consultation.Contribution: Implementation of PEC requires alternative approaches that do not extend consultations (such as GREAT and maybe digital solutions) as well as commitment to facility organisation for PEC from managers.

Piloting of virtual group education for diabetes in Cape Town: An exploratory qualitative study

BACKGROUND

Diabetes is a major public health problem. During the coronavirus disease 2019 (COVID-19) pandemic, patient education and counselling (PEC) for diabetes were curtailed. This project explored the possibility of offering group empowerment and training (GREAT) for diabetes via computer or tablets and Zoom video conferencing. The aim was to explore whether this was feasible in the low-income community context of primary health care in Cape Town, South Africa.

METHODS

Three dieticians facilitated four sessions of GREAT for diabetes with a group of five patients with type-2 diabetes. Once the programme was completed, focus group interviews were held with the facilitators and the patients to explore their experience. Interviews were recorded and analysed using a simplified framework method.

RESULTS

Usual primary care was not offering PEC and service delivery was brief and mechanistic. The content, resources and group processes were successfully translated into the virtual environment. The guiding style of communication was more difficult. Patients reported changes in their self-management and appreciated being able to save time and money while participating from home. Patients required considerable support and training to use the technology. All participants were concerned about safety and crime with the hardware.

CONCLUSION

It was feasible to conduct GREAT for diabetes via tablets and Zoom video conferencing in this low-income community. To implement at scale, a number of concerns need to be addressed. The feasibility of conducting the sessions via smartphone technology should be evaluated.Contribution: Demonstrates how digital technology could be used to develop new ways of empowering people with type 2 diabetes.

Key considerations for choosing a statistical method to deal with incomplete treatment adherence in pragmatic trials

Pragmatic trials offer practical means of obtaining real-world evidence to help improve decision-making in comparative effectiveness settings. Unfortunately, incomplete adherence is a common problem in pragmatic trials. The commonly used methods in randomized control trials often cannot handle the added complexity imposed by incomplete adherence, resulting in biased estimates. Several naive methods and advanced causal inference methods (e.g., inverse probability weighting and instrumental variable-based approaches) have been used in the literature to deal with incomplete adherence. Practitioners and applied researchers are often confused about which method to consider under a given setting. This current work is aimed to review commonly used statistical methods to deal with non-adherence along with their key assumptions, advantages, and limitations, with a particular focus on pragmatic trials. We have listed the applicable settings for these methods and provided a summary of available software. All methods were applied to two hypothetical datasets to demonstrate how these methods perform in a given scenario, along with the R codes. The key considerations include the type of intervention strategy (point treatment settings, where treatment is administered only once versus sustained treatment settings, where treatment has to be continued over time) and availability of data (e.g., the extent of measured or unmeasured covariates that are associated with adherence, dependent confounding impacted by past treatment, and potential violation of assumptions). This study will guide practitioners and applied researchers to use the appropriate statistical method to address incomplete adherence in pragmatic trial settings for both the point and sustained treatment strategies.

A comparative review of nutrition education intervention duration and impact on reduction of prediabetes or Type 2 diabetes mellitus among adults aged 45 years or older

Prediabetes and Type 2 diabetes mellitus (T2DM) is increasingly prevalent and both conditions have a variety of comorbidities. There are many programs aimed at the reduction or prevention of prediabetes and/or T2DM. However, only a few studies have evaluated the effect of intervention duration and evidence-based frameworks on specific populations at risk for prediabetes or T2DM. This review evaluated evidence-based lifestyle intervention programs to determine whether the duration of programming relates to the efficacy of evidence-based lifestyle change interventions. The aim was to assess relevant outcomes of these interventions in prediabetic or T2DM individuals aged 45 and older. The PRISMA framework was followed. Searches systematically screened and evaluated 2654 articles. Thirteen articles met the inclusion/exclusion criteria. Databases searched included: PubMed; SCOPUS; ProQuest; Biomed Central; SpringerLink; ScienceDirect; EBSCOHost; JSTOR; Taylor & Francis; Wiley Online; BioOne; CINAHL; SAGE Journal; and Google Scholar (2009-2022). Identifying the most effective timeframe for lifestyle intervention programming to reduce the risks associated with prediabetes/T2DM can help providers develop appropriate educational initiatives for patients at risk for pre-diabetes and/or T2DM. After screening, there were 13 studies which met the review criteria. All of the studies included in this comparative review used evidence-based interventions. Evidence-based lifestyle intervention programs that are ≥12 months produced significant and consistent results in mediating outcomes related to prediabetes/T2DM than <12-month programs in adults aged 45 years and older.

The application and reporting of motivational interviewing in managing adolescent obesity: A scoping review and stakeholder consultation

Motivational interviewing (MI) is an evidence-based counseling approach that can help individuals make positive behavioral and cognitive changes for managing obesity. We conducted a scoping review to summarize evidence on fidelity and key elements of MI-based interventions for managing adolescent obesity and examine the reporting of these interventions. Ten electronic databases and gray literature were searched systematically and included literature from January 1983 to February 2022, and 26 studies were included. Data on MI features, delivery context, training, and fidelity to treatment were summarized. Fidelity was assessed using an assessment grid with five domains-theory, training, implementation, treatment receipt, and treatment enactment. The last step of the review involved stakeholder consultation with clinician-scientists and researchers with experience in MI and managing adolescent obesity. Thirteen stakeholders were interviewed about our review findings on MI and treatment fidelity. Our analyses revealed that MI-based interventions for managing adolescent obesity had "low treatment fidelity"; no studies had "high treatment fidelity" across all five domains. Fidelity strategies adhered to the most was theory, and treatment enactment was the lowest. Stakeholders mentioned that "low treatment fidelity" may be due to increased time to complete fidelity assessments and increased cost associated with treatment fidelity. These findings have implications for planning, implementing, and evaluating MI-based interventions for managing adolescent obesity.

Peer support and social networking interventions in diabetes self-management in Kenya and Uganda: A scoping review

Background

Diabetes mellitus is a growing worldwide health challenge especially in sub-Saharan Africa. While the use and effectiveness of diabetes self-management interventions is well documented in high-income countries, little information exists in sub-Saharan Africa. Therefore, this study attempted to synthesize information in the literature on the use and efficacy of peer support and social networking in diabetes self-management in Kenya and Uganda.

Objective

The purpose of this scoping review is to summarize research on the extent of use and efficacy of peer support and social networking interventions in diabetes self-management in Kenya and Uganda.

Design

We searched PubMed, ScienceDirect and Cochrane Library databases for articles reporting peer support and social networking interventions in Kenya and Uganda published in English between 2000 and September 2021. Key words encapsulated three major themes: peer support, social networking and self-management. Hand searches were also conducted to select eligible papers. Data was extracted using a form prepared and piloted in line with PRISMA-ScR guidelines.

Results

Thirteen peer reviewed articles were selected for analysis. Eleven studies reported peer support interventions while two focused on social networks in diabetes self-management. Peer support and social networking interventions incorporated microfinance and group medical visits, diabetes self-management education, telephone support and Medication Adherence Clubs. Most interventions were delivered by multidisciplinary teams comprising nurses and other professionals, peer educators, peer leaders and community health workers. Most interventions were effective and led to improvements in HbA1c and blood pressure, eating behaviors and physical activity and social support.

Conclusions

The limited studies available show that peer support and social networking interventions have mixed results on health and other outcomes. Importantly, most studies reported significant improvements in clinical outcomes. Further research is needed on the nature and mechanisms through which peer support and social network characteristics affect health outcomes.

