Community- and mHealth-based integrated management of diabetes in primary healthcare in Rwanda (D²Rwanda): the protocol of a mixed-methods study including a cluster randomised controlled trial

Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the diabetes-39 (D-39) questionnaire

Background

In recent years, more importance is being given to the assessment of quality of life (QoL) among diabetic patients as a measure of their health and the goal of all health interventions. Other studies have reported a high prevalence of diabetes-related effects on; however, there is a knowledge gap in the region of Sub-Saharan Africa, as is the case for Rwanda, where the prevalence of diabetes is expected to rise over the next decade. The aim of this study is to report on the translation and cultural adaptation of the Diabetes-39 (D-39) questionnaire into the Kinyarwanda and its psychometric properties among diabetic patients in Rwanda.

Methods

The D-39 questionnaire—a five-scale, disease-specific QoL questionnaire—was translated from English to Kinyarwanda, then back-translated to English. A consensus meeting discussed discrepancies and agreed on changes. Interviews were conducted with 26 participants before producing a final version. For the psychometric evaluation, the adapted version was administered to 309 patients with diabetes mellitus. Participants either came from a separate cluster-randomised controlled trial or were recruited ad hoc for this study. The evaluation included testing internal consistency, known group validity, and construct validity.

Results

Participants’ mean age was 51 ± 12.7 years with a predominance of women (64%) in the sample. All five scales of the questionnaire showed a good internal consistency, with composite reliability of above 0.7. The five-factor model of the questionnaire was fitted to the 39 items. Although the fit was not exact, there was a satisfactory approximate fit (CFI = 0.93, TLI = 0.92, RMSEA = 0.05). There was a good discriminant validity except for the “social burden” and “anxiety and worry” scales (inter-factor correlation = 0.80).

Conclusions

Diabetes-39 is a questionnaire developed in English that was adapted and translated into Kinyarwanda. The Kinyarwanda version of D-39 is a reliable and valid instrument to measure QoL among diabetic patients in Rwanda. The questionnaire can be helpful in research and clinical practice improving health outcomes for patients with diabetes in Rwanda and other Kinyarwanda-competent areas in the sub-region. However, certain cross-cultural differences should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02034-5.

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services

Background

Arterial hypertension (aHT) is the leading cardiovascular disease (CVD) risk factor in sub-Saharan Africa; it remains, however, underdiagnosed, and undertreated. Community-based care services could potentially expand access to aHT diagnosis and treatment in underserved communities. In this scoping review, we catalogued, described, and appraised community-based care models for aHT in sub-Saharan Africa, considering their acceptability, engagement in care and clinical outcomes. Additionally, we developed a framework to design and describe service delivery models for long-term aHT care.

Methods

We searched relevant references in Embase Elsevier, MEDLINE Ovid, CINAHL EBSCOhost and Scopus. Included studies described models where substantial care occurred outside a formal health facility and reported on acceptability, blood pressure (BP) control, engagement in care, or end-organ damage. We summarized the interventions’ characteristics, effectiveness, and evaluated the quality of included studies. Considering the common integrating elements of aHT care services, we conceptualized a general framework to guide the design of service models for aHT.

Results

We identified 18,695 records, screened 4,954 and included twelve studies. Four types of aHT care models were identified: services provided at community pharmacies, out-of-facility, household services, and aHT treatment groups. Two studies reported on acceptability, eleven on BP control, ten on engagement in care and one on end-organ damage. Most studies reported significant reductions in BP values and improved access to comprehensive CVDs services through task-sharing. Major reported shortcomings included high attrition rates and their nature as parallel, non-integrated models of care. The overall quality of the studies was low, with high risk of bias, and most of the studies did not include comparisons with routine facility-based care.

Conclusions

The overall quality of available evidence on community-based aHT care is low. Published models of care are very heterogeneous and available evidence is insufficient to recommend or refute further scale up in sub-Sahara Africa. We propose that future projects and studies implementing and assessing community-based models for aHT care are designed and described according to six building blocks: providers, target groups, components, location, time of service delivery, and their use of information systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13467-4.

Remote Monitoring Systems for Patients With Chronic Diseases in Primary Health Care: Systematic Review

Background

The digital age, with digital sensors, the Internet of Things (IoT), and big data tools, has opened new opportunities for improving the delivery of health care services, with remote monitoring systems playing a crucial role and improving access to patients. The versatility of these systems has been demonstrated during the current COVID-19 pandemic. Health remote monitoring systems (HRMS) present various advantages such as the reduction in patient load at hospitals and health centers. Patients that would most benefit from HRMS are those with chronic diseases, older adults, and patients that experience less severe symptoms recovering from SARS-CoV-2 viral infection.

