Impact of COVID-19 on diabetes mellitus outcomes and care in sub-Saharan Africa: A scoping review

Impact of COVID-19 on diabetes mellitus outcomes and care in sub-Saharan Africa: A scoping review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Impact of COVID-19 on diabetes mellitus outcomes and care in sub-Saharan Africa: A scoping review View ORCID Profile Wenceslaus Sseguya , Silver Bahendeka , View ORCID Profile Sara MacLennan , View ORCID Profile Nimesh Mody , View ORCID Profile Aravinda Meera Guntupalli doi: https://doi.org/10.1101/2024.04.10.24305598 Wenceslaus Sseguya 1 Institute of Applied Health Sciences, University of Aberdeen , Aberdeen, United Kingdom 4 Department of Internal Medicine, St Francis Hospital Nsambya , Kampala, Uganda Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Wenceslaus Sseguya For correspondence: w.sseguya.21{at}abdn.ac.uk Silver Bahendeka 3 Mother Kevin Postgraduate Medical School, Uganda Martyrs University , Kampala, Uganda 4 Department of Internal Medicine, St Francis Hospital Nsambya , Kampala, Uganda Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sara MacLennan 1 Institute of Applied Health Sciences, University of Aberdeen , Aberdeen, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sara MacLennan Nimesh Mody 2 Institute of Medical Sciences, University of Aberdeen , Aberdeen, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Nimesh Mody Aravinda Meera Guntupalli 1 Institute of Applied Health Sciences, University of Aberdeen , Aberdeen, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Aravinda Meera Guntupalli Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Background The COVID-19 pandemic impacted diabetes mellitus clinical outcomes and chronic care globally. However, little is known about its impact in low-resource settings such as sub-Saharan Africa. Hence, to address this, we systematically conducted a scoping review to explore the COVID-19 impact on diabetes outcomes and care in countries of sub-Saharan Africa. Methods We applied our search strategy to PubMed, Web of Science, CINAHL, African Index Medicus, Google Scholar, Cochrane Library, Scopus, Science Direct, ERIC and Embase to obtain relevant articles published from January 2020 to March 2023. Two independent reviewers were involved in the screening of retrieved articles. Data from eligible articles were extracted from quantitative, qualitative and mixed methods studies. Numerical data were summarised using descriptive statistics, while a thematic framework was used to categorise and identify themes for qualitative data. Results We found 42 of the retrieved 360 articles eligible, mainly from South Africa, Ethiopia and Ghana (73.4%). COVID-19 increased the risk of death (OR 1.30 – 9.0, 95% CI), hospitalisation (OR 3.30 – 3.73: 95% CI), and severity (OR: 1.30-4.05, 95% CI) in persons with diabetes mellitus. COVID-19 also increased the risk of developing diabetes mellitus in hospitalised cases. The pandemic, on the other hand, was associated with disruptions in patient self-management routine and diabetes mellitus care service delivery. Three major themes emerged, namely, (i) patient-related health management challenges, (ii) diabetes mellitus care service delivery challenges, and (iii) reorganisation of diabetes mellitus care delivery. Conclusion COVID-19 increased mortality and morbidity among people living with diabetes mellitus. In addition, the COVID-19 pandemic worsened diabetes mellitus care management. Sub-Saharan African countries should, therefore, institute appropriate policy considerations for persons with diabetes mellitus during widespread emergencies. Introduction Global evidence suggests that the coronavirus disease 2019 (COVID-19) resulted in a worldwide surge in mortality, morbidity, and disability, which predominantly occurred among older adults and individuals with chronic disease conditions [ 1 , 2 ]. COVID-19 has been reported to worsen diabetes mellitus (DM) clinical outcomes in particular, and DM care in general generally [ 3 – 8 ]. However, very little in this context is known in low- and middle-income countries, particularly in sub-Saharan Africa (SSA). While SSA is estimated to be host to 24 million of the estimated 537 million people with DM globally, the region records the highest rate of DM-related premature mortality [ 9 ]. Furthermore, SSA is predicted to experience the highest rate of rise in DM prevalence than any other region by 2040, depicting the magnitude of a growing threat [ 9 ]. DM is an under-researched area in SSA, which may underlie the limited understanding of the scale of the