Glycaemic control among type 2 diabetes patients in sub-Saharan Africa from 2012 to 2022: a systematic review and meta-analysis

BACKGROUND

There is an increased burden of diabetes globally including in sub-Saharan Africa. The literature shows that glycaemic control among type 2 diabetes patients is poor in most countries in sub-Saharan Africa. Understanding the factors influencing glycaemic control in this region is therefore important to develop interventions to optimize glycaemic control. We carried out a systematic review to determine the prevalence and factors associated with glycaemic control in sub-Saharan Africa to inform the development of a glycaemic control framework in the Democratic Republic of the Congo.

METHODS

We searched five databases (African Index Medicus, Africa-Wide Information, Global Health, PubMed, and Web of Science) using the following search terms: type-2 diabetes, glycaemic control, and sub-Saharan Africa. Only peer-reviewed articles from January 2012 to May 2022 were eligible for this review. Two reviewers, independently, selected articles, assessed their methodological quality using Joanna Briggs checklists, and extracted data. A meta-analysis was performed to estimate the prevalence of glycaemic control. Factors associated with glycaemic control were presented as a narrative synthesis due to heterogeneity as assessed by the I².

RESULTS

A total of 74 studies, involving 21,133 participants were included in the review. The pooled prevalence of good glycaemic control was 30% (95% CI:27.6-32.9). The glycaemic control prevalence ranged from 10-60%. Younger and older age, gender, lower income, absence of health insurance, low level of education, place of residence, family history of diabetes, longer duration of diabetes, pill burden, treatment regimen, side effects, use of statins or antihypertensives, alcohol consumption, smoking, presence of comorbidities/complications, and poor management were associated with poor glycaemic control. On the other hand, positive perceived family support, adequate coping strategies, high diabetes health literacy, dietary adherence, exercise practice, attendance to follow-up, and medication adherence were associated with good glycaemic control.

CONCLUSION

Suboptimal glycaemic control is pervasive among patients with type-2 diabetes in sub-Saharan Africa and poses a significant public health challenge. While urgent interventions are required to optimize glycaemic control in this region, these should consider sociodemographic, lifestyle, clinical, and treatment-related factors. This systematic review and meta-analysis protocol is registered in PROSPERO under CRD 42021237941.

Effectiveness of Motivational Interviewing in Managing Overweight and Obesity : A Systematic Review and Meta-analysis

BACKGROUND

Motivational interviewing (MI) is potentially useful in management of overweight and obesity, but staff training and increased delivery time are barriers, and its effectiveness independent of other behavioral components is unclear.

PURPOSE

To assess the independent contribution of MI as part of a behavioral weight management program (BWMP) in controlling weight and improving psychological well-being.

DATA SOURCES

6 electronic databases and 2 trial registries, searched from database inception through 24 September 2021.

STUDY SELECTION

Randomized controlled trials in adults or adolescents aimed at weight loss or maintenance and comparing programs incorporating MI versus interventions without MI.

DATA EXTRACTION

Two reviewers independently screened studies, extracted data, and assessed risk of bias. Outcomes included weight, anxiety, depression, quality of life, and other aspects of psychological well-being. Pooled mean differences or standardized mean differences were obtained using random- and fixed-effects meta-analyses.

DATA SYNTHESIS

Forty-six studies involving 11 077 participants, predominantly with obesity, were included. At 6 months, BWMPs using MI were more effective than no/minimal intervention (-0.88 [95% CI, -1.27 to -0.48] kg; I ² = 0%) but were not statistically significantly more effective than lower-intensity (-0.88 [CI, -2.39 to 0.62] kg; I ² = 55.8%) or similar-intensity (-1.36 [CI, -2.80 to 0.07] kg; I ² = 18.8%) BWMPs. At 1 year, data were too sparse to pool comparisons with no/minimal intervention, but MI did not produce statistically significantly greater weight change compared with lower-intensity (-1.16 [CI, -2.49 to 0.17] kg; I ² = 88.7%) or similar-intensity (-0.18 [CI, -2.40 to 2.04] kg; I ² = 72.7%) BWMPs without MI. Studies with 18-month follow-up were also sparse; MI did not produce statistically significant benefit in any of the comparator categories. There was no evidence of subgroup differences based on study, participant, or intervention characteristics. Too few studies assessed effects on psychological well-being to pool, but data did not suggest that MI was independently effective.

LIMITATIONS

High statistical heterogeneity among studies, largely unexplained by sensitivity and subgroup analyses; stratification by comparator intensity and follow-up duration resulted in pooling of few studies.

CONCLUSION

There is no evidence that MI increases effectiveness of BWMPs in controlling weight. Given the intensive training required for its delivery, MI may not be a worthwhile addition to BWMPs.

PRIMARY FUNDING SOURCE

National Institute for Health Research Biomedical Research Centre. (PROSPERO: CRD42020177259).

Health Promotion Workforce in South Africa: Direction from the Australian Health Promotion Association

BACKGROUND

South Africa's progress towards forming a health promotion workforce lags behind the health promotion career opportunities and professional standards guided by the Australian Health Promotion Association (AHPA), from which South Africa can learn valuable lessons.

PROBLEM STATEMENT

Despite the existence of a national health promotion strategy, inconsistencies in health promotion workforce standards are a national reality. In one of the ten National Health Insurance pilot districts in South Africa, researchers investigated healthcare workers' experiences of the barriers and enablers for the health promotion workforce.

METHODOLOGY

A qualitative explorative descriptive design was used. Healthcare workers (health promoters, n=8; operational managers, n=6; senior managers, n=3) in Dr Kenneth Kaunda District's public health sector were sampled using purposive proportional quota sampling. Data were gathered through semi-structured individual interviews until data saturation was reached (N=17). Transcribed interviews were thematically analysed, supported by ATLAS.ti 8.

RESULTS

Five themes and 13 sub-themes emerged, and barriers to the health promotion workforce exceeded enablers. Health promotion workforce structure and policies were deficient. Managerial supervision and monitoring were lacking. The health promotion workforce received insufficient resources with limited implementation of health promotion programmes. Formal and informal health promotion training was necessary.

RECOMMENDATIONS

The AHPA's proposed Health Promotion Workforce model is considered, focusing on a clear workforce structure, strengthened by managerial buy-in and efficient monitoring and evaluation. Formal and informal health promotion training and advocacy of the health promotion workforce industry are highlighted. Countries with emerging economies and similar health systems to South Africa might find this article useful.

Randomised controlled trials on prevention, diagnosis and treatment of diabetes in African countries: a systematic review

OBJECTIVES

The epidemiological transition from infectious to chronic diseases leads to novel challenges in African health systems. The prevalence of diabetes mellitus (DM) is increasing dramatically. Undiagnosed and undertreated DM leads to numerous complications including end-organ damage and death. Our objectives were to collect the best locally generated evidence on DM interventions, identify knowledge gaps and determine underexplored research areas.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

PARTICIPANTS AND SETTING

African patients in primary, secondary and tertiary prevention, diagnosis and treatment DM type 1 (DM1), type 2 (DM2) and gestational DM (GDM).

OUTCOME

All-cause mortality, glycaemic control, complications, quality of life, hospital admission, treatment adherence and costs.

DATA SOURCES

Articles published in MEDLINE Ovid, CENTRAL, CINAHL, African Journals Online and African Index Medicus and the International Clinical Trials Registry Platform in English language without time restrictions. The systematic search was last updated in October 2020.

