Poor glycaemic control: prevalence, factors and implications for the care of patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo: a cross-sectional study.

Introduction: Diabetes is a significant problem in sub-Saharan Africa and achieving glycaemic control poses a health challenge among patients living with type 2 diabetes. There are limited data on glycaemic control in Kinshasa, Democratic Republic of the Congo. This study assessed the prevalence and factors associated with glycaemic control to inform potential interventions to improve glycaemic control in Kinshasa. Methods: This was a cross-sectional study conducted between November 2021-September 2022 among patients recruited from 20 randomly selected health facilities in Kinshasa. Participants were asked to complete a structured questionnaire and to provide two millilitres of blood for Hb1AC assay. Poor glycaemic control was defined as HbA1c ≥7%. Univariate and multivariable logistic regressions were performed to identify factors associated with poor glycaemic control. Results: A total of 620 participants were recruited for this study. Study participants had a median age of 60 (IQR=53.5-69) years with the majority being female (66.1%), unemployed (67.8%), having income below the poverty line (76.4%), and without health insurance (92.1%). About two-thirds of the participants (420; 67.6%) had poor glycaemic control. Participants on monotherapy with insulin (AOR=1.64, 95%CI [1.10-2.45]) and those on a treatment duration ≥7 years (AOR=1.45, 95%CI [1.01-2.08]) were associated with increased odds of poor glycaemic control while being overweight (AOR= 0.47, 95%CI [0.26-0.85]) and those with uncontrolled blood pressure (AOR=0.65, 95% CI [0.48-0.90]) were protective for poor glycaemic control. Conclusion: Poor glycaemic control is prevalent among patients with type 2 diabetes in Kinshasa, DRC. Being on insulin alone and a duration of diabetes treatment equal or more than 7 years predisposed to poor glycaemic control. By contrary, having uncontrolled blood pressure and being overweight had protective effect against poor glycaemic control. These links between uncontrolled blood pressure and overweight on the one hand, and glycaemic control on the other are unusual. These reflect, among other things, the specific characteristics of diabetes in sub Saharan Africa.

Type 2 diabetes in the Democratic Republic of Congo: an urgent need for a management framework.

Glycaemic control is of one the main goals for managing type 2 diabetes. In sub-Saharan Africa and the Democratic Republic of the Congo, studies have reported alarming poor control rates. Patients with poor glycaemic control are exposed to complications leading to high cost of care and deteriorated quality of life. In recent studies by our group, we have demonstrated that poor glycaemic control is high and driven by proximal (individual) and distal (structural) factors in Kinshasa, Democratic Republic of the Congo. Financial constraints impacted many aspects of care at multiple levels from the Government to persons living with diabetes. Financial constraints prevented good preparation, organization and access to diabetes care. Difficulties in implementing lifestyle changes, lack of health literacy and limited healthcare support were also contributing to poor glycaemic control. Through a Delphi study, a group of experts reached a consensus on five potential strategies for improving glycaemic control in the Democratic Republic of Congo as follows: changing the healthcare system for better diabetes care extended to other noncommunicable diseases, ensuring consistent financing of the healthcare, augmenting the awareness of diabetes among the general population and the persons living with diabetes, easing the adoption of lifestyle modifications and reducing the burden of undiagnosed diabetes. This paper reflects on the urgent need for an improved management framework for diabetes care in the Democratic Republic of the Congo. Specifically, the Government needs to increase the investment in the prevention and treatment of noncommunicable diseases including diabetes.

Perspectives for glycaemic control in type 2 diabetes in Kinshasa, Democratic Republic of the Congo.