COVID-19 impact on persons living with DM (PLWD) and related vulnerabilities within the region. To address this gap, we carried out a scoping review to assimilate knowledge in this area that supports evidence-based policy consideration and stimulates future research in this field in SSA. We, therefore systematically conducted a scoping review of published qualitative, quantitative and mixed methods literature to explore the COVID-19 impact on DM outcomes and care in SSA. Our scoping review aimed to: (i) identify and characterise impact of COVID-19 infection on clinical outcomes of DM; (ii) describe DM care aspects that were impacted by the COVID-19 pandemic; and (iii) identify existing gaps in knowledge and research. Methods Study design We report our scoping review in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) (S1 PRISMA-ScR Checklist). The initial protocol for this scoping review is reposited with Open Science Framework [ https://doi.org/10.17605/OSF.IO/9JCKF ]. Data sources and search strategy We searched ten electronic databases, i.e., PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), African Index Medicus, Google Scholar, Cochrane Library, Scopus, Science Direct, Education Resource Information Centre (ERIC) and Embase. We defined our search strategy guided by the SPIDER (Sample population, Phenomenon of Interest, Design, Evaluation and Research type) framework as outlined by Cooke et al. [ 10 ] to identify relevant literature from qualitative and mixed methods studies. Additionally, to capture relevant literature from quantitative studies, we enriched our search strategy by incorporating appropriate elements of the PICO (Population, Intervention, Comparison and Outcome) framework [ 11 ]. The detailed search strategy applied to all citation databases with their respective search strings is provided as supplementary material (S2 Search strategy). A search across all databases was initially conducted in May 2022 and later updated using the same search strategy in March 2023 to include any relevant records published between the two periods. This also opened up possibilities for including studies with data on various ‘waves’ of COVID-19 infection and emerging interventions as the pandemic progressed. All retrieved records were merged into a single MS ® Excel file for subsequent removal of duplicate records and screening. Selection criteria The retrieved records were screened for eligibility through two stages, i.e., an initial review of article title and abstract and a subsequent full-text review of articles to be considered in final inclusion. An initial screening for the title and abstract was independently conducted by WS and AMG and reviewed by SB, who also resolved any disagreements in screening decisions. The same approach was applied for full-text screening. We defined agreement as a matching decision independently held by the reviewers involved in the screening process. The inclusion criteria were (i) articles from any country listed under SSA by the World Bank in 2021 [ 12 ], (ii) articles focusing on or concerning DM and COVID-19, (ii) peer-reviewed articles and reports and (iv) published from 01 January 2020 – 22 March 2023. The exclusion criteria were (i) no full-text availability, (ii) articles not published in the English language, (iii) non-human studies, (iv) reviews, (v) articles with irrelevant scope, (vi) duplicate articles, and (vii) articles published as multicountry studies involving countries outside SSA but without disaggregation of country-specific data ( Fig 1 ). Download figure Open in new tab Fig. 1: PRISMA-ScR diagram reporting outcomes of the systematic scoping review process. Data extraction and management Data variables of interest from the selected articles were extracted and charted in the extraction form. The data extraction form was developed by WS and reviewed by AMG, SB, and SM. It was then tested with two randomly selected articles from each set of quantitative, qualitative, and mixed methods studies for appropriateness. Appropriate revisions were made and continuously refined and updated throughout the data extraction process. Data extraction and charting were conducted by WS and independently reviewed by AMG and SB during the extraction and charting phase. Data synthesis We used an inductive thematic approach to synthesise and collate findings of qualitative and mixed-methods studies and open-ended results of quantitative studies. We used SPSS ® version 27.0 (IBM Corp, Armonk: New York) to summarise findings from quantitative studies as mean (SD), range (minimum and maximum), proportions