Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial

A critical review of literature and a conceptual framework for organizing and researching urban health and community health services in low- and middle-income countries

Low- and middle-income countries (LMICs) are rapidly urbanizing, and in response to this, there is an expansion in the body of scholarship and significant policy interest in urban healthcare provision. The idea and the reality of 'urban advantage' have meant that health research in LMICs has disproportionately focused on health and healthcare provision in rural contexts and is yet to sufficiently engage with urban health as actively. We contend that this research and practice can benefit from a more explicit engagement with the rich conceptual understandings that have emerged in other disciplines around the urban condition. Our critical review included publications from four databases (MEDLINE, EMBASE, CINAHL, and Social Sciences Citation Index) and two Community Health Worker (CHW) resource hubs. We draw upon scholarship anchored in sociology to unpack the nature and features of the urban condition; we use these theoretical insights to critically review the literature on urban community health worker programs as a case to reflect on community health practice and urban health research in LMIC contexts. Through this analysis, we delineate key features of the urban, such as heterogeneity, secondary spaces and ties, size and density, visibility and anonymity, precarious work and living conditions, crime, and insecurity, and specifically the social location of the urban CHWs and present their implications for community health practice. We propose a conceptual framework for a distinct imagination of the urban to guide health research and practice in urban health and community health programs in the LMIC context. The framework will enable researchers and practitioners to better engage with what entails a 'community' and a 'community health program' in urban contexts.

Therapeutic patient education programs on diabetes in sub-Saharan Africa: A systematic review

BACKGROUND

Diabetes is a chronic disease associated with the potential for blindness, kidney failure, heart attacks, strokes, and lower limb amputations. The global prevalence of diabetes is rising, particularly in the sub-Saharan African (SSA) region, where accessing treatment and antidiabetic drugs is complex, leading to challenges in managing the condition. Intentional and structured therapeutic education has demonstrated its ability to enhance health outcomes in diabetes patients. Given the numerous healthcare deficiencies in sub-Saharan Africa, the authors have reevaluated the role of therapeutic patient education (TPE) in this context.

METHODS

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We queried four databases between March 14 and June 30, 2023 and conducted Cochrane's Risk of Bias analysis on the included studies. Subsequently, a qualitative synthesis of the results was performed.

RESULTS

The final analysis included thirteen studies. Seven of these, which assessed glycemic control, reported statistically significant results. Additionally, other clinical parameters such as body mass index (BMI), blood pressure, and lipid levels also exhibited some significant improvements. Knowledge substantially increased following the intervention, while attitude, self-care practices, and medication adherence showed no significant improvements. Nurse-led and peer-led intervention programs produced positive outcomes, whereas technology-based intervention methods did not yield favorable results.

CONCLUSION

TPE programs in sub-Saharan Africa have a significant impact on both clinical and non-clinical outcomes in diabetes patients. However, the sustainability of these outcomes remains uncertain. Further research is needed to assess the long-term effects of TPE on diabetes patients.

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.

The sustainability of group empowerment and training for people with diabetes in South Africa

BACKGROUND

Group empowerment and training (GREAT) for people with type 2 diabetes enables self-management and lifestyle modification. GREAT for diabetes was implemented in primary care facilities in five South African provinces in the beginning of 2022. The aim was to evaluate implementation and to particularly explore factors that influenced the sustainability of implementation.

METHODS

An exploratory, descriptive qualitative study conducted semi-structured individual interviews with 17 key stakeholders at the end of 2023. Interviews explored factors within a theory of change framework derived from an initial evaluation in 2022. Data were analysed using the framework method and ATLAS.ti.

RESULTS

Implementation and scale-up was sustained in the Western Cape. Governance and financing at a provincial and district level were key to health system structures. Space, staffing, resource materials and monitoring of implementation were key to the inputs. Facility managers, training and performance of facilitators, including the whole team, selecting patients, patient flow and appointments, stakeholder support and clinical governance were key to service delivery. Facilities that had implemented, reported reaching 300 patients per year. A range of motivational, behavioural and clinical outcomes were reported. Future implementation could include community health workers and group empowerment for insulin initiation.

CONCLUSION

Implementation and scale-up was only sustained in one province and a range of factors related to sustained implementation were identified.Contribution: The factors identified can guide the successful implementation and scale-up of GREAT for diabetes in South Africa.

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.

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.

Effectiveness of interventions based on patient empowerment in the control of type 2 diabetes in sub-Saharan Africa: A review of randomized controlled trials

Background

It is estimated that 1.6 million deaths worldwide were directly caused by diabetes in 2016, and the burden of diabetes has been increasing rapidly in low- and middle-income countries. This study reviews existing interventions based on patient empowerment and their effectiveness in controlling diabetes in sub-Saharan Africa.

