https://orcid.org/0000-0002-8988-779X
Figures
Abstract
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.
Citation: Iwelomen O, Toniolo J, Preux P-M, Beloni P (2024) Therapeutic patient education programs on diabetes in sub-Saharan Africa: A systematic review. PLoS ONE 19(6): e0299526. https://doi.org/10.1371/journal.pone.0299526
Editor: Francis Xavier Kasujja, Medical Research Council / Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, UGANDA
Received: October 20, 2023; Accepted: February 13, 2024; Published: June 27, 2024
Copyright: © 2024 Iwelomen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Diabetes mellitus (DM) is a chronic metabolic disease characterized by high blood sugar level, leading over time to severe damage to the heart, blood vessels, eyes, kidneys, and nerves [1]. Diabetes is one of the world’s greatest public health problems, imposing a heavy global burden on public health as well as socio-economic development [2]. The sub-Saharan Africa (SSA) region is expected to experience the largest percentage increase in diabetes incidence of any region in the world [3]. In 2015, the International Diabetes Federation (IDF) estimated that there were 24 million adults with diabetes in the sub-Saharan African region in 2021 [4]. This is a significant increase from the 14.2 million people with diabetes in 2015. The figures are estimated to increase to 33 million by 2030 and 55 million by 2045 [4].
Despite the earlier perception of low non-communicable disease (NCD) mortality rates, current evidence suggests that SSA is now on the cusp of epidemiological transition with a contemporary double burden of disease from NCDs associated with persistent infectious disease [5]. Yet external and internal funding for health care needs continues to focus on communicable diseases while neglecting the needs of large populations suffering from excessive morbidity and mortality from NCDs [6].
The increasing number of people with diabetes in SSA has been attributed to the aging population, dietary and lifestyle changes [7]. Some risk factors for Type 2 diabetes mellitus (T2DM) such as obesity, poor diet, insufficient physical activity, alcohol consumption and smoking are modifiable by behavioral and environmental changes [8]. The main goal of diabetes treatment is to keep blood sugar levels normal and prevent complications [9].
Healthcare providers tend to talk to patients about their illness rather than training them in day-to-day management of their condition, resulting in low self-management knowledge [10]. Therapeutic patient education (TPE) is a relevant approach to this problem while allowing patients to develop skills to better manage their condition. A diabetes TPE program would aim to educate patients on; choice of healthy lifestyles (healthy diet, physical activity, smoking cessation, weight management and effective strategies to cope with stress); Self-management of disease (taking and management of medications and, when clinically appropriate, self-monitoring of blood sugar and blood pressure) as well as prevention of diabetes complications (self-monitoring of foot health; active participation in screening for diseases of the eye, foot and kidney complications) [9]. Studies have shown the impact of TPE as a clinically and cost-effective solution to improve biomedical and psychosocial outcomes in people with metabolic disorders [11–14].
With the many gaps in care delivery in SSA, there has been little effort to build the structures needed to promote safe and effective self-management strategies [15]. This raises questions about the involvement of TPE programs in a context where access to care and quality treatment is limited and expensive and its impact on people with diabetes to self-manage their condition and reduce complications.
A review was conducted to assess the level of self-management in people with diabetes in sub-Saharan Africa [16]. Another study exposed barriers to patient nonadherence to self-management intervention recommendations in Africa [17]. A recent scoping review examined diabetes self-management education interventions in the WHO African Region, offering valuable insights [18]. While similar, our study employs a more systematic methodology and aims to provide a unique perspective, enhancing and expanding existing literature to deepen our understanding of the challenges and opportunities specific to the SSA region. Our review serves to provide an overview of diabetes TPE programs in SSA, exposing actors, methods, and relative outcomes on patient health status. The question in this review was: what role do TPE programs play in health-related outcomes of persons with diabetes mellitus in SSA compared to standard care?
Materials and methods
Search strategy
This systematic review was conducted following the Cochrane guidelines for conducting systematic reviews [19] and is reported using the PRISMA guidelines for writing and reading literature reviews and meta-analyses [20]. This review was registered on PROSPERO (ID: CRD42023440701). Four electronic databases (PubMed, Web of Science, CINAHL and Google Scholar) were systematically searched for relevant publications between March 14 and June 30, 2023. A preliminary search was performed to derive keywords based on the PICO search question then ’title and abstract search’ was performed on each database and Boolean operators were used when applicable.