and frequencies, where appropriate. Due to the variability in methodological designs of interventions and outcome measures across studies, a meta-analysis was not performed. Results Selection and characteristics of included studies A total of 360 unique records were retrieved from database searches, 42 of which were eligible for final inclusion ( Fig 1 ). Inter-reviewer reliability analysis using the Cohen’s kappa showed substantial agreement between reviewers at title and abstract screening (k=0.626, p<0.01), and moderate agreement at full-text screening (k=0.545, p<0.01). The detailed description of information of the included studies is shown in Table 1 . View this table: View inline View popup Table 1: extraction of data from included studies. The included studies were all observational but dominated by cross-sectional design (69%), with sample sizes ranging from 18 [ 13 ] to 3,460,932 [ 14 ]. The studies were predominantly retrospective (66.7%) and published between 2021 and 2022 (85.7%). The majority originated in South Africa (40.5%) and were mainly hospital-based (83.3%) and employed quantitative methods (90.4%). The extracted data variables were, DM prevalence among COVID-19 cases, outcomes of DM related to COVID-19 and their predictors, patient-related health management aspects, DM care service delivery aspects, and organisation of DM care related to the pandemic. Prevalence and incidence of DM among COVID-19 cases As shown in Table 2 , comorbidity of DM and COVID-19 was very prevalent, with up to 51% pre-existing cases reported, and a mean (SD) figure of 23% (±13.8). Prevalence as high as 31.1% was also reported for new-onset DM among COVID-19 hospitalised cases, and a high incidence rate of 37/1,000 person days [ 50 ]. View this table: View inline View popup Table 2: Studies reporting on different COVID-19 outcome variables. COVID-19-related outcomes of DM and their predictors As shown in Table 2 , mortality, hospitalisation, severity, and complications were the major outcomes related to COVID-19 in DM. The proportions of COVID-19-attributed mortality [ 17 , 19 , 24 , 28 , 29 , 32 , 33 , 42 , 46 , 47 ], hospitalisation [ 27 ], and severity [ 20 , 30 , 39 , 46 ] for PLWD were noticeable to high across the studies. The major predictors of COVID-19-related mortality and hospitalisation in PLWD were age, gender, DM treatment, and glycaemic control. For every 5-year age interval, being male, insulin treatment and HbA1c ≥7.0% were independently associated with higher odds for both COVID-19-related mortality [ 14 , 16 , 18 , 33 ] and hospitalisation [ 16 ]. On the other hand, new-onset DM, defined as DM diagnosed in hospitalised COVID-19 patients with prior normoglycaemia, was associated with age over 41 years, male gender and urban residence [ 50 , 52 ]. Impact of the COVID-19 pandemic on DM care Using an inductive thematic approach, we constructed three major themes from qualitative, mixed methods studies and open-ended quantitative results. The findings were thematically categorised as patient-related health management challenges, DM care service delivery challenges, and reorganisation of DM care delivery (S3 Themes). Table 3 presents a summary of studies that reported on each theme category. View this table: View inline View popup Table 3: Studies reporting COVID-19 pandemic’s impact on various aspects of DM care management. Patient-related health management challenges The three sub-themes that emerged under patient-related health management challenges were, self-management challenges, affordability challenges, and health service accessibility challenges. Self-management challenges reported among PLWD during the COVID-19 pandemic include reduced daily meal frequency [ 36 , 37 ], inadequate physical activity [ 26 , 37 ], and worsening glycaemic control [ 15 , 33 , 34 ]. Affordability challenges were related to increased costs of medicines [ 13 ] and reduced individual or household income [ 37 ]. PLWD also experienced health service accessibility challenges reported as increased clinic waiting time [ 13 ] and limited transport means to healthcare facilities [ 16 , 51 ]. Type 1 DM-specific challenges were limited food access, reduced affordability of living costs and accessibility of DM care services [ 37 ]. DM care service delivery challenges Four sub-themes emerged under DM care delivery challenges, namely, health workforce challenges [ 13 , 34 ], healthcare infrastructure challenges [ 13 , 34 ], health information management challenges [ 13 , 25 ], and medicines and medical supplies [ 13 ]. Health workforce challenges were characterised