RESULTS

Out of 3736 identified publications, we included 60 eligible studies conducted in 15 countries, 75% were conducted in urban healthcare settings, including 10 112 participants. We included 8 studies on DM1, 6 on GDM, 2 on pre-DM, 37 on mainly DM2 including 7 on DM-related complications. The design of the studied intervention was heterogeneous with a focus on educational strategies. The other studies investigated the efficacy of nutritional strategies including food supplementations, pharmacological strategies and strategies to enhance physical activity. Seven studies included interventions on DM-related complications.

CONCLUSIONS

Research activities increased in recent years, but available evidence is still not representative for all African countries. There is a big lack of evidence in primary healthcare and rural settings, implementation research, pharmacological interventions, especially in poorer countries. Nevertheless, the identified studies offer a variety of effective interventions that can inform medical care and future research.

PROSPERO REGISTRATION NUMBER

CRD42019122785.

Determining the frequency and level of task-sharing for hypertension management in LMICs: A systematic review and meta-analysis

BACKGROUND

Low- and middle-income countries (LMICs) bear a disproportionately higher burden of Cardiovascular Disease (CVD). Team-based care approach adds capacity to improve blood pressure (BP) control. This updated review aimed to test team-based care efficacy at different levels of hypertension team-based care complexity.

METHODS

We searched PubMed, Embase, Cochrane, and CINAHL for newer articles on task-sharing interventions to manage hypertension in LMICs. Levels of tasks complexity performed by healthcare workers added to the clinical team in hypertension control programs were categorized as administrative tasks (level 1), basic clinical tasks (level 2), and/or advanced clinical tasks (level 3). Meta-analysis using an inverse variance weighted random-effects model summarized trial-based evidence on the efficacy of team-based care on BP control, compared with usual care.

FINDINGS

Forty-three RCT articles were included in the meta-analysis: 31 studies from the previous systematic review, 12 articles from the updated search. The pooled mean effect for team-based care was a -4.6 mm Hg (95% CI: -5.8, -3.4, I²  = 80.2%) decrease in systolic BP compared with usual care. We found similar comparative reduction among different levels of team-based care complexity, i.e., administrative and basic clinical tasks (-4.7 mm Hg, 95% CI: -6.8, -2.2; I²  = 79.8%); and advanced clinical tasks (-4.5 mmHg, 95%CI: -6.1, -3.3; I²  = 81%). Systolic BP was reduced most by team-based care involving pharmacists (-7.3 mm Hg, 95% CI: -9.2, -5.4; I²  = 67.2%); followed by nurses (-5.1 mm Hg, 95% CI: -8.0, -2.2; I²  = 72.7%), dieticians (-4.7 mmHg, 95%CI: -7.1, -2.3; I²  = 0.0%), then community health workers (-3.3 mm Hg, 95% CI: -4.8, -1.8; I²  = 77.3%).

INTERPRETATION

Overall, team-based hypertension care interventions consistently contributed to lower systolic BP compared to usual care; the effect size varies by the clinical training of the healthcare team members.

FUNDING

Resolve To Save Lives (RTSL) Vital Strategies, Danielle Cazabon, Andrew E. Moran, Yvonne Commodore-Mensah receive salary support from Resolve to Save Lives, an initiative of Vital Strategies. Resolve to Save Lives is jointly supported by grants from Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.

The influence of clinic care on perceptions and knowledge of non-communicable diseases and physical activity from a low-resourced community: a mixed-method study

Background

Health promotion for the management of risk factors for non-communicable diseases (NCDs) is an integral part of standard care in South Africa. Most persons presenting with NCDs utilise public primary health care centres for disease management. This mixed-methods study aimed at expanding current understanding of the the influence of standard clinic care (usual care) on perceptions and knowledge of risk factors for NCDs and physical activity (PA) among persons from a low-resourced community. Qualitatively the perceptions of women from a low-resourced community about risk factors for NCDs and PA were explored throughout 24-weeks of standard clinic care. Parallel quantitative data was collected to describe changes in risk factors for NCDs and trends in self-reported knowledge about risk factors of NCDs and PA.

Method

A convergent-parallel mixed-methods research design was used. The study was carried out in a public primary health care setting, in the North West Province, South Africa. From a convenience sample of 100 participants, 77 African women aged between 34 and 79 years were recruited for the study. Data were collected at three time-points including baseline, 12 weeks, and 24 weeks of a standard clinic care health-promotion programme. The qualitative data was collected during focus group discussions, and the quantitative data included questionnaires on knowledge of physical activity and risk factors for NCDs as well as anthropometric and biological measurements. Qualitative and quantitative data were analysed independently for each phase and then consolidated for interpretation. All data was collected in the same setting.

Results

Participants' initial understanding and perceptions of NCD risk factors were poor. Qualitative findings showed that participants knew little about the specific physical activity they could engage in and the role of PA in NCD management. Participants preferred low-intensity activities. Heart-disease knowledge improved significantly at 12 weeks intervention compared to baseline MD = -3.655, p < 0.001. There were improvements in PA knowledge at 12 weeks from baseline MD = -0.625 p = 0.02. There were significant weight (MD = 1.420, p = 0.002) and waist circumference reductions (MD = 0.621, p = 0.02) from baseline to 24 weeks.

Conclusion

Standard clinic care improved knowledge of physical activity and risk factors for NCDs, but perceptions of risk factors for NCDs and PA were unchanged. This study offers insight into the perceptions held by women from a low-resource setting and how future interventions to manage and prevent NCDs should be structured.

Trial registration

PACTR201609001771813.

Effectiveness of Strategies for Nutritional Therapy for Patients with Type 2 Diabetes and/or Hypertension in Primary Care: A Systematic Review and Meta-Analysis

A central aspect to the management of type 2 Diabetes Mellitus (T2DM) and hypertension is promoting a healthy lifestyle, and nutritional therapy (NT) can support patients achieving glycemic control and blood pressure targets. This systematic review aimed to evaluate the effectiveness of NT in the management of patients with T2DM and/or hypertension in primary care. Primary outcomes were HbA1c, systolic blood pressure (SBP) and diastolic blood pressure (DBP). Thirty-nine studies were included, thirty on T2DM and nine on hypertension. With a moderate quality of evidence, educational/counseling programs and food replacement programs in primary care likely reduce HbA1c on patients with T2DM (mean difference (MD): −0.37, 95% CI: −0.57 to −0.17, 7437 patients, 27 studies; MD: −0.54, 95% CI: −0.75 to −0.32, 440 patients, 2 studies, respectively). Mediterranean diet for T2DM was accessed by one study, and no difference between the groups was found. Educational and counseling programs likely reduce DBP in patients with hypertension (MD: −1.79, 95% CI: −3.46, −0.12, 2840 patients, 9 studies, moderate quality of the evidence), but the effect in SBP was unclear due to risk of bias and imprecision. Nutritional therapy strategies (i.e., educational/counseling programs and food replacement programs) in primary care improved HbA1c in patients with T2DM and DBP in individuals with hypertension.

Approaches and outcomes of community health worker's interventions for hypertension management and control in low-income and middle-income countries: systematic review

OBJECTIVES

To critically appraise the scope, content and outcomes of community health worker (CHW) interventions designed to reduce blood pressure (BP) in low-income and middle-income countries (LMICs).

METHOD

We performed a database search (PUBMED, EMBASE, CINAHL, PsycINFO, OpenGrey, Cochrane Central Trials Register and Cochrane Database of Systematic Reviews) to identify studies in LMICs from 2000 to 2020. Eligible studies were interventional studies published in English and reporting CHW interventions for management of BP in LMICs. Two independent reviewers screened the titles, abstracts and full texts of publications for eligibility and inclusion. Relevant information was extracted from these studies using a tailored template. Risk of bias was assessed using the Cochrane collaboration risk of bias tool. Qualitative synthesis of results was done through general summary of the characteristics and findings of each study. We also analysed the patterns of interventions and their outcomes across the studies. Results were presented in form of narrative and tables.

