Effectiveness of a group diabetes education programme in underserved communities in South Africa: Pragmatic cluster randomized control trial Prof Bob Mash 1, Prof Krisela Steyn 2, Prof Naomi Levitt 2,3, Prof Merrick Zwarenstein 4, Prof Stephen Rollnick 5, Ms Hilary Rhode 1 1 Division of Family Medicine and Primary Care, Stellenbosch University 2 Chronic Diseases Initiative in Africa 3 Diabetic Medicine and Endocrinology, University of Cape Town 4 Institute for Clinical Evaluative Sciences and Department of Health Policy, Management and Evaluation, University of Toronto 5 Professor of Health Care Communication, Department of Primary Care and Public Health, Cardiff University This project was supported by a BRIDGES Grant from the International Diabetes Federation. BRIDGES, an International Diabetes Federation project, is supported by an educational grant from Lilly Diabetes (ST09-040) and by funds from CDIA (United Health) and Stellenbosch University.

Aim To evaluate, by means of a pragmatic cluster randomized controlled trial, the effectiveness of a group diabetes education programme delivered by trained health promoters with a guiding (derived from motivational interviewing) style, in community health centres in Cape Town, South Africa.

Method 17 community health centres in each arm 710 patients with type 2 diabetes in intervention 860 patients with type 2 diabetes in control Data collection at baseline and 12-months Primary outcomes: Improved diabetes self-care activities, 5% weight loss, HbA1c reduction of 1 percentage point Secondary outcomes: Improved diabetes-specific self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol and quality of life Mash B, Levitt N, Steyn K, Zwarenstein M, Rollnick S. Effectiveness of a group diabetes education programme in underserved communities in South Africa: pragmatic cluster randomized control trial. BMC Family Practice 2012; 13(126): doi:1186/

Intervention StructureResourcesCommunication

Structure 4 sessions: ◦ Understanding diabetes ◦ Lifestyle modification ◦ Understanding medication ◦ Avoiding complications 60 minutes On day of usual attendance - monthly people

Communication Guiding style Collaboration Empathy Independence Evocation Navigation Skills Exchange information (elicit- provide-elicit) Open questions Summaries and active listening

Resources

Training of health promoters

Process evaluation Patients that attended reported change in self-care activities Structure and resources were relevant, understandable, useful Health promoters perceived as mostly competent and confident Health promoters reported a significant shift in their way of communicating that was appreciated by patients Serfontein F, Mash B. Views of patients on a group diabetes education programme using motivational interviewing in South African primary care: Qualitative study. In Press S Afr Fam Pract J

Process evaluation Direct observation and analysis of sessions showed good delivery of content, but partial fidelity to the guiding style Suitable space was a problem Patient attendance was a problem (40% only) Communication with patients sometimes a problem Botes AS, Majikela- Dlangamandla B, Mash R. The ability of health promoters to deliver group diabetes education in South African primary care. Afr J Prm Health Care Fam Med. 2013;5(1), Art. #484, 8 pages. phcfm.v5i1.484

Results: 12 months

Conclusion Effect not as impressive as in other studies (see Cochrane review on group diabetes education) Effect on blood pressure clinically significant and useful Likely to be cost-effective Consider integration into chronic care system for NCDs with other diseases Department of health has requested training of all other health promoters

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