The keywords for each database queried were composed of: "patient education", "self-management education", "educational therapy", "therapeutic education", "therapeutic patient education", "patient compliance", "self-management”, “diabetes self-care”, “intervention program”, “diabetes”, “diabetes mellitus”, “sub-Saharan Africa”, “SSA”, “sub-Sahara”.
For PubMed, MeSH terms and the name of each country in SSA following the Library of Congress list [21] were included. The other databases were searched with the same keywords, but the search strategy was adapted to the specificities of each database. Databases were searched and articles were selected independently by two researchers under the supervision of a third experienced researcher. A table summarizing the different search strategy is available in S1 Appendix.
Screening and selection criteria
After the database search, the results were exported to Zotero, a bibliographic management software, where duplicates were removed and then moved to Rayyan QCRI software for title and abstract screening. Studies were independently reviewed and assessed for eligibility by two authors (OI and JT). A third researcher was consulted to resolve any disagreements that arose (PB). The final step was to review eligibility by reading the full-text articles to determine which would be included and which would not. Studies were included in this review if they met the following inclusion criteria; 1) They took place in at least one country in sub-Saharan Africa, 2) Participants were people with type 1 or type 2 DM, 3) The study evaluated a TPE intervention versus standard care, 4) The study measured change in a health-related outcome.
All published intervention studies—RCTs, non-RCTs, quasi-experimental, were included if they met the criteria. There were no limitations on the date and language of the article published or the impact factor of the journal. Qualitative studies, observational studies, uncontrolled studies, systematic reviews, and grey literature were not included.
Data extraction and analysis
Relevant data were extracted from eligible articles using a Microsoft Excel spreadsheet. These included author name, date of publication, journal, and country of study; the main objective of the study; study design and participants; key outcome measures; composition, method, duration, and frequency of intervention; main results and limitations cited in the studies.
A risk of bias analysis was performed on each of the included studies using the Cochrane ‘Risk of Bias’ 2.0 tool [22]. A risk of bias assessment was performed in 5 domains (randomization process, blinding, missing outcome data, outcome measurement and outcome reporting). The risk of bias judgments for each domain are ’low risk of bias’, ’some concerns’ or ’high risk of bias’. Judgments are based on responses to signaling questions. We adopted the risk of bias tool to assess non-RCTs included in the review to expose biases inherent in the study design.
A qualitative synthesis was performed after data extraction and quality assessment.
Ethical approval was not required for this study.
Results
Description of selected studies
Out of a pool of 2,497 articles identified from the database, 25 full-text articles were assessed for eligibility. Four articles were excluded due to mismatches in the study population—not in SSA region (n = 1) and study design (qualitative, cohort, no control group and non-related interventions) (n = 8) (Fig 1). The final analysis included 13 distinct studies from 16 articles, all published between 2010 and 2021. These studies encompassed various research designs: 11 randomized controlled trials, 1 quasi-experimental study, and 1 non-randomized controlled trial. The sample sizes of these studies ranged from 28 to 1,569 patients.
In total, 3,017 persons with diabetes participated in these studies, with 932 being male and 2,085 female participants. Twelve studies exclusively recruited adult participants, while one study focused on children and young adults. Nine studies centered on Type 2 Diabetes Mellitus (T2DM), one focused solely on Type 1 Diabetes Mellitus (T1DM), and three included both persons with T1DM and persons with T2DM. Seven studies were conducted in a tertiary hospital, 2 in secondary institutions and 4 in a primary health care facility. The geographical distribution of these studies was as follows: South Africa (n = 5), Nigeria (n = 2), Cameroon (n = 1), Ethiopia (n = 1), Rwanda (n = 1), Mali (n = 1), Kenya (n = 1), and Ghana (n = 1). Table 1 provides an overview of the characteristics of each study, along with pertinent results.
Composition and methods of intervention
The education contents of the interventions were tailored or corresponded with the American Association of Diabetes Educators 7 core themes in diabetes education: Health eating, being active, self- monitoring, medication taking, problem solving, reducing complications and stress management [40]. However, two interventions were focused on nutrition and one study was a physical activity and dietary intervention [24,27,28,39]. Although multiple themes were incorporated into each intervention, all studies shared a central objective: evaluating the impact of patient education programs on the health outcomes of persons with diabetes. The primary outcome assessed in all studies was the clinical health status of participants. Some studies also evaluated participants’ knowledge, [24,28,31,33,35,37,39] attitudes, and adherence to recommendations [25,28,31,37,38] reduction of acute complications [28,35], and the feasibility and acceptability of technology-based intervention methods [35,36,38].
