Structured diabetes self-management education and glycaemic control in low resource urban primary care settings

Abstract

Setting the context Still waters run deep. Type 2 diabetes, the commonest form of diabetes, is largely an asymptomatic disease. The pathophysiologic defects often continue irrespective of attainment of euglycaemia.1,2 Globally diabetes is cascading out of control, fuelled by obesity3 and sedentary lifestyles4 and perpetuated by gestational diabetes5 and epigenetic changes.6 Currently the number of people living with diabetes has crossed the half a billion mark 7 and if current trends persist, the projections are that, 783 million people will be living with diabetes by 2045. Alarmingly, for every person who is known to have diabetes, there is another who is undiagnosed. The global prevalence of undiagnosed diabetes among adults aged 20-79 years is 45% (240 million cases of undiagnosed diabetes). Africa has the highest proportion of undiagnosed diabetes with a prevalence of 56%.8 The prevalence of diabetes is highest among the elderly aged between 75-79 years.7 Prevalence rates are higher in high-income countries and range between 8.3 -12%.7 Prevalence rates are lower in low- and middle-income countries (LMIC)7 and are lowest in Africa with prevalence rates of 6%.7 The projected increase in prevalence over the next 25 years is however highest in sub-Saharan Africa. This situation can be likened to a tsunami. If Africa continues on this trajectory, with rapid urbanisation and commercialisation, diabetes will “explode” on the continent.9 Sub-Saharan Africa especially will experience a 134% rise in prevalence7 relative to existing rates as depicted in Figure 1 below. These predictions are grim for a continent with limited resources and weak health systems. A continent already battling with a double burden of disease; a continent where the COVID- 19 pandemic has caused a worsening in several health indices.10-12 The chronic nature of diabetes, however, presents an opportunity to make gains before complications develop. Aggressive glycaemic control, preferably earlier on in the disease process, prevents and delays both the onset of diabetes13 and microvascular complications.14,15 The foundation of diabetes care is lifestyle modification, sustained over a lifetime and this entails healthy food and intense exercise on a regular basis. More comprehensively framed, this entails meal planning and timing, portion control, reading labels, monitoring blood glucose, adjusting medications, keeping routine reviews, managing stress, and keeping fit. Managing diabetes requires self-management education. To effectively turn the tide and halt the devastating effects of poorly controlled diabetes, diabetes self-management education (DSME) should be accessible to all people living with diabetes and persons at increased risk for diabetes. Technology opens a world of opportunity for disseminating self-management education. Unfortunately, this may not hold true in many low-middle income countries, where 80% of people living with diabetes reside.7 In resource constrained settings, reaching people with low health literacy and numeracy is particularly challenging. In high-income countries DSME has been shown to achieve comparable HbA1c reductions to therapeutic agents.16 For low-income countries and specifically, sub-Saharan Africa the literature on effectiveness of DSME is sparce and conflicting.17 Given the gravity of the projections for the African content, with 24 million people living with diabetes residing in Africa, there is the need to urgently find effective ways of delivering DSME in Africa. This entails exploring existing DSME programs and assessing the diabetes self-management knowledge and behaviours of people living with diabetes in low-resource settings, to be able to tailor DSME programs to their culture and literacy levels