Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review

Jean Claude Mutabazi; Mahmoud Werfalli; Angeli Rawat; Ezekiel Musa; Tawanda Chivese; Shane Norris; Katherine Murphy; Helen Trottier; Naomi Levitt; Christina Zarowsky

doi:10.5334/ijic.5608

Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review

Int J Integr Care. 2022 Sep 21;22(3):21. doi: 10.5334/ijic.5608. eCollection 2022 Jul-Sep.

Authors

Jean Claude Mutabazi^{1

2

3}, Mahmoud Werfalli⁴, Angeli Rawat⁵, Ezekiel Musa⁴, Tawanda Chivese^{4

6}, Shane Norris^{6

7}, Katherine Murphy^{4

6}, Helen Trottier^{1

3}, Naomi Levitt^{4

6}, Christina Zarowsky^{1

2}

Affiliations

¹ Département de Médecine Sociale et Préventive, École de Santé Publique, Université de Montréal, Pavillon 7101, Avenue du Parc, Montreal, QC, H3N 1X7, Canada.
² Centre de Recherche en Santé Publique (CReSP), Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Canada.
³ Centre de Recherche du Centre Hospitalier Universitaire Sainte Justine, Montréal, H3T 1C5, QC, Canada.
⁴ Department of Medicine, Faculty of Health Science, University of Cape Town, Chronic Disease Initiative for Africa, Cape Town, Western Cape, South Africa.
⁵ The School of Population and Public Health, University of British Colombia, Vancouver, Canada.
⁶ Integrated Intervention for DIAbetes risks after GestatiOnal diabetes (IINDIAGO), Department of Medicine, Faculty of Health Science, University of Cape Town, Cape Town, Western Cape, South Africa.
⁷ University of Witwatersrand, Paediatrics and Child Health Johannesburg, Gauteng, South Africa.

Abstract

Introduction: Many adults diagnosed with gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) also have other known or unknown comorbid conditions. The rising prevalence of GDM and T2DM within a broader context of multimorbidity can best be addressed through an integrated management response, instead of stand-alone programs targeting specific infectious and/or chronic diseases.

Aim: To describe GDM and T2DM screening, care and cost-effectiveness outcomes in the context of multimorbidity through integrated interventions in Africa.

Methods: A systematic review of all published studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I) was used to assess risk of bias. Data synthesis was conducted using narrative synthesis of included studies.

Results: A total of 9 out of 13 included studies reported integrated diabetes mellitus (DM) screening, 7 included integrated care and 9 studies addressed cases of newly detected DM who were asymptomatic in pre-diabetes stage. Only 1 study clearly analysed cost-effectiveness in home-based care; another 5 did not evaluate cost-effectiveness but discussed potential cost benefits of an integrated approach to DM screening and care. Compared to partial integration, only 2 fully integrated interventions yielded tangible results regarding DM screening, care and early detection of cases despite many that reported barriers to its sustainability.

Conclusion: Though few, integrated interventions for screening and/or care of DM in the context of multimorbidity within available resources in health systems throughout Africa exist and suggest that this approach is possible and could improve health outcomes.

Keywords: diabetes mellitus; gestational diabetes; health systems; integrated care; multimorbidity; syndemic; type 2 diabetes.

Grants and funding

No funding was received for the study but it was part of a PhD project. The first author, JCM held a PhD scholarship of her supervisor Christina Zarowsky from the Canadian Institutes of Health Research (CIHR) under the “Team Grant – Implementation Research in the Prevention and Treatment of Type II Diabetes in Low- and Middle-Income Countries” competition. This funding was for the following randomized trial: integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO). HT holds a salary award (chercheur-boursier) from the “Fond de la recherche en santé- du Québec (FRQ-S)” and a salary award (New Investigator Salary Award) from Canadian Institutes of Health Research (CIHR).