Method

PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO and Global Health were searched through August 2018, for randomized controlled trials of educational interventions on adherence to the medication plan and lifestyle changes among adults aged 18 years and over with type 2 diabetes. Random-effects meta-analysis was used.

Results

Eleven publications from nine studies involving 2743 participants met the inclusion criteria. The duration of interventions with group education and individual education ranged from 3 to 12 months. For six studies comprising 1549 participants with meta-analysable data on glycaemic control (HbA1c), there were statistically significant differences between intervention and control groups: mean difference was -0.57 [95% confidence interval (CI) -0.75, -0.40] (P < .00001, I2 = 27%). Seven studies with meta-analysable data on blood pressure showed statistically significant differences between groups in favour of interventions. Subgroup analyses on glycaemic control showed that long-term interventions were more effective than short-term interventions and lifestyle interventions were more effective than diabetes self-management education.

Conclusion

This review supports the findings that interventions based on patient empowerment may improve glycaemia (HbA1c) and blood pressure in patients with diabetes. The long-term and lifestyle interventions appear to be the most effective interventions for glycaemic control.

The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature

Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.

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.

Development of a Tool to Increase Physical Activity among People at Risk for Diabetes in Low-Resourced Communities in Cape Town

Targeted lifestyle interventions, including physical activity (PA), have been proven to prevent or delay the onset of diabetes. South Africa’s unique context, complex environment and varied cultures and ethnicities require tailored interventions. Our objective was to develop a context-appropriate tool for the South African Diabetes Prevention Programme’s PA lifestyle component in order to enable people at risk of developing diabetes to adopt PA. We used mixed methods to inform the development of the tool. Descriptive analyses of baseline survey data included socio-demographics, anthropometrics, blood pressure and biochemical measurements, reported medical history, PA behaviours, and built environment information. Focus group discussions assisted in understanding perceived challenges, barriers and facilitators/opportunities to PA. A literature search on successful South African PA interventions was done, and PA experts in Cape Town were consulted. Quantitative data were analysed using the software R, version 3.4.4 and qualitative data were thematically analysed. Participants (n = 316) recruited were mostly black (54.4%) and of mixed-ancestry (44.6%); they were mainly female (80.1%), obese (75.2%), and had an haemoglobin A1c (HbA1c) above 5.7% (65.5%), with 30% having hypertension and 87% (self-reported) meeting the World Health Organisation (WHO) PA recommendation. Main barriers to PA practice were safety, cost and accessibility of sports facilities, and laziness. We included practising moderate-intensity aerobic and resistance exercises and take-home self-help materials as recommended. By combining results, we produced a targeted, practical and promotional PA booklet.

Development, feasibility, acceptability and potential effectiveness of a healthy lifestyle programme delivered in churches in urban and rural South Africa

Rising levels of obesity in South Africa require innovation in community-level lifestyle change programmes. Our aim was to co-develop Impilo neZenkolo ('Health through Faith'), a healthy lifestyle programme for low-income, black South Africans delivered through churches, and evaluate its feasibility, acceptability and potential effectiveness. In the first phase we developed programme materials with church members. In the second phase we trained lay leaders to deliver the programme and assessed feasibility, acceptability (observation, focus groups and interviews) and potential effectiveness (pre and post measurement of weight, hip and waist circumferences, blood pressure, self-reported physical activity, dietary habits, health status, self-esteem, psychological distress). The study was conducted in four churches in urban and rural South Africa. The development workshops led to increased focus on positive benefits of participation, widening inclusion criteria to all adults and greater emphasis on Christian ethos. Challenges to feasibility included: recruitment of churches; scheduling of programme sessions (leading to one church not delivering the programme); attendance at the programme (63% attended more than half of the 12 weekly sessions); and poor programme fidelity (in particular in teaching behaviour change techniques). Aspects of the programme were acceptable, particularly the way in which the programme was aligned with a Christian ethos. There was some indication that amongst the 42/68 (62%) for whom we were obtained pre- and post-programme measurements the programme has potential to support weight loss. We conclude that a healthy lifestyle programme for low-income, black South Africans, delivered through churches, may be viable with extensive re-development of delivery strategies. These include finding external funding for the programme, endorsement from national level denominational organisations and the professionalization of programme leadership, including paid rather than volunteer leaders to ensure sufficient time can be spent in training.