Glycaemic control is a significant problem in the Democratic Republic of the Congo (DRC), the perspectives associated with glycaemic control are not fully known as previous studies rarely explored patients' perspectives and lived experiences. This qualitative study described the perspectives regarding glycaemic control among persons with type 2 diabetes in Kinshasa, DRC. A total of 23 participants were purposively selected in seven health centres in Kinshasa. In-depth interviews were used for data collection. The study used a phenomenology approach, and deductive, constructionist and thematic analysis. Data analysis was performed using the MAXQDA 2022. Five themes were identified as perspectives for glycaemic control in Kinshasa: financial constraints, limited social and relational support, difficulties with lifestyle changes, beliefs and practices about diabetes and ability to adapt for caring for the illness. Themes were integrated using social cognitive theory. Participants expressed that they were unable to achieve better glycaemic control due to financial constraints, limited social and relational support and difficulty in changing their lifestyle. Their beliefs and practices about diabetes also constituted a barrier. Our results showed that lack of adequate funding is a major determinant of glycaemic control and therefore it is crucial to integrate a consistent and reliable funding system for care of people living with diabetes. Persons with diabetes must be empowered to successfully adapt to the requirements of diabetes care. In this process, support for people living with type 2 diabetes is also essential and should involve their families as well as healthcare providers.

Consensus on potential interventions for improving glycaemic control among patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo: a Delphi study.

BACKGROUND: Poor glycaemic control is a multifactorial and complex problem with dire clinical and economic implications. In the Democratic Republic of the Congo, recent studies have shown alarming poor control rates. There is no policy framework to guide corrective actions. OBJECTIVES: To build a consensus on interventions to improve glycaemic control among patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo. METHODS: This was a two-round electronic Delphi study involving 31 local and 5 international experts. The experts rated proposed interventions from previous studies on glycaemic control in sub-Saharan Africa and Kinshasa on a 4-Likert scale questionnaire. Additionally, the experts were asked to suggest other recommendations useful for the purpose. The mode, mean and standard deviation of each statement were calculated for each round. RESULTS: Participants reached consensus in five domains that included 39 statements on how to improve glycaemic control in Kinshasa: strengthening the health system, enhancing the awareness of diabetes, alleviating the financial burden of diabetes, enhancing the adoption of lifestyle modifications, and reducing the proportion of undiagnosed diabetes. CONCLUSIONS: Improved glycaemic control needs to be considered within the broader framework of managing noncommunicable diseases in a more integrated, coordinated and better financed healthcare system. Further studies are needed to operationalise the interventions identified for successful implementation.

Exploring barriers to switching "on time" to second-line antiretroviral therapy among nurses in primary health care facilities, Ekurhuleni Health District, South Africa.

BACKGROUND: Ensuring that all HIV-infected people receive antiretroviral therapy (ART) and achieve viral suppression are key South African strategies to end the AIDS epidemic in the country. National HIV treatment guidelines recommend an immediate switch to second-line ART following virological failure with first-line ART. Nurses based in district health facilities are at the forefront of implementing this recommendation. While there are often delays in switching and in some instances no switch, the reasons for and barriers to delayed switching are not well understood at the primary care level. AIM: To explore the views of frontline nursing staff about factors contributing to delayed switching of patients who have failed first-line ART regimen in Ekurhuleni district, South Africa. METHODS: A qualitative study was conducted among 21 purposively sampled nurses who provide HIV treatment and care to patients in 12 primary health care (PHC) facilities in Ekurhuleni Health District, Gauteng Province, South Africa. Individual in-depth interviews explored nurses' experiences regarding their recognition of virological failure and understanding of "on time" switching to second-line ART. Interviews probed the circumstances contributing to delays in switching. After digital audio recording and transcription, manual inductive thematic analysis was used to analyse the data. FINDINGS: Multiple barriers were identified: 1) Healthcare provider factors included a lack of knowledge and confidence coupled with demotivation in the workplace; 2) Patient issues similarly comprised a lack of knowledge as well as resistance to being switched to another drug regimen and loss to follow up; 3) Systems factors were poor facility leadership, shortages of medication, staffing constraints, and the inability to trace laboratory results, especially for migrant patients. CONCLUSION: Reasons for delayed switching of patients to second-line ART are multifactorial and require integrated interventions at health provider, patient and health system levels.

Protocol: Developing a framework to improve glycaemic control among patients with type 2 diabetes mellitus in Kinshasa, Democratic Republic of the Congo.

