
Diabetes Care 2015;38:e110-e111 | DOI: 10.2337/dc15-0353
In sub-Saharan Africa, projections anticipate a 110% rise in the number of people with diabetes mellitus (DM) from 19.8 million to 41.5 million by 2035 (1) . This growth is attributed primarily to the multiple downstream ramifications of urbanization and westernization. Poor access to medications, finances, transportation, and skilled health care providers trained in DM management is a barrier that contributes to poor outcomes for patients with DM (2). As a result, patients are often forced to rely on self-management without guidance from the formal health care sector. To combat this barrier, diabetes self-management support (DSMS) programs sustain psychosocial support and education by incorporating lay DM patients as peer support group leaders at the community level (3, 4) . Limited data exist for DSMS outcomes in low-and middleincome countries (LMICs). The imminent rise of DM and the logistical challenges of health delivery in LMICs mandate a culturally-and resource-appropriate model of sustainable education and support at the community level.
We conducted a proof-of-concept study to evaluate the impact of a 6-month DSMS intervention on DM and cardiovascular disease risk factors in western Kenya. This pre-post implementation study was initiated at peri-urban and rural DM clinics in the catchment area of the Moi Teaching and Referral Hospital. Participants (n 5 148) were enrolled from clinics and then divided into 12 groups based on location of residence. Eligibility criteria included age $18 years and diagnosis and treatment of type 1 or type 2 DM for at least 2 years prior to enrollment. From each group, a peer leader completed a 4-week training per the International Diabetes Federation Peer Leader Manual (3). Peer leaders guided bimonthly group meetings, which focused on self-empowerment and problem-solving surrounding behavioral modification and self-management skills. Outcomes measured include change in glycosylated hemoglobin (HbA 1c ) level, systolic blood pressure (SBP), DM knowledge, and BMI. Generalized linear mixed models were used to estimate changes in primary outcomes, adjusting for potential confounding variables.
Following the 6-month study period, HbA 1c improved (b20.17, SE 0.09, P 5 0.050), after adjusting for age with a median decrease from 9.6% (81 mmol/mol) to 8.7% (72 mmol/mol). Sex, education, peer group, tribe, glucometer use, insulin use, and BMI were not independently associated with HbA 1c improvement. SBP also improved (b25.67, SE 1.64, P 5 0.001), with a median decrease from 132.4 mmHg to 127.5 mmHg. There were no changes in DM knowledge or BMI. Nine of the 12 groups elected to continue ongoing peer group meetings even after the study period and stipend support ended.
This study is the first to report positive outcomes for peer-led, in-person DSMS groups in an LMIC. Implementation of DSMS in western Kenya significantly improved HbA 1c and SBP after 6 months. Longer follow-up and inclusion of a control group are warranted in future implementation studies. The rising burden of DM in LMICs warrants a call for novel approaches at the community level. The DSMS model has great potential to answer this call.
Funding. This project was supported by National Institutes of Health Research Training Grant #R25 TW009337, funded by the Fogarty International Center and the National Heart, Lung, and Blood Institute of the National Institutes of Health. The authors thank Abbott for providing glucose testing supplies and Abbott Fund for providing funding to support this effort. Duality of Interest. S.D.P. has received fees for serving as a speaker and consultant for Abbott within the past 3 years. No other potential conflicts of interest relevant to this article were reported. Author Contributions. P.H.P. designed the study, collected and analyzed data, and wrote,

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