Implementation of blood glucose self-monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda: 6 months open randomised controlled trial

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Implementation of self-monitoring of blood glucose for patients with insulin-dependent diabetes at a rural non-communicable disease clinic in Neno, Malawi

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a widely accepted standard of practice for management of insulin-dependentdiabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report ofimplementation of SMBG in a rural, low-income country setting.

OBJECTIVES

To evaluate adherence and change in clinical outcomes with SMBG implementation at two rural hospitals in Neno, Malawi.

METHODS

Forty-eight patients with type 1 and insulin-dependent type 2 diabetes were trained to use glucometers and logbooks. Participantsmonitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluateglucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked anddocumented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a6-month period.

RESULTS

Participants brought their glucometers and logbooks to the clinic 95 - 100% of the time. Adherence with measuring glucose valuesand recording them in logbooks eight times a week was high (mean (standard deviation) 69.4% (15.7) and 69.0% (16.6), respectively). MeanHbA1c decreased from 9.0% (75 mmol/mol) at enrolment to 7.8% (62 mmol/mol) at 6 months (mean difference 1.2% (95% confidenceinterval (CI) 0.6 - 2.0; p=0.0005). The difference was greater for type 1 diabetes (1.6%; 95% CI 0.6 - 2.7; p=0.0031) than for type 2 diabetes(0.9%; 95% CI 0.1 - 1.9; p=0.0630). There was no documented increase in hypoglycaemic events, and no hospitalisations or deaths occurred.

CONCLUSION

SMBG is feasible for patients with insulin-dependent diabetes in a rural SSA population, and may be associated with improvedHbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research onlong-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda

BACKGROUND

The prevalence of type 2 diabetes in sub Saharan Africa (SSA) has been on the rise. Effective control of blood glucose is key towards reducing the risk of diabetes complications. Findings mainly from high-income countries have demonstrated the effectiveness of self-monitoring of blood-glucose (SMBG) in controlling blood glucose levels. However, there are limited studies describing the implementation of SMBG in rural SSA. This study explores the feasibility and effectiveness of implementing SMBG among patients diagnosed with insulin-dependent type 2 diabetes in rural Rwanda.

METHODS

Participants were randomized into intervention (n = 42) and control (n = 38) groups. The intervention group received a glucose-meter, blood test-strips, log-book, waste management box and training on SMBG in addition to usual care. The control group continued with their usual care consisting of, routine monthly medical consultation and health education. The primary outcomes were adherence to the implementation of SMBG (testing schedule and recording data in the log-book) and change in hemoglobin A1c. Descriptive statistics and a paired t-test were used to analyze the primary outcomes.

RESULTS

In both the intervention and control arms, majority of the participants were female (59.5% vs 52.6%) and married (71.4% vs 73.7%). Most had at most a primary level education (83.3% vs. 89.4%) and were farmers (54.8% vs. 50.0%). Among those in the intervention group, 63.4% showed good adherence to implementing SMBG based on the number of tests recorded in the glucose meter. Only 20.3% demonstrated accurate recording of the glucose level tests in log-books. The mean difference of the HbA1C from baseline to six months post-intervention was significantly better among the intervention group -0.94% (95% CI -1.46, -0.41) compared to the control group 0.73% (95% CI -0.09, 1.54) p < 0.001.

CONCLUSION

Our study showed that among patients with insulin-dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log-book.

TRIAL REGISTRATION

The trial was registered retrospectively on the Pan African Clinical Trial Registry, on 17^th May 2019. The registration number is PACTR201905538846394.

Diabetic Complications and Associated Factors: A 5-Year Facility-Based Retrospective Study at a Tertiary Hospital in Rwanda

INTRODUCTION

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by hyperglycemia resulting from defects in insulin production, insulin action, or both. Despite advances in DM diagnosis and management, the incidence of DM-related complications remains high. This study aimed to determine patterns of common complications and associated factors among hospitalized patients in Rwanda.

METHODS

A cross-sectional study, with retrospective chart review, was conducted at CHUK from July to August, 2021. Charts for DM patients admitted from January 2016 to December 2020 were considered while those inaccessible at the time of data collection were excluded. Linear regression model was used to assess the relationship between dependent and independent variables with a p < 0.05 considered statistically significant.

RESULTS

A total of 246 charts were reviewed. The median age was 56 years (IQR: 14-90). More than half of participants (n = 135; 54.9%) were females; majority from the Central region (n = 138; 56.7%). Recorded DM risk factors included alcohol intake (n = 81; 48.5%); smoking (n = 40; 24.2%), obesity (n = 43; 52.4%), and family history of DM (n = 27; 56.3%). Majority (n = 153; 84.5%) had type 2 DM and (n = 147; 69%) had known their diagnosis for at least 6 years. Hypertension (n = 124, 50.4%), acute hyperglycemic state (n = 59, 24%), nephropathy (n = 58, 23.6%), and stroke (n = 38, 15.4%) were frequently reported complications. Nearly all participants (n = 81, 95.2%) with complications had poor glycemic control. Alcohol intake, age ≥45 years, and T1DM were associated with higher odds of DM complications (aOR = 8, 95% CI = 2-32.6, p = 0.003, aOR = 6.2, 95% CI = 1.4-27.6, p = 0.016 and aOR = 14.1, 95% CI = 1.2-161.5, p = 0.034, respectively). Duration of DM (p = 0.001) was significant at bivariate analysis.

CONCLUSION

DM complications were prevalent among the studied population with poor glycemic control mainly influenced by alcohol consumption and duration of DM. Expansion of integrated DM and hypertension screening services to lower-level centers is needed to reduce the associated morbidity and mortality.