Assessing the extent and effectiveness of diabetes self-management education in public health care institutions in Harare, Zimbabwe

Nkomani, Sanele (2016-12)

Thesis (MNutr)--Stellenbosch University, 2016.

Thesis

ENGLISH SUMMARY : Introduction: Nutrition focused diabetes self-management education (DSME) provided by a dietitian or diabetes educator considerably improves glycaemic control, reduces the rate of complications, and reduces costs. Little is known about the effectiveness of DSME interventions, despite the rising prevalence of type 2 diabetes (T2DM) in Harare. This study therefore aimed to assess the extent to which existing DSME interventions improve nutrition focused knowledge, attitudes and practices (KAP). Secondly, health facility resoures to support effective DSME were assessed. Methods: A cross sectional survey design was used to determine nutrition focused diabetes KAP for 156 participants with T2DM attending eight public health facilities within the Harare metropole. The final sample size detected an effect size of 0.4 between two groups perceived to differ with regard to DSME received, i.e. central hospital outpatient clinic attendees and city health clinic attendess. Two (out of two) central hospital clinics in Harare were selected and six city health clinics (representing six of nine health districts in Harare) were selected using a multiple stage sampling strategy. Participants were divided equally between the two groups. Mean KAP scores from a reseacher designed questionnaire were compared between clinic groups, consultation with a dietitian and a diabetes educator. Nineteen health professionals involved in diabetes management at the sampled facilities also completed a self assessment on the primary care resources available to deliver quality DSME at their respective clinics. Results: The majority of participants (90.3%, n=139) reported recieving DSME, while fewer had consulted a dietitian (49.0%, n=76) or diabetes educator (52.0%, n=80). Dietitian (χ2=10.61,p=0.01) and diabetes educator (χ2=12.31,p=0.00) led interventions occurred more frequently at central hospitals. Participants showed better knowledge (p<0.01), and attitudes (p<0.00) for other self-care behaviours compared to nutrition knowledge (p<0.01). Significantly higher levels of knowledge were observed for central hospital clinic atendees (p=0.00), consultation with a dietitian (p<0.01) or diabetes educator (p=0.00). However, no differences were observed in attitudes for clinic group (p=0.10), consultation with a dietitian (p=0.30) or diabetes educator (p=0.19). Only those that had consulted a dietitian reported better adherence to dietary guidelines (p=0.00) and physical activity (p=0.02) self-care behaviours. Over half of the health professionals (57.9%, n=19) and (68.4%, n=19) scored resources for patient and organisational support respectively as inconsistent and limited. Health professionals from city health clinics rated their patient (p<0.01) and organisational (p<0.01) support capacity higher than health professionals from central hospital clinics. Conclusion: DSME intervention occurs more frequently at central hospitals, although no evidence of structured DSME programmes exists. Only dietitian led interventions significantly improved both knowledge and practices, highlighting a need to scale up dietetic intervention, particularly in city health clinics were very little DSME occurs. Health professional perceived resources for DSME to be inadequate and inconsistent, revealing the need for improved training of health professonals involved in diabetes management.

AFRIKAANSE OPSOMMING : Inleiding: Voeding-gefokusde opleiding omDiabetes self te kan bestuur [Diabetes self-management education (DSME)] wat verskaf word deur ‘n dieetkundige of diabetes-opvoeder verbeter glisemiese kontrole, verlaag die voorkoms van komplikasies en verlaag koste aansienlik. Nieteenstaande die stygende prevalensie van diabetes in Harare, is daar relatief min inligting beskikbaar aangaande die effektiwiteit van DSME intervensies. Hierdie studie het dus ten doel gehad om die effek van DSME intervensies op verbetering van voeding-gefokusde kennis, houding en praktyke te bepaal. Tweedens is die hulpbronne van gesondheidsorginstansies vir die ondersteuning van effektiewe DSME bepaal. Metodes: ‘n Dwarssnit studie ontwerp is gebruik om voeding gefokusde diabetes kennis, houding en praktyke van 156 deelnemers met T2DM, wat agt publieke gesondheidsorginstansies in die Harare metropool besoek, te bepaal. Die finale steekproef kon ‘n effekgrootte van 0.4 tussen die twee groepe wat vermoedelik verskil ten opsigte van DSME ontvang, naamlik sentrale hospitaal kliniek pasiënte en stads gesondheidskliniek pasiënte bepaal. Twee (uit twee) sentrale hospitaal klinieke in Harare en ses stads gesondheidsklinieke (wat ses uit die nege gesondheids distrikte verteenwoordig) was geselekteer deur middle van ‘n veelvuldige stadium steekproefstrategie. Deelnemers was gelyk verdeel tussen die twee groepe. Gemiddelde kennis, houding en praktyke (nakoming) tellings van ‘n navorser-ontwikkelde vraelys is vergelyk tussen kliniek groepe, konsultasies met ‘n dieetkundige en ‘n diabetes-opvoeder. Negentien gesondheidswerkers betrokke by diabetes bestuur by die geselekteerde fassiliteite het ook ‘n self-evaluasie van primêre sorg hulpbronne beskikbaar by die klinieke vir lewering van kwaliteit DSME voltooi. Resultate: Die meerderheid deelnemers (90.3%, n=139) het aangedui dat hul blootstelling gehad het aan DSME, terwyl ‘n kleiner persentasie ‘n dieetkundige (49.0%,n=76) of diabetes-opvoeder (52.0%,n=80) besoek het. Dieetkundiges (χ2=10.61,p=0.01) en diabetes-opvoeder (χ2=12.31,p=0.00) intervensies het meer algemeen voorgekom by sentrale hospitale. Deelnemers het beter kennis (p<0.01) en gedrag (p<0.00) getoon vir ander selfsorgpraktyke vergeleke met voedingkennis (p<0.01). Deelnemers wat sentraal hospitaalklinieke (p=0.00), ‘n dieetkundige (p<0.01) of diabetes-opvoeder (p=0.00) besoek het, het almal hoër kennisvlakke getoon. Geen verskille is gevind in houding vir kliniek groep (p=0.10), of konsultasie met ‘n dieetkundige (p=0.30) of diabetes-opvoeding nie (p=0.19). Slegs diegene wat ‘n dieetkundige konsulteer het, het beter navolging van dieet (p=0.00) en fisiese aktiwiteit (p=0.02) selfsorg-gedrag rapporteer. Meer as die helfde van die Gesondheidswerkers (57%, n=19) en (68.4%, n=19) het hulpbronne vir pasiënt- en organisatoriese ondersteuning onderskeidelik, aangedui as beperk. Gesondheidswerkers van stads gesondheidsklinieke het hul pasiënt- (p<0.01) en organisatoriese (p<0.01) ondersteuning vermoeë hoër geag as diegene van sentrale hospitaal klinieke. Gevolgtrekking: DSME intervensie gebeur meer gereeld by sentrale hospitaal klinieke, alhoewel daar geen bewyse van gestruktureerde DSME programme bestaan nie. Slegs intervensies gelewer deur dieetkundiges het tot beduidende verbetering in kennis en praktyke aanleiding gegee. Laasgenoemde versterk die behoefte om dieetkundige intervensies te verbeter, veral by stads gesondheidsklinieke waar weinige DSME plaasvind. Gesondheidswerkers het sekere aspekte van DSME as onvoldoende geag, wat die behoefte versterk om gesondheidswerkers voldoende op te lei in diabetes hantering.

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