RESULTS

Of the 1557 articles identified, 14 met the predefined criteria. Of these, 12 were cluster randomised trials whereas two were pretest/post-test studies. The CHW interventions were mainly community-based and focused on behaviour change for promoting BP control among hypertensive patients as well as healthy individuals. The interventions had positive effects in the BP reduction, linkage to care, treatment adherence and in reducing cardivascular-disease risk level.

DISCUSSION AND CONCLUSION

The current review is limited in that, a meta-analysis to show the overall effect of CHW interventions in the management of hypertension was not possible due to the diversity of the interventions, and outcomes of the studies included in the review. Summarised outcomes of individual studies showed CHW enhanced the control and management of hypertension. Further studies are needed to indicate the impact and cost-effectiveness of CHW-led interventions in the control and management of hypertension in LMICs.

Evaluating the implementation of the GREAT4Diabetes WhatsApp Chatbot to educate people with type-2 diabetes in Cape Town during the coronavirus pandemic: Convergent mixed methods (Preprint)

Background

In South Africa, diabetes is a leading cause of morbidity and mortality, which was exacerbated during the COVID-19 pandemic. Most education and counseling activities were stopped during the lockdown, and the GREAT4Diabetes WhatsApp Chatbot was innovated to fill this gap.

Objective

This study aimed to evaluate the implementation of the chatbot in Cape Town, South Africa, between May and October 2021.

Methods

Convergent mixed methods were used to evaluate the implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, cost, coverage, effects, and sustainability. Quantitative data were derived from the chatbot and analyzed using the SPSS. Qualitative data were collected from key informants and analyzed using the framework method assisted by Atlas-ti. The chatbot provided users with 16 voice messages and graphics in English, Afrikaans, or Xhosa. Messages focused on COVID-19 infection and self-management of type 2 diabetes.

Results

The chatbot was adopted by the Metro Health Services to assist people with diabetes who had restricted health care during the lockdown and were at a higher risk of hospitalization and death from COVID-19 infection. The chatbot was disseminated via health care workers in primary care facilities and local nonprofit organizations and via local media and television. Two technical glitches interrupted the dissemination but did not substantially affect user behavior. Minor changes were made to the chatbot to improve its utility. Many patients had access to smartphones and were able to use the chatbot via WhatsApp. Overall, 8158 people connected with the chatbot and 4577 (56.1%) proceeded to listen to the messages, with 12.56% (575/4577) of them listening to all 16 messages, mostly within 32 days. The incremental setup costs were ZAR 255,000 (US $16,876) and operational costs over 6 months were ZAR 462,473 (US $30,607). More than 90% of the users who listened to each message found them useful. Of the 533 who completed the whole program, 351 (71.1%) said they changed their self-management a lot and 87.6% (369/421) were more confident. Most users changed their lifestyles in terms of diet (315/414, 76.1%) and physical activity (222/414, 53.6%). Health care workers also saw benefits to patients and recommended that the service continues. Sustainability of the chatbot will depend on the future policy of the provincial Department of Health toward mobile health and the willingness to contract with Aviro Health. There is the potential to go to scale and include other languages and chronic conditions.

Conclusions

The chatbot shows great potential to complement traditional health care approaches for people with diabetes and assist with more comprehensive patient education. Further research is needed to fully explore the patient’s experience of the chatbot and evaluate its effectiveness in our context.

Analysis approaches to address treatment nonadherence in pragmatic trials with point-treatment settings: a simulation study

Background

Two-stage least square [2SLS] and two-stage residual inclusion [2SRI] are popularly used instrumental variable (IV) methods to address medication nonadherence in pragmatic trials with point treatment settings. These methods require assumptions, e.g., exclusion restriction, although they are known to handle unmeasured confounding. The newer IV-method, nonparametric causal bound [NPCB], showed promise in reducing uncertainty compared to usual IV-methods. The inverse probability-weighted per-protocol [IP-weighted PP] method is useful in the same setting but requires different assumptions, e.g., no unmeasured confounding. Although all of these methods are aimed to address the same nonadherence problem, comprehensive simulations to compare performances of them are absent in the literature.

Methods

We performed extensive simulations to compare the performances of the above methods in addressing nonadherence when: (1) exclusion restriction satisfied and no unmeasured confounding, (2) exclusion restriction is met but unmeasured confounding present, and (3) exclusion restriction is violated. Our simulations varied parameters such as, levels of adherence rates, unmeasured confounding, and exclusion restriction violations. Risk differences were estimated, and we compared performances in terms of bias, standard error (SE), mean squared error (MSE), and 95% confidence interval coverage probability.

Results

For setting (1), 2SLS and 2SRI have small bias and nominal coverage. IP-weighted PP outperforms these IV-methods in terms of smaller MSE but produces high MSE when nonadherence is very high. For setting (2), IP-weighted-PP generally performs poorly compared to 2SLS and 2SRI in term of bias, and both-stages adjusted IV-methods improve precision than naive IV-methods. For setting (3), IV-methods perform worst in all scenarios, and IP-weighted-PP produces unbiased estimates and small MSE when confounders are adjusted. NPCB produces larger uncertainty bound width in almost all scenarios. We also analyze a two-arm trial to estimate vitamin-A supplementation effect on childhood mortality after addressing nonadherence.

Conclusions

Understanding finite sample characteristics of these methods will guide future researchers in determining suitable analysis strategies. Since assumptions are different and often untestable for IP-weighted PP and IV methods, we suggest analyzing data using both IP-weighted PP and IV approaches in search of a robust conclusion.

Prevention and management of type 2 diabetes mellitus in Uganda and South Africa: Findings from the SMART2D pragmatic implementation trial

Health systems in many low- and middle-income countries are struggling to manage type 2 diabetes (T2D). Management of glycaemia via well-organized care can reduce T2D incidence, and associated morbidity and mortality. The primary aim of this study was to evaluate the effectiveness of facility plus community care interventions (integrated care), compared to facility only care interventions (facility care) towards improvement of T2D outcomes in Uganda and South Africa. A pragmatic cluster randomized trial design was used to compare outcomes among participants with T2D and those at high risk. The trial had two study arms; the integrated care arm, and the facility care arm; and in Uganda only, an additional usual care arm. Participants were enrolled at nine primary health facilities in Uganda, and two in South Africa. Participants were adults aged 30 to 75 years, and followed for up to 12 months. Primary outcomes were glycaemic control among participants with T2D, and reduction in HbA1c > = 3 mmol/mol among participants at high risk. Secondary outcomes were retention into care and incident T2D. Adjusted analysis revealed significantly higher retention into care comparing integrated care and facility care versus usual care in Uganda and integrated care versus facility care in South Africa. The effect was particularly high among participants at high risk in Uganda with an incident rate ratio of 2.46 [1.33-4.53] for the facility care arm and 3.52 [2.13-5.80] for the integrated care arm. No improvement in glycaemic control or reduction in HbA1c was found in either country. However, considerable and unbalanced loss to follow-up compromised assessment of the intervention effect on HbA1c. Study interventions significantly improved retention into care, especially compared to usual care in Uganda. This highlights the need for adequate primary care for T2D and suggest a role for the community in T2D prevention. Trial registration number: ISRCTN11913581.

Towards a better understanding of self-management interventions in type 2 diabetes: A meta-regression analysis

AIMS

Attributes that operationally conceptualize diabetes self-management education (DSME) interventions have never been studied previously to assess their impact on relevant outcomes of interest in people with type 2 diabetes (T2D). The aim of this study was to determine the impact of existing interventions classified by their delivery of skills or information related attributes on immediate (knowledge), intermediate (physical activity), post-intermediate (HbA1c), and long-term (quality of life) outcomes in people with T2D.

