Evaluation of an adapted version of the Diabetes Prevention Program for low- and middle-income countries: A cluster randomized trial to evaluate "Lifestyle Africa" in South Africa

Task-sharing for non-communicable disease prevention and control in low- and middle-income countries in the context of health worker shortages: A systematic review

Health workers are pivotal for non-communicable disease (NCD) service delivery, yet often are unavailable in low- and middle-income countries (LMICs). There is limited evidence on what NCD-related tasks non-physician health workers (NPHWs) can perform and their effectiveness. This study aims to understand how task-sharing is used to improve NCD prevention and control in LMICs. We also explored barriers, facilitators, and unexpected consequences of task-sharing. Databases searched in two phases and included MEDLINE, EMBASE, CENTRAL, CINAHL, Cochrane, and clinical trial registries, and references of included studies from inception until 31st July 2024. We included randomised control trials (RCTs), cluster RCTs, and associated process evaluation and cost effectiveness studies. The risk of bias was assessed using the Cochrane Risk of Bias Tool v2. PROSPERO: CRD42022315701. The study found 5527 citations, 427 full texts were screened and 149 studies (total population sample>432567) from 31 countries were included. Most studies were on tasks shared with nurses (n=83) and community health workers (n=65). Most studies focussed on cardiovascular disease (n=47), mental health (n=48), diabetes (n=27), cancer (n=20), and respiratory diseases (n=10). Seventeen studies included two or more conditions. Eighty-one percent (n=120) of studies reported at least one positive primary outcome, while 19 studies reported neutral results, one reported a negative result, eight (5.4%) reported mixed positive and neutral results, and one reported neutral and negative findings. Economic analyses indicated that task-sharing reduced total healthcare costs. Task-sharing is an effective intervention for NCDs in LMICs. It is essential to enhance the competencies and training of NPHWs, provide resources to augment their capabilities, and formalise their role in the health system and community. Optimising task-sharing for NCDs requires a holistic approach that strengthens health systems while supporting NPHWs in effectively addressing the diverse needs of their communities. Registration: PROSPERO CRD42022315701.

Evaluation of a Smartphone-Based Weight Loss Intervention with Telephone Support for Merchant Women With Obesity in Côte d'Ivoire: Protocol for a Randomized Controlled Trial

BACKGROUND

The obesity rate among women in Côte d'Ivoire is rising, particularly in urban areas. Merchantry is the leading occupation for women in the country, and merchant women face a high risk of obesity owing to their sedentary lifestyle. A previous survey indicated that the obesity rate among merchant women was 30%, double the national average. Furthermore, 82.2% of merchant women with obesity were unaware of their condition, and 40.1% expressed no interest in losing weight. While most weight loss programs target individuals ready to lose weight, community interventions should also address those with minimal readiness. Additionally, low-cost weight-loss interventions that do not require health professionals are needed in countries with limited medical resources. Smartphones could offer a cost-effective solution as they enable self-monitoring and remote communication.

OBJECTIVE

This study will evaluate a low-cost smartphone-based intervention that targets individuals who are not ready to lose weight without the involvement of health professionals.

METHODS

The intervention will run for 6 months, and its efficacy will be assessed in an unblinded, parallel-group, randomized controlled trial with 108 participants per group. All direct interventions for participants in this study will be carried out by staff without medical qualifications. The intervention group will receive weighing scales and be encouraged to record their weight with a smartphone app. Health education will be provided via weekly group messages and monthly phone calls. The evaluation will be conducted face-to-face. The primary outcome will be the weight change, and the secondary outcome will be differences in body fat percentage, abdominal circumference, and stage of behavioral change in weight loss behaviors from baseline to 3, 6, and 12 months.

RESULTS

In accordance with this protocol, the recruitment of participants started on August 26, 2024. A total of 216 participants were allocated, with 108 in the intervention group and 108 in the control group. The baseline survey began on November 15, 2024, and is currently ongoing as of the end of November 2024.

