Training Community Health Workers for diabetes management in low- and middle-income countries: A systematic review
ABSTRACT
Background:
Type 2 diabetes mellitus (T2DM) is a significant public health challenge that disproportionately impacts low- and middle-income countries (LMICs), which account for 73% of the global cases. Owing to resource constraints, these nations have adopted task-shifting strategies using community health workers (CHWs); however, there is limited evidence regarding the effectiveness of training CHWs in diabetes management.
Objective:
A systematic review was conducted to answer the question: Does training community health workers in diabetes (Type 2) improve the efficacy of diabetes screening and management at the community level in LMICs?
Methods:
The review was conducted by two reviewers, supervised by two supervisors, and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA) guidelines. We conducted a comprehensive search across databases including PubMed, MEDLINE Ovid, Scopus, EBMR, and CINAHL for studies published between January 2000 and April 2024. All randomized and non-randomized controlled trials and observational studies assessing CHW training in diabetes management in LMICs were included. The primary outcome of interest was the mean change in HbA1c percentage levels. Data were synthesized narratively for training characteristics and study outcomes. The Risk of Bias 2 tool and the ROBINS-I tool were used for quality assessment.
Results:
A total of 3,387 studies were screened, 69 were found eligible for full-text review, and four (three RCTs and one before-and-after study, totalling ~1,000 patients) were included for further narrative analysis. One of the three RCTs reported statistically significant effects, with a mean HbA1c difference of –0.24%. In contrast, all other studies reported reduced HbA1c levels that were not statistically significant. Risk of bias among RCTs was generally moderate (some concerns, with one trial at high risk), and the observational study had a serious risk of bias. A meta-analysis was not performed due to the limited number of RCTs.
Conclusions:
Training CHWs in diabetes (Type 2) management has shown potential for improving glycemic control in LMIC settings, with one trial demonstrating a significant reduction in HbA1c. Strengthening and standardizing CHW training might be an effective strategy to enhance diabetes care in underserved settings. Future larger trials and implementation research can help maximize the impact of CHWs against the growing diabetes burden. Clinical Trial: PROSPERO CRD42022341717
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