Various theories, models, and frameworks guided the development of educational programs in these studies. These included self-determination theory, cognitive theory, and motivational interviewing, as well as the learning nest approach and skilled helper model [24,25,27,31]. Some interventions adapted international guidelines and programs for the provision of TPE to suit local and cultural contexts, particularly regarding nutrition [27,31,39]. Educational materials such as leaflets, brochures, and illustrations facilitated group discussions, which took place in different formats including group sessions (n = 14), individual sessions (n = 4), WhatsApp groups (n = 1), text messaging (n = 4), and phone calls (n = 1). Several programs included follow-up sessions and SMS reminders. The frequency of group sessions varied from 4 to 16 (mean frequency = 8), and the duration of interventions ranged from 4 weeks to 1 year (mean duration = 9 months). Lead instructors for these interventions were nurses (n = 4), dietitians and nutrition specialists (n = 2), health promoters and educators (n = 1), peer educators (n = 1), and multidisciplinary medical teams (n = 5).
Clinical results and method of evaluation
The clinical outcomes assessed across the studies included glycemic control (n = 13), body mass index (BMI) (n = 11), blood pressure (n = 9), and lipid profile (n = 4). In all studies the outcomes were evaluates by comparing the mean differences between the endpoints of the two intervention arms to baseline. Among the 13 studies measuring glycemic control, six reported a significant mean difference in HbA1c levels [24,29–31,38,39], while one reported a significant mean difference using fasting blood sugar (FBS) [26]. However, no significant difference was found in the study that measured glycemic status using random blood glucose (RBG) [36]. Two out of 11 studies observed a significant reduction in mean BMI in the intervention group compared to the control group [29,31], and five studies reported a significant reduction in blood pressure compared to the control group [25,29,31,32,39]. Only one out of four studies recorded positive results in terms of lipid levels [24].
Knowledge, attitude, and compliance
Six studies evaluated participants’ knowledge of diabetes and self-management post-intervention, obtaining knowledge scores through questionnaires and scales. All but one of the studies reported a significant improvement in participants’ knowledge following the intervention or when compared to a control group [31]. Other outcomes assessed included physical activity (n = 4), diet (n = 4), foot care practices (n = 2), and medication adherence (n = 3). Of the four studies measuring physical activity, one observed an improvement in the intervention group [25]. One out of four studies reported positive results regarding dietary patterns and adherence to dietary recommendations [25]. Similarly, one study reported improved foot care practices [38] while no significant positive change was observed in medication adherence [31,37,38].
Risk of bias and methodological limitations
We conducted a quality assessment of each study using Cochrane’s risk of bias tool (Fig 2). In summary, three studies exhibited questionable randomization processes, while two did not perform any randomization. Due to the nature of the interventions, it was not feasible to blind participants and administrators; however, some studies reported blinding of outcome assessors or control groups. Eight out of the 13 studies included in this review were assessed as having a low risk of bias.
Four studies were described as having a small sample size, [26,27,35,39] and four reported high attrition rates [24–26,33]. Two studies that utilized random blood glucose (RBG) and fasting blood sugar (FBS) instead of HbA1c for measuring glycemic status faced limitations in assessing this parameter [26,36]. In two studies, self-reported data was collected to measure adherence to medication, diet, and physical activity [35,37], while one study employed an unvalidated questionnaire [28].
Discussion
TPE plays a vital role in managing chronic diseases, such as diabetes [10]. Structured programs in various studies have demonstrated their ability to enhance patient self-management skills, effectively controlling their condition and reducing complications [41,42]. Sub-Saharan Africa (SSA) is on the brink of an epidemiological transition, where non-communicable diseases have become predominant, further adding to the already substantial burden of communicable disease [5]. As this burden increases, more efficient and effective interventions become imperative. Our study is particularly significant as it offers a comprehensive overview of all structured intervention programs implemented in the Sub-Saharan African region.
