Evaluation of the “Take Five School”: An education programme for people with Type 2 Diabetes in the Western Cape, South Africa

Abstract

Aim

To evaluate the Take Five School (TFS) group education programme for patients with Type 2 Diabetes in South Africa.

Methods

Questionnaires, administered before and after 4 sessions of an hour each of group education, measured the effect on self-care activities in 84 patients from 6 different clinics. Individual interviews with health care workers (HCWs) and focus group interviews (FGI's) with patients explored attitudes.

Results

A significant improvement in adherence to a diabetic diet, physical activity, foot care and the perceived ability to teach others was seen. There was no significant change in smoking or adherence to medication. Qualitative data revealed that comprehensive education was appreciated, that the group process was deemed supportive, that HCWs doubt the effect of education in general and that a combination of group and individual sessions was seen as an option worth exploring. Strengths, weaknesses, opportunities and threats to the TFS are identified. Recommendations are made to improve the programme and its environment.

Conclusion

Significant self-reported improvements in self-care activities after a group-education programme support the view that introducing structured group education for Type 2 Diabetics in a South African public sector primary care context holds promise. Group education for diabetics, especially in resource limited settings, should be sustained and further research should focus on clinical outcomes.

Introduction

In 2011 the prevalence of diabetes in South Africa was estimated to be 6.5% in the age group 20–79 years [1]. Diabetes is currently the fourth most common diagnosis in primary care [2] and contributes significantly to the burden of disease in South Africa [3], [4].

The management of this growing number of patients falls mostly on primary care and guidelines recommend medical management as well as patient education [5], [6]. Patients need ongoing support and motivation [7], as well as “a minimum threshold of diabetic knowledge” for successful self-management and life style change [8].

Education, motivation and support are seen as key components of a structured education programme [5], [6], [9], [10]. The international call to integrate structured education programmes into comprehensive diabetes care is not only evidence based [7], but increasingly rights-based [11], [12].

Reviews by both Deakin [13] and Steinbekke [14] conclude cautiously that group based education could be effective in improvements in clinical, lifestyle and psychosocial outcomes. Rickheim et al. [15] concluded that group education is equal or better, depending on the outcome selected, to individual education and might be more cost effective. The NICE guideline states that diabetes education has a low cost, and therefore even minimal improvements will result in a cost-effective intervention [9].

The goals of educational programmes should be adapted to local needs, but are generally aimed at metabolic control, preventing complications and improving quality of life, whilst keeping costs acceptable [8]. Topics to be addressed are basic pathophysiology of diabetes, treatment options, self monitoring and injection, acute and chronic complications, foot care, substance use, family planning and pregnancy, stress management, nutrition and physical activity whilst also including the family [5]. Trento states that “lifestyle intervention requires delivery of continuing patient education and care without increasing clinical workload and with measurable outcomes” [16]. She concludes that “routinely delivered group care is a feasible and cost-effective approach to improve metabolic control and quality of life in type 2 diabetes” [16]. This could be true also in the setting of low or middle income countries, where 80% of the world's diabetics live [1].

How should this structured education be offered in the South African public, primary health care setting, where individual, ad hoc counselling is the norm? [17] The “Take Five School” programme was introduced in the Eden District of the Western Cape by a small group of HCWs aiming to provide effective small group diabetes education over four sessions of an hour each. It was never formally evaluated and it is questioned whether this programme can serve as a model for managing Type 2 Diabetes or other chronic diseases.

This study aimed to evaluate the TFS and was intended to measure the short term effects on self-care activities and to explore the opinions and experiences of patients and HCWs who had been involved in the programme.