METHODS

PubMed, Embase, PsycINFO, and Cochrane Library/Cochrane CENTRAL as well as the grey literature were searched to identify interventional studies that examined the impact of DSME interventions on the four different outcomes. Eligible studies were selected and appraised independently by two reviewers. A meta-regression analysis was performed to determine the impact of delivery of the skills- and information-related attributes on the chosen outcomes.

RESULTS

142 studies (n = 25,511 participants) provided data, of which 39 studies (n = 5278) reported on knowledge, 39 studies (n = 8323) on physical activity, 99 studies (n = 17,178) on HbA1c and 24 studies (n = 5147) on quality of life outcomes. Meta-regression analyses demonstrated that skills-related attributes had an estimated effect suggesting improvement in knowledge (SMD [standardized mean difference] increase of 0.80; P = 0.025) and that information-related attributes had an estimated effect suggesting improvement in quality of life (SMD increase of 0.96; P = 0.405). Skill- and information-related attributes did not have an estimated effect suggesting improvement in physical activity or in HbA1c.

CONCLUSIONS

The study findings demonstrate that the skills and information related attributes contribute to different outcomes for people with T2D. This study provides, for the first time, preliminary evidence for differential association of the individual DSME attributes with different levels of outcome.

Self-management Behavior Interventions for Type 2 Diabetes Mellitus: A Review

BACKGROUND: Diabetes mellitus is chronic diseases with serious complications and reduces the quality of life of patients. Evidence based strategies to enhance diabetes self-management may prevent complications and enhance the quality of life for patients is needed. AIM: This study to summarize the types of intervention strategies used to enhance diabetes self-management behaviors in adult individuals type 2 diabetes mellitus (T2DM). METHOD: This study was used Literature review randomized controlled trials study. PubMed, Scopus, Web of Science, and Cochrane Library data base were used. Jadad scale checklist was used to evaluate quality appraisal included in the study. RESULTS: Twenty-six randomized controlled trials studies were included in this review. Overall, quality of the studies was high-quality. Varied interventions included studies at different countries were found to enhance diabetes self-management behaviors in T2DM patients. In addition, almost type interventions were reported a significant enhancement diabetes self-management behaviors especially in adults with type 2 diabetes patients. CONCLUSION: Varied self-management behavior interventions in diabetes mellitus. This review suggested for investigate best intervention to enhance diabetes self-management behaviors in different cultural for best outcomes.

Self-management interventions for adults with stroke: A scoping review

BACKGROUND

Stroke is a principal cause of mortality and disability globally. Numerous studies have contributed to the knowledge base regarding self-management interventions among chronic disease patients, but there are few such studies for patients with stroke. Therefore, it is necessary to analyze self-management interventions among stroke patients. This scoping review aimed to systematically identify and describe randomized controlled trials (RCTs) of self-management interventions for adults with stroke.

METHODS

A review team carried out a scoping review on stroke and self-management interventions based on the methodology of Arksey and O'Malley, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). PubMed, Embase, Web of Science, CINAHL Plus Full Text, Medline Plus Full Text, and Cochrane Central Register of Controlled Trials were searched from inception to July 2020.

RESULTS

Fifty-four RCTs were included. The most popular study design is comparing a self-management intervention to usual care or waitlist control condition. Physical activity is the most common intervention topic, and interventions were mainly delivered face to face. The majority of interventions were located in inpatient and multiple settings. Interventions were conducted by various providers, with nurses the most common provider group. Symptom management was the most frequently reported outcome domain that improved.

CONCLUSIONS

Self-management interventions benefit the symptom management of stroke patients a lot. The reasonable time for intervention is at least 6-12 months. Multifarious intervention topics, delivery formats, and providers are adopted mostly to meet the multiple needs of this population. Physical activity was the most popular topic currently. Studies comparing the effect of different types of self-management interventions are required in the future.

Amankwah J. Diabetes self-management education interventions in the WHO African Region: A scoping review

INTRODUCTION

Diabetes mellitus (DM) is one of the commonest chronic diseases worldwide. Self-Management Education (SME) is regarded as a critical element of treatment for all people with diabetes, as well as those at risk of developing the condition. While a great variety of diabetes self-management education (DSME) interventions are available in high-income countries, limited information exists on educational programs for the prevention and management of diabetes complications in Africa. This study, therefore, aimed at synthesizing information in the literature to describe the state of the science of DSME interventions in the WHO African Region.

MATERIALS AND METHODS

The study is a scoping review, which followed the standard PRISMA guidelines for conducting and reporting scoping reviews. A systematic keyword and subject headings searches were conducted on six electronic databases (PubMed, Scopus, MEDLINE, EMBASE, PsychINFO and the Cochrane Central Register of Controlled Trials) to identify relevant English language publications on DSME from 2000 through 2020. Titles and abstracts of the search results were screened to select eligible papers for full text reading. All eligible papers were retrieved and full text screening was done by three independent reviewers to select studies for inclusion in the final analysis.

RESULTS

Nineteen studies were included in the review. The interventions identified were individually oriented, group-based, individually oriented & group-based, and information technology-based DSME programs. Outcomes of the interventions were mixed. While the majority yielded significant positive results on HbA1c, diabetes knowledge, blood pressure, blood sugar and foot care practices; few demonstrated positive outcomes on self-efficacy, BMI, physical activity; self-monitoring of blood glucose, medication adherence, smoking and alcohol consumption.

CONCLUSIONS

The limited studies available indicate that DSME interventions in the WHO African Region have mixed effects on patient behaviors and health outcomes. That notwithstanding, the majority of the interventions demonstrated statistically significant positive effects on HbA1c, the main outcome measure in most DSME intervention studies.

Effectiveness and safety of self-management interventions among adult type 2 diabetes mellitus patients in sub-Saharan Africa: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate and synthesize evidence on the effectiveness and safety of self-management interventions among adult type 2 diabetes mellitus patients in sub-Saharan Africa.

INTRODUCTION

Type two diabetes mellitus is a large and growing problem in sub-Saharan Africa. Several randomized controlled trials have been conducted assessing a range of self-management interventions among adult patients in sub-Saharan African settings. A comprehensive systematic review on the effectiveness and safety of these self-management interventions is required to inform health policy. This will allow for wide implementation of evidence-based self-management interventions in adults with type 2 diabetes mellitus in sub-Saharan Africa.

INCLUSION CRITERIA

This systematic review will include randomized controlled trials assessing the effectiveness and safety of self-management interventions among adult type 2 diabetes mellitus patients in sub-Saharan Africa.

METHODS

The authors will undertake a systematic search for published and unpublished studies using the following sources: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Global Health (EBSCOhost), Directory of Open Access Journals, OpenGrey, EthOS, and ProQuest Dissertations and Theses. No language restrictions will be applied. The review will be conducted in accordance with the JBI methodology for systematic reviews of effectiveness. Narrative synthesis will be conducted, followed by meta-analysis, where feasible.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021237506.

Patient education program for Brazilians living with diabetes and prediabetes: findings from a development study

Background

Globally, the incidence of diabetes is increasing and strategies to reach a comprehensive approach of care are needed, including education in self-management. This is particularly true in low and middle-income countries where the number of people living with diabetes is higher than in the high-income ones. This article describes the development of a structured patient education program for Brazilians living with diabetes or prediabetes.