Our study comprised 13 experimental controlled studies that assessed structured TPE programs in comparison to control groups receiving standard care. Nearly all the selected studies reported significant results in either clinical or non-clinical parameters. This reinforces positive findings from research conducted in various other global regions and among diverse populations [43–45]. Six studies revealed a noteworthy reduction in HbA1C levels when compared to the control groups [24,29–31,38,39]. Enhanced glycemic control has been shown to relatively reduce cardiovascular complications, as a 1% reduction in HbA1C levels, according to a UK study, can reduce cardiovascular complications by 25% [46]. Moreover, most of the studies addressing the secondary outcome of blood pressure yielded favorable outcomes, which is particularly relevant given that hypertension is a crucial risk factor for diabetic complications. However, substantial results concerning significant weight loss and improved lipid profiles were limited. Many studies reportedly lacked sufficient statistical power to detect significant differences in secondary clinical outcomes [26,27,35,39].
The behavioral aspect is another equally critical facet of evaluating patient therapeutic education. However, the behavioral component as an outcome of the intervention received limited evaluation in most studies. Positive behavioral changes are pivotal for long-term self-management [47]. While the knowledge component was assessed in most studies, with all but one showing significant improvements in patient knowledge through questionnaires and knowledge scales after the intervention, some studies reported that the knowledge level, while significantly better than that of the control group, still fell short [27,39]. This may be attributed to the literacy levels of participants or the methods of instruction. The low baseline knowledge of participants underscores the existing state of diabetes management in the SSA region. Improved knowledge has been directly correlated with enhanced self-care practices [48,49]. However, from the studies, it is evident that improved knowledge did not consistently translate into better adherence. Other factors affecting adherence include socioeconomic status, patient motivation, cost, and time constraints, as indicated by a study on the barriers faced by patients in self-management [17]. These are factors that must be taken into consideration when delivering patient therapeutic education. Some studies reportedly distributed glucometers, pedometers, and logbooks to participants, which were reported to enhance compliance among participants and yield positive clinical outcomes [24–29].
The method, duration, frequency, and facilitators are components of TPE programs that contribute to their success. A combination of group sessions and individual sessions has been found to yield the best results in a previously conducted study for better reinforcement [50]. Various modes of delivery were employed for the interventions in our studies, with group sessions being the most prevalent. Technology-mediated interventions did not yield the expected results; however, only a small number of studies employed this approach [35,36,38]. While multidisciplinary teams are reported to be the most effective facilitators of TPE programs [51], nurse and peer-led interventions have proven effective in various interventions from our study [30,31,32,38]. This is especially important in this region, which faces a shortage of healthcare workers [52]. In situations where doctors are unavailable, nurses can facilitate the programs, and in the absence of nurses, trained peer educators can be a viable option. Previous studies on nurse-led and peer-led interventions in diabetes self-management have yielded positive results [53,54]. A few studies have shown a positive correlation between the program’s duration and outcomes [55]; however, our study did not reveal any strong relationship between the frequency or duration of programs and positive outcomes.
The interventions in this study were primarily conducted in tertiary hospitals located in large urban areas and capital cities. This affects the generalizability of the findings to the predominantly rural population that still lacks access to basic care and treatment and has lower literacy levels [56,57]. The participants’ literacy level was a recurring exclusion criterion for the interventions. TPE programs should not only be introduced at the primary care level but should also be adapted to reach populations with varying socioeconomic and literacy levels. This can be achieved through communication in native dialects and the use of teaching materials tailored to the cultural context [58]. Diabetes self-care practices predominantly occur within households and can influence diabetes management behaviors [59]. Consequently, there is a need to involve families in these programs [60] In sub-Saharan Africa, one must not disregard the familial context, which remains a source of patient support and motivation [61].
Several limitations were reported in the studies. A significant number of studies reported short follow-up periods. For instance, one study showed significant positive results at four months post-intervention but failed to sustain these results at 12 months [24]. While the primary aim of the program may be to improve clinical outcomes, it is equally important to measure the program’s sustainability. Therefore, more studies with longer follow-up periods are required to assess the lasting impact of the intervention on patient self-management competence. In addition, high attrition and low attendance rates of participants also diminished the statistical power of several studies. This is a significant public health concern, along with low referral rates as cited in a study [62]. Qualitative studies should be conducted to comprehend the experiences of patients and their reasons for not participating in these programs, leading to a needs assessment aimed at enhancing program quality and better adaptation to patients’ resources.
