Cost of diabetes mellitus in Africa: a systematic review of existing literature

Patient-Perceived Challenges to Type 2 Diabetes Self-Management in Sub-Saharan Africa: A Qualitative Exploratory Study

PURPOSE

The purpose of the study was to explore patient-reported challenges influencing type 2 diabetes self-management in a diabetes center in Ethiopia.

METHODS

Exploratory qualitative interviews were conducted with purposively sampled patients with type 2 diabetes. Thematic data analysis was performed to identify challenges to diabetes self-management, and the themes were interpreted using Leininger's sunrise model.

RESULTS

Thirty patients with type 2 diabetes participated. Four themes were identified regarding challenges to type 2 diabetes self-management: (1) cultural values and beliefs, (2) kinship and social factors, (3) educational factors, and (4) economic conditions. Sociocultural factors and low income intersected to significantly impede effective diabetes self-management. Sociocultural contexts strongly influenced patient beliefs and interpretations related to diabetes self-care. Misconceptions and limited awareness of diabetes, reliance on herbal remedies, ritual fasting, and prioritization of family needs over individual needs also involved challenges for diabetes self-care. Poverty influenced access to diabetes care. Many patients faced difficulties in adhering to healthy diets for diabetes due to limited income and food costs, and some patients reduced medication doses, including insulin, to manage costs effectively.

CONCLUSION

The study highlighted the pressing need for comprehensive and culturally appropriate patient education and empowerment interventions involving various stakeholders to enhance knowledge, understanding, and self-efficacy in diabetes self-management. Urgent attention is needed to ensure patients have access to affordable and sustainable diabetes medications and healthy diets for diabetes through financial incentives. These findings can be considered in designing tailored strategies for improving self-management practice in diabetes care in Ethiopia.

"Did You Wash Your Hands?" The Socioeconomic Inequalities Preventing Youth From Adopting Protective Behaviors During COVID-19 in South Africa

Background. Behavior change has been a critical factor in slowing the spread of COVID-19. In South Africa where infection rates are high, research is needed on the protective behaviors adopted by youth who have low infection rates but are carriers of the virus. Aims. The purpose of this study is to (1) identify the protective behaviors young people adopted during the pandemic and (2) to estimate the probability of positive behavior change by demographic and socioeconomic characteristics. Methods. The study uses data from the South African National Income Dynamics-Coronavirus Rapid Mobile Survey 2020. The sample includes 985 (n) youth aged 15-24 years. The outcome of interest is behavior change due to the Coronavirus. Cross-tabulations and an adjusted binary logistic regression model showing odds ratios, are fit to the data. Results. Not all youth adopted protective behaviors. The most prevalent behaviors adopted include washing hands (67.75%) and staying at home (54.02%). Youth in households with six or more members are more likely to change their behaviors (ORs = 1.67 and 1.64, both p-values < .05). However, youth who do not have access to water to wash hands (OR = 0.71), reside in households with food insecurity (OR = 0.94), and those living in nonformal housing (OR = 0.69) are less likely to adopt behavior change. Conclusion. Due to the socioeconomic inequalities associated with behavior change, there is need for more tailored approaches to address youth living in impoverished households in the country.

The relationship between adipose tissue RAAS activity and the risk factors of prediabetes in different ethnicities: A protocol for a systematic review and meta-analysis

BACKGROUND

The incidence and prevalence of prediabetes has become a global concern. The risk factors of prediabetes, such as insulin resistance, adiposity, lipotoxicity and obesity, in conjunction with the alteration of the renin-angiotensin-aldosterone system (RAAS), have been positively correlated with the high morbidity and mortality rate. Thus, this systematic review seeks to establish the relationship between the risk factors of prediabetes, namely insulin resistance adiposity, lipotoxicity, obesity and the RAAS. Therefore, a synthesis of these risk factors, their clinical indicators and the RAAS components will be compiled in order to establish the association between the RAAS alteration and obesity in prediabetic patients.

METHODS

This protocol for a systematic review was developed in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) standards. This will be accomplished by searching clinical Medical Subject Headings categories in MEDLINE with full texts, EMBASE, Web of Science, PubMed, Cochrane Library, Academic Search Complete, ICTRP and ClinicalTrial.gov. Reviewers will examine all of the findings and select the studies that meet the qualifying criteria. To check for bias, the Downs and Black Checklist will be used, followed by a Review Manager v5. A Forrest plot will be used for the meta-analysis and sensitivity analysis. Furthermore, the strength of the evidence will be assessed utilizing the Grading of Recommendations Assessment, Development, and Evaluation procedure (GRADE). The protocol has been registered with PROSPERO CRD42022320252. This systematic review and meta-analysis will include published randomized clinical trials, observational studies and case-control studies from the years 2000 to 2022.

The role of social support and self-management on glycemic control of type 2 diabetes mellitus with complications in Ghana: A cross-sectional study

Background and Aims

Diabetes mellitus (DM) can result in detrimental complications which are connected with long-term impairments and disabilities. Chronic complications are well-known consequences of type 2 diabetes mellitus (T2DM) progression, which reduce patient quality of life, place a burden on the healthcare system, and increase mortality. Measures to promote health outcomes for people with DM are scanty; the study therefore aimed at determining the effects of self-management and social support on glycemic control of T2DM with complications in Ghana.

Methods

A cross-sectional design using convenience sampling was conducted on 400 T2DM patients using Hensarling's Diabetes Family Support Scale and Summary of Diabetes Self‑Care Activities scale. Data analysis was conducted using descriptive, Pearson Moment Product Correlation and Binary Logistic Regression on self-management, social support, and glycemic control in T2DM patients.

Results

Social support among participants was high and there was a positive correlation or relationship between social support and T2DM self-management. There was a correlation between social support and self-management (r = 0.149, p < 0.05) and diet control (r = 0.221, p < 0.05). The results also showed a significant correlation between medication adherence and glycemic management (r = 0.116, p < 0.05) while female T2DM participants, individuals with at least primary education were less likely to have low self-management relative to T2DM.

Conclusion

Though the level of T2DM self-management was high it does not translate to good glycemic control. Focused health education programs should be incorporated into patients' care plans which will be particularly relevant for patients with T2DM and will contribute to positive physiological and psychological outcomes. Furthermore, a more robust monitoring and follow-up scheme should be scaled up or instituted for patients with T2DM.

Levels of health expenditure and payment coping mechanisms for persons living with diabetes and hypertension both singly and in comorbidity in Enugu, Southeast, Nigeria

Context:

The burden of diabetes mellitus (DM) and hypertension (HTN) both singly and in comorbidity has gained increased attention, especially in developing countries and this has great socioeconomic consequences. In Nigeria, the prevalence of both diseases is known to be increasing, while government health expenditure (HE) is not.

Aim:

The study examined the levels of expenditure and payment coping mechanisms for persons living with diabetes and HTN both singly and in comorbidity in Enugu, Nigeria.

Methods:

The study was a quantitative, cross-sectional, descriptive study done among patients attending the medical outpatient clinics. HTN and DM are the two noncommunicable diseases that were considered in this study. Data were separated into those with diabetes, HTN, or both. A descriptive analysis of sociodemographic characteristics was done. Analysis was done by estimating the direct and indirect costs. The catastrophic HE was also conducted. The mean, Chi-square, and P value were calculated in each group to assess differences in association.

Results:

Respondents were 817 with a mean age of 62.3 years. Respondents’ mean monthly income after food expenditure was N39465.43 ($129.0). One month earlier, 36.5%, 32.4%, and 31.1% of respondents spent more than 10% of their income on diabetes, HTN and in comorbidity, respectively, while in the current visit, 43.2%, 22.8%, and 32.0% of respondents spend more than 10% of their income on diabetes, HTN, and in comorbidity, respectively.

Conclusion:

The study shows that out-of-pocket is a major method of payment for diabetes and HTN. Therefore, the two diseases need to be included in the national safety net.

Cross-sectional study of the burden and determinants of non-medical and opportunity costs of accessing chronic disease care in rural Tanzania

OBJECTIVES

Countries in sub-Saharan Africa are seeking to improve access to healthcare through health insurance. However, patients still bear non-medical costs and opportunity costs in terms of lost work days. The burden of these costs is particularly high for people with chronic diseases (CDs) who require regular healthcare. This study quantified the non-medical and opportunity costs faced by patients with CD in Tanzania and identified factors that drive these costs.

METHODS

From November 2020 to January 2021, we conducted a cross-sectional patient survey at 35 healthcare facilities in rural Tanzania. Using the human capital approach to value the non-medical cost of seeking healthcare, we employed multilevel linear regression to analyse the impact of CDs and health insurance on non-medical costs and negative binomial regression to investigate the factors associated with opportunity costs of illness among patients with CDs.