Methods

These steps were undertaken: 1) a 4-phase needs assessment (literature search of local diabetes guidelines, environmental scan, evaluation of information needs of patients identified by diabetes experts, and patient focus groups); and, 2) the translation and cultural adaptation of the patient guide (preparation, translation, back-translation, back-translation review, harmonization, and proofreading).

Results

Four of the seven guidelines identified include educational aspects of diabetes management. No structured education program was reported from the environmental scan. Regarding the information needs, 15 diabetes experts identified their patients’ needs, who referred that they have high information needs for topics related to their health condition. Finally, results from six patient focus groups were clustered into six themes (self-management, physical activity, eating habits, diabetes medication, psychosocial being, and sleep), all embedded into the new education program. Constructive theory, adult learning principles, and the Health Action Process Approach model were used in program development and will be used in delivery. The developed program consists of 18 educational sessions strategically mapped and sequenced to support the program learning outcomes and a patient guide with 17 chapters organized into five sections, matched with weekly lectures.

Conclusions

This program is a sequential and theoretical strategic intervention that can reach programs in Brazil to support diabetes and prediabetes patient education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11300-y.

Lifestyle Interventions to Improve Glycemic Control in Adults with Type 2 Diabetes Living in Low-and-Middle Income Countries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs)

Alongside glucose lowering therapy, clinical guidelines recommend lifestyle interventions as cornerstone in the care of people living with type 2 diabetes (T2DM). There is a specific need for an up-to-date review assessing the effectiveness of lifestyle interventions for people with T2DM living in low-and-middle income countries (MICs). Four electronic databases were searched for RCTs published between 1990 and 2020. T2DM, lifestyle interventions, LMICs and their synonyms were used as search terms. Data codebooks were developed and data were extracted. Narrative synthesis and meta-analysis were conducted using random effects models to calculate mean differences (MD) and standardized mean differences (SMD) and 95% confidence intervals (CI). Of 1284 articles identified, 30 RCTs (n = 16,670 participants) met the inclusion criteria. Pooled analysis revealed significant improvement in HBA1c (MD −0.63; CI: −0.86, −0.40), FBG (SMD −0.35; CI: −0.54, −0.16) and BMI (MD −0.5; CI: −0.8, −0.2). In terms of intervention characteristics, those that included promoted self-management using multiple education components (e.g., diet, physical activity, medication adherence, smoking cessation) and were delivered by healthcare professionals in a hospital/clinic setting were deemed most effective. However, when interpreting these results, it is important to consider that most included studies were evaluated as being of low quality and there was a significant amount of intervention characteristics heterogeneity. There is a need for further well-designed studies to inform the evidence base on which lifestyle interventions are most effective for glycemic control in adults with T2DM living in LMICs.

Effectiveness of an adapted diabetes nutrition education program on clinical status, dietary behaviors and behavior mediators in adults with type 2 diabetes: a randomized controlled trial

PURPOSE

This study evaluated the effectiveness of an adapted social-cognitive theory underpinned diabetes nutrition education program (NEP) on: clinical (HbA1c, BMI, blood lipids, blood pressure) and selected dietary behaviors (starchy foods and energy intake, vegetables and fruit intake) and behavior mediators (knowledge and diabetes management self-efficacy) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A tertiary hospital outpatient adults (40-70 years) with poorly controlled (HbA1c ≥ 8 %) T2DM were randomized to either intervention group (n = 39: NEP, 7-monthly group education sessions, bi-monthly follow-up sessions, 15-minute individual session, workbook + education materials) or control group (n = 38: education materials only). NEP aimed to improve clinical status through improved dietary behaviors and behavior mediators. Outcomes and changes in diabetes medication were assessed at six and 12 months. Intention-to-treat analysis was conducted. ANCOVA compared the groups (baseline values, age, sex adjustments).

RESULTS

Forty-eight (62.3 %) participants completed the study. Intervention group compared to the control group had lower (-0.53 %), clinically meaningful HbA1c (primary outcome) at 6 months, albeit not sustained at 12 months. Compared to the control group, the intervention group had significantly lower: (i) systolic blood pressure at six and 12 months (ii) diastolic pressure at 12 months, (iii) energy intake at six-months, (iv) up-titration of insulin at six and 12 months and higher diabetes knowledge scores at six months.

CONCLUSIONS

NEP had limited effects on HbA1c, targeted dietary behaviors and behavior mediators but showed positive effects on blood pressure. The NEP health cost savings potential supports the need for improving program participation.

TRIAL REGISTRATION

ClinicalTrials.gov. number NCT03334773; 7 November 2017 retrospectively registered.

The effects of diabetes self-management interventions on physiological outcomes in people living with diabetes in Africa: A systematic review and meta-analysis

AIM

To examine the effects of diabetes self-management interventions on physiological outcomes among people living with diabetes in Africa compared with patients receiving usual care.

METHODS

Relevant databases including PubMed, CINAHL Complete, Scopus, the Cochrane Library and Google Scholar were searched from inception to 28 September 2019, for randomised controlled trials (RCTs) involving adults living with diabetes in Africa. Nine RCTs were included in the review, and the quality of the studies was assessed using Cochrane's collaboration risk of bias tools.

RESULTS

A meta-analysis of the outcomes showed the significant effects of diabetes self-management interventions on blood pressure, total cholesterol and body mass index, whereas non-significant and inconclusive results were obtained for waist circumference and glycosylated haemoglobin, respectively.

CONCLUSIONS

The diabetes self-management interventions (DSM) effectively improved many physiological outcomes, but their effectiveness in HbA_1c was inconclusive, suggesting a need for modifications in DSM interventions for African people living with diabetes.

Needs and resources of people with type 2 diabetes in peri-urban Cochabamba, Bolivia: a people-centred perspective

BACKGROUND

The rising prevalence of type 2 diabetes results in a worldwide public healthcare crisis, especially in low- and middle-income countries (LMICs) with unprepared and overburdened health systems mainly focused on infectious diseases and maternal and child health. Studies regarding type 2 diabetes in LMICs describe specific interventions ignoring a comprehensive analysis of the local factors people see influential to their health. This study aims to meet this research gap by exploring what people with type 2 diabetes in Bolivia need to maintain or improve their health, how important they perceive those identified needs and to what extent these needs are met.

METHODS

From March until May 2019, 33 persons with type 2 diabetes from three periurban municipalities of the department of Cochabamba participated in this study. The concept mapping methodology by Trochim, a highly structured qualitative brainstorming method, was used to generate and structure a broad range of perspectives on what the participants considered instrumental for their health.

RESULTS

The brainstorming resulted in 156 original statements condensed into 72 conceptually different needs and resources, structured under nine conceptual clusters and four action domains. These domains illustrated with vital needs were: (1) self-management with use of plants and the possibility to measure sugar levels periodically; (2) healthcare providers with the need to trust and receive a uniform diagnosis and treatment plan; (3) health system with opportune access to care and (4) community with community participation in health and safety, including removal of stray dogs.

CONCLUSIONS

This study identifies mostly contextual factors like low literacy levels, linguistic problems in care, the need to articulate people's worldview including traditional use of natural remedies with the Bolivian health system and the lack of expertise on type 2 diabetes by primary health care providers. Understanding the needs and structuring them in different areas wherein action is required serves as a foundation for the planning and evaluation of an integrated people centred care program for people with type 2 diabetes. This participative method serves as a tool to implement the often theoretical concept of integrated people centred health care in health policy and program development.

Pathways to Care for Patients With Type 2 Diabetes and HIV/AIDS Comorbidities in Soweto, South Africa: An Ethnographic Study

Patients with type 2 diabetes are referred to tertiary hospitals in Soweto although their care could be managed at primary health care clinics. Primary health care needs to be strengthened by addressing health systemic challenges to provide integrated care for comorbid type 2 diabetes and HIV/AIDS.

