Challenging Assumptions for Low-Income Countries
A recently published study of people living with type 1 diabetes in two rural clinics in Malawi found a high level of acceptability and satisfaction among those using continuous glucose monitoring, suggesting that the technology is feasible in low-income settings.
At a PEN-Plus clinic in rural Malawi, Victor Kaphaso, an advanced noncommunicable diseases nurse with Partners In Health, provides Kerefasi Wiliyamu, a 14-year-old living with type 1 diabetes, with advice about monitoring his insulin levels. Photo: Karin Schermbrucker/Slingshot Media for Partners In Health
Living with type 1 diabetes in any setting can be challenging, but people living with the disease in low-income countries often face additional barriers to care. Those living in remote rural settings, for example, may lack access to home glucose meters, and even those with access may have only a limited supply of test strips.
“For many years, continuous glucose monitoring—a technology that measures blood glucose continuously and in real-time—has been considered the standard of care for people living with type 1 diabetes in many high-income countries,” said Dr. Alma Adler, director of research at the Center for Integration Science in Global Health Equity at Brigham and Women’s Hospital. “Yet it remains unavailable in most low-income countries, especially when people have low literacy levels, limited facility with numbers, and no access to electricity.”
Dr. Adler and colleagues at the Center for Integration Science, Partners In Health, Massachusetts General Hospital, and Kamuzu Central Hospital in Lilongwe, Malawi, conducted a small randomized controlled trial that compared continuous glucose monitoring (CGM) with glucose monitoring in two rural clinics in the Neno district of Malawi. The study, the first trial of its kind, randomized 42 study subjects and followed up with them for three months.
The research team found that people tolerated the CGM well and were able to charge the devices with solar chargers. Unfortunately, low numeric literacy caused most participants to struggle with typing in the codes needed to change the sensors, resulting in increased numbers of clinic visits.
Despite that setback, the researchers found that participants using CGM had greater numbers of lifestyle-change suggestions and dose adjustments than those using glucose meters.
The study results were recently published in an article in BMJ Open, “Appropriateness and acceptability of continuous glucose monitoring in people with type 1 diabetes at rural first-level hospitals in Malawi: a qualitative study.”
“While our study wasn’t large enough to show statistical significance, people using CGM had a trend of lower blood glucose levels than those using glucose meters,” said Dr. Adler, who served as senior author of the study. “Just as important, the interviews we conducted with participants and their caregivers showed that most of them were happy using CGM. The participants also found the technology helped them learn about their disease and how to control their blood glucose levels.”
The most common complaints of those using CGM centered on the inability to change their own sensors and the beeping of the alarms, which irritated some participants and made them feel stigmatized when the alerts sounded in public.
“The results from the first randomized controlled trial of CGM use in a rural area of a low-income country suggest that CGM use is both feasible and acceptable,” said Dr. Adler. “While CGM may have its challenges, we hope to see people in low-income countries have broader access to this lifesaving technology. This access would be an important step in ensuring global health equity.”