Implementation of self-monitoring of blood glucose for patients with insulin-dependent diabetes at a rural non-communicable disease clinic in Neno, Malawi.

BACKGROUND: Self-monitoring of blood glucose (SMBG) is a widely accepted standard of practice for management of insulin-dependentdiabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report ofimplementation of SMBG in a rural, low-income country setting. OBJECTIVES: To evaluate adherence and change in clinical outcomes with SMBG implementation at two rural hospitals in Neno, Malawi. METHODS: Forty-eight patients with type 1 and insulin-dependent type 2 diabetes were trained to use glucometers and logbooks. Participantsmonitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluateglucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked anddocumented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a6-month period. RESULTS: Participants brought their glucometers and logbooks to the clinic 95 - 100% of the time. Adherence with measuring glucose valuesand recording them in logbooks eight times a week was high (mean (standard deviation) 69.4% (15.7) and 69.0% (16.6), respectively). MeanHbA1c decreased from 9.0% (75 mmol/mol) at enrolment to 7.8% (62 mmol/mol) at 6 months (mean difference 1.2% (95% confidenceinterval (CI) 0.6 - 2.0; p=0.0005). The difference was greater for type 1 diabetes (1.6%; 95% CI 0.6 - 2.7; p=0.0031) than for type 2 diabetes(0.9%; 95% CI 0.1 - 1.9; p=0.0630). There was no documented increase in hypoglycaemic events, and no hospitalisations or deaths occurred. CONCLUSION: SMBG is feasible for patients with insulin-dependent diabetes in a rural SSA population, and may be associated with improvedHbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research onlong-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.

Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014.

SETTING: Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. OBJECTIVE: To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. DESIGN: A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. RESULTS: Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. CONCLUSION: By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.

Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes.

SETTING: In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care. OBJECTIVE: To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda. DESIGN: We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes. RESULTS: Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma. CONCLUSION: Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.