RESULTS

Among 1748 patients surveyed, 534 had at least one CD, 20% of which had comorbidities. Patients with CDs incurred significantly higher non-medical costs than other patients, with an average of US$2.79 (SD: 3.36) compared with US$2.03 (SD: 2.82). In addition, they incur a monthly illness-related opportunity cost of US$10.19 (US$0-59.34). Factors associated with higher non-medical costs included multimorbidities, hypertension, health insurance and seeking care at hospitals rather than other facilities. Patients seeking hypertension care at hospitals experienced 35% higher costs compared with those visiting other facilities. Additionally, patients with comorbidities, older age, less education and those requiring medication more frequently lost workdays.

CONCLUSION

Outpatient care in Tanzania imposes considerable non-medical costs, particularly for people with CDs, besides illness-related opportunity costs. Despite having health insurance, patients with CDs who seek outpatient care in hospitals face higher financial burdens than other patients. Policies to improve the availability and quality of CD care in dispensaries and health centres could reduce these costs.

Community-based models of care for management of type 2 diabetes mellitus among non-pregnant adults in sub-Saharan Africa: A scoping review

INTRODUCTION

The prevalence of type 2 diabetes mellitus (T2DM) and associated morbidity and mortality are increasing in sub-Saharan Africa (SSA). To facilitate access to quality care and improve treatment outcomes, there is a need for innovative community care models and optimized use of non-physician healthcare workers bringing diagnosis and care closer to patients' homes.

AIM

We aimed to describe with a scoping review different models of community-based care for non-pregnant adults with T2DM in SSA, and to synthesize the outcomes in terms of engagement in care, blood sugar control, acceptability, and end-organ damage. We further aimed to critically appraise the different models of care and compare community-based to facility-based care if data were available.

METHODS

We searched Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus, supplemented with backward and forward citation searches. We included cohort studies, randomized trials and case-control studies that reported on non-pregnant individuals diagnosed with T2DM in SSA, who received a substantial part of care in the community. Only studies which reported at least one of our outcomes of interest were included. A narrative analysis was done, and comparisons made between community-based and facility-based models, where within-study comparison was reported.

RESULTS

We retrieved 5,335 unique studies, four of which met our inclusion criteria. Most studies were excluded because interventions were facility-based; community care interventions described in the studies were only add-on features of a primarily facility-based care; and studies did not report outcomes of interest. The included studies reported on a total of 383 individuals with T2DM. Three different community care models were identified. 1) A community-initiated model where diagnosis, treatment and monitoring occurred primarily in the community. This model reported a higher linkage and engagement in care at 9 months compared to the corresponding facility model, but only slight reductions of average blood glucose levels at six months compared to baseline. 2) A facility-originated community model where after treatment initiation, a substantial part of follow-up was offered at community level. Two studies reported such a model of care, both had as core component home-delivery of medication. Acceptability of this approach was high. But neither study found improved T2DM control when compared to facility care 3) An eHealth model with high acceptability scores for both patients and care providers, and an absolute 1.76% reduction in average HbA1c levels at two months compared to baseline. There were no reported outcomes on end-organ damage. All four studies were rated as being at high risk for bias.

CONCLUSION

Evidence on models of care for persons with T2DM in SSA where a substantial part of care is shifted to the community is scant. Whereas available literature indicates high acceptability of community-based care, we found no conclusive data on their effectiveness in controlling blood sugar and preventing complications. Evidence from larger scale studies, ideally randomized trials with clinically relevant endpoints is needed before roll-out of community-based T2DM care can be recommended in SSA.

Modulatory Properties of Vitamin D in Type 2 Diabetic Patients: A Focus on Inflammation and Dyslipidemia

BACKGROUND

Evidence from preclinical studies has found a correlation between the development of type 2 diabetes (T2D) and vitamin D deficiency. However, evidence from randomized controlled trials (RCTs) revealed inconclusive results on vitamin D supplementation. We explored the effect of vitamin D on inflammation and dyslipidemia in T2D.

METHODS

We comprehensively searched for RCTs evaluating the effect of vitamin D in T2D on PubMed. Data were analyzed using Review Manager 5.3 and reports, such as standardized mean difference (SMD) and 95% confidence intervals (CI) at a 5% significant level using a random effect model.

RESULTS

This study revealed a significant reduction in tumor necrosis factor-alpha (TNF-α) SMD = (-0.51, 95%CI (-0.93, -0.09); p = 0.02), high sensitivity C-reactive protein (hs-CRP) SMD = (-1.06, 95%CI (-1.67, -0.45); p < 0.05) in vitamin D compared to placebo. Additionally, interleukin-6 (IL-6) exhibited a marginal effect SMD = (-0.52, 95%CI (-1.05, 0.01), p = 0.05). Furthermore, a significant reduction in the level of triglycerides SMD = (-0.65, 95%CI (-1.11, -0.18), p < 0.05) was observed, concomitant to a significantly increased high-density lipoprotein (HDL) level SMD = (0.53, 95%CI (0.08, 0.98), p = 0.02). However, no statistically significant changes were observed in total cholesterols SMD = (-0.16, 95%CI (-0.57, 0.24), p = 0.43) and low-density lipoprotein (LDL) SMD = (-0.06, 95%CI (-0.37, 0.24), p = 0.67).

CONCLUSIONS

These findings suggest that vitamin D supplementation may be beneficial in ameliorating inflammation and dyslipidemia in T2D patients.

Adherence to diabetic foot care recommendations and associated factors among people with diabetes in Eastern Ethiopia: a multicentre cross-sectional study

OBJECTIVE

This study aimed to determine the level of adherence to foot care recommendations and associated factors among people with diabetes on follow-up in public hospitals in Eastern Ethiopia.

SETTING

An institutional-based cross-sectional study was conducted in public hospitals found in Eastern Ethiopia from 25 February to 25 March 2022.

PARTICIPANTS

A total of 419 patients with chronic diabetes who visited diabetic clinics in public hospitals in Eastern Ethiopia for follow-up were included.

MAIN OUTCOME MEASURE

The level of adherence to diabetic foot care recommendations and associated factors.

RESULTS

The findings indicated that 44.3% (95% CI: 39.3, 49.0) of people with diabetes had inadequate adherence to diabetic foot care recommendations. Age between 28-37 (adjusted OR (AOR)=1.10; 95% CI: 1.27, 5.63) and 38-47 years (AOR=2.19; 95% CI: 2.74, 8.89), rural residence (AOR=1.71; 95% CI: 1.15, 2.57), absence of comorbidity (AOR=2.22; 95% CI:1.34, 5.14), obesity (AOR=1.43; 95% CI: 1.10, 5.05) and inadequate foot care knowledge (AOR=2.10; 95% CI: 1.52, 4.35) were factors significantly associated with inadequate adherence to diabetic foot care recommendations.

CONCLUSION

More than two-fifths of people with diabetes had inadequate adherence to diabetic foot care recommendations. Younger age, rural residence, absence of comorbidity, obesity and inadequate foot care knowledge were significantly associated with inadequate adherence to diabetic foot care recommendations. It is very essential to educate people with diabetes about the importance of foot care recommendations in preventing and delaying the risks of foot-related problems and complications.

Are outpatient costs for hypertension and diabetes care affordable? Evidence from Western Kenya

BACKGROUND

Diabetes and hypertension pose a significant socio-economic burden in developing countries such as Kenya, where financial risk-protection mechanisms remain inadequate. This proves to be a great barrier towards achieving universal health care in such settings unless mechanisms are put in place to ensure greater access and affordability to non-communicable disease (NCD) management services.

AIM

This article aims to examine outpatient management services costs for patients with diabetes and hypertension attending public primary healthcare facilities.

SETTING

The study was conducted in Busia and Trans-Nzoia counties in Western Kenya in facilities supported by the PIC4C project, between August 2020 and December 2020.

METHODS

This cross-sectional survey included 719 adult participants. Structured interviewer-administered questionnaires were used to collect information on healthcare-seeking behaviour and associated costs. The annual direct and indirect costs borne by patients were computed by disease type and level of healthcare facility visited.

RESULTS

Patients with both diabetes and hypertension incurred higher annual costs (KES 13 149) compared to those with either diabetes (KES 8408) or hypertension (KES 7458). Patients attending dispensaries and other public healthcare facilities incurred less direct costs compared to those who visited private clinics. Furthermore, a higher proportionate catastrophic healthcare expenditure of 41.83% was noted among uninsured patients.

CONCLUSION

Despite this study being conducted in facilities that had an ongoing NCDs care project that increased access to subsidised medication, we still reported a substantially high cost of managing diabetes and hypertension among patients attending primary healthcare facilities in Western Kenya, with a greater burden among those with comorbidities.Contribution: Evidenced by the results that there is enormous financial burden borne by patients with chronic diseases such as hypertension and diabetes; we recommend that universal healthcare coverage that offers comprehensive care for NCDs be urgently rolled out alongside strengthening of lower-level public healthcare systems.

Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania

COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.

Audit of essential knowledge of diabetes in patients with diabetes in Zimbabwe

Introduction

in Zimbabwe, the organized diabetes education in the governmental health care system is limited, but the Diabetes Association has some educational activities in which persons with diabetes can participate. In this study, the purpose was to measure essential knowledge of diabetes and its management in persons with diabetes living in Zimbabwe.

Methods

a cross-sectional descriptive study design was used to audit essential knowledge of diabetes and its management in persons with type 2 diabetes through a survey of 64 persons attending meetings at the Zimbabwe Diabetes Association. Both descriptive and analytic statistical methods were used.

Results

in general respondents have acceptable knowledge of diabetes, whereas their knowledge of glycaemic control is low (45%), likewise their knowledge of how to manage medical treatment when ill. Knowledge concerning lifestyle-related issues was generally low. Respondents had limited knowledge about changes in blood glucose during physical activity (18%) and their knowledge about appropriate food for people with diabetes was low (67%). Most respondents were aware of the importance of regular examinations to avoid long-term complications related to diabetes (>87%) but their knowledge of how to prevent foot complications and perform daily preventive foot care was limited (73 %).

Conclusion

there is limited knowledge of diabetes in Zimbabwean persons with type 2 diabetes even if they have participated in educational activities at the patient associations. This further supports the need for development of education for patients in health care which requires increased competence in the field among health care staff.

Exploring cost drivers to improve disease management: the case of type 2 diabetes at a tertiary hospital in Burundi, Africa

Background

In Burundi, the International Diabetes Federation estimated the prevalence of diabetes mellitus (DM) as high as 2.4% in adults aged between 20 and 79 years old. Thus, the healthcare expenditure for the treatment of diabetic patients is considerably high.

Objective

This study explores the economic burden of type 2 DM and its cost drivers at a tertiary hospital in 2018. It included adult type 2 DM patients who received treatment from a tertiary hospital (Hospital Prince Regent Charles) in 2018. In this study, 81 patients were included.

Methods

Data on illness treatment and complications were collected through patient interviews and by reviewing patients' medical and financial records. A stepwise multiple linear regression model was used to explore factors affecting the cost of type 2 diabetes mellitus.

Results

The average total cost per patient per year was estimated at $2621.06. The fitted cost model had an adjusted R² of 0.427, which explained up to 43% of the variation in the total cost. The results suggest primary cost drivers such as treatment regimen, duration of the disease, payment method, and number of complications.

Conclusion

The findings confirm the profound economic burden of type 2 DM and the need to improve patient care and prevent disease progression. The establishment of a special clinic for patients with diabetes is recommended, as is financial support for underprivileged patients. A specific focus on cost drivers could help establish appropriate disease management programs to control the costs for type 2 diabetes patients.

Economic Burden of Diabetes and Hypertension: A Study of Direct and Indirect Cost of Treatment in Southeast Nigeria

The prevalence of diabetes mellitus and hypertension is increasing yearly in many low- and middle-income countries such as Nigeria. The increasing burden of these noncommunicable diseases has led to an increase in the overall cost of health care. This study aimed at determining the direct and indirect health care costs of diabetes mellitus and hypertension occurring both singly and in co-morbidity. The study was undertaken in the Enugu State University Teaching Hospital (a tertiary hospital) in Enugu State, Southeast Nigeria. Data were collected using a pre-tested questionnaire. Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had hypertension, and 28% had both diabetes mellitus and hypertension in co-morbidity. Direct costs of treating diabetes mellitus and hypertension in the month before the survey were $28.40 and $19.35, respectively, while the indirect costs of treatment in the month before the study were $7.36 and $5.51, respectively. Direct and indirect costs for diabetes mellitus and hypertension in co-morbidity were $37.00 and $4.62, respectively. A concentration index showed that diabetes mellitus and hypertension were more evident among the poor than the rich. The economic cost when compared with patients’ income revealed that >25% of their income is spent monthly on health care.

The Effect of Vitamin D on Inflammation and Dyslipidemia in Type 2 Diabetes Mellitus: Protocol for a Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Type 2 diabetes mellitus is a chronic disease that contributes to an increasing global burden on the health system. It has a high chance of leading to macrovascular complications and cardiovascular disease. As an inflammatory condition, it would be essential to target inflammatory pathways when developing therapeutic drugs for type 2 diabetes mellitus.

OBJECTIVE

We aimed to evaluate the effect of vitamin D on markers of inflammation and lipid profile among adult patients with diabetes.

METHODS

A systematic review will seek studies published on Embase, Google Scholar, PubMed, Web of Science, and Science Direct. This planned systematic review and meta-analysis will be limited to randomized controlled trials; moreover, the search will include published studies regarding the effects of vitamin D on pro-inflammatory cytokines and lipid profiles. The review will include studies published from inception until December 30, 2022. The study identification and selection will be based on the eligibility criteria by 2 independent reviewers. Additionally, a meta-analysis will only be performed if more than 2 studies are available and explore the same outcomes, and this will be analyzed using RevMan (version 5.4.1). The quality and risk of bias will be assessed following the Cochrane risk of bias tool and Jadad checklist.

RESULTS

The process for searching literature review has already started, and this is conducted independently by 2 reviewers using a predefined eligibility and "participants, intervention, comparator, and outcome" criteria. This systematic review and meta-analysis will not require any direct involvement of patients and the public; thus, no ethical approval was required.

CONCLUSIONS

The findings obtained from the proposed study will be presented in scientific seminars, journal clubs, and conferences and published in peer-reviewed journals.

TRIAL REGISTRATION

International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202260022; https://inplasy.com/?s=INPLASY202260022.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/42193.

A Scoping Review of Trials Designed to Achieve Remission of Type 2 Diabetes with Lifestyle Intervention Alone: Implications for Sub-Saharan Africa

According to the International Diabetes Federation, sub-Saharan Africa is experiencing the highest anticipate increase in the prevalence of type 2 diabetes (T2D) in the world and has the highest percent of people living with T2D who are undiagnosed. Therefore, diagnosis and treatment need prioritization. However, pharmacological hypoglycemics are often unavailable and bariatric surgery is not an option. Therefore, the ability to induce T2D remission through lifestyle intervention alone (LSI-alone) needs assessment. This scoping review evaluated trials designed to induce T2D remission by LSI-alone. PubMed, Embase, Cochrane, and CINAHL databases were searched for trials designed to induce T2D remission through LSI-alone. Of the 928 identified, 63 duplicates were removed. With abstract review, 727 irrelevant articles were excluded. After full-text review, 112 inappropriate articles were removed. The remaining 26 articles described 16 trials. These trials were published between 1984 and 2021 and were conducted in 10 countries, none of which were in Africa. Remission rates varied across trials. Predictors of remission were 10% weight loss and higher BMI, lower A1C and shorter T2D duration at enrollment. However, LSI-alone regimens for newly diagnosed and established T2D were very different. In newly diagnosed T2D, LSI-alone were relatively low-cost and focused on exercise and dietary counseling with or without calorie restriction (~1500 kcal/d). Presumably due to differences in cost, LSI-alone trials in newly diagnosed T2D had higher enrollments and longer duration. For established T2D trials, the focus was on arduous phased dietary interventions; phase 1: low-calorie meal replacement (<1000 kcal/day); phase 2: food re-introduction; phase 3: weight maintenance. In short, LSI-alone can induce remission in both newly diagnosed and established T2D. To demonstrate efficacy in Africa, initial trials could focus on newly diagnosed T2D. Insight gained could provide proof of concept and a foundation in Africa on which successful studies of LSI-alone in established T2D could be built.

Persons with Diabetes' Perceptions of Family Burden and Associated Factors

BACKGROUND

Families of a person with diabetes play a vital part in diabetes management since their support helps with regimen engagement in self-management behaviors. However, focal information on the family burden of diabetes is lacking. This study is aimed at, therefore, assessing the persons with diabetes' perceptions of family burden and associated factors at a university hospital.

METHODS AND MATERIALS

A facility-based cross-sectional study design was conducted from July 26 to September 26, 2021on 403 persons' with diabetes attending Jimma Medical Center diabetic clinic, the study sample was selected using a simple random sampling method. The data was collected using the Zarit burden questionnaire through face-to-face interviews. Descriptive statistics (mean, standard deviation, frequency, and percentages) were ordered logistic regression, and statistical significance was declared at P value ≤0.05. Results and Discussion. About 36.8% of the patient was in mild to moderate family burden of diabetes. Farmer (AOR 5.419; CI: 1.18, 24.872), living with partners and family (AOR: 0.110, CI: 0.018, 0.659), comorbidity (AOR 5.419; CI: 1.18, 24.872), oral hypoglycemic agent (AOR: 0.380, CI: 0.191, 0.758), and being never hospitalized before because of diabetes (AOR: 0.044, CI: 0.003, 0.571) was statistically associated with a family burden.