Self-management of diabetes in Sub-Saharan Africa: a systematic review

BACKGROUND

The prevalence of diabetes in sub-Saharan Africa has increased rapidly over the last years. Self-management is a key element for the proper management, but strategies are currently lacking in this context. This systematic review aims to describe the level of self-management among persons living with type 2 diabetes mellitus in sub-Saharan Africa.

METHOD

Relevant databases including PubMed, Web of Science and Google Scholar were searched up to September 2016. Studies reporting self-management behavior of people with type 2 diabetes mellitus and living in sub-Saharan Africa were included.

RESULTS

A total of 550 abstracts and 109 full-text articles were assessed. Forty-three studies, mainly observational, met the inclusion criteria. The studies showed that patients rarely self-monitored their glucose levels, had low frequency/duration of physical activity, moderately adhered to recommended dietary and medication behavior, had poor level of knowledge regarding diabetes related complications and sought traditional or herbal medicines beside of their biomedical treatment. The analysis also revealed a lack of studies on psychosocial aspects.

CONCLUSION

Except for the psychosocial area, there is a good amount of recent studies on self-management behavior of type 2 diabetes mellitus sub-Saharan Africa. These studies indicate that self-management in sub-Saharan Africa is poor and therefore a serious threat to the health of individuals and the health systems capacity.

The development of the visual screening tool for anxiety disorders and depression: Addressing barriers to screening for depression and anxiety disorders in hypertension and/or diabetes

Background

There is a lack of screening tools for common mental disorders that can be applied across cultures, languages and levels of education in people with diabetes and hypertension.

Aim

To develop a visual screening tool for depression and anxiety disorders that is applicable across cultures and levels of education.

Setting

Participants were purposively recruited from two not-for-profit organisations and two public health facilities – a maternal mental health unit and a primary health care centre.

Method

This was a qualitative cross-sectional study. Thirteen drawings based on the Hospital Anxiety and Depression Scale depicting symptoms of anxiety disorders and depression were drawn. Participants described emotions and thoughts depicted in the drawings. Data were analysed through content analysis.

Results

Thirty-one women (66%) and 16 men (34%) participated in the development of the visual screening tool. The mean age was 34 (standard deviation [SD] 12.46). There were 32 (68%) black participants, 11 (23%) mixed race participants and 4 (9%) white participants. Two participants (4%) had no schooling, 14 (31%) primary schooling, 8 (18%) senior schooling, 13 (29%) matric qualification and 8 (18%) had post-matric qualification. Participants correctly described 10 out of the 13 visual depiction of symptoms as associated with depression and anxiety disorders, with no differences between levels of education and cultural groups.

Conclusion

Ten drawings were appropriate for inclusion in the visual screening tool for anxiety disorders and depression (VISTAD). The VISTAD will be validated against the mini international neuropsychiatric interview (MINI) in a primary care population with hypertension and/or diabetes.

Factors predicting community participation in patients living with stroke, in the Western Cape, South Africa

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa. Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews. Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors. Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients' participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors. Implications for Rehabilitation Community participation in the general population of stroke survivors' is largely determined by their mobility function. Determinants of community participation among stroke survivors essentially vary according to age and gender. Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients' demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

Effectiveness of motivational interviewing for improving physical activity self-management for adults with type 2 diabetes: A review

Objectives This review examines the effectiveness of motivational interviewing for physical activity self-management for adults diagnosed with diabetes mellitus type 2. Motivational interviewing is a patient centered individually tailored counseling intervention that aims to elicit a patient's own motivation for health behavior change. Review questions include (a) How have motivational interviewing methods been applied to physical activity interventions for adults with diabetes mellitus type 2? (b) What motivational interviewing approaches are associated with successful physical activity outcomes with diabetes mellitus 2? Methods Database searches used PubMed, CINAHL, and PsycINFO for the years 2000 to 2016. Criteria for inclusion was motivational interviewing used as the principal intervention in the tradition of Miller and Rollnick, measurement of physical activity, statistical significance reported for physical activity outcomes, quantitative research, and articles written in English. Results A total of nine studies met review criteria and four included motivational interviewing interventions associated with significant physical activity outcomes. Discussion Findings suggest motivational interviewing sessions should target a minimal number of self-management behaviors, be delivered by counselors proficient in motivational interviewing, and use motivational interviewing protocols with an emphasis placed either on duration or frequency of sessions.

