Quality of type 2 diabetes care based on glycaemia in sub-sahara africa: A systematic review

Background: Diabetes Mellitus is an increasing medical problem in Sub-Saharan Africa (SSA). Current evidence suggests an epidemic proportion of this condition in this developing region, largely due to increasing urbanization and epidemiological transition. There are suggestions that the quality of diabetes care in Africa is suboptimal. However, there is unclear evidence to substantiate these claims. There was the need to systematically assess and summarise the existing evidence on quality of care among patients with type 2 diabetes mellitus (T2DM), whilst identifying any gaps in information and exploring possible barriers to care in a SSA context. This will provide policy makers and health care providers with a systematic overview of the available evidence on the state of diabetes care in this region from which they can base decision making. Aim and Objectives: The aim of the systematic review was to examine the existing quality of management of type 2 diabetes in SSA by addressing the following questions: i. How good is the current control of type 2 DM in SSA based on indicator outcome of glycaemia? ii. Have implemented strategies, treatment or interventions improved glycaemic control of type 2 DM in Sub-Saharan African countries? Methods: This study was a systematic review of quantitative studies. The population comprised people with type 2 diabetes in sub-Saharan Africa. All ages, gender, ethnicities irrespective of race, residence, locality, immigration status, educational background and socio-economic status were included. The studies included cross-sectional studies, experimental, quasi-experimental studies, observational studies and review papers. Only full papers as opposed to abstracts were included in the review. Conference proceedings, editorials and case reports were excluded. Two databases were explored to develop search strategies – MEDLINE via Pubmed (1946 to February 2013) and EMBASE via Ovid (1974 to April 2013). Terms such as glycaemia and hyperglycaemia, and terms related to these were used in the search strategy. The search included searching reference lists of derived papers and contacting experts. Data on measures of glycaemic control as primary outcome of interest were extracted and summarised upon. Secondary outcomes included process measures like the frequency of blood glucose levels documentation. Duration of diagnosed diabetes and assessment of diabetes complications were considered. The interventions or implementation strategies within studies or data collected on these were also assessed. Study quality was assessed based on components in a quality assessment tool from the Effective Public Health Practice Project. Results: Thirteen published studies were identified and included in the review. Eleven of these were cross-sectional studies, one was a prospective cohort study and another combined cross-sectional and cohort study. Education on diabetes management and prevention of complications seemed to be the most consistent intervention carried out, followed by drug treatment with oral hypoglycaemic agents and Insulin, then dietary measures. Target levels of HbA1c were generally less than 7% in almost all the studies. This is in keeping with the IDF and ADA guidelines. Target glycaemic control were consistently seen in less than 50% of the patients within studies. Conclusion: This review found the quality of care of type 2 diabetes based on glycaemic control, to be sub-optimal in sub-Sahara African countries. Therefore, quality of care needs to be improved upon in this region. It is likely that several interventions, mainly secondary preventive strategies, and implementation strategies identified would improve quality of care in this region. Targeted interventions and strategies specific to the local populace would be beneficial.