In Rwanda, the prevalence of known type 1 diabetes mellitus in seven  districts of the country is 16.4 per 100,000 in young adults under 25 years old. The objective of this study was to compare the glycemic control of type 1 diabetes youth before and after the diabetes camp in Rwanda. A quasi experimental design using a longitudinal approach to compare the glycemic control before and after camp was used; 97 type 1 diabetes youth of both sexes, average age of 21 years were assigned into 8 groups and every group attended 5 days of diabetes education at the camp. Medical records about glycated hemoglobin levels before and 3 months after the camp were extracted from the database of Rwanda Diabetes Association and were analyzed to identify the impact of the educational camp. The mean  difference between the glycemic control before and 3 months after the camp revealed a statistically  significant decrease of 2.1% HbA1c (P-value = 0.02). As conclusion, this study found that diabetes educational camp is an effective strategy to improve Rwandan type 1 diabetes youth’s glycemic control. ________________________________________________________________________Key words: Rwanda, type 1 diabetes, youth, camp, glycemic contro

El-Khatib, Ziad

Gishoma, Crispin

Hobabagabo, Arsene

Kabeza, Claudine B.

Kanagasabai, Thirumagal

Kateera, Brenda A.

English

AJOL - African Journals Online

Rwanda Journal of  Medicine and Health Sciences Vol. 2 No.1, 201921The impact of  educational camp on glycemic control of  Rwandan type 1 diabetes youthClaudine B. Kabeza1*, Thirumagal Kanagasabai2, Brenda A. Kateera3, Crispin Gishoma4, Arsene Hobabagabo4, Ziad El-Khatib51 University of  Rwanda, College of  Medicine and Health Sciences, Rwamagana Campus, Rwanda2 Institute for Health and Social Policy, McGill University, Québec3 University of  Rwanda, College of  Medicine and Health Sciences, Kigali, Rwanda4 Rwanda Diabetes Association5 Department of  Global Health and Social Medicine, Harvard Medical School, Boston, USA; Partners in Health Inshuti mu Buzima, Rwinkwavu, Rwanda; Department of  Public Health Sciences, Karolinska Institute, Stockholm, Sweden; World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT), Québec, Canada*Corresponding author: Claudine B. Kabeza, University of  Rwanda, College of  Medicine and Health Sciences, Rwamagana Campus, Rwanda, Email: claudine.kabeza@gmail.com________________________________________________________________________Abstract In Rwanda, the prevalence of  known type 1 diabetes mellitus in seven districts of  the country is 16.4 per 100,000 in young adults under 25 years old. The objective of  this study was to compare the glycemic control of  type 1 diabetes youth before and after the diabetes camp in Rwanda. A quasi experimental design using a longitudinal approach to compare the glycemic control before and after camp was used; 97 type 1 diabetes youth of  both sexes, average age of  21 years were assigned into 8 groups and every group attended 5 days of  diabetes education at the camp. Medical records about glycated hemoglobin levels before and 3 months after the camp were extracted from the database of  Rwanda Diabetes Association and were analyzed to identify the impact of  the educational camp. The mean difference between the glycemic control before and 3 months after the camp revealed a statistically significant decrease of  2.1% HbA1c (P-value = 0.02).  As conclusion, this study found that diabetes educational camp is an effective strategy to improve Rwandan type 1 diabetes youth’s glycemic control.________________________________________________________________________Key words: Rwanda, type 1 diabetes, youth, camp, glycemic controlIntroductionType 1 diabetes mellitus (T1DM) is one of  the most common chronic conditions in children, and it represents a global public health challenge.[1] According to the International Diabetes Federation 8th Atlas 2017, the number of  children and adolescents below 20 years known to have type 1 diabetes is estimated to be 1,106,200 globally with 50,600 cases from Africa region.[2] The prevalence of  type 1 diabetes from birth to 14 years of  age in sub-Saharan Africa was ~0.009% in 2013.[3] In Rwanda, the prevalence of  known T1DM in seven districts of  the country is 16.4 per 100,000 in young adults, age <25 years.[4]Adolescents face particular challenges as they learn to take responsibility for their diabetes.[5] Among these challenges are unhealthy weight control behaviors and the lack of  understanding of  insulin manipulation for optimal glucose level.