CONCLUSION

About one-fourth of diabetic patient-perceived mild to the moderate family burden of diabetes, persons with diabetes who work as farmers and have comorbidities have a higher opinion of family burden, whereas those who live with partners or family members, use oral hypoglycemic medications, and have never been hospitalized for diabetes have a lower view of family burden due to diabetes. The results of this study suggest that strategies for health promotion, intervention, and prevention of diabetes at the family level should consider the interaction between family member burden and the patient's sociodemographic and disease-related factors. A further large-scale study is required to validate these findings.

Leaving no one behind in health: Financial hardship to access health care in Ethiopia

BACKGROUND

Financial hardship (of health care) is a global and a national priority area. All people should be protected from financial hardship to ensure inclusive better health outcome. However, financial hardship of healthcare has not been well studied in Ethiopia in general and in Debre Tabor town in particular. Therefore, this study aimed to assess the incidence of financial hardship of healthcare and associated factors among households in Debre Tabor town.

METHODS

Community based cross sectional study was conducted, from May 24/2022 to June 17/2022, on 423 (selected through simple random sampling) households. Financial hardship was measured through catastrophic (using 10% threshold level) and impoverishing (using $1.90 poverty line) health expenditures. Patient perspective bottom up and prevalence based costing approach were used. Indirect cost was estimated through human capital approach. Bi-variable and multiple logistic regressions were used.

RESULTS

The response rate was 95%. The mean household annual healthcare expenditure was Ethiopian birr 12050.64 ($227.37). About 37.1% (95%CI: 32, 42%) of the households spend catastrophic health expenditure with a 10% threshold level and 10.4% of households were impoverished with $1.90 per day poverty line. Being old, with age above 60, (AOR: 4.21, CI: 1.23, 14.45), being non-insured (AOR: 2.19, CI: 1.04, 4.62), chronically ill (AOR: 7.20, CI: 3.64, 14.26), seeking traditional healthcare (AOR: 2.63, CI: 1.37. 5.05) and being socially unsupported (AOR: 2.77, CI: 1.25, 6.17) were statistically significant factors for catastrophic health expenditure.

CONCLUSION

The study showed that significant number of households was not yet protected from financial hardship of healthcare. The financial hardship of health care is stronger among the less privileged populations: non-insured, the chronically diseased, the elder and socially unsupported. Therefore, financial risk protection strategies should be strengthened by the concerned bodies.

Informal Support Networks of Tanzanians With Chronic Diseases: Predictors of Support Provision and Treatment Adherence

Objectives: To examine the role of NCD patients' social ties as informal caregivers and whether receiving their support is associated with engagement in care. Methods: NCD outpatients (N2 = 100) in rural Tanzania completed a cross-sectional questionnaire to characterize the support role of their social ties (N1 = 304). Bivariate analyses explored predictors of social support and whether social support is associated with engagement in care. Results: This study found that 87% of participants had health insurance, yet 25% received financial support for financing healthcare. Patient gender, age and marital status were found to be important predictors of social support, with NCD-related disability and disease severity being predictive to a lesser degree. Monthly receipt of both material and non-material support were associated with increased odds of adherence to prescribed medications. Conclusion: These findings indicate that patients' social ties play an important role in filling the gaps in formal social health protection and incur substantial costs by doing so. The instrumental role of even non-material social support in promoting engagement in care deserves greater attention when developing policies for improving this population's engagement in care.

Economic Burden of Diabetic Mellitus Among Patients on Follow-up Care in Hospitals of Southwest Shewa Zone, Central Ethiopia

BACKGROUND

Diabetes has emerged as one of the most serious health issues of the twenty-first century. Diabetes and its complications expose individuals and their families to catastrophic healthcare costs, which have a severe impact on the country's economy. Though the prevalence of diabetes is rising quicker in Ethiopia, little is known about its economic impact. Hence, this study aimed to determine the total cost of diabetic mellitus and associated factors among patients attending hospitals in Southwest Shewa zone, Central Ethiopia.

METHODS

The study was conducted among diabetes patients who were on care and treatment from September to October 2020. Direct costs were calculated using the micro-costing technique, while indirect costs were calculated using the human capital approach. The statistical significance of cost difference between the groups of patient characteristics was determined using Wilcoxon and Kruskal-Wallis mean rank sum tests, and the factors associated with a total cost of illness were identified with Generalized Linear Model (GLM).

RESULTS

Out of the planned patients, 398 have responded and were included in the analysis; making a response rate of 98.5%. The mean monthly total cost of diabetic mellitus was US$ 37.7(95% CI, 23.45-51.95). Direct and indirect costs constituted 76.2% and 23.8% of the total cost, respectively. The mean direct and indirect cost of diabetic mellitus per patient per month was US$ 28.73(95% CI, 17.17-40.29) and US$ 9.50 (95% CI, 1.99-16.99) respectively. Statistical mean cost differences were observed by gender, age groups, family size, and comorbidities. The total cost of illness was associated with residence (p=0.007), family size (p=0.001), presence of co-morbidities (p=0.04), and history of ever-stopping treatments (p<0.0001).

CONCLUSIONS

The total cost of diabetes condition was relatively high compared to other related literatures. The medical expenditures accounted for most direct costs for diabetic patients. As a result, the government should provide sufficient resources to safeguard patients against catastrophic medical costs. Efforts should be made to enhance access to diabetes care, and the supply of diabetic medications at all levels of health facilities.

Economic Burden of Diabetes and Hypertension: A Study of Direct and Indirect Cost of Treatment in Southeast Nigeria

The prevalence of diabetes mellitus and hypertension is increasing yearly in many low- and middle-income countries such as Nigeria. The increasing burden of these noncommunicable diseases has led to an increase in the overall cost of health care. This study aimed at determining the direct and indirect health care costs of diabetes mellitus and hypertension occurring both singly and in co-morbidity. The study was undertaken in the Enugu State University Teaching Hospital (a tertiary hospital) in Enugu State, Southeast Nigeria. Data were collected using a pre-tested questionnaire. Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had hypertension, and 28% had both diabetes mellitus and hypertension in co-morbidity. Direct costs of treating diabetes mellitus and hypertension in the month before the survey were $28.40 and $19.35, respectively, while the indirect costs of treatment in the month before the study were $7.36 and $5.51, respectively. Direct and indirect costs for diabetes mellitus and hypertension in co-morbidity were $37.00 and $4.62, respectively. A concentration index showed that diabetes mellitus and hypertension were more evident among the poor than the rich. The economic cost when compared with patients' income revealed that >25% of their income is spent monthly on health care.

Influence of traditional processing and genotypes on the antioxidant and antihyperglycaemic activities of yellow-fleshed cassava

Yellow-fleshed cassava root (YFCR) is processed into traditional products that may influence its bioactivities. In this study, the antioxidant and anti-hyperglycaemic activities of three traditional products (lafun, fufu and gari) from five genotypes (IITA-TMS-IBA070337, 182961, 182962, 182986, 183044) of YFCR were evaluated. The YFCR genotypes were grown at the International Institute of Tropical Agriculture (IITA) research field, Ibadan. The bioactive constituents (total carotenoids, total phenolics, tannins and total flavonoids), antioxidant [2,2-azinobis (3-ethyl-benzothiazoline-6-sulfonic acid) radical cation (ABTS^•+) and 1,1-diphenyl-2- picrylhydrazyl radical (DPPH^•) scavenging capacities, and reducing power], and starch-digesting enzymes (α-amylase and α-glucosidase) inhibitory activities of the products were determined using standard laboratory methods. The glucose response of the products was assessed in human subjects. The concentrations of the bioactive constituents of the products from different genotypes varied significantly (p < 0.05). The ABTS^•+ and DPPH^• scavenging capacities and the reducing power of the products also differed significantly (p < 0.05), such that the lafun from IITA-TMS-IBA182962, IITA-TMS-IBA070337 and IITA-TMS-IBA070337 had the strongest ABTS^•+ and DPPH^• scavenging capacities, and reducing power, respectively. The α-amylase and α-glucosidase inhibitory activities of the three products differed significantly (p < 0.05), with the lafun from IITA-TMS-IBA070337 and IITA-TMS-IBA07033 having the strongest α-amylase and α-glucosidase inhibitory activity, respectively. Also, the lafun from IITA-TMS-182986 had the least glucose response, while the fufu from IITA-TMS-IBA070337 had the highest glucose response. Overall, the lafun from different genotypes of YFCR had the most potent antioxidant and starch-digesting enzymes inhibitory activities and the least glucose responses. Hence, lafun may be a promising dietary intervention targeting oxidative stress, hyperglycaemia, and their resultant type 2 diabetes.