Background:

South Africa is experiencing colliding epidemics of HIV/AIDS and noncommunicable diseases. In response, the National Department of Health has implemented integrated chronic disease management aimed at strengthening primary health care (PHC) facilities to manage chronic illnesses. However, chronic care is still fragmented. This study explored how the health system functions to care for patients with comorbid type 2 diabetes (T2DM) and HIV/AIDS at a tertiary hospital in Soweto, South Africa.

Methods:

We employed ethnographic methods encompassing clinical observations and qualitative interviews with health care providers at the hospital (n=30). Data were transcribed verbatim and thematically analyzed using QSR NVivo 12 software.

Findings:

Health systemic challenges such as the lack of medication, untrained nurses, and a limited number of doctors at PHC clinics necessitated patient referrals to a tertiary hospital. At the hospital, patients with T2DM were managed first at the medical outpatient clinic before they were referred to a specialty clinic. Those with comorbidities attended different clinics at the hospital partly due to the structure of the tertiary hospital that offers specialized care. In addition, little to no collaboration occurred among health care providers due to poor communication, noncentralized patient information, and staff shortage. As a result, patients experienced disjointed care.

Conclusion:

PHC clinics in Soweto need to be strengthened by training nurses to diagnose and manage patients with T2DM and also by ensuring adequate medical supplies. We recommend that the medical outpatient clinic at a tertiary hospital should also be strengthened to offer integrated and collaborative care to patients with T2DM and other comorbidities. Addressing key systemic challenges such as staff shortages and noncentralized patient information will create a patient-centered as opposed to disease-specific approach to care.

Barriers and facilitators of implementation of a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda using the Consolidated Framework for Implementation Research

Background

In low- and middle-income countries, there is an increasing attention towards community approaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have explored the implementation processes of such interventions to inform their scale up and sustainability. Using the consolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencing the implementation of a community CVD programme led by community health workers (CHWs) in Mukono and Buikwe districts in Uganda.

Methods

This qualitative study is a process evaluation of an ongoing type II hybrid stepped wedge cluster trial guided by the CFIR. Data for this analysis were collected through regular meetings and focus group discussions (FGDs) conducted during the first cycle (6 months) of intervention implementation. A total of 20 CHWs participated in the implementation programme in 20 villages during the first cycle. Meeting reports and FGD transcripts were analysed following inductive thematic analysis with the aid of Nvivo 12.6 to generate emerging themes and sub-themes and thereafter deductive analysis was used to map themes and sub-themes onto the CFIR domains and constructs.

Results

The barriers to intervention implementation were the complexity of the intervention (complexity), compatibility with community culture (culture), the lack of an enabling environment for behaviour change (patient needs and resources) and mistrust of CHWs by community members (relative priority). In addition, the low community awareness of CVD (tension for change), competing demands (other personal attributes) and unfavourable policies (external policy and incentives) impeded intervention implementation. On the other hand, facilitators of intervention implementation were availability of inputs and protective equipment (design quality and packaging), training of CHWs (Available resources), working with community structures including leaders and groups (process—opinion leaders), frequent support supervision and engagements (process—formally appointed internal implementation leaders) and access to quality health services (process—champions).

Conclusion

Using the CFIR, we identified drivers of implementation success or failure for a community CVD prevention programme in a low-income context. These findings are key to inform the design of impactful, scalable and sustainable CHW programmes for non-communicable diseases prevention and control.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-020-01065-0.

Self-management in face-to-face peer support for adults with type 2 diabetes living in low- or middle-income countries: a systematic review

Background

Peer support has been recognised as a promising strategy to improve self-management in patients living with chronic conditions, such as Type 2 diabetes (T2D). The purpose of the review was to synthesise the best available evidence on face-to-face peer support models for adults with T2D in low and middle-income countries (LMICs).

Methods

We searched Medline, Cumulative Index to Nursing and Allied Health, Literature Academic Search Ultimate, PsycINFO, CAB Abstracts, Health Source: Nursing/Academic Edition, SPORTDiscus, Africa-Wide Information, MasterFILE Premier, SocINDEX, ERIC, PsycARTICLES, Open Dissertations, Communication & Mass Media Complete, Health Source-Consumer Edition and Google Scholar for the period January 2000 to December 2017. Reference list checking and contact with authors were additional sources of data. Screening of papers, critical appraisal and data extraction were carried out independently by at least two reviewers.

Results

From 3092 abstracts retrieved from database searches, data was extracted from 12 papers. There was no consistency in design, setting, outcomes or measurement instruments amongst the papers. The papers were associated with improvements in various clinical and behavioural outcomes. Diabetic patients and community health workers (CHWs) were identified as two common face-to-face peer support models. The recruitment and selection of diabetic patients as peer supporters focused on patients from the community, with good glycaemic control and/or leadership skills, who were recommended by healthcare professionals. Recruitment of CHWs as peer supporters was done from an existing infrastructure of CHWs in the community and, thus, selection criteria were poorly described. The training of peer supporters featured as an important component, highlighting who provided training and the duration and content covered in training. Motivational interviewing was the most common theory basis of training used in the peer support interventions. Face-to-face, group and/or individual-based peer support was often supplemented by other peer support methods. The supervision of peer supporters was generally poorly described.

Conclusions

The comprehensive synthesis of the best available evidence has led to new insights regarding face-to-face peer support as a self-management strategy for patients with T2D in LMICs. Face-to-face peer support may be implemented in innovative ways to improve the quality of life of patients with T2D.

Trial registration

PROSPERO trial registry number, CRD 42018103261.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09954-1.

Task-sharing interventions for improving control of diabetes in low-income and middle-income countries: a systematic review and meta-analysis

Background

Task-sharing interventions using non-physician health-care workers might be a potential diabetes management strategy in health systems that are constrained by physician shortages, such as those in low-income and middle-income countries (LMICs).

Methods

We did a systematic review and meta-analysis of task-sharing intervention strategies for managing type 2 diabetes in LMICs. We searched PubMed, Embase, and CINAHL from database inception to Sept 25, 2019, for studies that were randomised control trials or cluster randomised trials with task-shifted or task-shared interventions delivered to adults (≥18 years) by non-physician health workers versus usual care, done in LMICs with glycated haemoglobin (HbA_1c) or fasting blood sugar (FBS) as outcome measures. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Random-effects model meta-analysis was used to estimate the population average pooled mean difference for HbA_1c and FBS with 95% CIs. Our study protocol was registered in the PROSPERO database (CRD42018081015).

Findings

We found 4213 studies from the literature search, of which 46 (1·1%) were eligible for the narrative synthesis, including a total of 16 973 participants. 16 of these studies were excluded from the meta-analysis due to high risk of bias. 24 studies with a total of 5345 participants were included in the meta-analysis of HbA_1c and 18 studies with a total of 3287 participants for FBS. Interventions led to an average reduction in HbA_1c when tasks were delivered by nurses (averaged pooled mean difference −0·54% [95% CI −0·89 to −0·18]; I²=80%) and pharmacists (−0·91% [–1·15 to −0·68]; I²=58%), but not when they were delivered by dietitians (−0·50% [–1·10 to 0·09]; I²=54%) or community health workers (0·05% [0·03 to 0·07]; I²=0%). A reduction in average FBS was also observed when interventions were delivered by pharmacists (average pooled mean difference −36·26 mg/dL [–52·60 to −19·92]; I²=78%) but not nurses (−7·46 mg/dL [–18·44 to 3·52]; I²=79%) or community health workers (−5·41 [–12·74 to 1·92]; I²=71%). Only one study reported on FBS when tasks were delivered by dietitians, with a mean difference of −35·00 mg/dL (−65·96 to −4·04).

