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

Abstract

AimTo 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.MethodsThis 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 HbA1c 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.ResultsA 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.ConclusionThe 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.What’s new?The study adds to the scarce literature on diabetes education in Africa in the face of a growing public health problem in this continent.The study demonstrates a statistically and clinically significant reduction in participants’ mean blood pressure 1 year after the educational intervention.The study adds to the small amount of literature on group motivational interviewing type interventions for diabetes.The study adds to the small amount of literature on the use of lower-/mid-level health workers for diabetes education.

How can clinical practices pragmatically increase physical activity for patients with type 2 diabetes? A systematic review

“…This suggests that PA interventions conducted in more real-world settings may be less effective when compared to studies in more idealized and heavily resourced contexts. Nevertheless, among the behavioral interventions that we ranked in the most pragmatic tertile by composite PRECIS-2 scores, four interventions by SperlHillen et al [39], Christian et al [50], Di Loreto et al [53], and Glasgow et al [54] effectively improved PA outcomes-two of these four effective PA interventions also improved HbA1c outcomes [31,45].…”

“…Other review articles have lamented the lack of data on fidelity of intervention delivery in RCTs and have noted this as a limitation to identifying key moderators of PA interventions [76]. The highly pragmatic and effective intervention by Di Loreto et al that we studied in the present review balanced the competing clinical demands and fidelity to intervention techniques by condensing several effective behavioral change techniques into a simple yet tailored counseling checklist which identified enjoyable and appropriate PA options at the individual level and encouraged patients to continue with these programs through the use of social support, problem-solving, and PA tracking [45]. Another important component of this intervention that used the counseling checklist was to deliver the intervention directly after a 30-min clinical in-person assessment of T2D that allowed the opportunity to address competing clinical concerns immediately prior to delivering the behavioral counseling [53].…”

Intensive Patient Education Improves Glycaemic Control in Diabetes Compared to Conventional Education: A Randomised Controlled Trial in a Nigerian Tertiary Care Hospital

“…However, a small number of RCTs evaluating DSME interventions for people with diabetes have been conducted in other LMICs, including Costa Rica, China and Thailand, and have also demonstrated clinically significant improvements in biomedical outcomes [12, 14, 15]. Conversely, an RCT of a DSME programme in under-served communities in South Africa produced no positive results relating to biomedical outcomes, but a process evaluation indicated serious problems with the running of the programme and with patient attendance [13]. Trials of similar diabetes (and CVD) educational guidelines as used here, along with clinical guidelines, are also on-going in Swaziland, Pakistan and China by the COMDIS-HSD group, and the guides, training modules and tools are all freely available online for adaptation in other LMICs (http://comdis-hsd.leeds.ac.uk/resources/technical-guidelines/).…”

The case for behavioural change counselling for the prevention of NCDs and improvement of self-management of chronic conditions

“…17 The intervention consisted of four group education/counselling sessions led by a health promoter with a variety of educational materials and tools for use in group activities. The health promoters were trained to deliver the content in a guiding style derived from motivational interviewing.…”