One of our study’s limitations encompasses the heterogeneous nature of the study designs. Non-randomization and the absence of blinding of participants increase the risk of bias in our selected studies. Additionally, there was substantial variability in the educational content and themes of the intervention. Consequently, we did not categorize or synthesize the data collected in the studies based on the theme of each intervention. Each program had a theme that ranged from nutrition education to physical activity and self-blood glucose monitoring, and a combination of themes and activities of varying depth and intensity. Therefore, we were unable to assess which area had a greater or lesser impact. Nevertheless, despite differences in content and delivery mode, most of the interventions reported significant results in one or more clinical parameters. We recognize that nearly all our included studies focused on T2DM, therefore, our synthesis may not be applicable to T1DM patients. It is also worthy to note that our study relied on common health research databases, but a limitation is acknowledged for not including specific African databases like the African Index Medicus. This omission may exclude relevant studies from local journals or not indexed in widely recognized databases. Future research should consider incorporating these databases for a more comprehensive literature exploration.
Conclusion
TPE programs in sub-Saharan Africa have significant impact on the clinical outcomes of people with diabetes and on improving knowledge and developing skills to self-manage their condition. However, the lasting impact of these programs remains uncertain. Further studies are needed to measure the long-term impacts of TPE programs on patient health status. Extra efforts should be made to include population of all literacy levels and family participation should be built into the programs. The authors also recommend that TPE programs be implemented at the primary health care level where diabetes in the patient is precocious for the prevention of complications.
Reporting Method: PRISMA
References
- 1.
WHO package of essential noncommunicable (PEN) disease interventions for primary health care [Internet]. [cited 2023 May 12]. https://www.who.int/publications-detail-redirect/9789240009226.
- 2. Lin X, Xu Y, Pan X, Xu J, Ding Y, Sun X, et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Sci Rep. 2020 Sep 8;10:14790. pmid:32901098
- 3.
Alebiosu O. IDF diabetes atlas seventh edition. [cited 2023 May 25]; https://www.academia.edu/39753161/idf_diabetes_atlas_seventh_edition.
- 4.
IDF diabetes atlas tenth edition [internet]. [cited 2023 May 12]. https://diabetesatlas.org/.
- 5. Yuyun MF, Sliwa K, Kengne AP, Mocumbi AO, Bukhman G. Cardiovascular diseases in sub-Saharan africa compared to high-income countries: an epidemiological perspective. Glob heart. 2020 Feb 12;15(1):15. pmid:32489788
- 6. Gouda HN, Charlson F, Sorsdahl K, Ahmadzada S, Ferrari AJ, Erskine H, et al. Burden of non-communicable diseases in sub-Saharan Africa, 1990–2017: results from the Global Burden of Disease Study 2017. The Lancet Global Health. 2019 Oct 1;7(10):e1375–87. pmid:31537368
- 7.
Motala A. Diabetes trends in Africa. Vol. 18, diabetes-metabolism research and reviews. 111 river st, hoboken 07030–5774, NJ USA: Wiley; 2002. p. S14–20.
- 8.
Ley SH, Schulze MB, Hivert MF, Meigs JB, Hu FB. Risk factors for type 2 diabetes. In: Cowie CC, Casagrande SS, Menke A, Cissell MA, Eberhardt MS, Meigs JB, et al., editors. Diabetes in America [Internet]. 3rd ed. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases (US); 2018 [cited 2023 May 25]. http://www.ncbi.nlm.nih.gov/books/NBK567966/.
- 9. The 2017 SEMDSA Guidelines for the Management of Type 2 Diabetes | Journal of Endocrinology, Metabolism and Diabetes of South Africa. [cited 2023 May 12]; http://jemdsa.co.za/index.php/JEMDSA/article/view/647.
- 10.
World Health Organization. Regional Office for Europe. Therapeutic patient education: continuing education programmes for health care providers in the field of prevention of chronic diseases: report of a WHO working group [Internet]. World Health Organization. Regional Office for Europe; 1998 [cited 2023 May 10]. viii, 76 p. https://apps.who.int/iris/handle/10665/108151.
