Glycemic control among patients with type 2 diabetes in a low resource setting in Rwanda: a prospective cohort study.

Introduction: diabetes is a leading cause of death, disability, and high healthcare costs, especially among patients with poor glycemic control. Providing decentralized diabetes care to patients in low-income countries remains a major challenge. We aimed to assess hemoglobin A1C (HbA1c) level of patients enrolled in primary-level non-communicable disease clinics of Rwamagana, Rwanda, and identify predictors associated with a) change in HbA1c level over a 6-month period or b) achieving HbA1c <7%. We also explored whether living in a community with a home-based care practitioner was associated with HbA1c-related outcomes. Methods: we conducted structured interviews and HbA1c testing among patients with type 2 diabetes at baseline and after six months. Multivariable linear regression and multivariable logistic regression were used. Results: hundred and thirty (130) participants enrolled at baseline, and 123 patients remained in the study after six months. At baseline, 26% of patients had HbA1c <7%. After 6-months, 37% of patients had HbA1c <7%. Factors correlated with the greatest improvements in HbA1c were having HbA1c >9% at baseline, while factors associated with having HbA1c <7% after six months included older age and having HbA1c <7% at baseline. We did not find significant associations between home-based care practitioners and improvement in HbA1c level or achieving HbA1c <7. Conclusion: the number of patients with well-controlled glycemia improved over time during this study but was still low overall. Care provided by home-based care practitioners was not associated with six-month HbA1c outcomes. Enhanced care is needed to achieve glycemia control in primary healthcare settings.

A scoping review on family medicine in sub-Saharan Africa: practice, positioning and impact in African health care systems.

BACKGROUND: Family medicine (FM) is a relatively new discipline in sub-Saharan Africa (SSA), still struggling to find its place in the African health systems. The aim of this review was to describe the current status of FM in SSA and to map existing evidence of its strengths, weaknesses, effectiveness and impact, and to identify knowledge gaps. METHODS: A scoping review was conducted by systematically searching a wide variety of databases to map the existing evidence. Articles exploring FM as a concept/philosophy, a discipline, and clinical practice in SSA, published in peer-reviewed journals from 2000 onwards and in English language, were included. Included articles were entered in a matrix and then analysed for themes. Findings were presented and validated at a Primafamed network meeting, Gauteng 2018. RESULTS: A total of 73 articles matching the criteria were included. FM was first established in South Africa and Nigeria, followed by Ghana, several East African countries and more recently additional Southern African countries. In 2009, the Rustenburg statement of consensus described FM in SSA. Implementation of the discipline and the roles and responsibilities of family physicians (FPs) varied between and within countries depending on the needs in the health system structure and the local situation. Most FPs were deployed in district hospitals and levels of the health system, other than primary care. The positioning of FPs in SSA health systems is probably due to their scarcity and the broader mal-distribution of physicians. Strengths such as being an "all- round specialist", providing mentorship and supervision, as well as weaknesses such as unclear responsibilities and positioning in the health system were identified. Several studies showed positive perceptions of the impact of FM, although only a few health impact studies were done, with mixed results. CONCLUSIONS: FM is a developing discipline in SSA. Stronger evidence on the impact of FM on the health of populations requires a critical mass of FPs and shared clarity of their position in the health system. As FM continues to grow in SSA, we suggest improved government support so that its added value and impact on health systems in terms of health equity and universal health coverage can be meaningfully explored.