Evaluation of in vitro and in vivo Glycemic Index of common staples made from varieties of White Yam (Dioscorea rotundata)

Consumption of high Glycemic Index (GI) foods is a risk factor for increasing prevalence of diabetes mellitus (DM). The extent of variation in starch digestibility and GI of Yam varieties and products is not yet fully understood. This study was therefore designed to evaluate in vitro and in vivo Glycemic Index properties of commonly consumed products prepared from varieties of White Yam. Four products (boiled, fried, pounded yam, and Amala) were prepared from 5 common varieties of Yam and evaluated for Digestible Starch (DS) and Resistant Starch (RS). Based on results, two products-pounded yam and Amala-were processed from three of the most popular varieties. Analysis of Rapidly Digestible Starch (RDS), Slowly Digestible Starch (SDS), and estimated in vitro GI (eGI) were then carried out in this stage. Glycemic Index (GI) of these products consumed by apparently healthy young adults were also determined. Variety Amula had highest DS in Amala (19.1/100 g) and pounded Yam (20.4/100 g) while variety Alumaco had highest RS in all the products (2.9–3.3/100 g). When compared with RS in its raw tuber, RS of Alumaco generally increased after processing. Variety Alumaco had lowest RDS in Amala (0.6/100 g) and pounded yam (0.3/100 g) while eGI was lowest in Alumaco made into Amala (53) and pounded yam (48). Assessment of GI resulted in high GI for all products across each variety. Irrespective of variety, processing Yam into Amala released RDS fraction faster when compared with pounded yam. Generally, even though the products are considered as having high GI, Amala raised eGI and GI faster than Pounded yam. Variety-Alumaco particularly showed favorable properties applicable to dietary management of diabetes. Exploring more processing methods and genetic diversity is recommended.

Health economics of diabetic foot ulcer and recent trends to accelerate treatment

Diabetic foot ulcer is a preventable complication of diabetes that imposes a significant burden on the community. It leads to amputation and increased disability if left untreated and thus bears profound implications on the individual, the community and the health system at large. Diabetic foot (DF) is an area of research interest where interdisciplinary researchers are trying to elucidate the best strategy to halt the progression of chronic diabetic wounds. It is an area where tissue engineering research is making a strong impact through the use of scaffolds and skin substitutes for diabetic wound healing. This review aims at discussing the geographical health economics, its impact on healing and factors influencing financial costs of DFU. The upcoming economic and clinical impacts due to disease outbreak such as the 2020 COVID-19 has also been discussed. Finally, it will discuss novel therapy available with emphasis on skin tissue engineering scaffolds with a cost-benefit analysis. The review aims at promoting better management of people with diabetes with emphasis on emerging treatments and technologies.

Prevalence of microvascular and macrovascular complications of diabetes in newly diagnosed type 2 diabetes in low-and-middle-income countries: A systematic review and meta-analysis

There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings.

Economic burden of road traffic injuries in sub-Saharan Africa: a systematic review of existing literature

OBJECTIVE

This systematic review aims to explore and synthesise existing literature on the direct and indirect costs from road traffic injuries (RTIs) in sub-Saharan Africa (SSA), the quality of existing evidence, methods used to estimate and report these costs, and the factors that drive the costs.

METHODOLOGY

MEDLINE, SCOPUS, ProQuest Central, Web of Science, Global Index Medicus, Embase, World Bank Group e-Library, Econlit, Google Scholar and WHO webpages were searched for relevant literature. References of selected papers were also examined for related articles. Screening was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were included in this review if they were published by March 2019, written in English, conducted in SSA and reported original findings on the cost of illness or economic burden of RTIs. The results were systematically examined, and the quality assessed by two reviewers using a modified Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

Eleven studies met the inclusion criteria. RTIs can cost between INT$119 and 178 634 per injury and INT$486 and 12 845 per hospitalisation. Findings show variability in costing methods and inadequacies in the quality of existing evidence. Prolonged hospital stays, surgical sundries and severity of injury were the most common factors associated with cost.

CONCLUSION

While available data are limited, evidence shows that the economic burden of RTIs in SSA is high. Poor quality of existing evidence and heterogeneity in costing methods limit the generalisability of costs reported.

Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings - an empirical socio-economic cohort study in Tanzania and Uganda

BACKGROUND

Integration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking. We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed.

METHODS

2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations.

RESULTS

Their average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately. Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics' mean efficiency benchmark score was 0.86 (range 0.30-1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2-23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities.

CONCLUSION

Integration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa's ageing populations. Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.

Current utilization patterns for long-acting insulin analogues including biosimilars among selected Asian countries and the implications for the future

INTRODUCTION

Prevalence rates for diabetes mellitus continue to rise, which, coupled with increasing costs of complications, has appreciably increased expenditure in recent years. Poor glycaemic control including hypoglycaemia enhances complication rates and associated morbidity, mortality and costs. Consequently, this needs to be addressed. Whilst the majority of patients with diabetes have type-2 diabetes, a considerable number of patients with diabetes require insulin to help control their diabetes. Long-acting insulin analogues were developed to reduce hypoglycaemia associated with insulin and help improve adherence, which can be a concern. However, their considerably higher costs have impacted on their funding and use, especially in countries with affordability issues. Biosimilars can help reduce the costs of long-acting insulin analogues thereby increasing available choices. However, the availability and use of long-acting insulin analogues can be affected by limited price reductions versus originators and limited demand-side initiatives to encourage their use. Consequently, we wanted to assess current utilisation rates for long-acting insulin analogues, especially biosimilars, and the rationale for patterns seen, across multiple Asian countries ranging from Japan (high-income) to Pakistan (lower-income) to inform future strategies.

METHODOLOGY

Multiple approaches including assessing utilization and prices of insulins including biosimilars among six Asian countries and comparing the findings especially with other middle-income countries.

RESULTS

Typically, there was increasing use of long-acting insulin analogues among the selected Asian countries. This was especially the case enhanced by biosimilars in Bangladesh, India, and Malaysia reflecting their perceived benefits. However, there was limited use in Pakistan due to issues of affordability similar to a number of African countries. The high use of biosimilars in Bangladesh, India and Malaysia was helped by issues of affordability and local production. The limited use of biosimilars in Japan and Korea reflects limited price reductions and demand-side initiatives similar to a number of European countries.

CONCLUSIONS

Increasing use of long-acting insulin analogues across countries is welcomed, adding to the range of insulins available, which increasingly includes biosimilars. A number of activities are needed to enhance the use of long-acting insulin analogue biosimilars in Japan, Korea and Pakistan.

Anemia in diabetes mellitus in Africa: A systematic review and meta-analysis

AIMS

Anemia accelerates chronic complications of diabetes mellitus (DM). We aimed to conduct a systematic review and meta-analysis to estimate the prevalence of anemia among people with DM in Africa.

METHODS

A search of studies was conducted in the main databases (Medline, EMBASE, Scopus, CINAHL, AJOL and Google Scholar) and the reference lists of selected studies. Observational studies that met the eligibility criteria were included in this meta-analysis. There was no limitation in terms of language.

RESULTS

We obtained data from 27 eligible studies, including 5913 patients. The pooled prevalence of anemia was 35% (95% CI: 28%-42%, I² = 97.7%, p < 0.01). In sub-group analysis, the pooled prevalence was higher in people with diabetic foot lesions (56%, 95% CI: 49%-63%, I² = 51.04%, p = 0.100) than in the general population of people with diabetes (30%, 95% CI: 23%-37%, I² = 97.6%, p < 0.01). Pooled prevalence rates were also higher in; males than females (34% vs 31%), type II DM than type I DM (35% vs 26%), and in patients with poor glycemic control compared to those with good glycemic control (33% vs. 22%).

CONCLUSIONS

The prevalence of anemia in DM was high warranting enhanced clinical and public health interventions.

Solving the problem of access to cardiovascular medicines: revolving fund pharmacy models in rural western Kenya

Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5–25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.

Prevalence and determinants of poor glycaemic control amongst patients with diabetes followed at Vanga Evangelical Hospital, Democratic Republic of the Congo

Background

The prevalence of diabetes mellitus is increasing dramatically in developing countries, where diabetic patients usually present with poor glycaemic control, leading to complications and worsening the prognosis.

Aim

The aim of this study was to determine the extent of poor glycaemic control and its determinants in diabetic patients.

Setting

The study was conducted in a rural area of the province of Kwilu, Democratic Republic of the Congo.