CONCLUSIONS

This study will be the first in sub-Saharan African countries to implement a smartphone app-based weight loss program in sub-Saharan Africa that does not require direct intervention by health care professionals but specifically targets communities. Furthermore, if the effectiveness of this program is confirmed, it has the potential to serve as a low-cost sustainable weight loss model at the policy level.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/69264.

Physical activity interventions implemented for older people in Sub-Saharan Africa: a scoping review

BACKGROUND

Sub-Saharan Africa mirrors global patterns with an expanding elderly demographic, frequently characterised by a high incidence of non-communicable diseases (NCDs), manifesting as multimorbidity. Physical activity (PA) is a validated intervention for managing the increasing prevalence of NCDs in this demographic.

OBJECTIVE

This review aimed to elucidate the extent of PA interventions implemented in Sub-Saharan Africa for managing NCDs in older people (OP).

ELIGIBILITY CRITERIA

This review synthesised randomised controlled trials published in English since 2010, focusing on PA interventions for managing NCDs or associated risk factors in OP in Sub-Saharan Africa.

SOURCES OF EVIDENCE

The Joanna Briggs Institute methodology for scoping reviews was implemented with searches in the following databases: PubMed, EBSCOhost (Academic Search Premier AfricaWide Information, CINAHL, Health Sources Premier Academic/Nursing), Scopus and ProQuest.

CHARTING METHODS

Extraction and reporting adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses-Scoping Reviews framework, ensuring rigorous and systematic synthesis.

RESULTS

A total of 3754 studies were initially identified, with 67 studies ultimately included after applying the exclusion criteria. The synthesised trials tested primarily supervised structured PA interventions (n=30), education on PA and lifestyle (n=30) and combined structured PA with lifestyle education (n=7). A structured supervised PA regimen combining aerobic exercise at 60-80% of maximum heart rate (three 45-60 min sessions per week) and resistance training starting at 50% of one-repetition maximum (3 weekly sessions of three sets with 10-12 repetitions per muscle group), progressively increasing to 60%, was the most effective in reducing risk factors associated with NCDs in this cohort.

CONCLUSION

This analysis confirms that a structured PA regimen paired with lifestyle education significantly mitigates NCDs in Sub-Saharan Africa's elderly population. Furthermore, it highlights the imperative for further investigation into non-pharmacological strategies, especially those targeting hypertension, diabetes and cognitive health disorders.

Feasibility of prevention of type 2 diabetes in low- and middle-income countries

Type 2 diabetes is a leading cause of global mortality and morbidity. Nearly 80% of individuals with diabetes live in low- and middle-income countries (LMICs), where nearly half of those with the condition remain undiagnosed. The majority of known cases have sub-optimal clinical outcomes. Moreover, large populations with impaired glucose tolerance and/or impaired fasting glucose contribute to the rapid increase in type 2 diabetes. Globally, priority should be given to limit the population with diabetes, especially in LMICs, alongside actions to optimise the care of people diagnosed with diabetes. Primary prevention studies in LMICs have generated evidence to show the efficacy and scalability of strategies to fully prevent or delay the development of diabetes in high-risk groups. However, these are mainly limited to certain countries in Asia, particularly China and India. The studies have indicated that prevention policies are effective in populations with a high risk of type 2 diabetes, and they also have long-term benefits, not only for the risk of type 2 diabetes but also for the risk of associated metabolic disorders, such as CVDs. For the effective conduct of national programmes, innovative mechanisms must be implemented, such as the use of information technology, joint efforts of multiple teams implementing similar programmes, and involvement of governmental and non-governmental partnerships. Continuous monitoring and long-term studies are required to assess the utility of these programmes. The effectiveness of such programmes in LMICs has not been proven over the longer term, except in China. Despite the available evidence, the feasibility of prevention strategies for type 2 diabetes in LMICs at population level remains an enigma. There remain challenges in the form of cultural, societal and economic constraints; insufficient infrastructure and healthcare capacity; and the non-fully elucidated natural history and determinants of type 2 diabetes in LMICs.

