Informing the development of a self-management care programme for older people with type 2 diabetes attending community health centres in Cape Town, South Africa

Diabetes is a growing problem globally, with the major impact being experienced in low and middle-income countries. In 2017, there were an estimated 122.8 million people over the age of 65 years living with diabetes globally, with a prevalence of 18.8% and 3.2 million deaths at this age. If the trends continue, the number of people living with diabetes over the age of 65 years will be 253.4 million in 2045.This is being driven by demographic changes including the ageing of the population. In South Africa, diabetes is a major cause of morbidity and mortality and a burden to the overstretched health services, community, family and people with the disease. Self- care management is a cornerstone of diabetes care. The purpose of this thesis is to inform the development of a self-care management programme for older people attending public sector primary health care services in Cape Town, South Africa by using the PRECEDE planning model. This model provides an eight-phase framework for health care professionals to determine, develop, implement and assess health promotion programmes, as well as the application of health promotion theories systematically within such programmes. The thesis incorporates five interlinked studies, presented as five publications, two published and three in review: The first was a systematic review of studies that assessed the prevalence of type 2 diabetes mellitus among older people in African countries conducted between 2000 and 2015 with the objective of providing data for the monitoring of future trends. This demonstrates that type 2 diabetes is not rare in individuals aged 55 years and older across Africa – the overall prevalence of diabetes was 13.7% (95% CI 11·3–16·3) and was twofold higher in studies based on the oral glucose tolerance test than in those using fasting plasma blood glucose. The second is a secondary analysis of the Study on global AGEing and adult health (SAGE) South Africa Wave 1 data that examined the prevalence of self-reported diabetes and the association between diabetes and each of health-related quality of life and disability amongst South Africa’s older adults. The results were that diabetes was associated with lower quality of life and greater disability: it represented not only a risk factor for disability but was associated with a range of impairments and co-morbidities predisposing to loss of autonomy. The third, a cross-sectional survey, examines the knowledge of older people with diabetes attending primary care clinics in Cape Town, South Africa, about living with and managing their diabetes; and aims to determine the relationship of social support, especially that of family and friends with their self-management. Its major finding is that there was a lack of knowledge about the complications of diabetes, suggesting that the available diabetes educational opportunities have not been effective. Importantly, however, social support was positively associated with both knowledge and a number of self-care aspects. The fourth is a qualitative study consisting of documentary review and individual interviews with key informants to investigate the current policies, programmes and any other interventions as they relate to older people with diabetes. This found that generally older persons face numerous barriers in managing their condition. Further, there are multiple efforts to re-orientate the healthcare system to focus more effectively on non-communicable diseases for the population which would benefit older patients with diabetes. Finally, the study includes a systematic review of peer and non-professional health worker-led diabetes self-management programmes (COMP-DSMP) in low and middle-income country primary health care settings, and also examines the implementation strategies and associated diabetes-related health outcomes This found equivocal evidence supporting the use of COMP-DSMP for people with diabetes in these countries and suggested that the models of a peer/CHW-led programme need to be further explored, especially given the inevitability of a professional healthcare workforce shortage in LMICs. In conclusion, this research study has described the extent of the need for developing and evaluating education programmes that focus on older people with diabetes and emphasises the role of family and friends. Whilst there have been some significant policy interventions pertaining to the protection of the health and welfare of older persons in SA, the needs of this vulnerable group remain relatively low on the list of priorities in terms of focus and resource allocation. In this context, older people, as a distinct group, are also not a strong focus in current health policy relating to the provision of NCD care. This thesis alerts policymakers and clinicians to some of the specific issues considered to be pertinent and important in the care and management of older persons with diabetes. Many of these would also be applicable to older individuals with other chronic conditions