In Kinshasa, Democratic Republic of the Congo (DRC), between 68-86% of patients with type 2 diabetes present with poor glycaemic control leading to increased risk of complications and high cost of care. Identifying the factors driving glycaemic control is essential for better management. There is lack of data on factors associated with poor glycaemic control and targeted interventions in the DRC. This study aims to determine the factors associated with type 2 diabetes control and develop an appropriate intervention package in Kinshasa. The study will comprise of three sub-studies as follows: the first sub-study being a concurrent parallel mixed-methods cross-sectional study to determine factors driving poor glycaemic control among patients in Kinshasa. A total of 614 patients will be invited to participate in a cross-sectional study and respond to standardized questionnaires. A minimum of 20 purposively selected patients will participate in the qualitative study that will involve in-depth interviews about their perspectives on glycaemic control. In the quantitative study, multivariable logistic regression will be performed to determine factors associated with glycaemic control, after identifying the confounding factors. In the qualitative study, thematic analysis will be performed. Findings of the quantitative and qualitative studies on factors that are associated with glycaemic control will be triangulated. And allow to conduct the second sub-study, a qualitative inquiry with a minimum of 20 healthcare providers and 20 patients, selected purposively, to explore their perspectives about potential interventions to improve glycaemic control. At the last, the findings of both sub-studies will be subjected to an anonymous electronic three-round process Delphi study involving 25 stakeholders on the intervention package to develop a framework to optimise glycaemic control in Kinshasa. The implementation of the intervention package will occur after the completion of this study with expected substantial impact on the patients, healthcare providers, and health system.

Glycaemic control among type 2 diabetes patients in sub-Saharan Africa from 2012 to 2022: a systematic review and meta-analysis.

BACKGROUND: There is an increased burden of diabetes globally including in sub-Saharan Africa. The literature shows that glycaemic control among type 2 diabetes patients is poor in most countries in sub-Saharan Africa. Understanding the factors influencing glycaemic control in this region is therefore important to develop interventions to optimize glycaemic control. We carried out a systematic review to determine the prevalence and factors associated with glycaemic control in sub-Saharan Africa to inform the development of a glycaemic control framework in the Democratic Republic of the Congo. METHODS: We searched five databases (African Index Medicus, Africa-Wide Information, Global Health, PubMed, and Web of Science) using the following search terms: type-2 diabetes, glycaemic control, and sub-Saharan Africa. Only peer-reviewed articles from January 2012 to May 2022 were eligible for this review. Two reviewers, independently, selected articles, assessed their methodological quality using Joanna Briggs checklists, and extracted data. A meta-analysis was performed to estimate the prevalence of glycaemic control. Factors associated with glycaemic control were presented as a narrative synthesis due to heterogeneity as assessed by the I2. RESULTS: A total of 74 studies, involving 21,133 participants were included in the review. The pooled prevalence of good glycaemic control was 30% (95% CI:27.6-32.9). The glycaemic control prevalence ranged from 10-60%. Younger and older age, gender, lower income, absence of health insurance, low level of education, place of residence, family history of diabetes, longer duration of diabetes, pill burden, treatment regimen, side effects, use of statins or antihypertensives, alcohol consumption, smoking, presence of comorbidities/complications, and poor management were associated with poor glycaemic control. On the other hand, positive perceived family support, adequate coping strategies, high diabetes health literacy, dietary adherence, exercise practice, attendance to follow-up, and medication adherence were associated with good glycaemic control. CONCLUSION: Suboptimal glycaemic control is pervasive among patients with type-2 diabetes in sub-Saharan Africa and poses a significant public health challenge. While urgent interventions are required to optimize glycaemic control in this region, these should consider sociodemographic, lifestyle, clinical, and treatment-related factors. This systematic review and meta-analysis protocol is registered in PROSPERO under CRD 42021237941.

Effect of a brief motivational interview and text message intervention targeting tobacco smoking, alcohol use and medication adherence to improve tuberculosis treatment outcomes in adult patients with tuberculosis: a multicentre, randomised controlled trial of the ProLife programme in South Africa.