[6] According to Pihoker et al.,[7] diabetes camps are prospects for children and adolescents for enjoying a camping experience in a secure environment and to live in a setting where they can share diabetes care with other campers who have diabetes. Educational camps are considered as one of  the best intervention strategies for improving glycemic control and insulin adjustment through education of  adolescents with T1DM, in a high-income setting.[8] However, according to our knowledge, such interventions have not been tested in limited-resource settings, such as Rwanda, where over 1,500 youth and young adults, live with T1DM.[9] Rwanda Diabetes Association hosts a yearly summer youth camp, in the city of  Kigali, targeting T1DM patients, of  age 14-25 years. The objective of  this study was to compare the glycemic control of  T1DM youth at the camp at two time points, including prior the camp and 3 months after the 2015 diabetes educational camp. MethodsStudy settingSince 2013, the Rwanda Diabetes Association organizes an educational summer camp for one hundred adolescents living with T1DM. Those adolescents are recruited from another program managed by Rwanda Diabetes Association called “life for a child”. Since https://dx.doi.org/10.4314/rjmhs.v2i1.4 Rwanda Journal of  Medicine and Health Sciences Vol. 2 No.1, 2019222004, the program has helped about 1,500 children and adolescents from the four provinces of  Rwanda and the city of  Kigali. In this study, we evaluated the impact of  the educational camp, on a sample of  100 young adults, living with T1DM, during the summer camp of  July 2015. The type of  care provided for all the adolescents in the program is similar, with no special formal educational training about diabetes knowledge and management being given to them by the association. Study designThis study used a quantitative research design with 3 months of  follow-up. Records of  the participants’ glycated hemoglobin (HbA1c) levels of  the month of  the camp were checked from the Rwanda Diabetes Association database and saved. A quasi-experimental design using a longitudinal approach to compare the glycemic control of  T1DM youth before and after diabetes camp was used. The duration of  the camp was five days, the group was educated about diabetes knowledge and self-management skills. Participants’ glycated hemoglobin (HbA1c) levels were assessed in post evaluation three months after the camp. Ethical considerationsPermission to conduct the study was obtained from the Rwanda Diabetes Association and from the Institutional Review Board of  the University of  Rwanda College of  Medicine and Health Sciences (CMHS/IRB/015/2015). For informed consents, young adults, below age 21, we obtained informed assent from them and informed consent from their parents. For adults, >21 years of  age, we obtained their informed consent. The participation was voluntary, no compensation was provided, and participants were informed of  their right to withdraw from the study at any time. Anonymity and confidentiality of  the participants were protected by the coding their names, storage of  data in a safe, locked facility, and access was given to only the research personnel.  Target population and sampling techniqueThe target population was T1DM adolescents of  both sexes (between the ages of  14 and 25 years) who were chosen by the Rwanda Diabetes Association to attend the summer educational camp. The total number of  participants was one hundred and attempts were made to recruit all of  them in the study but only ninety-seven persons consented to participate in the study.MeasurementsThe assessment form had a section of  personal and socio-demographic characteristics (gender, age, educational level, family history of  diabetes, year of  diabetes diagnosis, type of  insulin used and the number of  insulin injections per day). Review of  records Data were collected from the records of  the Rwanda Diabetes Association on every camp participant about glycemic control as measured by glycated hemoglobin (HbA1c) level. The glucose levels were well controlled if  the HbA1c was equal or below 7.5%, and uncontrolled if  HbA1c above 7.5%). The HbA1c levels were collected, at baseline, prior the intervention, and three months at the time of  the follow-up.Selection of  participantsEvery year, the Rwanda Diabetes Association conducts a random selection of  new participants, among the total number of  T1DM adolescents, who never participated in previous educational camps. The study response rate was 97%. Educational phaseThe main goal of  the educational camp was to improve the adolescents’ knowledge, self-management skills about diabetes and their glycemic control through a behavioral education program. Selection of  methodsThe study participants (n = 97) were divided into eight groups of  16 adolescents each. Every group attended five sessions during the five days of  the educational camp. Each group was led by an educator