by health workers’ hesitancy towards work and the limited number of available DM specialists. This resulted in fewer active health workers at health facilities that increased workload [ 13 , 34 ]. At the same time, inadequate healthcare infrastructure limited available physical clinic space due to overwhelming patient numbers [ 13 , 34 ]. The COVID-19 pandemic was also characterised by poor management of health information and medical records attributed to the heavy workload of health workers and the fear of the risk of cross-infection while collecting patient data [ 13 , 25 ]. Additionally, the pandemic worsened shortages of medicine and medical supplies at health facilities [ 13 ]. Reorganisation of DM care delivery Four sub-themes, as shown in Table 3 , were categorised under the reorganisation of DM care delivery as a result of the pandemic, namely, patient-level reorganisation of care access [ 25 , 34 , 51 ], clinic-level reorganisation in management [ 34 ], and community-level reorganisation of community health worker services [ 25 , 34 , 51 ]. The reorganisation of DM care delivery was in response to the challenges patients and healthcare facilities faced in accessing and delivering DM care services. The interventions included delivery of patient medicines to their homes through their community health workers [ 25 , 34 , 51 ], which addressed the risk of infection and mitigated the health facility accessibility challenges faced by patients during lockdowns [ 34 ]. At clinic level, routine non-communicable disease ‘walk-in’ clinics were replaced with a clinic booking system to manage patient appointments and control clinic patient numbers [ 34 ]. At the community level, community health workers were empowered to monitor and follow up on patients with non-communicable diseases, including DM, aimed at reducing the workload of health facility staff [ 25 , 34 , 51 ]. Discussion Our scoping review of 42 articles highlighted COVID-19’s impact on DM outcomes and care in SSA. It also lays down existing gaps in knowledge and research. To the best of our knowledge, this is the first systematic scoping review in SSA to investigate outcomes of DM with COVID-19 and the pandemic’s effect on DM care. Our results show an inequitable representation in DM research in countries of SSA, with research outputs mainly contributed by South Africa. Overall, our scoping review shows that COVID-19 increased the risk of mortality and hospitalisation in PLWD, which were associated with older age, poor glycaemic control, insulin use and being male. These risk factors have also been reported in the US [ 57 ], China [ 58 ] and the UK [ 59 ]. We observed that PLWD had up to nine times higher risk of death, more than three times higher risk of hospitalisation and up to four times higher risk for severity due to COVID-19 compared to those without DM. Notably, similar findings but with varying levels of mortality and morbidity have been reported in China and the USA by Kumar et al. [ 60 ]. They revealed higher odds of COVID-19-related mortality (2.16, 95% CI: 1.74-2.65) and severity (2.75, 95% CI: 2.09-3.62) in PLWD than those without DM. COVID-19’s impact on DM clinical outcomes in SSA is significant and consistent with reports from the World Health Organization that indicate COVID-19 is deadlier in PLWD in Africa due to the region’s characteristic poor glycaemic control [ 61 , 62 ]. Additionally, COVID-19 was associated with an increased risk of developing new-onset DM, especially among hospitalised COVID cases over 41 years, males and urban residents. We observed a DM incident rate of 13.7/1,000 person-days (the equivalent of 5/1,000 person-years) and a prevalence of new-onset DM of up to 31% among COVID-19 cases in SSA. This rate is, however, considerably lower than what has been reported in the US (23-83/1,000 person-years) [ 63 ], England (37.2/1,000 person-years) [ 64 ] and China (13.5/1,000 person-years) [ 65 ]. Whereas the variation in diabetes incidence among COVID-19 patients in SSA may be due to underreporting, COVID-19’s epidemiological threat to the growing burden of DM in SSA needs to be tracked. As a pandemic, COVID-19 also impacted DM indirectly by causing disruptions in patient self-management routines and delivery of DM services in SSA. As our scoping review highlights, this impact manifested through challenges posed by instituted COVID-19 restrictions. For PLWD, we observe that this negatively affected their dietary intake and engagement in physical activity and limited their access to healthcare. The experience in SSA was however, in marked contrast