Objective

This paper aimed to perform a systematic review of the literature of HRMS in primary health care (PHC) settings, identifying the current status of the digitalization of health processes, remote data acquisition, and interactions between health care personnel and patients.

Methods

A systematic literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to identify articles that explored interventions with HRMS in patients with chronic diseases in the PHC setting.

Results

The literature review yielded 123 publications, 18 of which met the predefined inclusion criteria. The selected articles highlighted that sensors and wearables are already being used in multiple scenarios related to chronic disease management at the PHC level. The studies focused mostly on patients with diabetes (9/26, 35%) and cardiovascular diseases (7/26, 27%). During the evaluation of the implementation of these interventions, the major difficulty that stood out was the integration of information into already existing systems in the PHC infrastructure and in changing working processes of PHC professionals (83%).

Conclusions

The PHC context integrates multidisciplinary teams and patients with often complex, chronic pathologies. Despite the theoretical framework, objective identification of problems, and involvement of stakeholders in the design and implementation processes, these interventions mostly fail to scale up. Despite the inherent limitations of conducting a systematic literature review, the small number of studies in the PHC context is a relevant limitation. This study aimed to demonstrate the importance of matching technological development to the working PHC processes in interventions regarding the use of sensors and wearables for remote monitoring as a source of information for chronic disease management, so that information with clinical value is not lost along the way.

Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the problem areas in diabetes (PAID) questionnaire

Background

High prevalence rates in diabetes-related distress have been observed in several studies; however, in the region of Sub-Saharan Africa evidence is lacking as is, for example, the case for Rwanda, where diabetes prevalence is expected to increase over the next decade. The aim of this study is to report on the translation and cultural adaption of the problem areas in diabetes (PAID) questionnaire into Kinyarwanda and its psychometric properties.

Methods

The questionnaire was translated following a standard procedure. Interviews were conducted with 29 participants before producing a final version. For the psychometric evaluation, a sample of 266 patients with diabetes mellitus, aged 21–64 years old were examined. Participants either came from a separate cluster-randomised controlled trial or were recruited ad-hoc for this study. The evaluation included testing internal consistency, known groups validity, and construct validity. A series of confirmatory factor analysis were conducted investigating seven previously established factorial structures. An exploratory factor analysis (EFA) was also carried out to examine the structure further.

Results

The full scale showed good internal reliability (Cronbach’s α = 0.88). A four-factor solution previously tested in Spain with subdimensions of emotional, treatment, food-related and social-support problems demonstrated adequate approximate fit (RMSEA = 0.056; CFI = 0.951; TLI = 0.943). The EFA revealed a four-factor structure; however, two of these factors were not as homogeneous and easily interpretable as those of the Spanish model.

Conclusions

The psychometric properties of the Kinyarwanda version of PAID are acceptable. The questionnaire can be helpful in research and clinical practice in Rwanda, however certain cross-cultural differences should be taken into account.

Analysis of Effectiveness and Psychological Techniques Implemented in mHealth Solutions for Middle-Aged and Elderly Adults with Type 2 Diabetes: A Narrative Review of the Literature

BACKGROUND

in diabetes, multiple mHealth solutions were produced and implemented for self-management behaviors. However, little research on the effectiveness of psychological techniques implemented within these mHealth solutions was carried out, and even less with the elderly population where technological barriers might exist. Reliable evidence generated through a comprehensive evaluation of mHealth interventions may accelerate its growth for successful long-term implementation and to help to experience mHealth benefits in an enhanced way in all ages.

OBJECTIVE

this study aimed to review mHealth solutions for diabetes self-management in older adults (adherence to treatments and glycemic control) by analyzing the effectiveness of specific psychological techniques implemented.

METHODS

a narrative review was conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. PubMed (Medline) and American Psychological Association (APA) PsycInfo databases were searched for published papers that addressed eHealth solutions' effectiveness for diabetes self-management. Studies in English, Spanish, and/or German of any design were screened, with no time constraints regarding the year of publication. A qualitative analysis of the selected papers was conducted in several steps.