- 11. Mauri A, Schmidt S, Sosero V, Sambataro M, Nollino L, Fabris F, et al. A structured therapeutic education program for children and adolescents with type 1 diabetes: an analysis of the efficacy of the ‘Pediatric Education for Diabetes’ project. Minerva Pediatr (Torino). 2021 Apr;73(2):159–66. pmid:28176508
- 12. Moriyama M, Nakano M, Kuroe Y, Nin K, Niitani M, Nakaya T. Efficacy of a self-management education program for people with type 2 diabetes: Results of a 12-month trial. Japan Journal of Nursing Science. 2009;6(1):51–63. pmid:19566639
- 13. Wu X, Guo X, Zhang Z. The efficacy of mobile phone apps for lifestyle modification in diabetes: Systematic review and meta-analysis. JMIR Mhealth Uhealth. 2019 Jan 15;7(1):e12297. pmid:30664494
- 14. Trouilloud D, Regnier J. Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control. Glob Health Promot. 2013 Jun;20(2 Suppl):94–8. pmid:23678503
- 15. Pastakia SD, Pekny CR, Manyara SM, Fischer L. Diabetes in sub-Saharan Africa—from policy to practice to progress: targeting the existing gaps for future care for diabetes. Diabetes Metab Syndr Obes. 2017 Jun 22;10:247–63. pmid:28790858
- 16. Stephani V, Opoku D, Beran D. Self-management of diabetes in Sub-Saharan Africa: a systematic review. BMC Public Health. 2018 Sep 29;18:1148. pmid:30268115
- 17. Bekele H, Asefa A, Getachew B, Belete AM. Barriers and strategies to lifestyle and dietary pattern interventions for prevention and management of type-2 diabetes in Africa, Systematic review. J Diabetes Res. 2020;2020:7948712. pmid:32766315
- 18. Kumah E, Otchere G, Ankomah SE, Fusheini A, Kokuro C, Aduo-Adjei K, et al. Diabetes self-management education interventions in the WHO African Region: A scoping review. PLoS One. 2021 Aug 17;16(8):e0256123. pmid:34403455
- 19.
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions [Internet]. Wiley-Blackwell; 2019 [cited 2023 May 18]. https://research.monash.edu/en/publications/cochrane-handbook-for-systematic-reviews-of-interventions.
- 20. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. pmid:33782057
- 21.
Section—Africana Collections: An Illustrated Guide (Library of Congress—African & Middle Eastern Division) [Internet]. [cited 2023 May 25]. https://www.loc.gov/rr/amed/guide/afr-countrylist.html.
- 22. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug 28;366:l4898. pmid:31462531
- 23. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009 Jul 21;6(7):e1000097. pmid:19621072
- 24. VR AJ, V CM, JB P. A daily physical activity and diet intervention for individuals with type 2 diabetes mellitus: a randomized controlled trial. South African Journal of Physiotherapy. 2010;66(2):9–16.
- 25. Mash B, Levitt N, Steyn K, Zwarenstein M, Rollnick S. Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial. BMC Family Practice. 2012 Dec;13. pmid:23265076
- 26. Afemikhe J, Chipps J. An evaluation of a multidisciplinary patient centred type 2 diabetes self-management education programme in Edo State, Nigeria. Africa Journal of Nursing & Midwifery. 2015;17:S165–79.
- 27. Muchiri JW, Gericke GJ, Rheeder P. Effect of a nutrition education programme on clinical status and dietary behaviours of adults with type 2 diabetes in a resource-limited setting in South Africa: a randomised controlled trial. Public Health Nutrition. 2016 Jan;19(1):142–55. pmid:25872641
- 28. Muchiri JW, Gericke GJ, Rheeder P. Impact of nutrition education on diabetes knowledge and attitudes of adults with type 2 diabetes living in a resource-limited setting in South Africa: a randomised controlled trial. Journal of endocrinology metabolism and diabetes of South Africa. 2016;21(2):26–34.
- 29. Etienne A, David WT, Vincent K, Brian R, Patrick K, Cyprien N, et al. Effects of a lifestyle education program on glycemic control among patients with diabetes at Kigali University Hospital, Rwanda: A randomized controlled trial. Diabetes Research And Clinical Practice. 2017 Apr;126:129–37. pmid:28237859
- 30. Essien O, Otu A, Umoh V, Enang O, Hicks JP, Walley J. Intensive patient education improves glycemic control in diabetes compared to conventional education: a randomized controlled trial in a Nigerian tertiary care hospital. PloS one. 2017;12(1):e0168835.