Interpretation

Task sharing interventions with non-physician healthcare workers show moderate effectiveness in diabetes management in LMIC settings. Although relatively high heterogeneity limits the interpretation of the overall findings, interventions led by pharmacists and nurses in LMICs with relatively high physician density are effective strategies in the management of diabetes.

Funding

Wellcome Trust–Department of Biotechnology India Alliance.

Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs.

METHODS AND FINDINGS

We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes.

CONCLUSIONS

In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

The effectiveness of peer and community health worker-led self-management support programs for improving diabetes health-related outcomes in adults in low- and-middle-income countries: a systematic review

OBJECTIVE

Community-based peer and community health worker-led diabetes self-management programs (COMP-DSMP) can benefit diabetes care, but the supporting evidence has been inadequately assessed. This systematic review explores the nature of COMP-DSMP in low- and middle-income countries' (LMIC) primary care settings and evaluates implementation strategies and diabetes-related health outcomes.

METHODS

We searched the Cochrane Library, PubMed-MEDLINE, SCOPUS, CINAHL PsycINFO Database, International Clinical Trials Registry Platform, Clinicaltrials.gov, Pan African Clinical Trials Registry (PACTR), and HINARI (Health InterNetwork Access to Research Initiative) for studies that evaluated a COMP-DSMP in adults with either type 1 or type 2 diabetes in World Bank-defined LMIC from January 2000 to December 2019. Randomised and non-randomised controlled trials with at least 3 months follow-up and reporting on a behavioural, a primary psychological, and/or a clinical outcome were included. Implementation strategies were analysed using the standardised implementation framework by Proctor et al. Heterogeneity in study designs, outcomes, the scale of measurements, and measurement times precluded meta-analysis; thus, a narrative description of studies is provided.

RESULTS

Of the 702 records identified, eleven studies with 6090 participants were included. COMP-DSMPs were inconsistently associated with improvements in clinical, behavioural, and psychological outcomes. Many of the included studies were evaluated as being of low quality, most had a substantial risk of bias, and there was a significant heterogeneity of the intervention characteristics (for example, peer definition, selection, recruitment, training and type, dose, and duration of delivered intervention), such that generalisation was not possible.

CONCLUSIONS

The level of evidence of this systematic review was considered low according to the GRADE criteria. The existing evidence however does show some improvements in outcomes. We recommend ongoing, but well-designed studies using a framework such as the MRC framework for the development and evaluation of complex interventions to inform the evidence base on the contribution of COMP-DSMP in LMIC.

A randomized clinical trial of mobile phone motivational interviewing for alcohol use problems in Kenya

AIM

To test the effectiveness of a motivational interviewing (MI) intervention using the mobile phone among adults with alcohol use problems.

DESIGN

A randomized clinical trial of mobile MI and standard in-person MI with 1- and 6-month follow-up, including a 1-month waitlist control followed by mobile MI.

SETTING

A primary health center in rural Kenya.

PARTICIPANTS

Three hundred adults screening positive for alcohol use problems were randomized and received immediate mobile MI (n = 89), in-person MI (n = 65) or delayed mobile MI (n = 76) for waiting-list controls 1 month after no treatment, with 70 unable to be reached for intervention.

INTERVENTION AND COMPARATOR

One MI session was provided either immediately by mobile phone, in-person at the health center or delayed by 1 month and then provided by mobile phone.

MEASUREMENTS

Alcohol use problems were repeatedly assessed using the Alcohol Use Disorder Identification Test (AUDIT) and the shorter AUDIT-C. The primary outcome was difference in alcohol score 1 month after no intervention for waiting-list control versus 1 month after MI for mobile MI. The secondary outcomes were difference in alcohol score for in-person MI versus mobile MI one and 6 months after MI.

FINDINGS

For our primary outcome, average AUDIT-C scores were nearly three points higher (difference = 2.88, 95% confidence interval = 2.11, 3.66) for waiting-list controls after 1 month of no intervention versus mobile MI 1 month after intervention. Results for secondary outcomes supported the null hypothesis of no difference between in-person and mobile MI at 1 month (Bayes factor = 0.22), but were inconclusive at 6 months (Bayes factor = 0.41).

CONCLUSION

Mobile phone-based motivational interviewing may be an effective treatment for alcohol use problems among adults visiting primary care in Kenya. Providing mobile motivational interviewing may help clinicians in rural areas to reach patients needing treatment for alcohol use problems.

Community-based interventions for prevention of Type 2 diabetes in low- and middle-income countries: a systematic review

Type 2 diabetes is an increasing burden in low- and middle-income countries (LMICs). Knowledge of effective prevention programs in LMICs is thus important. The aim of this review was to establish an overview of studies evaluating the effectiveness of community-based interventions for prevention of Type 2 diabetes in LMICs. A literature review with searches in the databases using MEDLINE in Ovid (Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE and Version (R); Embase; PsycINFO; Global Health; and Google Scholar) between 1 January 2000 and 31 December 2015 was conducted. Only 10 studies that met our selection criteria were included; 3 were randomized controlled trials, 2 non-randomized controlled trials and 5 were pre-and post-intervention studies. About 9 of 10 studies reported significant reduction in both the glycated hemoglobin (HbA1c) and fasting blood glucose (FBG) levels as a result of the intervention. A majority of the studies included multicomponent interventions such as education and behavioral encompassing both individual and group work, and included health education, nutrition education, nutrition counseling, exercise and promoting physical activity, psychosocial approaches and lifestyle modification. The interventions were delivered by community health workers, volunteers, social workers, community nutritionists and community nurses. Comparisons between studies, however, was not possible due to substantial heterogeneity in study design. This review contributes to the current literature on community-based interventions for prevention of Type 2 diabetes in LMICs, acknowledging the community-based approach can be effective in prevention and control of Type 2 diabetes. Due to the heterogeneity across study designs, outcomes and in terms of variation and duration of interventions, only limited conclusions can be drawn about the effectiveness of interventions. More evidence from randomized controlled trials on culturally tailored, community-based interventions is needed to compare findings and test implementation in practice.

The impact of intensified clinical care on glycaemic control in patients with type 2 diabetes at Khayelitsha Community Health Centre, South Africa: Quasi-experimental study

AIM

The aim was to evaluate the effect on glycaemic control of more intensive care for patients with very uncontrolled type-2 diabetes (HbA1c>10%) at Khayelitsha Community Health Centre, South Africa.

METHODS

A pragmatic, quasi-experimental study. Patients with HBA1c>10% were consecutively selected into a 6-month programme of intensified care involving monthly visits to a doctor, diabetes group education, escalation of treatment, and more frequent HbA1c testing by either point-of-care (POC) or laboratory. Participants were their own controls in a retrospective analysis of usual care during the previous year.

RESULTS

At baseline 236 patients had a mean HbA1c of 12.1%. The mean difference in HbA1c in the intervention group was -1.1% (p<0.001). The intervention group were exposed to group diabetes education (100% vs 0%), more visits (3.8 vs 3.2, p<0.001), more HbA1c tests (2.2 vs 0.9, p<0.001). There was no difference in increased dose of insulin between the groups or between POC and standard laboratory intervention sub-groups.

CONCLUSION

The introduction of group diabetes education was the most likely explanation for improved glycaemic control in this poor, under-resourced, public sector, peri-urban setting. The study demonstrates a feasible approach to improving diabetes care in the South African context.