Methods

This research comprised a cross-sectional study involving 300 Type 1 and 2 diabetic patients attending Vanga Evangelical Hospital in the Democratic Republic of the Congo from January 2018 to March 2018. Patients’ sociodemographic, clinical and biological characteristics, accessibility to the health structure and treatment were described. The determinants of poor glycaemic control were identified using multivariate logistic regression at the p < 0.05 level of statistical significance.

Results

The mean age of participants was 46.9 ± 16.3 years, 68.4% were men, and 62.3% had Type 2 diabetes mellitus. Poor glycaemic control was present in 78% of patients. The independent determinants of poor glycaemic control were tobacco use (adjusted odds ratio [aOR]: 2.01 [1.77–5.20], p = 0.015), the presence of comorbidities (aOR: 2.86 [1.95–6.65], p = 0.007), the presence of a factor contributing to hyperglycaemia (aOR: 2.74 [1.83–3.67], p = 0.014), missing scheduled appointments (aOR: 2.59 [1.94–7.13], p = 0.006) and non-adherence to treatment (aOR: 4.09 [1.35–6.39], p = 0.008).

Conclusion

This study shows that more than three-quarters of diabetics undergoing treatment are not controlled, with mainly patient-related factors as the main explanatory factors for this poor glycaemic control. Therefore, the establishment of a therapeutic education programme and wider integration of diabetes care services, mainly at the primary level of the healthcare pyramid, should contribute to improved diabetes treatment.

Economic costs of terminal care for selected non-communicable diseases from a healthcare perspective: a review of mortality records from a tertiary hospital in Nigeria

INTRODUCTION

WHO revealed that morbidity and mortality from non-communicable diseases (NCDs) are on the increase and NCDs accounted for approximately 29% of all deaths in Nigeria in 2016. This study was conducted to estimate the economic cost of selected NCDs-lung cancer, liver cancer and liver cirrhosis. These diseases are known to be associated with key modifiable health risk behaviours (smoking and alcohol use), which are prevalent in Nigeria and often commence during the adolescent years.

METHODS

Data were obtained between 2016 and 2017, from mortality records of patients managed for the selected diseases in the University College Hospital, a major referral centre in Nigeria. Information on costs of treatment, clinic visits, admission and transportation was obtained. Average costs of terminal in-patient care and transportation costs (in 2020 prices) were computed per patient. Costs were converted to the US dollar equivalent using the current official rate of US$1: ₦360.50.

RESULTS

Twenty-two (out of 90 cases recorded) could be retrieved and all the patients had been diagnosed in the terminal stages of the disease. The average direct costs were ₦510 152.62 (US$1415.13) for an average of 49.2 days of terminal care for lung cancer; ₦308 950.27 (US$857.00) and ₦238 121.83 (US$660.53) for an average of 16.6 and 21.7 days of terminal care for patients managed for liver cancer and liver cirrhosis, respectively.

CONCLUSION

The economic costs of each of the diseases were very high. Findings emphasise the need for aggressive efforts to promote primary prevention, improve early diagnosis and provide affordable treatment in view of the fact that the monthly minimum wage is less than US$85.00 and treatment costs are borne out-of-pocket by the generality of the population in Nigeria.

Effect of processing and variety on starch digestibility and glycemic index of popular foods made from cassava (Manihot esculenta)

In Sub-Saharan Africa (SSA), the prevalence of diabetes mellitus (DM) is rapidly increasing even in populations with significant undernutrition. The role of energy dense staple crops such as cassava is under query and not yet well understood. In this study, varieties of cassava, made into popular SSA products (fufu and gari dough) were studied for their resistant starch (RS), rapidly digestible starch (RDS) and glycemic index (GI). While the glycemic properties of the varieties studied did not differ significantly, processing any variety into either fufu or gari distinctly impacted RS, RDS and predicted GI (pGI) differently. Specifically, fufu had highest range of RS (1.1-2.1 g/100 g) while gari dough had highest RDS (1.1-1.4 g/100 g) and pGI (54-67). The results from this probe imply that fufu, when consumed, will release glucose in a slower manner than gari, therefore may be better suited in the dietary prevention and management of DM.

Monetary value of disability-adjusted life years lost from all causes in Mauritius in 2019

Background: The Republic of Mauritius had a total of 422,567 disability-adjusted life years (DALYs) from all causes in 2019. This study aimed to estimate the monetary value of DALYs lost in 2019 from all causes in Mauritius and those projected to be lost in 2030; and to estimate the monetary value of DALYs savings in 2030 if Mauritius were to attain the national targets related to five targets of the United Nations Sustainable Development Goal 3 on good health and well-being. Methods: The human capital approach was used to monetarily value DALYs lost from 157 causes in 2019. The monetary value of DALYs lost in 2019 from each cause was calculated from the product of net gross domestic product (GDP) per capita in Mauritius and the number of DALYs lost from a specific cause. The percentage reductions implied in the SDG3 targets were used to project the monetary values of DALYs expected in 2030. The potential savings equal the monetary value of DALYs lost in 2019 less the monetary value of DALYs expected in 2030. Results:  The DALYs lost in 2019 had a total monetary value of Int$ 9.46 billion and a mean value of Int$ 22,389 per DALY. Of this amount, 84.2% resulted from non-communicable diseases; 8.7% from communicable, maternal, neonatal, and nutritional diseases; and 7.1% from injuries. Full attainment of national targets related to the five SDG3 targets would avert DALYs losses to the value of Int$ 2.4 billion. Conclusions: Diseases and injuries cause a significant annual DALYs loss with substantive monetary value. Fully achieving the five SDG3 targets could save Mauritius nearly 8% of its total GDP in 2019. To achieve such savings, Mauritius needs to strengthen further the national health system, other systems that tackle the social determinants of health, and the national health research system.

Are Ethiopian diabetic patients protected from financial hardship?

Background

Globally, diabetes mellitus exerts an economic burden on patients and their families. However, the economic burden of diabetes mellitus and its associated factors were not well studied in Ethiopia. Therefore, the aim of this study is to assess the economic burden of diabetes mellitus and its associated factors among diabetic patients in public hospitals of Bahir Dar city administration, Ethiopia.

Methods

Across sectional study was conducted on 422 diabetic patients. The patients were selected by simple random sampling method. The prevalence-based model was used to estimate the costs on patients’ perspective. Bottom up and human capital approaches were used to estimate the direct and indirect costs of the patients respectively. Wealth index was constructed using principal component analysis by SPSS. Forty percent of nonfood threshold level was used to measure catastrophic diabetic care expenditure of diabetic patients. Whereas, the World Bank poverty line (the $1.90-a-day poverty line) was used to measure impoverishment of patients due to expenses of diabetes mellitus care. Data were entered by Epi data version 3.1and exported to SPSS version 23 for analysis. Simple and multiple logistic regressions were used.

Results

Four hundred one respondents were interviewed with response rate of 95%. We found that 239 (59.6%) diabetic patients incurred catastrophic diabetic care expenditure at 40% nonfood threshold level. Whereas, 20 (5%) diabetic patients were impoverished by diabetic care spending at the $1.90-a-day poverty line. Educational status of respondent, educational status of the head of household, occupation and wealth status were statistically associated with the catastrophic diabetic care expenditure.

Conclusions

The study revealed that the economic burden of diabetic care is very disastrous among the less privileged populations: the less educated, the poorest and unemployed. Therefore, all concerned stakeholders should design ways that can reduce the financial hardship of diabetic care among diabetic patients.

In vitro antidiabetic potentials, antioxidant activities and phytochemical profile of african black pepper (Piper guineense)

Background

Diabetes mellitus is a metabolic disorder of glucose metabolism and management of blood glucose level is the hallmark in the treatment of this disease. The present study investigated chemical composition, in vitro antioxidant and antidiabetic activity of different fractions of 80% methanol Piper guineense leaves extract.

Materials and methods

The crude methanolic extract of P. guineense was obtained following 80% methanol cold extraction and was successively partitioned with dichloromethane (DCM), ethyl acetate (EtOAc), n-butanol (nBuOH) and aqueous solvents to give four fractions. The chemical composition of the fractions from P. guineense was determined using gas chromatography coupled with mass spectrometry (GC-MS) and their potentials as antioxidant and anti-diabetes were evaluated.