with reports from India [ 66 ] and the UK [ 67 ], which showed no notable negative COVID-19 impact on access to essential services among PLWD. This stark variation may be explained by the different countries’ approaches to containing COVID-19, which in most SSA countries mainly targeted geographical containment, closure of non-essential services and prohibition of gatherings [ 68 ]. These unprecedented approaches created blockades to accessibility and affordability of various services, including health and social services [ 69 – 71 ]. On other grounds, there was a considerable shortage of health workforce, physical infrastructure and severe shortages of DM medicine and medical supplies. Whereas we acknowledge the pre-existence of challenges in the health workforce, healthcare infrastructure and medical supplies in SSA before the COVID-19 pandemic, the magnitude might have worsened during the pandemic due to a shift in healthcare resource prioritisation toward COVID-19 [ 72 ][ 73 ][ 74 ][ 73 , 75 ]. Interestingly, we also observed from our scoping review that the pandemic presented some opportunities for DM care innovation. For instance, the delivery of medicine to patient homes implemented in South Africa reportedly reduced the risk of COVID-19 infection among PLWD, mitigated DM care access challenges and ensured continued chronic patient follow-up [ 40 ]. Home delivery of medicine has also been reported to improve treatment adherence among chronic disease patients in Rwanda, which shows its feasibility in other SSA countries [ 76 ]. The pandemic, as demonstrated in South Africa, has also evidenced the value of integrating chronic non-communicable disease prevention and care in the services of community health workers. Additionally, clinic booking systems introduced to replace walk-in clinics in public health centres were found to mitigate clinic overcrowding, reduce clinic waiting time, and provide better doctor-to-patient time. These changes in the reorganisation of healthcare service delivery proved vital in addressing many challenges posed by the COVID-19 pandemic and offer lessons to policy and practice in future planning. Gaps in knowledge and research In our scoping review, we note various gaps in knowledge that can inform subsequent research. Firstly, there is a gap in the published literature on the use of guidelines for managing COVID-19 and DM in SSA countries, which would help evaluate their appropriateness for future similar occurrences. Secondly, the studies in our scoping review did not report on vaccine uptake or how the different ‘waves’ of COVID-19 infection influenced COVID-19 outcomes among PLWD. This would provide an understanding of the outcomes of PLWD across evolving pandemic dynamics and health system interventions. Exploiting research opportunities to address such gaps in knowledge can provide further and comprehensive understanding to shape appropriate post-pandemic DM care approaches and health system preparedness in addressing chronic care vulnerabilities during possible future pandemics. Limitations While this scoping review provides reliable information by scoping various research types and sources, there are some limitations. Firstly, our scoping review only included articles published in English. This may have limited studies published from non-English speaking countries within SSA; therefore, some relevant studies may have been missed. However, considering what was retrieved from most SSA countries, we predict this number to be likely minimal. Secondly, the included studies were dominated by three countries, which may limit the generalisation of findings to SSA. Thirdly, the studies were mainly conducted in the initial phase of the pandemic in 2020, indicating that changes experienced after that may render some findings unrepresentative of the post-2020 dynamics including the impact of emerging COVID-19 variants. Moreover, the limited disaggregation of data by studies in our scoping review, especially age, gender and type of DM, limited the drawing of specific conclusions and analyses. Finally, we only included peer-reviewed literature, which may have excluded some valuable literature sources such as manuscripts, institutional reports and archives. Nevertheless, this scoping review provided critical information and insights on how COVID-19 impacted PLWD and healthcare systems in SSA. Conclusions COVID-19 increased mortality and morbidity among PLWD and the occurrence of DM. In addition, the pandemic worsened DM self-care and DM service delivery generally. 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