from the Rwanda Diabetes Association and researcher or a research assistant.The educational sessions covered the following components: a) Information about diabetes and its complications, b) Insulin medication and glucose monitoring and recording, c) Nutrition and diabetes, and d) Exercise and foot care. The teaching methods used were lecturing, interactive educational sessions and group discussions in order to discover the main ideas that needed to be discussed. Group discussions facilitated the participants in sharing information, enhanced their self-confidence and motivated them to keep participating in the study. In addition, some demonstrations assisted the participants to understand some aspects of  self-management such as insulin injection. Colored posters and role plays were used to provide information about insulin injection techniques, injection sites, hypoglycemia and hyperglycemia signs, the diabetes food pyramid, and about the foot care.Rwanda Journal of  Medicine and Health Sciences Vol. 2 No.1, 201923Statistical analysisData were collected, coded, tabulated and analyzed using McNemar test (Chi Square) for categorical variables, Wilcoxon test and paired t-test for continuous variables. Data analysis was done using SPSS v16.0 (SPSS, Chicago, IL) and Stata SE 13.ResultsThe sample comprised of  97 T1DM adolescents, of  whom 38 (39.2%) were males and 59 (60.8%) were females. Sixteen (16.5%) adolescents were between 14 and 17 years old, 35 (36.1%) were 18 to 21 years, and 46 (47.4%) were 22 to 25 years old. The mean age of  the participants was 20.93 ± 3.23 years, which was not significantly different between males and females (p = 0.94). Thirty-two (33%) participants did not complete the primary school, while 56 (57.7%) had primary school 7 (7.2%) completed secondary school, and only 2 (2.1%) had completed higher level of  education. However, differences between the sexes and education level were not found (p = 0.16). The number of  participants who reported having diabetes history in the family was 26 (26.8%), which did not vary amongst the sexes (p = 0.57). Twenty-six (26.8%) of  the participants reported to have been diagnosed with type 1 diabetes in years 2007-2009 and 2010-2012 while only 6 participants (6.2%) have been diagnosed before 2000. The mean length of  time since diabetes diagnosis was 5.2 years; this did not vary by sex. Most participants use “Both Fast-acting and Long-acting insulin” (n=92 (94.8%)) while “Mixed-Mixtard” (n=1; 1.0%)) and both “Levemir” and “Lentus” were used by two participants (2.1%). No statistical difference between the year of  diabetes diagnosis and the types of  insulin used was found (p = 0.26). Two insulin injections per day was reported by 46 (47.4%) participants, while 45 (46.4%) participants had three injections per day, and 6 (6.2%) participants took 1 insulin injection per day. However, the year of  diabetes diagnosis and the number of  insulin injections per day were not related (p = 0.26), but the type of  insulin used and the number of  insulin injections used per day were related (p = 0.01).4 6 8 10 12 14HbA1C levels before camp HbA1C levels 3 months after campFigure 1. Comparison between the glycated hemoglobin levels (% HbA1c) of  Rwandan type 1 diabetes adolescents before and 3 months after the completion of  diabetes camp.The median HbA1c of  all adolescents before the camp was 10.2% (Interquartile range (IQR) = 8.2-14) whereas three months after the camp, it was 8.1% (IQR 6.8-9.8) (<0.01). Before the educational camp, only 15 adolescents (15.5%) had controlled glucose levels (HbA1c <7.5%). Three months after completion of  the camp, 39 participants (40.2%) had controlled glucose levels (p <0.01).DiscussionIn this study of  comparing the glycemic control of  type 1 diabetes youth before and after diabetes camp from Rwanda diabetes association, we found that the HbA1c decreased slightly 3 months after the camp. The mean score of  HbA1c of  all adolescents before the camp was found to be 10.2% ± 2.8% while the mean score after 3 months follow-up was 8.1% ± 2.3%. The mean difference between both scores revealed a statistically significant decrease of  2.1% HbA1c (p = 0.02). These results are similar to results of  several studies[10–14]  where positive effects of  educational interventions impacted  HbA1c levels of   camp participants. Some studies qualified the impact of  educational camps on HbA1c of  participants as significant[11–13] whereas others found it trivial.[10,14]The slight improvement of  glycemic control 3 months after educational camp is being attributed more to the lack of  consistency of  diabetes self-management skills rather than to poor diabetes knowledge.