- 31. Debussche X, Besancon S, Balcou-Debussche M, Ferdynus C, Delisle H, Huiart L, et al. Structured peer-led diabetes self-management and support in a low-income country: The ST2EP randomised controlled trial in Mali. Plos One. 2018 Jan;13(1).
- 32. Hailu FB, Hjortdahl P, Moen A. Nurse-led diabetes self-management education improves clinical parameters in Ethiopia. Frontiers In Public Health. 2018 Oct;6. pmid:30406070
- 33. Hailu FB, Moen A, Hjortdahl P. Diabetes Self-Management Education (DSME)—Effect on Knowledge, Self-Care Behavior, and Self-Efficacy Among Type 2 Diabetes Patients in Ethiopia: A Controlled Clinical Trial. Diabetes Metabolic Syndrome And Obesity-Targets And Therapy. 2019;12:2489–99. pmid:31819574
- 34. Gathu CW, Shabani J, Kunyiha N, Ratansi R. Effect of diabetes self-management education on glycaemic control among type 2 diabetic patients at a family medicine clinic in Kenya: A randomised controlled trial. African journal of primary health care & family medicine. 2018 Nov;10(1):e1–9.
- 35. Sap S, Kondo E, Sobngwi E, Mbono R, Tatah S, ra, et al. Effect of patient education through a social network in young patients with type 1 diabetes in a Sub-Saharan context. Pediatric diabetes. 2019 May;20(3):361–5. pmid:30779272
- 36. Owolabi EO, Ter Goon D, Ajayi AI. Efficacy, acceptability and feasibility of daily text-messaging in promoting glycaemic control and other clinical outcomes in a low-resource setting of South Africa: A randomised controlled trial. Plos One. 2019 Nov;14(11).
- 37. Owolabi EO, Ter Goon D, Ajayi AI. Impact of mobile phone text messaging intervention on adherence among patients with diabetes in a rural setting A randomized controlled trial. Medicine. 2020 Mar;99(12).
- 38. Asante E, Bam V, Diji AKA, Lomotey AY, Owusu Boateng A, Sarfo-Kantanka O, et al. Pilot mobile phone intervention in promoting type 2 diabetes management in an urban area in ghana: a randomized controlled trial. The Diabetes Educator. 2020 Oct;46(5):455–64. pmid:32998649
- 39. Muchiri JW, Gericke GJ, Rheeder P. Effectiveness of an adapted diabetes nutrition education program on clinical status, dietary behaviors and behavior mediators in adults with type 2 diabetes: a randomized controlled trial. Journal of diabetes and metabolic disorders. 2021 Jun;20(1):293–306 pmid:34222067
- 40.
ADCES7 Self-Care Behaviors- The Framework for Optimal Self-Management [Internet]. [cited 2023 Oct 9]. https://www.diabeteseducator.org/practice/practice-tools/app-resources/the-aade7-self-care-behaviors-the-framework-for-optimal-self-management
- 41. Lamptey R, Robben MP, Amoakoh-Coleman M, Boateng D, Grobbee DE, Davies MJ, et al. Structured diabetes self-management education and glycaemic control in low- and middle-income countries: A systematic review. Diabet Med J Br Diabet Assoc. 2022 Aug;39(8):e14812. pmid:35179792
- 42. Correia JC, Waqas A, Assal JP, Davies MJ, Somers F, Golay A, et al. Effectiveness of therapeutic patient education interventions for chronic diseases: A systematic review and meta-analyses of randomized controlled trials. Front Med. 2022;9:996528. pmid:36760883
- 43. Hildebrand JA, Billimek J, Lee JA, Sorkin DH, Olshansky EF, Clancy SL, et al. Effect of diabetes self-management education on glycemic control in Latino adults with type 2 diabetes: A systematic review and meta-analysis. Patient Educ Couns. 2020 Feb;103(2):266–75. pmid:31542186
- 44. Mikhael EM, Hassali MA, Hussain SA. Effectiveness of diabetes self-management educational programs for type 2 diabetes mellitus patients in Middle East countries: A Systematic Review. Diabetes Metab Syndr Obes. 2020 Jan 13;13:117–138. pmid:32021358.
