Discussion
irregular diabetes, diabetes
DISEASE, BLIND, COMPLICATIONS, DIABETES
Our aim was to study the association between structured DSME, and glycaemic control. Our results show that, in people living with diabetes (PLD) in resource-constrained settings, structured DSME may not be associated with change in HbA1c at 3-months. A clinically relevant reduction in HbA1c was observed in the intervention group but not in the control group.Reduction in HbA1c is associated with less micro-vascular complications and may also reflect better self-management routines. In sub-Saharan Africa, many PLD have poor self-management skills and poor diabetes outcomes [There are multiple and complex barriers to self-management in low-resource settings. These barriers include irregular diabetes supplies, financial constraints, low health literacy and culture [The DSME intervention we tested was culturally tailored for the Ghanaian population, and linguistically suited to low-literacy levels. This may potentially explain the clinically relevant and significant reduction in HbA1c within the intervention group. HbA1c is dependent on self-management routines. The changes in the summary of diabetes self-care activities scores suggest an improvement in self-management routines within the intervention group.Our findings align with findings from most previous studies [The studies included in this systematic review share some characteristics with our study and this may contribute to the congruence in the findings [The baseline mean HbA1c was over 10% in Hailu et al.’s study among participants in Ethiopia. Additionally, 50% of their study population had lived with diabetes for over 10 years and participants received six sessions of DSME over a 9-month period [In summary, despite the case-mix variation between studies there is homogeneity in the estimates of the association between structured DSME and glycaemic control in PLD in Africa [Our findings of a null association between structured DSME and glycaemic control are inconsistent with studies from Kuwait, Nigeria, and our recently published systematic review of structured DSME in low- middle-income countries[Our findings on HbA1c are consistent with those of Davies et al. in a study undertaken in the UK[In resource constrained-settings intervention contact time can limit sustainability and scalability of a structured education program. It is not clear what the relation between intervention contact time and reduction in HbA1c is. DSME Interventions with contact time greater or equal to 10 h, have been shown to be associated with significant reductions in HbA1c in a systematic review of over 100 varieties of DSME programs [For most participants in our study, health literacy was low, and the monthly cost of care was greater than half of their monthly income. The average cost of managing one person with diabetes in a clinic in Accra in 2009 was about US$ 28 monthly [Our inability to standardise usual care between groups is also a potential source of bias. Due to the nature of the intervention, it was not possible to blind assessors, and this might be responsible for ascertainment bias. However, the primary outcome, change in HbA1c was an objective outcome thus limiting the risk of bias. Higher baseline HbA1c values in the intervention group, may indicate that those in the intervention group had more advanced disease. This difference could also have biased our estimate. Reassuringly these differences were not statistically significant; pointing to a robust randomization. Stratification on baseline HbA1c would have resulted in more balanced groups. At the time of randomisation however,, baseline HbA1c values were not known.The randomised controlled trial design, and the use of a culturally adapted intervention are strengths of this study. This design increases the internal validity of the estimate of the effect of structured education on glycaemic control in the population.The study was set in Ghana, in two public health facilities, where the national health insurance scheme is the main means of healthcare financing. Our findings may therefore not be generalisable to community-based interventions or private facilities. We excluded participants who were not ambulant, could not participate in group activities and who were not primarily responsible for their care, thus further limiting the generalisability of our findings.