Dyslipidemia in Adults with Type 2 Diabetes in a Rural Community in Ganadougou, Mali: A Cross-Sectional Study

Dyslipidemia is a disorder where abnormally lipid concentrations circulate in the bloodstream. The disorder is common in type 2 diabetics (T2D) and is linked with T2D comorbidities, particularly cardiovascular disease. Dyslipidemia in T2D is typically characterized by elevated plasma triglyceride and low high-density lipoprotein cholesterol (HDL-C) levels. There is a significant gap in the literature regarding dyslipidemia in rural parts of Africa, where lipid profiles may not be captured through routine surveillance. This study aimed to characterize the prevalence and demo-graphic profile of dyslipidemia in T2D in the rural community of Ganadougou, Mali. We performed a cross-sectional study of 104 subjects with T2D in Ganadougou between November 2021 and March 2022. Demographic and lipid profiles were collected through cross-sectional surveys and serological analyses. The overall prevalence of dyslipidemia in T2D patients was 87.5% (91/104), which did not differ by sex (P = .368). High low-density lipoprotein cholesterol (LDL-C) was the most common lipid abnormality (78.9%, [82/104]). Dyslipidemia was associated with age and hypertension status (P = .013 and.036, respectively). High total and high LDL-C parameters were significantly associated with hypertension (P = .029 and .006, respectively). In low-resource settings such as rural Mali, there is a critical need to improve infrastructure for routine dyslipidemia screening to guide its prevention and intervention approaches. The high rates of dyslipidemia observed in Gandadougou, consistent with concomitant increases in cardiovascular diseases in Africa suggest that lipid profile assessments should be incorporated into routine medical care for T2D patients in African rural settings.

Cost-effectiveness of Lifestyle Africa: an adaptation of the diabetes prevention programme for delivery by community health workers in urban South Africa

BACKGROUND

Lifestyle Africa is an adapted version of the Diabetes Prevention Program designed for delivery by community health workers to socioeconomically disadvantaged populations in low- and middle-income countries (LMICs). Results from the Lifestyle Africa trial conducted in an under-resourced community in South Africa indicated that the programme had a significant effect on reducing haemoglobin A1c (HbA1c).

OBJECTIVE

To estimate the cost of implementation and the cost-effectiveness (in cost per point reduction in HbA1c) of the Lifestyle Africa programme to inform decision-makers of the resources required and the value of this intervention.

METHODS

Interviews were held with project administrators to identify the activities and resources required to implement the intervention. A direct-measure micro-costing approach was used to determine the number of units and unit cost for each resource. The incremental cost per one point improvement in HbA1c was calculated.

RESULTS

The intervention equated to 71 United States dollars (USD) in implementation costs per participant and a 0.26 improvement in HbA1c per participant.

CONCLUSIONS

Lifestyle Africa reduced HbA1c for relatively little cost and holds promise for addressing chronic disease in LMIC. Decision-makers should consider the comparative clinical effectiveness and cost-effectiveness of this intervention when making resource allocation decisions.

TRIAL REGISTRATION

Trial registration is at ClinicalTrials.gov (NCT03342274).

Design Research to Embed mHealth into a Community-Led Blood Pressure Management System in Uganda: Protocol for a Mixed Methods Study

BACKGROUND

Uncontrolled hypertension is a leading risk factor for cardiovascular diseases. In Uganda, such diseases account for approximately 10% of all deaths, with 1 in 5 adults having hypertension (>90% of the hypertensive cases are uncontrolled). Although basic health care in the country is available free of cost at government facilities, regularly accessing medication to control hypertension is difficult because supply chain challenges impede availability. Clients therefore frequently suspend treatment or buy medication individually at private facilities or pharmacies (incurring significant costs). In recent years, mobile health (mHealth) interventions have shown increasing potential in addressing health system challenges in sub-Saharan Africa, but the acceptability, feasibility, and uptake conditions of mobile money approaches to chronic disease management remain understudied.