OBJECTIVE: To investigate the effectiveness of a complex behavioural intervention, ProLife, on tuberculosis (TB) treatment success, medication adherence, alcohol use and tobacco smoking. DESIGN: Multicentre, individual, randomised controlled trial where participants were assigned (1:1) to the ProLife intervention or usual care. SETTING: 27 primary care clinics in South Africa. PARTICIPANTS: 574 adults starting treatment for drug-sensitive pulmonary TB who smoked tobacco or reported harmful/hazardous alcohol use. INTERVENTIONS: The intervention, delivered by lay health workers (LHWs), consisted of three brief motivational interviewing (MI) sessions, augmented with short message service (SMS) messages, targeting medication adherence, alcohol use and tobacco smoking. OUTCOME MEASURES: The primary outcome was successful versus unsuccessful TB treatment at 6-9 months, from TB records. Secondary outcomes were biochemically confirmed sustained smoking cessation, reduction in the Alcohol Use Disorder Identification Test (AUDIT) score, improved TB and antiretroviral therapy (ART) adherence and ART initiation, each measured at 3 and 6 months by questionnaires; and cure rates in patients who had bacteriology-confirmed TB at baseline, from TB records. RESULTS: Between 15 November 2018 and 31 August 2019, 574 participants were randomised to receive either the intervention (n=283) or usual care (n=291). TB treatment success rates did not differ significantly between intervention (67.8%) and control (70.1%; OR 0.9, 95% CI 0.64% to 1.27%). There was no evidence of an effect at 3 and 6 months, respectively, on continuous smoking abstinence (OR 0.65, 95% CI 0.37 to 1.14; OR 0.76, 95% CI 0.35 to 1.63), TB medication adherence (OR 1.22, 95% CI 0.52 to 2.87; OR 0.89, 95% CI 0.26 to 3.07), taking ART (OR 0.79, 95% CI 0.38 to 1.65; OR 2.05, 95% CI 0.80 to 5.27) or AUDIT scores (mean score difference 0.55, 95% CI -1.01 to 2.11; -0.04, 95% CI -2.0 to 1.91) and adjusting for baseline values. Cure rates were not significantly higher (OR 1.16, 95% CI 0.83 to 1.63). CONCLUSIONS: Simultaneous targeting of multiple health risk behaviours with MI and SMS using LHWs may not be an effective approach to improve TB outcomes. TRIAL REGISTRATION NUMBER: ISRCTN62728852.

Cervical cancer screening in a population of black South African women with high HIV prevalence: A cross-sectional study.

Cervical cancer is largely preventable through early detection, but screening uptake remains low among black women in South Africa. The purpose of this study was to determine the prevalence and factors associated with cervical cancer screening in the past 10 years among black African women in primary health care (PHC) clinics, in Gauteng Province, South Africa. This was a cross-sectional study involving 672 consecutively recruited black women at cervical cancer screening programs in PHC clinics between 2017 and 2020. An interviewer-administered questionnaire covered socio-demographics, HIV status, sexual history, cervical cancer risk factors knowledge, and screening behaviours in the past 10 years. The mean age of participants was 38 years. More than half (63%) were aged 30-49 years. Most completed high school education (75%), were unemployed (61%), single (60%), and HIV positive (48%). Only 285 (42.4%) of participants reported screening for cervical cancer in the past 10 years. Of participants that reported receiving information on screening, 27.6% (n = 176) and 13.97% (n = 89) did so from healthcare facilities and community platforms respectively. Participants aged 30 years or more were more likely to report for cervical cancer screening as compared to other categories in the past 10 years. The study found low cervical cancer screening prevalence. This calls for health education campaigns and prevention strategies that would target individual patients' contexts and stages of behavioral change. Such strategies must also consider socio-demographic and clinical correlates of cervical cancer screening and promote better integration into PHC services in South Africa.

ImPROving TB outcomes by modifying LIFE-style behaviours through a brief motivational intervention followed by short text messages (ProLife): study protocol for a randomised controlled trial.

BACKGROUND: South Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes. METHODS: This is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups. DISCUSSION: This trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018.