On the 20th of November, SAMRC President and CEO, Prof Ntobeko Ntusi hosted a lecture at the Medicina campus in Cape Town. The event was opened by Prof Ntusi, who welcomed and introduced the speaker, Prof Nuala McGrath who presented “Diabetes Together: a couples-focused intervention to support self-management of Type 2 Diabetes in South Africa”.
Non-communicable Diseases (NCDs), which include diabetes, obesity, cardiovascular and mental health disorders, have a high prevalence in South Africa, with as many as 1 in 5 people (about 20% of the population) in the country living with multi-morbidity i.e. living with more than one chronic illness at the same time. Self-management of these conditions can be a daily challenge, requiring changes in lifestyle behaviours, particularly for people living with diabetes.
Prof McGrath then delivered her talk, in which she provided insight into the development of the Diabetes Together intervention, while mentioning her previous research focusing on couples’ interventions to promote couples HIV testing and how the couples approach could improve uptake of other preventative health screening. The Diabetes Together intervention was developed in partnership with Prof Naomi Levitt and the Chronic Disease Initiative for Africa (CDIA) group at the University of Cape Town. The intervention provided a safe space for couples to learn and talk about diabetes, to share their concerns and complications, their fears and how to cope with difficult times, leading to a shared understanding of the disease.
Prof. McGrath explained “Establishing shared understanding of diabetes within couples becomes an opportunity for increased discussions about how to manage diabetes, and for the couple to participate in more shared activities that assist in the daily self-management of diabetes.” It employs behaviour change techniques and comprises of 3 workshops focussed on education and skills development, such as communication skills, stress management and goal setting activities, using a mixture of didactic and participatory elements to engage participants. Up to four couples counselling sessions are offered post-workshops. The Diabetes Together intervention was piloted at the Groote Schuur Hospital in the Cape Town metro, and in 3 areas in the western Cape i.e. Gugulethu, Elsies River and Mitchel’s Plain at places of worship.
Couple counselling sessions helped couples to ‘open up’ to each other, with participants also recognising that communication is key in relationships and the importance of tone of voice, listening and respect in conversations. Post-intervention, participants reported that involving partners mattered, and they now had a shared understanding which could help them to face diabetes together, and also assisted them to continue and sustain efforts, to become closer and work together. “Ultimately the intervention aims at supporting couples to work more collaboratively together to make lifestyle changes that will lead to improved self-management. Participants were very satisfied with the programme, and we are excited to evaluate the intervention as our next step” added Prof McGrath.
The lecture was followed by a Q&A session, which was filled with engagement and discussion around several important issues. There were questions on cultural issues and how these may affect uptake. The study team had collected qualitative data documenting couples’ experiences and perceptions of living with diabetes in their relationship and found little differences in the barriers and facilitators to self-management reported in studies conducted elsewhere, and the Diabetes Together intervention content was informed by the many diabetes interventions that have been employed in South Africa.
On issues of patriarchy, Prof McGrath responded that the gender roles module of the intervention initiated discussions among participants about the division of tasks within the household between partners, power dynamics and decision making about resources. The purpose of the workshops was to prime individual partners ahead of bringing the couple together to discuss important diabetes-related topics in their relationship in the facilitated environment of the couples counselling sessions. In response to a question about sample size, Prof McGrath mentioned that agreement regarding the definition of the primary outcome and study design are needed before the required sample size for an evaluation study is calculated.
A member of the audience asked for insights regarding age, in addition to gender differences, as uncontrolled diabetes is seen in younger individuals more frequently, Prof McGrath indicated that the study data didn’t suggest any differences in facilitators or barriers of self-management due to age, although it was noted that couples were generally 40+ years.
A question about the diabetes information that was shared with the participants, asking what it was and was it digital? Prof McGrath mentioned that the interventions were done face-to-face, and handouts were given to participants but no digital materials were used. Key diabetes facts presented were based on existing materials from successful interventions and were translated into IsiXhosa. A discussion on the credibility of information sources was used to provide participants with a way to investigate the veracity of new diabetes-related information that they hear in future.
There was a comment about church goers and partners, and co-habitation arrangement being a study criterion, and that this could potentially miss many individuals living with diabetes who don’t have a partner. Prof McGrath mentioned that indeed the aim was to leverage on the co-habitation arrangement and is important in this study as partners form part of the social environment and speaks to communal coping theory which focuses on primary partnerships, with intimacy and commitment to each other.
Question about how we can integrate the intervention into the standard practices of the healthcare system. Prof McGrath mentioned that the idea is to keep it out of the healthcare system, rather have it in the communities where they are needed, so that the benefit can be derived locally and in a local setting, while also continuing to stress the importance of couples to engage with their healthcare professionals regularly.
There was a question about outcomes and considering clinical outcomes vs people relevant outcomes and that we need to prioritise outcomes for the patient and make it people relevant but also valuable for clinicians and policy and decision makers. Prof Levitt, co-PI of the study, mentioned, “We have to aim to marry the two, the outcomes must be relevant to patients, considering the Patient-reported outcome measures (PROMS) review for people living with diabetes in low-income areas and that it needs to include aspects that are meaningful to communities. There is a need to enhance the use of surrogate markers such as HBA1c and blood pressure for example, while secondary outcomes which include relationship quality, reduced diabetes distress, enhanced intimacy and communication cannot be ignored”.
Offering final remarks, Prof Ntusi thanked the speaker for the excellent presentation and for sharing her experience and wished her well with the study going forward, while adding that based on the questions and discussion that it was clear that it piqued the interest of the audience both in attendance and online.
About the speaker
Prof Nuala McGrath is a Professor of Epidemiology and Sexual Health at the University of Southampton (UK), a Global Health Research Professor from the National Institute for Health and Care Research (NIHR, UK) and a Faculty member at the Africa Health Research Institute, KwaZulu-Natal.
Read the publication | HERE
For further reading | HERE
View some moments from the Lecture | HERE