Results

The percentage yields were 3.16, 2.22, 0.68 and 0.66% (w/w) in n-butanol, DCM, aqueous and ethyl acetate fractions of P. guineense methanolic extract, respectively. The GC-MS analyses identified a total of 71 and 34 phytochemicals in n-butanol and ethyl acetate fractions respectively. Tributyl acetylcitrate (10.95%) and phytol (9.11%) were the major components in the n-butanol fraction while ethyl piperonyl cyanoacetate (27.35%) and phytol (15.17%) were the major constituents in the ethyl acetate fraction. Ethyl acetate fraction had the highest ferric reducing antioxidant power with a value of 53.96 ± 0.40 mgAAE/g while n-butanol fraction possessed highest total antioxidant power (9.98 ± 0.15) followed by aqueous fraction (9.72 ± 0.02). The ethyl acetate and n-butanol fractions with IC50 value of 0.24 ± 0.07 and 0.83 ± 0.15 μg/mL respectively elicited significant inhibitory activities against α-glucosidase while only n-butanol fraction (IC50 = 0.33 ± 0.09 μg/ml) exhibited appreciable inhibition against α-amylase activity. However, none of the four fractions showed significant inhibitory activity towards dipeptidyl-peptidase-IV.

Conclusion

n-butanol and ethyl acetate fractions of 80% methanol P. guineense leaves extract can be a potential source of bioactive compounds of pharmacological importance in the management of diabetes.

Self-management of persons living with diabetes mellitus type 2: Experiences of diabetes nurse educators

Background

The global pandemic of diabetes mellitus type 2 (DM2) is the direct cause of significant health and economic problems for both governments and individuals owing to the high level of morbidity and mortality. South Africa has the second highest incidence of DM2 in sub-Saharan Africa.

Aim

This article describes the experiences of diabetes nurse educators in relation to self-management of DM2 of persons living with DM2.

Setting

This article involves nurse educators working in diabetes clinics in public and private hospitals in Nelson Mandela Bay Municipality, South Africa.

Methods

A semi-structured interview guide was used to collect data from a focus group interview comprising three participants and two individual interviews. The interviews were recorded with the permission of participants, transcribed and then coded using Tesch’s model of data analysis. Themes were agreed upon with the consensus of the researcher, two supervisors and an independent coder.

Results

Three themes were identified: (1) diabetes nurse educators have clear perceptions about the importance of self-management of DM2 of persons living with DM2, (2) there are factors that affect persons living with DM2 with respect to self-management and (3) there are ways in which professional nurses can assist persons living with DM2 in the self-management of their condition.

Conclusion

This article identified factors that diabetes nurse educators experienced in either assisting or hindering patients in self-management of their DM2. The diabetes nurse educators voiced their views on how professional nurses can provide support to the patients living with DM2.

Economic menace of diabetes in India: a systematic review

AIM

Diabetes mellitus is recognised as a major chronic pandemic disease that does not consider any ethnic and monetary background. There is a dearth of literature on the cost of diabetes in the Indian context. Therefore, the present study aims to capture the evidence from the literature on the cost of diabetes mellitus in India.

METHODS

An extensive literature was reviewed from ACADEMIA, NCBI, PubMed, ProQuest, EBSCO, Springer, JSTOR, Scopus and Google Scholar. The eligibility criterion is based on 'PICOS' procedure, and only those studies which are available in the English language, published between 1999 and February 2019, indexed in ABDC, EBSCO, ProQuest, Scopus and peer-reviewed journals are included.

RESULTS

A total of thirty-two studies were included in the present study. The result indicates that the median direct cost of diabetes was estimated to be ₹18,890/- p.a. for the north zone, ₹10,585/- p.a. for the south zone, ₹45,792/- p.a. for the north-east zone and ₹8822/- p.a. for the west zone. Similarly, the median indirect cost of diabetes was ₹18,146/- p.a. for the north zone, ₹1198/- p.a. for the south zone, ₹18,707/- p.a. for the north-east and ₹3949/- p.a. for the west zone.

CONCLUSION

The present study highlighted that diabetes poses a high economic burden on individuals/households. The study directed the need to arrange awareness campaign regarding diabetes and associated risk factors in order to minimise the burden of diabetes.

Economic cost of diabetes in the Eastern Mediterranean region countries: A meta-analysis

BACKGROUND AND AIMS

Non communicable diseases including diabetes imposes substantial financial burden on households, societies and nations in both developed and developing countries. However, there is no information on the extent of diabetes expenditure in the Eastern Mediterranean Region (EMRO). Therefore, this study aimed to identify the treatment costs of diabetes in this area. To our knowledge, this is the first systematic review on treatment expenditures of diabetes in EMRO countries.

METHODS

A comprehensive literature search was conducted in PUBMED, MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCES databases to find out published manuscripts on treatment cost of diabetes. Information was extracted using data extraction sheets and then the data were imported into STATA software version.11. Mean annual treatment cost of diabetes per patient, annual treatment costs of diabetes per patient by Diabetes Mellitus (DM) complications and finally, cost of chronic diabetes complications per patient were pooled and reported.

RESULTS

After reviewing title, abstract and the full text of identified articles; a total of seven studies were reported appropriate data for this meta-analysis. The pooled annual treatment cost per diabetes patient for EMRO countries was 1150 US$ (95% CI: 595-2221) which was 3358 US$ (95% CI: 2200-5124) in EMRO countries except of Iran compared to 255 US$ (92-708) in Iran. The treatment cost of diabetes was higher in males, insulin-used and in the patient with family history of diabetes. The cost of diabetes was significantly increased with the duration of diabetes (P = 0.001) as well. According to the results, the largest share of costs is related to medication costs. Finally, the pooled average annual treatment cost per patient by diabetes mellitus complications was varied from 2828 US$ in the patients that have cerebrovascular disease complication to 7261 US$ in the patients with Stroke complication.

CONCLUSIONS

This study demonstrated that the annual treatment cost of diabetes is varied within EMRO countries. Qatar and Iran have spent the highest and lowest cost for diabetes, respectively. This may be due to the large socioeconomic differences between countries and special conditions of them such as currency value in the region.

A Systematic Review of the Economic Burden of Type 2 Diabetes in Malaysia

Diabetes causes significant disabilities, reduced quality of life and mortality that imposes huge economic burden on societies and governments worldwide. Malaysia suffers a high diabetes burden in Asia, but the magnitude of healthcare expenditures documented to aid national health policy decision-making is limited. This systematic review aimed to document the economic burden of diabetes in Malaysia, and identify the factors associated with cost burden and the methods used to evaluate costs. Studies conducted between 2000 and 2019 were retrieved using three international databases (PubMed, Scopus, EMBASE) and one local database (MyCite), as well as manual searches. Peer reviewed research articles in English and Malay on economic evaluations of adult type 2 diabetes conducted in Malaysia were included. The review was registered with PROSPERO (CRD42020151857), reported according to PRISMA and used a quality checklist adapted for cost of illness studies. Data were extracted using a data extraction sheet that included study characteristics, total costs, different costing methods and a scoring system to assess the quality of studies reviewed. The review identified twelve eligible studies that conducted cost evaluations of type 2 diabetes in Malaysia. Variation exists in the costs and methods used in these studies. For direct costs, four studies evaluated costs related to complications and drugs, and two studies were related to outpatient and inpatient costs each. Indirect and intangible costs were estimated in one study. Four studies estimated capital and recurrent costs. The estimated total annual cost of diabetes in Malaysia was approximately USD 600 million. Age, type of hospitals or health provider, length of inpatient stay and frequency of outpatient visits were significantly associated with costs. The most frequent epidemiological approach employed was prevalence-based (n = 10), while cost analysis was the most common costing approach used. The current review offers the first documented evidence on cost estimates of diabetes in Malaysia.

Development of a graphic blood glucose monitoring chart for glycaemic control in diabetes mellitus: a modified Delphi method study

BACKGROUND

In Kenya 30% of patients admitted with ketoacidosis due to hyperglycaemia die within 48 hours of hospitalisation. Effective monitoring of blood glucose levels is critical for glycaemic control and prevention of mortality. Kenya public hospitals lack a graphic blood glucose monitoring tool.

AIMS

To develop a graphic blood glucose monitoring tool.

METHODS

Modified Delphi technique was used for consensus-building among nurses on the features of an appropriate blood glucose monitoring tool. A total of 150 nurses selected by purposive sampling participated in the study. Data were collected for 24 months through sequential interactive rounds and workshops using a questionnaire. At every round, consensus was reached if ≥75% of the nurses agreed or disagreed on a feature.

RESULTS

A graphic blood glucose monitoring chart was developed with the following features: time on the x-axis, blood glucose values on the y-axis, colour codes corresponding to blood glucose levels, existing conditions during blood glucose measurement.

SIGNIFICANCE

The chart may improve glycaemic control while stimulating further research on its effectiveness.

CONCLUSION

Modified Delphi method is useful for successive collation of judgments of nurse experts in the development of a graphic blood glucose monitoring chart.

Economic evaluations and cost analyses in posttraumatic stress disorder: a systematic review

BACKGROUND

Posttraumatic stress disorder is associated with a high economic burden. Costs of treatment are known to be high, and cost-effectiveness has been analysed for several treatment options.

