Randomized Controlled Trial on an Educative Structured Intervention by Peer Educators to Improve HbA1c of Patients With Type 2 Diabetes in the Sikasso Region in Mali

BACKGROUND AND RATIONALE

The World Health Organization (WHO), estimates that the number of people affected by diabetes will rise from 171 million in 2000 to 366 million in 2030, representing a prevalence of 2.8% to 4.4% supposing that obesity will progress. Developing countries will then represent 76% of the world diabetic patients. This growth has justified the alarming report issued by the WHO in 2005 for a rapid mobilization on these new health needs. Access to care, treatment, education and care for complications related to diabetes is a key feature of the resolution passed by the United Nations in December 2006 on diabetes to protect people with diabetes against exclusion situation and increased vulnerability. In developing countries, the explosion of diabetes epidemic and other chronic diseases, is a direct consequence of the widespread emergence of overweight and obesity. For developing countries, the major increase of obesity, which involves both the upper classes that the popular classes, is essentially linked to the emergence of a nutritional transition defined as a gradual change of diets, including a clear increase of fats of animal origin consumption. Finally, the increase of obesity in the southern countries, thus the emergence of chronic diseases like diabetes, is strengthened by the increase of life expectancy and by the growth of physical inactivity.Education on diabetes is known through several names: education of the patient,patient's therapeutic education. All these terms question about the diabetic person's place in a continuous progress involving permanent communication with a care team and the coordination of a care programme. The therapeutic education is more and more becoming a model of care for people with diabetes. Indeed, diabetes is a complex condition, which requires an effective medical management from caregivers and a good autonomous management from the person with diabetes. This dual approach helps to promote choice of healthy lifestyles, improve the quality of life and reduce direct and indirect health costs for society. Educational approaches set up must recognize the critical and fundamental role of psychosocial factors for effective diabetes education. In 1914, Elliott Joslin published a book in which he stressed the importance of training nurses to participate to the education on diabetes and its management [10]. In 1936, insulin appeared and specialized nursing in diabetes had expanded. It became clear that nurses should develop their skills when it comes to education and counselling as well as expertise in clinical care. The publication of the DCCT studies results in 1993 and UKPDS in 1998 amended the diabetes care, from the simple reduction of glycaemia and blood pressure, to the active prevention of complications and in to the intensification of treatment. It was a turning point in the role of diabetes educator. In developed countries, diabetes educators began by considering the key aspects of the insulin doses adaptation, of the changes in eating habits and of the screening for complications, paving the way for the work of specialised nurses and of other caregivers, such as dieticians, chiropodist in diabetes education. Several studies have highlighted, in developed countries, the challenge for health professionals to implement education activities for patients. Above the consideration of the different cultural contexts, the barriers often described by professionals for the establishment of effective patient education are the availability of time and the inadequacy of the initial and continuing training. At hospital, the particular context in which education situations took place do not necessarily encourage the effective setting up of prevention and health practice in every day life. In the context of African health systems that combine low human and financial resources with a very important turn over of staff, it is very difficult to establish specific curricula for diabetes educators, but also to mobilize health staff specifically for this task. In these particular settings, the involvement of peers in the assistance in daily management and living with diabetes, the Social and emotional support and the Linkage to clinical care seems to be a perfect tighten to complement the organization of diabetes care in these countries. The reviews of several studies have shown the very positive results of this approach that can be implemented by following several methodological models. For this study we have chosen to implement and evaluate the impact of the methodology: The Learning Nests approach : Group Education focusing on understanding of key concepts and interactions with social context. This approach developed by health professionals and human sciences seems to be the best suited for the socio economic and cultural contexts which are encountered in Africa. It is based on 5 principles- the building and setting up of learning situations which are based on scientific data of the medical and social/human sciences frame (socioconstructivism, didactic, learning of adults-):

• The integration of the context of life in developing the educational situation
• The work on the operational dimension (use of the knowledge for the action, decision making by the learner), with the support of individual booklets (for the teacher and for the learner)
• The intimate coupling of the educators training and the educational situations for learners
• The implementation in a long-term programme, with precise indicators of results

METHODS

Intended Audience and Setting