Diabetes self-management education interventions and self-management in low-resource settings: a mixed methods study

Abstract

Introduction Diabetes is largely a self-managed disease; thus, care outcomes are closely linked to selfmanagement behaviours. Structured self-management education (DSME) interventions are, however, largely unavailable in Africa. Aim We sought to characterise DSME interventions in two urban low-resource primary settings; and to explore diabetes self-management knowledge and behaviours, of persons living with diabetes (PLD). Research design and methods A convergent parallel mixed-methods study was conducted between January and February 2021 in Accra, Ghana. The sampling methods used for selecting participants were total enumeration, consecutive sampling, purposive and judgemental sampling. Multivariable regression models were used to study the association between diabetes self-management knowledge and behaviours. We employed inductive content analysis of informants' experiences and context, to complement the quantitative findings. Results In total, 425 PLD (70.1% (n = 298) females, mean age 58 years (SD 12), with a mean blood glucose of 9.4 mmol/l (SD 6.4)) participated in the quantitative study. Two managers, five professionals, two diabetes experts and 16 PLD participated in in-depth interviews. Finally, 24 PLD were involved in four focus group discussions. The median diabetes self-management knowledge score was 40% ((IQR 20-60). For every one unit increase in diabetes selfmanagement knowledge, there were corresponding increases in the diet (5%;[95% CI: 2%- 9%, p<0.05]), exercise (5%; [95% CI:2%-8%, p<0.05]) and glucose monitoring (4%;[95% CI:2%-5%, p<0.05]) domains of the diabetes self-care activities scale respectively. The DSME interventions studied, were unstructured and limited by resources. Financial constraints, conflicting messages, beliefs, and stigma were the themes underpinning self-management behaviour. Conclusions The DSME interventions studied were under-resourced, and unstructured. Diabetes selfmanagement knowledge though limited, was associated with self-management behaviour. DSME interventions in low resource settings should be culturally tailored and should incorporate sessions on mitigating financial constraints. Future studies should focus on creating structured DSME interventions suited to resource-constrained settings.