Diabetes and complications of the heart in Sub-Saharan Africa: An urgent need for improved awareness, diagnostics and management

Type 2 diabetes mellitus is no longer a disease of high income countries but a global health pandemic. With the continued and rapid increase in its prevalence worldwide it is forecasted that diabetes will be a leading cause of morbidity and mortality. A major concern stems from its role in development and progression of cardiovascular disease, including cardiac dysfunction and heart failure. Within low- and middle-income areas such as Sub-Saharan Africa the burden of diabetes is already significant driven by many factors, including, socioeconomic (urbanisation), nutritional (high-calorie "western-diet", obesity) and lifestyle (physical inactivity) changes. Insufficient economic and community resources, poor health care system development and chronic disease management, poor education, and a lack of preventative and diagnostic measures further aggravate the severity of the diabetes problem. This review outlines the burden of type 2 diabetes mellitus in Sub-Saharan Africa and highlights the need for improved community health care and regulations to reduce its epidemiological spread and devastating impact on health.

Nursing appointment and cardiometabolic control of diabetics: a randomized clinical trial

ABSTRACT Objective: to verify the effect of nursing appointment on cardiometabolic profile of people with Diabetes Mellitus type 2. Method: randomized controlled trial, developed with 134 individuals chosen for two groups: intervention and control. The intervention consisted of three nursing appointments alternated bimonthly, with two phone calls, over five months. The control group received usual care offered by the Health Unit. Data were collected through semi-structured interviews before and after the intervention, in addition to conducting laboratory tests. Results: after the intervention, a significant difference was shown in the amount of glycated hemoglobin (p = 0.006) and in the systolic blood pressure (p = 0.031), which were higher in the control group. Conclusion: besides being low-cost and easy to develop on the monitoring routine of people with diabetes, the intervention performed influenced positively the biochemical profile.

Cost-effectiveness of a diabetes group education program delivered by health promoters with a guiding style in underserved communities in Cape Town, South Africa

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of a group diabetes education program delivered by health promoters in community health centers in the Western Cape, South Africa.

METHODS

The effectiveness of the education program was derived from the outcomes of a pragmatic cluster randomized controlled trial (RCT). Incremental operational costs of the intervention, as implemented in the trial, were calculated. All these data were entered into a Markov micro-simulation model to simulate clinical outcomes and health costs that were expressed as an Incremental Cost Effectiveness Ratio (ICER).

RESULTS

The only significant effect from the RCT at one year was a reduction in blood pressure (systolic blood pressure -4.65 mmHg (95%CI:-9.18 to -0.12) and diastolic blood pressure -3.30 mmHg (95%CI:-5.35 to -1.26)). The ICER for the intervention, based on the assumption that the costs would recur every year and the effect could be maintained, was 1862 $/QALY gained.

CONCLUSION

A structured group education program performed by mid-level trained healthcare workers at community health centers, for the management of Type II diabetes in the Western Cape, South Africa is therefore cost-effective.

PRACTICE IMPLICATIONS

This cost-effectiveness analysis supports the more widespread implementation of this intervention in primary care within South Africa.

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

AIM

To evaluate the effectiveness of group education, led by health promoters using a guiding style, for people with type 2 diabetes in public sector community health centres in Cape Town.

METHODS

This was a pragmatic clustered randomized controlled trial with 17 randomly selected intervention and 17 control sites. A total of 860 patients with type 2 diabetes, regardless of therapy used, were recruited from the control sites and 710 were recruited from the intervention sites. The control sites offered usual care, while the intervention sites offered a total of four monthly sessions of group diabetes education led by a health promoter. Participants were measured at baseline and 12 months later. Primary outcomes were diabetes self-care activities, 5% weight loss and a 1% reduction in HbA(1c) levels. Secondary outcomes were self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c and mean total cholesterol levels and quality of life.

RESULTS

A total of 422 (59.4%) participants in the intervention group did not attend any education sessions. No significant improvement was found in any of the primary or secondary outcomes, apart from a significant reduction in mean systolic (-4.65 mmHg, 95% CI 9.18 to -0.12; P = 0.04) and diastolic blood pressure (-3.30 mmHg, 95% CI -5.35 to -1.26; P = 0.002). Process evaluation suggested that there were problems with finding suitable space for group education in these under-resourced settings, with patient attendance and with full adoption of a guiding style by the health promoters.

CONCLUSION

The reported effectiveness of group diabetes education offered by more highly trained professionals, in well-resourced settings, was not replicated in the present study, although the reduction in participants' mean blood pressure is likely to be of clinical significance.

African Primary Care Research: quantitative analysis and presentation of results

This article is part of a series on Primary Care Research Methods. The article describes types of continuous and categorical data, how to capture data in a spreadsheet, how to use descriptive and inferential statistics and, finally, gives advice on how to present the results in text, figures and tables. The article intends to help Master's level students with writing the data analysis section of their research proposal and presenting their results in their final research report.