OBJECTIVE

As no review on economic aspects of posttraumatic stress disorder exists, the aim of this study was to systematically review costs-of-illness studies and economic evaluations of therapeutic treatment for posttraumatic stress disorder, and to assess their quality.

METHOD

A systematic literature search was performed in March 2017 and was last updated in February 2020 in the databases PubMed, PsychInfo and NHS Economic Evaluation Database. Cost-of-illness studies and economic evaluations of treatment for posttraumatic stress disorder were selected. Extracted cost data were categorized as direct costs and indirect costs and inflated to 2015 US-$ purchasing power parities (PPP). Quality was assessed using an adapted cost-of-illness studies quality checklist, the Consensus on Health Economic Criteria list, and the questionnaire to assess relevance and credibility of modelling studies by the International Society for Pharmacoeconomics and Outcome Research.

RESULTS

In total, 13 cost-of-illness studies and 18 economic evaluations were included in the review. Annual direct excess costs ranged from 512 US-$ PPP to 19,435 US-$ PPP and annual indirect excess costs were 5,021 US-$ PPP per person. Trauma-focused cognitive-behavioural therapy (+selective serotonin re-uptake inhibitor) was found to be cost-effective compared with treatment as usual and no treatment. Overall, included studies were of low and moderate quality. Studies used inappropriate economic study designs and lacked information on the economic perspective used.

CONCLUSIONS

Posttraumatic stress disorder is a major public health problem that causes high healthcare costs. While trauma-focused cognitive-behavioural therapy was found to be cost-effective, further investigations regarding pharmacotherapy and other treatments are necessary.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

Diabetes and pre-diabetes among adults reaching health centers in Luanda, Angola: prevalence and associated factors

With the lack of surveys, surveillance program and/or statistical data, epidemiologic studies can provide a better understanding of diabetes in Sub-Saharan Africa. This was a cross-sectional survey to determine prevalence of diabetes and impaired fasting glucose (IFG) among adults attending six health centres in six different districts of Luanda (Angola) during August-November 2018, followed by a case-control study to assess the risk factors for IFG and diabetes in a subgroup of subjects not receiving treatment for diabetes. Factors associated with diabetes/IFG were assessed using a generalized ordered logit model and the effects were expressed as odds ratios (OR₁ for IFG/diabetes vs. no IFG/diabetes; OR₂ for diabetes vs. no diabetes) with 95% CI (confidence interval). Some 1,803 participants were included in the survey. Prevalence of diabetes was 12.0% (95%CI 10.5% to 13.5%) and prevalence of IFG was 9.0% (95%CI 7.7% to 10.4%). Older age (OR₁ = OR₂ 1.03, 95%CI 1.02 to 1.04), higher weight (OR₁ = OR₂ 1.01, 95%CI 1.01 to 1.03), having measured glycaemia before (OR₂ 2.07, 95%CI 1.29 to 3.31), feeling polyuria (OR₁ 1.93, 95%CI 1.13 to 3.28; OR₂ 2.18, 95%CI 1.32 to 3.59), feeling polydipsia (OR₁ 1.92, 95%CI 1.16 to 3.18), feeling weakness (OR₁ = OR₂ 2.22, 95%CI 1.39 to 3.55), consumption of free-sugars food/beverages (OR₁ = OR₂ 2.34, 95%CI 1.44 to 3.81) and time spent seated (OR₁ 1.80, 95%CI 1.17 to 2.76) were associated with increased likelihood of diabetes and/or IFG, while eating vegetables was associated with decreased likelihood of IFG or diabetes (OR₁ = OR₂ 0.69, 95%CI 0.47 to 0.99). In conclusion, the high prevalence of diabetes and IFG, with common unawareness of the disease, calls for appropriate interventions in Angolan urban settings. Further research may evaluate the impact of context-specific factors to enhance intervention strategies and feed the results into local health policies. In addition, such information may be useful for selecting high-risk subjects to test.

Barriers and Strategies to Lifestyle and Dietary Pattern Interventions for Prevention and Management of TYPE-2 Diabetes in Africa, Systematic Review

BACKGROUND

Diabetes mellitus is a major chronic illness in Africa that requires lifelong lifestyle interventions and pharmacological therapy. Lifestyle change is the most important aspect of diabetes care and includes diabetes self-management education and support, medical nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care.

PURPOSE

The purpose of this project was to review published articles that investigate lifestyle and dietary pattern interventions for diabetes prevention and management in Africa. Barriers to lifestyle interventions and strategies to overcome the barriers are also reviewed in this study.

METHODS

The article search was conducted in an electronic database search of PubMed, Google Scholar, and Cochrane Library. Studies were included if they were published between 2011 and 2019, if they were conducted in an African country, and were written in the English language.

RESULTS

Articles reviewed included several that examined the basic lifestyle and dietary pattern changes for all patients diagnosed with type 2 diabetes, on self-care behavior of type 2 diabetes patients, on the cost of diabetes in Africa, and on barriers for adherence to lifestyle and dietary changes in Africa, with strategies to address those barriers.

CONCLUSION

Lifestyle interventions including regular physical exercise, weight management, and adherence to health care professionals' recommendations on a healthy diet are the cornerstone in the prevention and management of diabetes in Africa. The main barriers to adherence were both systemic (population changes, poor access, western cultural influences, and low-quality healthcare) and personal (poverty and cost, educational status, and perceptions about the disease) in nature. The strategies for the barriers include health education programs, advocacy, and capacity building.

Patient costs of diabetes mellitus care in public health care facilities in Kenya

OBJECTIVE

To estimate the direct and indirect costs of diabetes mellitus care at five public health facilities in Kenya.

METHODS

We conducted a cross-sectional study in two counties where diabetes patients aged 18 years and above were interviewed. Data on care-seeking costs were obtained from 163 patients seeking diabetes care at five public facilities using the cost-of-illness approach. Medicines and user charges were classified as direct health care costs while expenses on transport, food, and accommodation were classified as direct non-health care costs. Productivity losses due to diabetes were classified as indirect costs. We computed annual direct and indirect costs borne by these patients.

RESULTS

More than half (57.7%) of sampled patients had hypertension comorbidity. Overall, the mean annual direct patient cost was KES 53 907 (95% CI, 43 625.4-64 188.6) (US$ 528.5 [95% CI, 427.7-629.3]). Medicines accounted for 52.4%, transport 22.6%, user charges 17.5%, and food 7.5% of total direct costs. Overall mean annual indirect cost was KES 23 174 (95% CI, 20 910-25 438.8) (US$ 227.2 [95% CI, 205-249.4]). Patients reporting hypertension comorbidity incurred higher costs compared with diabetes-only patients. The incidence of catastrophic costs was 63.1% (95% CI, 55.7-70.7) and increased to 75.4% (95% CI, 68.3-82.1) when transport costs were included.

CONCLUSION

There are substantial direct and indirect costs borne by diabetic patients in seeking care from public facilities in Kenya. High incidence of catastrophic costs suggests diabetes services are unaffordable to majority of diabetic patients and illustrate the urgent need to improve financial risk protection to ensure access to care.

Hypoglycemic and Toxic Effect of Morus mesozygia Leaf Extract on the Liver and Kidneys of Alloxan-Induced Hyperglycemic Wistar Rats

Purpose

We investigated the hypoglycemic and toxic effect of Morus mesozygia leaf extract on the liver and kidneys of alloxan-induced hyperglycemic wistar rats.

Method

Phytochemical analysis was done. Diabetes was induced by the use of alloxan monohydrate in six groups of rats, i.e., 200 mg/kg, 400 mg/kg, 800 mg/kg, glibenclamide, normal saline, and normal control group. Blood glucose was measured at the time of inoculation, then at 1, 2, 3, and 4 hours after. After 14 days, rats were killed under anesthesia; blood collected for measurement of total protein, albumin, TAGs, cholesterol, AST, ALT, urea, and creatinine; and whole tissue of liver and kidneys used for histological studies.

Results

The extract possessed antidiabetic effects between 400 mg/kg and 800 mg/kg doses, which we attributed to the presence of flavonoids, tannins, terpenoids, and amino acids. There was a drop in total protein and albumin with no statistical significance (P ≥ 0.05). The changes in levels of ALT, TAGs, cholesterol, AST, creatinine, and urea were not statistically different from the standard diabetic drug. The extract was protective against histological damage as there were no significant lesions suggestive of toxicities in the liver and kidneys at doses below 800 mg/kg.

Conclusion

We established credible evidence that Morus mesozygia leaf extract has hypoglycemic effects between 400 mg/kg and 800 mg/kg and that it is safe on the liver and kidneys of wistar rats at doses less than 800 mg/kg.