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-dependent diabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report of implementation 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. Participants monitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluate glucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked and documented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a 6-month period.Results Participants brought their glucometers and logbooks to the clinic 95 - 100% of the time. Adherence with measuring glucose values and recording them in logbooks eight times a week was high (mean (standard deviation) 69.4% (15.7) and 69.0% (16.6), respectively). Mean HbA1c decreased from 9.0% (75 mmol/mol) at enrolment to 7.8% (62 mmol/mol) at 6 months (mean difference 1.2% (95% confidence interval (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 improved HbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research on long-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.