Diabetes is a significant contributor to the burden of disease in South Africa
 and the prevalence in Africa is expected to increase by 80% over the next 15 years
. Self-reported prevalence rates for diabetes of 2.4% in men and 3.7% in women have been reported in South Africa
. However, studies in the Western Cape, one of the nine provinces of South Africa, suggest rates in urban areas as high as 33%
Approximately 80% of the 3,1 million population in the Cape Town Metropole are uninsured and rely on public sector facilities to manage their diabetes. Several previous studies in the Western Cape have illustrated the poor quality of care and outcomes for diabetic patients
[5, 6]. Almost 80% of patients were uncontrolled (HbA1c≥7%) in an audit of type 2 diabetes in Cape Town’s public sector in 2011
. Deficiencies in knowledge and self-care amongst patients and the inability of primary care providers to ameliorate this, have been identified as part of the problem. The population served by the public sector is characterized by low socio-economic status, low levels of education and low health literacy. The population served come from historically disadvantaged communities and speak mainly Afrikaans or Xhosa.
Primary care services in the country are largely nurse-led with the support of doctors. Other health workers, appropriate to the management of diabetes, such as dieticians and podiatrists, are usually not available. A variety of mid-level workers, such as health promoters, have been trained and employed in community health centres. Currently the education of diabetic patients and support of self-care has been left to the varied initiatives of individual health workers and there is no structured programme of education for people with diabetes in the Western Cape. Chronic care teams have identified that the health promoter should be the key person in delivering such a programme
Community health centres in the Western Cape are usually found in larger metropolitan areas or rural towns. Diabetic patients are often seen in such large numbers that a specific day is set aside each week for them to attend a diabetic “club”. At a given health centre patients are usually scheduled to attend the “club” as a group and are given appointments to be seen for review every 3 months.
During 2006–2008 the investigators were involved in an appreciative inquiry project to improve the annual review of the diabetic patients in the Cape Town Metropole. During this project the quality of care in the annual audit in terms of assessment of HbA1c, serum creatinine and cholesterol, retinal screening, foot screening and calculation of body mass index significantly improved
. At the end of this project staff articulated the need for a better approach to diabetes education and collaborated in designing the content of a more structured programme to be delievered by health promoters
Health promoters have a secondary school education up to at least Grade 8 and once employed have additional training in the knowledge and skills required to deliver health education messages and promote health. There are currently 120 health promoters in the Province and the policy of the Department of Health is to have a health promoter at every community health centre. A recent study showed that the current health promoters have a good knowledge of key diabetes education messages for patients
Although a variety of individual and group educational materials are available from non-government organizations and pharmaceutical companies, no materials are officially disseminated or recommended by the national or provincial Department of Health.
The relationship between health care provider and patient is recognized to have an important influence on patient understanding and adherence
. Motivational interviewing has been recommended as a more skilful guiding approach to eliciting lifestyle change and promoting self-care
 and a recent systematic review concluded that it out-performs traditional advice-giving in 80% of studies
[11, 12]. Professors Rollnick and Mash are members of the International Network of Motivational Interviewing Trainers and have experience with training and researching in this area
[10, 13]. Studies of individually-delivered motivational interviewing for diabetic patients have produced promising results
[14, 15]. A recent study of individual motivational interviewing for the prevention of diabetes also demonstrated a significant effect on achieving 5% weight loss
Group interactions have been found to be effective in diabetes education
 and local chronic care staff have indicated that this is the most practical approach in their very busy health centres
. A systematic review of group education in diabetes concluded that “The results of the meta-analyses in favour of group-based diabetes education programmes were: reduced glycated haemoglobin at four to six months (1.4%; 95% confidence interval (CI) 0.8 to 1.9; P < 0.00001), at 12–14 months (0.8%; 95% CI 0.7 to 1.0; P < 0.00001) and two years (1.0%; 95% CI 0.5 to 1.4; P< 0.00001); reduced fasting blood glucose levels at 12 months (1.2 mmol/L; 95% CI 0.7 to 1.6; P < 0.00001); reduced body weight at 12–14 months (1.6 Kg; 95% CI 0.3 to 3.0; P = 0.02); improved diabetes knowledge at 12–14 months (SMD 1.0; 95% CI 0.7 to1.2; P < 0.00001) and reduced systolic blood pressure at four to six months (5 mmHg: 95% CI 1 to 10; P = 0.01). There was also a reduced need for diabetes medication (odds ratio 11.8, 95% CI 5.2 to 26.9; P < 0.00001; RD = 0.2; NNT = 5). Therefore, for every five patients attending a group-based education programme we could expect one patient to reduce diabetes medication”
. Motivational interviewing in group format is a relatively new development; 12 published reports have emerged
[18, 19], which include three randomized trials and one study in the diabetes field
Despite evidence of the effectiveness of group diabetes education all of the trials have been conducted in high-income countries and by health professionals such as doctors or nurses. This trial will be the first in an African context and delivered by mid-level health workers. In addition the incorporation of group motivational interviewing will add to a small evidence base on this topic.
If the study demonstrates effectiveness of this educational intervention then it can be implemented throughout the Western Cape and may well be replicated in the rest of the country and possibly within the southern African Region. The study intends to inform policy makers and managers of the district health services and help them decide whether to implement the programme more widely.
Aim and objectives
Aim: To evaluate, by means of a pragmatic cluster randomized controlled trial, the effectiveness of a group diabetes education programme delivered by trained health promoters with a guiding (motivational interviewing) style, in community health centres in Cape Town, South Africa.
Objective 1: To evaluate effectiveness by assessing group changes in the following:
Primary outcomes: improved diabetes self-care activities, 5% weight loss, HbA1c reduction of 1 percentage point
Secondary outcomes: improved diabetes-specific self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c, mean total cholesterol and quality of life
Objective 2: To evaluate fidelity to the educational programme and motivational interviewing by use of audiotapes and scoring health promoters with the Motivational Interviewing Integrity Code.
Objective 3: To explore the experiences of the health promoters with regards to their training and delivery of the diabetes education programme.
Objective 4: To explore the experiences of patients who attend the diabetes education sessions.