OBJECTIVE

This study aims to design and pilot-test a mobile money-based intervention to increase the availability of antihypertensive medication and lower clients' out-of-pocket payments. We will build on existing local approaches and assess the acceptability, feasibility, and uptake of the designed intervention. Furthermore, rather than entering the study setting with a ready-made intervention, this research will place emphasis on gathering applied ethnographic insights early, which can then inform the parameters of the intervention prototype and concurrent trial.

METHODS

We will conduct a mixed methods study following a human-centered design approach. We will begin by conducting extensive qualitative research with a range of stakeholders (clients; health care providers; religious, cultural, and community leaders; academics; and policy makers at district and national levels) on their perceptions of hypertension management, money-saving systems, and mobile money in the context of health care. Our results will inform the design, iterative adaptation, and implementation of an mHealth-facilitated pooled financing intervention prototype. At study conclusion, the finalized prototype will be evaluated quantitatively via a randomized controlled trial.

RESULTS

As of August 2023, qualitative data collection, which started in November 2022, is ongoing, with data analysis of the first qualitative interviews underway to inform platform and implementation design. Recruitment for the quantitative part of this study began in August 2023.

CONCLUSIONS

Our results aim to inform the ongoing discourse on novel and sustainable pathways to facilitate access to medication for the management of hypertension in resource-constrained settings.

TRIAL REGISTRATION

German registry of clinical trials DRKS00030922; https://drks.de/search/en/trial/DRKS00030922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46614.

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.

Metformin for the prevention of diabetes among people with HIV and either impaired fasting glucose or impaired glucose tolerance (prediabetes) in Tanzania: a Phase II randomised placebo-controlled trial

AIMS/HYPOTHESIS

In sub-Saharan Africa (SSA), 5% of adults are living with type 2 diabetes and this is rising sharply, with a greater increase among people with HIV. Evidence on the efficacy of prevention strategies in this cohort is scarce. We conducted a Phase II double-blind placebo-controlled trial that aimed to determine the impact of metformin on blood glucose levels among people with prediabetes (defined as impaired fasting glucose [IFG] and/or impaired glucose tolerance [IGT]) and HIV in SSA.

METHODS

Adults (≥18 years old) who were stable in HIV care and found to have prediabetes (IFG and/or IGT) and who were attending hospitals in Dar es Salaam, Tanzania, were randomised to receive sustained-release metformin, 2000 mg daily, or matching placebo between 4 November 2019 and 21 July 2020. Randomisation used permuted blocks. Allocation was concealed in the trial database and made visible only to the Chief Pharmacist after consent was taken. All participants, research and clinical staff remained blinded to the allocation. Participants were provided with information on diet and lifestyle and had access to various health information following the start of the coronavirus disease 2019 (COVID-19) pandemic. Participants were followed up for 12 months. The primary outcome measure was capillary blood glucose measured 2 h following a 75 g glucose load. Analyses were by intention-to-treat.

RESULTS

In total, 364 participants (182 in each arm) were randomised to the metformin or placebo group. At enrolment, in the metformin and placebo arms, mean fasting glucose was 6.37 mmol/l (95% CI 6.23, 6.50) and 6.26 mmol/l (95% CI 6.15, 6.36), respectively, and mean 2 h glucose levels following a 75 g oral glucose load were 8.39 mmol/l (95% CI 8.22, 8.56) and 8.24 mmol/l (95% CI 8.07, 8.41), respectively. At the final assessment at 12 months, 145/182 (79.7%) individuals randomised to metformin compared with 158/182 (86.8%) randomised to placebo indicated that they had taken >95% of their medicines in the previous 28 days (p=0.068). At this visit, in the metformin and placebo arms, mean fasting glucose levels were 6.17 mmol/l (95% CI 6.03, 6.30) and 6.30 mmol/l (95% CI 6.18, 6.42), respectively, and mean 2 h glucose levels following a 75 g oral glucose load were 7.88 mmol/l (95% CI 7.65, 8.12) and 7.71 mmol/l (95% CI 7.49, 7.94), respectively. Using a linear mixed model controlling for respective baseline values, the mean difference between the metformin and placebo group (metformin-placebo) was -0.08 mmol/l (95% CI -0.37, 0.20) for fasting glucose and 0.20 mmol/l (95% CI -0.17, 0.58) for glucose levels 2 h post a 75 g glucose load. Weight was significantly lower in the metformin arm than in the placebo arm: using the linear mixed model adjusting for baseline values, the mean difference in weight was -1.47 kg (95% CI -2.58, -0.35). In total, 16/182 (8.8%) individuals had a serious adverse event (Grade 3 or Grade 4 in the Division of Acquired Immunodeficiency Syndrome [DAIDS] adverse event grading table) or died in the metformin arm compared with 18/182 (9.9%) in the placebo arm; these events were either unrelated to or unlikely to be related to the study drugs.