[7,10]In our study the poor improvement of  glycemic control 3 months after educational camp was due to lack of  proper diet and deficient social support especially from family members as reported by camp participants.  Strengths and LimitationsThe main strengths of  this study were the organization of  the educational sessions and its study design. However, the study had many limitations such as limited number of  the camp participants, short time of  educational camp and lack of  appropriate diet and family support after camp. To the Ministry of  Health of  Rwanda, we recommend to assist the Rwanda Diabetes association in organizing diabetes camps for a big number of  T1DM adolescents and for a long time period of  educational camp. To further researches, we suggest to conduct studies about quality of  life among T1D adolescents and factors associated to poor glycemic control.Authors’ Contribution C.K and T.K contributed to the conception and the design of  the research project. C.K. researched data. C.K., B.K. and Z.E.K. contributed to the analysis and Rwanda Journal of  Medicine and Health Sciences Vol. 2 No.1, 201924interpretation of  data. C.K. and Z.E.K. contributed to the discussion, reviewed, edited the manuscript and wrote the manuscript. C.G facilitated the process of  the research activities. C.G and A.H. approved the version to be published.Competing Interests Authors declare no competing financial, professional, or personal interests on the implementation or presentation of  the work described in this manuscript.The authors declare that this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.AcknowledgementsThe authors wish to thank the camp “It won’t stop my dreams”, all the T1DM campers for their good will to participate in this study; their efforts, courage and collaboration made it easy. Special thanks go the whole team from the Rwanda Diabetes Association for their cooperation in this study and for the devotion and endless care they provide to T1DM children and adolescents from the “Life for a child” program. References1.  Majaliwa ES, Elusiyan BEJ, Adesiyun OO, Laigong P, Adeniran  a K, Kandi CM, et al. Type 1 diabetes mellitus in the African population: epidemiology and management challenges. Acta Biomed. 2008;79:255–9. 2.  Atun R, Gale EAM. The challenge of  diabetes in sub-Saharan Africa. Lancet Diabetes Endocrinol. 2015;3:675–7. 3. International Diabetes Federation. International Diabetes Federation Diabetes Atlas. 8th ed. 2018. 4.  Marshall SL, Edidin D, Arena VC, Becker DJ, Bunker CH, Gishoma C, et al. Prevalence and incidence of  clinically recognized cases of  Type 1 diabetes in children and adolescents in Rwanda, Africa. Diabet Med. 2015;32:1186–92. 5.  Gage H, Hampson S, Skinner TC, Hart J, Storey L, Foxcroft D, et al. Educational and psychosocial programmes for adolescents with diabetes: Approaches, outcomes and cost-effectiveness. Patient Educ. Couns. 2004. p. 333–46. 6.  Ackard DM, Vik N, Neumark-Sztainer D, Schmitz KH, Hannan P, Jacobs DR. Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: Comparative prevalence and clinical implications. Pediatr Diabetes. 2008;9:312–9. 7.  Pihoker C, Forsander G, Wolfsdorf  J, Klingensmith G. The delivery of  ambulatory diabetes care to children and adolescents with diabetes. Pediatr Diabetes. 2009;10:58–70. 8.  Wang Y-CA, Stewart S, Tuli E, White P. Improved glycemic control in adolescents with type 1 diabetes mellitus who attend diabetes camp. Pediatr Diabetes. 2008;9:29–34. 9.  Rwanda Diabetes Association. The first Diabetes Youth Camp in Rwanda. 2013. 10. Santiprabhob J, Likitmaskul S, Kiattisakthavee P, Weerakulwattana P, Chaichanwattanakul K, Nakavachara P, et al. Glycemic control and the psychosocial benefits gained by patients with type 1 diabetes mellitus attending the diabetes camp. Patient Educ Couns. 2008;73:60–6. 11. Abolfotouh MA, Kamal MM, El-Bourgy MD, Mohamed SG. Quality of  life and glycemic control in adolescents with type 1 diabetes and the impact of  an education intervention. Int J Gen Med. 2011;4:141–52. 12.  Gucciardi E, Wing-Sheung V, B C, Manuel L, Sidani S. Diabetes self-management education features to improve diabetes education in women of  Black African/Caribbean and Hispanic/ Latin American ethnicity. Patient Educ Couns. 2013;92:235–45. 13. Kiblinger L, Braza NL. The Impact of  Diabetes Education on Improving Patient Outcomes. Insulin. 2007;2:24–30. 14.  Deichmann RE, Hebert AM, Harmeyer ED, Cazabon P, Chavis E. Effects of  a diabetes boot cAMP on hemoglobin a1c levels. Ochsner J. 2013;13:194–9. 

The impact of educational camp on glycemic control of Rwandan type 1 diabetes youth

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The impact of educational camp on glycemic control of Rwandan type 1 diabetes youth

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