RESULTS

this review found 38 studies setting up and analyzing mHealth solutions for older adults. Most research showed improvements in HbA1c, self-management behaviors, and medication adherence in T2DM patients post intervention. However, different mid-to-long term effects were found across studies, specifically concerning the maintenance and adherence to healthy behaviors. The most employed psychological framework was CBT, including techniques such as self-monitoring of outcome behaviors (mostly targeting glycemia measurements and healthy habits as physical activity and/or diet), tailored motivational feedback from medical staff, and psychoeducation or health coaches. The most successful mHealth intervention combined the feature of tailored feedback messages, interactive communication with healthcare professionals, and multifaceted functions.

CONCLUSIONS

there is a lack of elaborate and detailed information in the literature regarding the factors considered in the design and development of mHealth solutions used as interventions for T2DM self-management in the elderly. Documentation and inclusion of such vital information will foster a transparent and shared decision-making process that will ultimately lead to the development of useful and user-friendly self-management apps that can enhance the quality of life for diabetes patients. Further research adapting mHealth solutions to older adults' sensory deficits is necessary.

Quality of life among adult patients living with diabetes in Rwanda: a cross-sectional study in outpatient clinics

OBJECTIVES

To report on the disease-related quality of life of patients living with diabetes mellitus in Rwanda and identify its predictors.

DESIGN

Cross-sectional study, part of the baseline assessment of a cluster-randomised controlled trial.

SETTING

Outpatient clinics for non-communicable diseases of nine hospitals across Rwanda.

PARTICIPANTS

Between January and August 2019, 206 patients were recruited as part of the clinical trial. Eligible participants were those aged 21-80 years and with a diagnosis of diabetes mellitus for at least 6 months. Illiterate patients, those with severe hearing or visual impairments, those with severe mental health conditions, terminally ill, and those pregnant or in the postpartum period were excluded PRIMARY AND SECONDARY OUTCOME MEASURES: Disease-specific quality of life was measured with the Kinyarwanda version of the Diabetes-39 (D-39) questionnaire. A glycated haemoglobin (HbA1c) test was performed on all patients. Sociodemographic and clinical data were collected, including medical history, disease-related complications and comorbidities.

RESULTS

The worst affected dimensions of the D-39 were 'anxiety and worry' (mean=51.63, SD=25.51), 'sexual functioning' (mean=44.58, SD=37.02), and 'energy and mobility' (mean=42.71, SD=20.69). Duration of the disease and HbA1c values were not correlated with any of the D-39 dimensions. A moderating effect was identified between use of insulin and achieving a target HbA1c of 7% in the 'diabetes control' scale. The most frequent comorbidity was hypertension (49.0% of participants), which had a greater negative effect on the 'diabetes control' and 'social burden' scales in women. Higher education was a predictor of less impact on the 'social burden' and 'energy and mobility' scales.

CONCLUSIONS

Several variables were identified as predictors for the five dimensions of quality of life that were studied, providing opportunities for tailored preventive programmes. Further prospective studies are needed to determine causal relationships.

TRIAL REGISTRATION NUMBER

NCT03376607.

A qualitative study of users' experiences after 3 months: the first Rwandan diabetes self-management Smartphone application "Kir'App"

BACKGROUND

Owing to the increasing popularity of smartphones in Rwanda, almost 75% of the entire population currently has access to the internet. Although it has been shown that smartphone applications can support diabetes self-management, there was no diabetes self-management application available in Rwanda until April 2019. Based on the findings of a prior study assessing the needs and expectations of potential users, 'Kir'App' was developed to fill that void. The aim of this study was to evaluate users' experiences after 3 months of use of the first Kir'App prototype.

METHODS

The participants of the previous study were recruited to take part in the current study. Semi-structured, in-depth, face-to-face interviews were conducted. Findings were analysed thematically using Mayring's method of qualitative content analysis. Both deductive and inductive approaches were used to analyse transcripts according to the original categories and subcategories of the previous study.

RESULTS

A total of 14 people with either type 1 or type 2 diabetes participated in the study. Age of participants ranged from 19 to 70 years, with a mean age of 34.4 years. Seven of the eight original themes and one additional theme were subjoined: diabetes education and desired information provision; increased diabetes knowledge and awareness; monitoring and reminder functions; nutrition; physical activity; coping with burden of disease; app features; use behaviour and usability. Overall, participants stated that the app increased their diabetes knowledge and assisted them with their diabetes self-management.

CONCLUSIONS

We found that the first prototype of Kir'App meets the overall needs and expectations of participating Rwandan diabetics. Having followed a strict user-centred design process, their qualitative insights will help to further improve the app.