CONCLUSIONS/INTERPRETATION

Blood glucose decreased over time in both the metformin and placebo arms during the trial but did not differ significantly between the arms at 12 months of follow up. Metformin therapy was found to be safe for use in individuals with HIV and prediabetes. A larger trial with longer follow up is needed to establish if metformin can be safely used for the prevention of diabetes in people who have HIV.

TRIAL REGISTRATION

The trial is registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry ( www.isrctn.com/ ), registration number: ISCRTN76157257.

FUNDING

This research was funded by the National Institute for Health Research using UK aid from the UK Government to support global health research.

Implementing text-messaging to support and enhance delivery of health behavior change interventions in low- to middle-income countries: case study of the Lifestyle Africa intervention

The prevalence of non-communicable diseases, such as diabetes and cardiovascular disease, is rising in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the widely used Diabetes Prevention Program (DPP) are effective at reducing chronic disease risk, but have not been adapted for LMICs. Leveraging mobile health (mHealth) technology such as text messaging (SMS) to enhance reach and participant engagement with these interventions has great promise, yet we lack evidence-informed approaches to guide the integration of SMS specifically to support HBC interventions in LMIC contexts. To address this gap, we integrated guidance from the mHealth literature with expertise and first-hand experience to establish specific development steps for building and implementing SMS systems to support HBC programming in LMICs. Specifically, we provide real-world examples of each development step by describing our experience in designing and delivering an SMS system to support a culturally-adapted DPP designed for delivery in South Africa. We outline eight key SMS development steps, including: 1) determining if SMS is appropriate; 2) developing system architecture and programming; 3) developing theory-based messages; 4) developing SMS technology; 5) addressing international SMS delivery; 6) testing; 7) system training and technical support; and 8) cost considerations. We discuss lessons learned and extractable principles that may be of use to other mHealth and HBC researchers working in similar LMIC contexts.Trial registration Clinicaltrials.gov, NCT03342274 . Registered 10 November 2017.

Type 2 Diabetes Prevention Programs-From Proof-of-Concept Trials to National Intervention and Beyond

The prevention of type 2 diabetes (T2D) in high-risk people with lifestyle interventions has been demonstrated by several randomized controlled trials. The intervention effect has sustained up to 20 years in post-trial monitoring of T2D incidence. In 2000, Finland launched the national T2D prevention plan. For screening for high T2D risk, the non-laboratory Finnish Diabetes Risk Score was developed and widely used, also in other countries. The incidence of drug-treated T2D has decreased steadily since 2010. The US congress authorized public funding for a national diabetes prevention program (NDPP) in 2010. It was built around a 16-visit program that relies on referral from primary care and self-referral of persons with either prediabetes or by a diabetes risk test. The program uses a train-the-trainer program. In 2015 the program started the inclusion of online programs. There has been limited implementation of nationwide T2D prevention programs in other countries. Despite the convincing results from RCTs in China and India, no translation to the national level was introduced there. T2D prevention efforts in low-and middle-income countries are still limited, but results have been promising. Barriers to efficient interventions are greater in these countries than in high-income countries, where many barriers also exist. Health disparities by socioeconomic status exist for T2D and its risk factors and form a challenge for preventive interventions. It seems that a stronger commitment to T2D prevention is needed, such as the successful WHO Framework Convention on Tobacco Control, which legally binds the countries to act.