- 45. Mohamed A, Staite E, Ismail K, Winkley K. A systematic review of diabetes self-management education interventions for people with type 2 diabetes mellitus in the Asian Western Pacific (AWP) region. Nurs Open. 2019 Sep 3;6(4):1424–1437. pmid:31660170.
- 46. UKPDS, United Kingdom Prospective Diabetes Study 24: a 6-year, randomized, controlled trial comparing sulfonylurea, insulin, and metformin therapy in patients with newly diagnosed type 2 diabetes that could not be controlled with diet therapy. United Kingdom Prospective Diabetes Study Group, Ann. Intern. Med 128 (3) (1998) 165–175. [PubMed: 9454524]
- 47. Winkley K, Upsher R, Stahl D, Pollard D, Kasera A, Brennan A, et al. Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review. Health Technol Assess Winch Engl. 2020 Jun;24(28):1–232. pmid:32568666
- 48. Chawla SPS, Kaur S, Bharti A, Garg R, Kaur M, Soin D, et al. Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. J Fam Med Prim Care. 2019 Jan;8(1):261–8. pmid:30911517
- 49. Jamaludin TSS, Mohammad NM, Hassan M, Nurumal MS. Knowledge and practice on medication adherence among Type II diabetes mellitus patients. Enferm Clínica. 2021 Apr 1;31:S372–6.
- 50. Goudswaard AN, Stolk RP, Zuithoff NPA, De Valk HW, Rutten GEHM. Long-term effects of self-management education for patients with Type 2 diabetes taking maximal oral hypoglycaemic therapy: A randomized trial in primary care. Diabet Med. 2004;21(5):491–6.
- 51. Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al. National standards for diabetes self-management education and support. Diabetes Educ. 2012;38(5):619–29. pmid:22996411
- 52. Naicker S, Eastwood JB, Plange-Rhule J, Tutt RC. Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective. Clin Nephrol. 2010 Nov;74 Suppl 1:S129–133. pmid:20979978
- 53. Azmiardi A, Murti B, Febrinasari RP, Tamtomo DG. The effect of peer support in diabetes self-management education on glycemic control in patients with type 2 diabetes: a systematic review and meta-analysis. Epidemiol Health. 2021;43:e2021090. pmid:34696569
- 54. Cho MK, Kim MY. Self-management nursing intervention for controlling glucose among diabetes: a systematic review and meta-analysis. Int J Environ Res Public Health. 2021 Dec 3;18(23):12750. pmid:34886488
- 55. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2016 Jun;99(6):926–43. pmid:26658704
- 56. Sumida S, Kawata K. An analysis of the learning performance gap between urban and rural areas in sub-Saharan Africa. South African Journal of Education. 2021 May;41(2):1–17.
- 57. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health. 2016;37:395–412. pmid:26735432
- 58. Okamoto SK, Kulis S, Marsiglia FF, Holleran Steiker LK, Dustman P. A continuum of approaches toward developing culturally focused prevention interventions: From Adaptation to Grounding. J Prim Prev. 2014 Apr;35(2):103–12. pmid:24322970
- 59. Mphasha MH, Mothiba TM, Skaal L. Family support in the management of diabetes patients’ perspectives from Limpopo province in South Africa. BMC Public Health. 2022 Dec 23;22(1):2421. pmid:36564779
- 60. Barnes MD, Hanson CL, Novilla LB, Magnusson BM, Crandall AC, Bradford G. Family-centered health promotion: perspectives for engaging families and achieving better health outcomes. Inquiry. 2020 Jan 1;57:0046958020923537. pmid:32500768
- 61. Mphasha MH, Skaal L, Mothiba TM, Ngoatle C, Hlahla LS. Primary health care-family partnership for better diabetes outcomes of patients: a systematic review. Vol. 28, Journal Of Endocrinology Metabolism And Diabetes Of South Africa. 2–4 Park Square, Milton Park, Abingdon Ox14 4rn, Oxon, England: Routledge Journals, Taylor & Francis Ltd; 2023. P1–6.
- 62. Allory E, Lucas H, Maury A, Garlantezec R, Kendir C, Chapron A, et al. Perspectives of deprived patients on diabetes self-management programmes delivered by the local primary care team: a qualitative study on facilitators and barriers for participation, in France. BMC Health Serv Res. 2020 Sep 11;20(1):855. pmid:32917205